DISEASES OF WOMEN.
t^e-
J
f DISEASES OF WOMEN
INCLUDING
THEIR PATHOLOGY, CAUSATION, SYMPTOMS,
DIAGNOSIS, AND TREATMENT.
A MANUAL FOR STUDENTS AND PRACTITIONERS.
AETHUR W. EDIS, M.D., Lond., F.R.C.P., M.E.C.S.,
ASSISTANT OBSTETRIC PHYSICIAN TO THE MIDDLESEX HOSPITAL, CONSULTING OBSTETRIC PHYSICIAN TO
THE CITY PROVIDENT DISPENSARY, LATE VICE-PRESIDENT OF THE OBSTETRICAL SOCIETY
OF LONDON, LATE PHYSICIAN TO THE BRITISH LYING-IN HOSPITAL.
With One Hundred and Forty-Eight Illustrations,
PHILADELPHIA:
HEN^EY^ C. LEA'S SO:Nr & CO.
188 2.
(
Entered according to Act of Congress, in the year 1882,
By henry C. LEA'S SON & CO.,
In the oflBce of the Librarian of Congress at Washington, D. C.
All rights reserved.
PREFACE.
In the following pages I have attempted to present to the
student and junior practitioner such an account of the diseases
incidental to women as will prove a reliahle, practical clinical
guide.
Those who, from lack of time or opportunity during their stu-
dent career, neglected to make themselves familiar with a subject
which will form a most important item in the daily routine of
ordinary practice, may thus be enabled to repair the omission.
My endeavor has been to give an impartial account, and if, in
dealing with the subject of displacements of the uterus, too much
prominence should appear to have been given to their mechanical
treatment, it has been in order that the question should be fairly
represented, not that the practitioner is recommended to place too
great reliance upon mechanical appliances.
The task of condensing within the limits of a manual all that
has stood the test of time and experience in this specialty, has
been a difficult one. Doubtless many omissions will be found.
Still, I trust these may be rectified by encouraging the student to
investigate the subject of gynecology more exhaustively in larger
works.
I have to acknowledge my own indebtedness for much valuable
information to Dr. Barnes's " Clinical History of the Medical and
Surgical Diseases of Women," Dr. T. Gaillard Thomas's " Practi-
cal Treatise on the Diseases of Women," and other similar works
duly acknowledged in the text.
The diagnosis of abdominal tumors being generally one of much
difficulty to the student, has been given most exhaustively. The
functional disorders have also been entered into at some length,
(V)
VI PREFACE.
necessitating, of course, much repetition ; but as the young prac-
titioner is often compelled to study disease from its clinical aspect,
this portion of the work will not, I feel sure, be unappreciated.
The illustrations chiefly consist of outline diagrams representing
the various displacements of the uterus, methods of operation in
cases of ruptured perineum and vesico-vaginal fistulse, and differ-
ential diagnosis of tumors. Figures of instruments likely to be of
service to the practitioner have been incorporated in the text, as
being far more useful than letter-press descriptions. Many of the
makers' names appear upon these, but where not indicated I am
indebted to the courtesy of Messrs. Krohne and Seseman.
A copious index is appended, to facilitate reference, and every
effort has been made to render the work practically useful to the
busy practitioner.
A. W. E.
22 WiMPOLE Street, W.,
September^ 1881.
CONTENTS.
CHAPTER I.
INTRODUCTORY.
PAGE
Importance of Gaining the Confidence of the Patient, of Combining Firmness with Gen-
tleness, of being Neat and Cleanly in the Performance of Minor Operations — Mode
of Ascertaining Symptoms — Value of the Objective Contrasted with the Subjective
Symptoms — Form for Recording Cases — Question of the Necessity of Resorting to
an Examination — Disturbance of Menstruation, Menorrhagia, Dysmenorrhoea, and
Leucorrhoea as indications, 17
CHAPTER II.
MEANS OF PHYSICAL DIAGNOSIS.
Management of Patient during Physical Examination — Vaginal Touch — Conjoined
Manipulation or Bimanual Examination — Uterine Exploration by means of the
Sound — Utero-abdominal, -rectal, and -vaginal Exploration — Inspection of the
Vulval Outlet — Examination by the Speculum — Abdominal Inspection, Palpation,
Percussion, and Auscultation — Rectal Touch, Recto-abdominal, -vaginal, and -vesi-
cal Exploration — Rectal Exploration — Dilatation of Cervix Uteri by means of Tents
' • — Advantages of Using Laminaria over Sponge Tents — Dangers and Precautions —
Use of Hydrostatic Dilating Bags — Continuous Elastic Pressure — Aspirator or Ex-
ploring Needle — Examination of Discharges — Anaesthesia, 22
CHAPTER III.
MALFORMATIONS OF THE UTERUS.
Absence or Rudimentary Development of the Uterus— Uterus-bipartitus, -duplex, -uni-
cornis, -bicornis, -bilocularis — Infantile Uterus — Congenital and Acquired Atresia
Uteri — Symptoms — Diagnosis — Treatment — Conical Cervix and Stenosis of Os Ex-
ternum — Treatment — Stenosis of Os Internum — Dilatation and Incision, . . 49
CHAPTER IV.
DISPLACEMENTS OF THE UTERUS — ASCENT AND DESCENT OF THE UTERUS.
Normal Position of Utei'us — Causation of Displacements in General — Ascent of the
Uterus — Descent or Prolapse of the Uterus — Methods of replacing the Uterus —
Methods of Sustaining the Uterus — Pessaries — Surgical Treatment, ... 61
CHAPTER y.
DISPLACEMENTS OF THE UTERUS — Continued.
Anteversion and Anteflexion — Symptoms — Diagnosis — Treatment, .... 85
CHAPTER VI.
DISPLACEMENTS OF THE UTERUS — Continued.
Retroversion and Retroflexion — Symptoms — Diagnosis — Treatment, .... 104
(yii)
Vlll CONTENTS.
CHAPTEE YII. â–
DISPLACEMENTS OF THE UTERUS — Continued.
PAGl
Inversion of the Uterus — Varieties — Symptoms — Diagnosis — Treatment, . . . 12J
CHAPTEE YIII.
MENSTRUATION AND VASCULAR DISORDERS OF THE UTERUS.
Ovulation and Menstruation — Source of the Menstrual Blood — Vascular Disorders of
Uterus — Fluxion — Hyperaemia — Congestion or Engorgement of the Uterus and
Ovaries — Local depletion in, . 131
CHAPTEE IX.
INFLAMMATION OF THE UTERUS.
Acute Metritis and Acute Endometritis — Hot-water Vaginal Injections in, . . . 144
CHAPTEE X.
CHRONIC CERVICAL ENDOMETRITIS.
Mode of Applying Caustics to Cervical Canal, 153
CHAPTEE XI.
CHRONIC CORPOREAL ENDOMETRITIS.
General Treatment — Intra-uterine Medication — Fungoid or Villous Endometritis, . 161
CHAPTEE XII.
SUBINVOLUTION, HYPERTROPHY, AND HYPERPLASIA OF THE UTERUS, OR
CHRONIC METRITIS.
Treatment — Prophylactic — Curative — General — Local, 176
CHAPTEE XIII.
GRANULAR AND CYSTIC DEGENERATION OF THE CERVIX UTERI.
Treatment — Vaginal Douche — Injections — Medicated Pessaries — Caustic Applications —
Cystic or Follicular Degeneration of the Cervix — Syphilitic Ulceration of Cervix, . 188
CHAPTEE XIY.
HYPERTROPHIC ELONGATION AND LACERATION OF CERVIX UTERI.
Operations for, 199
CHAPTEE XV.
NEW GROWTHS OF THE UTERUS — UTERINE POLYPI.
Mucous, Glandular, Cellular, Placental, Fibrinous, and Fibroid Polypi — Treatment, . 210
CHAPTEE XYI.
NEW GROWTHS OF THE UTERUS — Continued.
Fibroid and Fibro-cystic Tumors of the Uterus — Varieties of Fibroids — DiflFerentiation
— Terminations — Treatment, Palliative and Curative — Surgical Treatment of —
Spaying for — Hysterectomy — Fibro-cystic Tumors, 219
CONTENTS. IX
CHAPTER XVII.
CANCER OF THE UTERUS.
PAGE
Cancer of Cervix Uteri — Epithelioma — Contagiousness of Cancer — Complication with
Pregnancy — Extirpation of the Uterus — Cancer of Body of Uterus — Sarcoma of the
Uterus, 239
CHAPTER XVIII.
DISEASES OF THE OVARIES.
Absence — Imperfect Development — Atrophy — Apoplexy — Displacement — Prolapse —
Hernia — Inflammation — Acute and Chronic Ovaritis— Battey's Operation, . . 263
CHAPTER XIX.
OVARIAN TUMORS.
Varieties — Cystomata — Simple — Contents — Cutaneous, Piliferous, or Dermoid Cysts —
Fibroid Tumor of Ovary — Cancer of Ovary — Extra-ovarian Tumors — Cysts of the
Fallopian Tubes — Tubo-ovarian Cysts — Cysts of the Broad Ligaments — Parovarian
Cysts — Cysts from Development of Wandering Ova, 275
CHAPTER XX.
OVARIAN TUMORS {continued), including the DIAGNOSIS OF ABDOM-
INAL TUMORS.
Symptoms — Course and Terminations — Bursting of the Tumor — Twisting of the Pedicle
— Bleeding from Surface of Cyst — Inflammation in Interior of Cysts -Adhesions-^
Methods in which Death is Produced — Diff"erential Diagnosis — Obesity with Tym-
, panitic Distention — Hysterical Tympanites — Phantom Tumors and Spurious Preg-
nancy — Ascites — The Three Varieties of Ovarian Cysts — Parovarian Cysts — Hyda-
tids — Renal Cysts — Pregnancy — Molar Pregnancy — Retained Encysted Foetus —
Ovarian Tumor Complicating Pregnancy — Fibroid Tumors of Uterus — Fibro-cystic
Tumors of Uterus — Haematometra — Phy so-haematometra — Hy drometra — Physo-
metra — Distention of Bladder — Encysted Dropsy, Encysted Abscess, and Other
Conditions — Diagnosis in Early Stage, of Adhesions, of Malignancy — Tapping —
Exploratory Incision — Medical Treatment, 289
CHAPTER XXI.
SURGICAL TREATMENT OF OVARIAN CYSTS, INCLUDING OVARIOTOMY.
Palliative — Paracentesis Abdominis — Tapping by the Vagina, by the Rectum — Curative
— Tapping Followed by Pressure, by Injections of Iodine — Formation of Permanent
Opening in Cyst — Ovariotomy — Indications for; Contra-indications — Precautions
before Operating — Preparation of Patient for Operation — Preparatory Arrangements
— Instruments — Assistants — Antiseptic Precautions — Anaesthesia — The Operation —
The Pedicle — Arrest of Haemorrhage — Cleansing of Peritoneal Cavity — Drainage —
Closure of Abdominal Wound — Application of Dressings — After-treatment — Sur-
gical Treatment, 318
CHAPTER XXII.
DISEASES OF THE BROAD LIGAMENTS, INCLUDING PELVIC CELLULITIS
AND PELVIC PERITONITIS.
Pelvic Cellulitis or Parametritis — Treatment of Pelvic Abscess — Pelvic Peritonitis or
Peri-metritis, 338
X CONTENTS.
CHAPTER XXIII.
PELVIC HEMATOCELE.
PAGE
Sources of the Haemorrhage — Differentiation — Treatment, 359
CHAPTER XXIV.
DISEASES OF THE FALLOPIAN TUBES, INCLUDING EXTRA-UTERINE GES-
TATION.
Salpingitis, or Inflammation of the Fallopian Tubes — Obstruction or Obliteration — Dila-
tation — Dropsy of Tubes — Ectopic or Extra-uterine Gestation — Varieties — Treat-
ment — Gastrotomy, . . 369
CHAPTER XXV.
DISEASES OF THE VULVA.
Eruptive Diseases — Sensitive Red Patches — Warts — Condylomata — Elephantiasis — •
Oozing Tumor of Labia — Lupus of Vulva — Cancer of Vulva — (Edema of Nymphae —
Hydrocele — Cystic Dilatation of Vulvo-vaginal Glands — Vulvitis — Inflammation
and Abscess of Vulvo-vaginal Glands — Phlegmonous Inflammation of Labia Majora
— Furuncles of the Labia — Varicose Dilatation of Veins of Vulva — Pudendal Haem-
orrhage — Hsematoma — Fatty and Fibro-cellular Tumors of Vulva — Pudendal Her-
nia — Hernia of Ovary — Hyperaesthesia of the Vulva — Fissure of the Vaginal Ori-
fice — Urethritis — Prolapsus Urethrae — Urethral Polypus — Angioma of the Urethra
— Cystic Dilatation of Urethra — Vascular Tumor of Urethra — Hyperplasia or Hyper-
trophy of Clitoris, . 389
CHAPTER XXVI.
CONGENITAL MALFORMATIONS AND DISEASES OF THE VAGINA.
Occlusion of the Vagina — Atresia Vulvas — Imperforate Hymen — Persistent Hymen —
Congenital Atresia Vaginae — Duplex Vagina — Prolapsus Vaginae — Cystocele Vagi-
nalis — Rectocele Vaginalis — Enterocele Vaginalis — Diphtheritic Inflammation of
Vagina — Cystic Tumors of Vagina — Cancer of Vagina — Vaginitis or Colpitis — Cica-
trices of Vagina — Cystitis, 413
CHAPTER XXVII.
LACERATION OF THE PERINEUM.
Time for Operation — Primary or Immediate Operation — Secondary Operation — Opera-
tion for Partial Rupture — Operation for Complete Rupture, 435
CHAPTER XXVIII.
FISTULiE OF THE FEMALE GENITAL ORGANS.
Vesico-vaginal Fistulae — Operation for — Simon's Method — Recto-vaginal Fistula, . . 447
CHAPTER XXIX.
Functional Disorders.
AMENORRHCEA, CHLOROSIS, VICARIOUS MENSTRUATION.
Amenorrhoea — Occult or Concealed Menstruation — Chlorosis — Diagnosis from Angemia —
Vicarious or Ectopic Menstruation, 456
CHAPTER XXX.
DYSMENORRHCEA.
Netti-algic — Spasmodic — Congestive or Inflammatory — Obstructive — Membranous, . 473
CONTENTS. XI
CHAPTER XXXI.
LEUCORRHCEA.
PACE
Causation — Diagnosis — Treatment — Infantile, 489
CHAPTER XXXII.
UTERINE HEMORRHAGE, MENORRHAGIA, AND METRORRHAGIA.
Causes — General and Local — Treatment — Haemorrhages connected with Pregnancy, . 495
CHAPTER XXXIII.
STERILITY.
Causes Producing — Treatment, 504
CHAPTER XXXIV.
CLIMACTERIC DISORDERS, INCLUDING PSEUDO-CYESIS.
Symptoms — Treatment — Pseudo-cyesis or Spurious Pregnancy — Diagnosis — Treatment, 517
CHAPTER XXXY.
HYSTERIA, VAGINISMUS, DYSPAREUNIA.
Hysteria — Causation — Symptoms — DiflFerentiation — Treatment — Seclusion and Rest —
Massage — Electricity — Diet and Regimen— Vaginismus — Dyspareunia — Causes —
Treatment, 523
CHAPTER XXXVI.
FUNCTIONAL DISORDERS OF THE BLADDER.
Irritability of the Bladder — Dysuria or Painful Micturition — Retention of Urine — Causa-
tion — Mode of Introducing the Female Catheter — Incontinence of Urine, . . 540
CHAPTER XXXVII.
PRURITUS VULVE, VAGINA, AND ANI, UTERINE DYSKINESIA, COCCYGO-
DYNIA, 652
INDEX, . 565
LIST OF ILLUSTRATIONS.
FIG. PAGE
1, Outline Diagram showing Section of Pelvis, 20
2, Method of Bimanual Examination (after Sims), 25
3. Uterine Sound, 27
4. Portable Uterine Sound, 27
6. Pergusson's Speculum, 31
6. Cusco's Bivalve Speculum, .......... 32
7. Modification of Cusco's Speculum, 32
8. Barnes's Speculum, ........... 33
9. Sims's Speculum, 33
10. Griffith's Speculum, 34
11. Heywood Smith's Modification of Sims's Speculum, 35
12. Neugebauer's Speculum, 35
13. Kegions of Abdomen, 37
14. A Sponge Tent, 40
15. A Laminaria Tent, .40
16. A Sponge Tent with Thread, 41
17'. Barnes's Tent Introducer, 41
18. Long Sponge Tent Forceps, with Slide, 41
19. Sponge Tents, showing diflferent Sizes, 42
20. Lawson Tait's Apparatus for Dilating Uterine Canal, 45
20 A. Dieulafoy's Aspirator, 46
21. Conoidal Cervix, 52
22. Simpson's Metrotome, 53
23. Kiichenmeister's Scissors, .......... 53
24. The Cavities of the Uterus and Cervix (after Bennet), . . . .54
25. Priestley's Portable Uterine Sound, 56
26. Priestley's Uterine Dilator, 56
27. Ellinger's Cervical Dilator, 56
28. Peaslee's Metrotome, 58
29. Green halgh's Metrotome, 58
30. Civiale's Urethrotome, 58
31. Longitudinal Section of Pelvic Organs, ....... 62
32. Diagram illustrating Stages of Prolapsus Uterus, 64
33. Hodge's Pessary, 72
34. Hodge's Pessary in situ, 73
35. Galabin's Pessary, 75
36. Greenhalgh's Elastic Spring Pessary, . 76
37. " " " 76
38. Annular Eing Pessary, ........•• 77
39. Barnes's Stem Pessary, . 77
40. Cup and Stem Pessary in siiu, 77
( xiii )
Xiv LIST OF ILLUSTRATIONS.
FIG.
PAGE
41. Duffin's Pessary, 77 ^
42. Cutter's Cup and Stem Pessary, 78 ;
43. Cutter's Ring Pessary, 78
44. Cutter's Pessary m situ, . . . . . ' . . • • .79
45. Elastic Gum Ring Pessary, 79
46. Globular Box-wood Pessary, 79
47. Zwanck's Pessary, 80
48. Godson's Modification of Zwanck's Pessary, 80
49. Duncan's Stem and Disk Pessary, . 81
50. The Degrees of Retroversion and Anteversion, 85
51. Graily Hewitt's Cradle Pessary, - . . ?8
52. Cradle Pessary in situ, .......... 88
53. Thomas's Anteversion Pessary, 89
54. Thomas's Hinged Pessary, 89
65. Galabin's Anteversion Pessary, 89
56. Anteflexion of Uterus, 90
57. Corporeal Flexion, 91
58. Cervical Flexion, 91
69. Cervico-corporeal Flexion, ......... 91
60. Fibroid in Anterior Wall of Uterus simulating Anteflexion, ... 95
61. Anteflexion of Uterus showing Position of Hodge's Pessary, ... 98
62. Fancourt Barnes's Anteflexion Pessary, 98
63. India-rubber Stem Pessary, 98
64. Barnes's Galvanic Stem Pessary, 99
66. Pessary with perforated Septum, 99
66. Peaslee's Stem Pessary, 100
67. Vulcanite Stem Pessary, 100
68. Wright's Intra-uterine Stern Pessary, 100
69. Thomas's Anteflexion Pessary, 102
70. Wynn Williams's Stem Pessary, 102
71. Lines of Incision in Flexion of the Cervix, . . . . . . 103
72. Probe-pointed Scissors, 103
73. Retroversion. Genu-pectoral Position, ....... 107
74. Replacement of Uterus by Genu-pectoral Position, ..... 107
75. Sims's Uterine Repositor, 109
76. Hodge's Pessary, 110
77. Albert Smith's Pessary, 110
78. Thomas's Retroversion Pessary, Ill
79. Greenhalgh's Pessary, Ill
80. Retroflexion of Uterus, . . .113
81. Hodge's Pessary for Retroversion, 120
82. Thomas's Retroflexion Pessary, 120
83. Thomas's Modification of Cutler's Pessary, 121
84. Meadows's Vulcanite Stem and Support, 122
85. Introversion, 123
86. Perversion, 123
87. Polypus, 125
88. Inversion, 125
89. Submucous Fibroid of Uterus, 126
90. Partial Inversion of Uterus, 126
91. Aveling's Uterine Repositor, 128
LIST OF ILLUSTRATIONS. XV
IG. PAGE
92. Spear-headed Needle for Puncturing, 140
93. Lance-headed Scarificator, 140
94. Improved Uterine Douche, 150
95. Playfair's Probe, 157
96. Atthill's Canula for Intra-uterine Medication, 171
97. The same, showing Canula and Stilette separated, 171
98. Vulcanite Intra-uterine Syringe with Kecurrent Stream, . . . . 174
99. Simpson's Uterine Scoop, . . . 174
100. Barnes's Vulcanite Tampon Introducer, 184
101. Spear-pointed Scarificator, 184
102. Tampon or Plug of Cotton- wool, 185
103. Siphon Douche, . 191
104. Higginson's Syringe, 192
105. Syringe for injecting Lotionj 192
106. Sponge-holder, 194
107. Sims's Curette, 197
108. Mode of placing Sutures after Amputation of the Vaginal Cervix, . . 201
109. Chassaignac's Wire-rope Ecraseur, 202
110. Lacerated Cervix, showing Application of Sutures, 208
111. Ovum Forcep, with Back, . 216
112. Wire-rope Ecraseur, with H. Smith's Adjustment, 216
113. Vulsellum Eorcep, curved, 216
114. Aveling's Polyptome, 217
115. Diagram illustrating the Varieties of Fibroids, 220
116. A Submucous Fibroid being gradually Transformed into a Fibroid
Polypus, 220
117; Sims's Guarded Tumor Hook, 232
118. Simon's Scoop, 253
119. Scoop bent at right angles, 253
120. Diagram illustrating Diagnosis of an Ovarian Tumor, .... 300
121. Diagram illustrating Diagnosis of Ascites, ...... 300
122. Differential characters of Ovarian and Ascitic Dropsies in Upright
Posture, 301
123. Spencer Wells's Ovariotomy Trocar, 330
124. Nelaton's Cyst Forcep, 331
125. Spencer Wells's small Clamp Forcep, 331
126. Spencer Wells's Clamp, 332
127. Ketro-uterine Haematocele (after Barnes), 359
128. Bladder Trocar, 367
129. Bryant's Urethral Speculum Dilator, 410
130. Paquelin's Thermo-cautery, ......... 410
131. Hsematometra from Imperforate Hymen, . .- 415
132. Spencer Wells's Improved Tapping Trocar, 417
133. Hodge's Pessary, with cross-bars, 423
134. Diagram illustrating the Perineal Body, 435
135. Diagram showing Surface Denuded and Sutures in Position, in Kuptured
Perineum, 440
136. Serres-fines, .441
137. Emmet's Operation for Lacerated Perineum, 443
138. Surface Denuded in Complete Perineal Kupture, and first two Sutures in
Position, 444
XVI LIST OF ILLUSTRATIONS.
FIG. PAGE
139. Lawson Tait's Method of Operation for Eepair of the Female Perineum, 445
140. Curved Sharp-pointed Scissors, 445
141. Spring Forceps, with Teeth, 450
142. Bozeman's Curved Uterine Scissors, 450
143. Vesico-vaginal Fistula Forcep, . . . . . . . . . 451
144. Durham's Curved Needles, 451
145. Diagram showing Simon's Method of Operation for Vesico-vaginal
Fistula, 452
146. Lane's Three-bladed Kectum Speculum, • 534
147. Sims's Glass Vaginal Dilator, . 535
148. Elastic Gum Vaginal Dilator, 535
DISEASES OF WOMEN,
C H A P T E R I.
/
INTRODUCTORY.
Ix Gynecology, to insure success, it is essential to gain the con-
fidence of your patient ; this can only be acquired by practice, and
the sooner the student learns the difference between gaining a
knowledge of the science and the art of his profession, the one
mutually assisting the other, the sooner w^ill he be in a position to
reconcile the subjective symptoms -with the objective signs, and to
ascribe to each their proper value and import.
Rational signs, w^hich appeal to our reason and not to our senses,
such as pain in the back, bearing downi, etc., wall often direct our
attention specially to the pelvic organs, and lead us to infer the
existence of disease there, w^hich is confirmed or otherwise by the
employment of certain " physical " examinations to be hereafter
described.
In no specialty is it so important to combine the suaviter in modo
w^ith the fortiter in re, for unless the practitioner be kind and s^^m-
pathetic, he wHll fail to elicit the symptoms he is expected to treat,
or to gain the confidence that is so essential to success ; and, on the
other hand, unless he be firm and decided his patient will despise
him and not follow his instructions.
He should be extremely neat and cleanly in the performance of
all examinations, minor operations, dressings, etc., for patients are
naturally indignant at finding stains of nitrate of silver or other
agents on their towels and personal linen, and are apt to consider
them as a proof of a want of knowledge as w^ell as of dexterity and
practice.
It has been well said,^ " that a cheerful face is a good tonic ; but
one must laugh little loith patients and not at all at them, for, how-
ever ridiculous their fancies may be, they must be reasoned, not
laughed, out of them."
On your first interview with a patient, you will do w^ell to hear
much and say little, for however much she may be agitated and
flurried, she wdll carefully treasure up any expression of opinion
you may incautiously let drop, that subsequent experience of her
case may not corroborate nor treatment substantiate.
1 Dr. Tilt, Uterine Therapeutics.
2 (17)
18 INTRODUCTORY.
By allowing the patient to tell her own tale in her own way,
although some little time will be lost, much will be gained from
her method of telling it ; ^and should she become somewhat discur-
sive, the practitioner can readily bring her back to the more im-
mediate symptoms by follow^ing up any clue that her narrative may
have given him, or elucidating more fully any special points for
investigation. Among hospital patients, more especially when we
have those voluble Celts to deal with, who habitually complain de
omnibus rebus et quibusdam aliis, it is often advisable to launch out m
medias res, and ask boldly, What do you complain of? Our sub-
sequent plan of action being determined by the nature of the com-
plaint; thus, if pain be the principal symptom, its seat, nature,
constancy or recurrence, duration, etc.
It is well to avoid putting leading questions, for the answers are
often very misleading, the patient either not understanding the
query, or thinking it right to say yes or no, depending upon the
manner in which the question is asked. A far better plan is to
lead up to the point you are anxious to ascertain, without, however,
suggesting an inference or allowing the patient to see the drift of
your queries.
In young and unmarried patients it is ahvays better to ascertain
the general condition of the principal functions before proceeding
to the discussion of the uterine symptoms, as the nervous, the cir-
culatory, the digestive, ascertaining the condition of the bowels,
and then inquiring as regards the menstrual functions, leucorrhoea,
dysmenorrhcea, etc. The duration and frequency of the catamenial
periods should always be noted, together with the fact of their
being scanty or profuse, painful or natural.
Much may be learned by a careful study of the physiognomy. It
is difficult to convey in words the significance of the various shades
of chloro-ansemia. It is an experience to be gained only by practice.
The appearance of anemia from incipient phthisis in the young
difiers materially from that of chlorosis, and this again from the
semi-chlorotic tinge due to hsematocele, or the pallor arising from
pelvic cellulitis, or the blanched aspect depending upon menor-
rhagia, or the cachexia from malignant disease of the uterus. And
yet the gradations are so slight that it w^ould need a thorough artist
to depict them aright. Again, in ovarian tumors the physiognomy
is m.ost characteristic. Functional disorders of the ovary stamp
their impress on the countenance as well as on the upper lip and
other portions of the face not usually hidden by hirsute appendages.
It is only after much experience that the young practitioner will
be enabled to estimate at their proper value the so-called subjective
symptoms, /. e., what the patient herself tells him; he will fre-
quently find that the objective signs, ?'. e., the actual physical con-
dition of the parts, are by no means in direct relation the one to
the other ; in fact, they often vary inversely — the more the complaint
the less the cause. Many young women refuse to acknow^ledge
they are ill or suffering until the fact is so patent to their frien(is
that it is useless any longer denying it; bashfulness, and a dislike
METHOD OF TAKING NOTES.
19
to be considered ill, or to adopt the requisite precautions, being
their chief motives in maintaining silence. Whereas among older
patients they are apt to exaggerate trifling ailments, and make
mountains of molehills, partly out of fear and partly to increase
our sympathy for their imagined sufferings.
' It will be advisable to have some systematic method of taking
notes, for by this means important points are less likely to be
overlooked, the cases are more uniform for reference, and much
needless time and trouble is saved.
A form similar to the one given, modified from Thomas, will be
f found to contain all that is requisite for ordinary cases, special facts
being noted in addition, depending upon the nature of the case.
Name Age Married?.
Date of first visit Address
No, of cliildren Date of last confinement....
No. of miscarriages Date of last miscarriage....
Age at first menstruation Date of last catamenia
How long ill
Principal symptoms
Supposed cause.
Present condition as regards
Regularity ,
Amount
Duration
Pain
Menstruation,
Discharge,
Pain, . .
Physical signs
{Character .
Amount....
Constancy.
r Locality
< Degree
I Character.
Diagnosis...
Treatment .
The order of filling in may be varied according to circumstances,
20
INTRODUCTORY.
but the several facts indicated should be ascertained before the
visit is completed.
An outline diagram, as in Fig. 1, filled in just after the exami-
nation, will save much time and convey more at a single glance
than mere written descriptions.
The question of the necessity of resorting to an examination,
where from the obscurity of the symptons, or, on the contrary,
from their pointing definitely to some local lesion or abnormal
condition, is one not always easy to be determined.
It is a point of great importance to decide, for on the one hand
we must make every allowance for that female modesty which is
Fig. 1.
Outline Diagram showing Section of Pelvis. (After Rowell.)
the best attribute of woman and the surest safeguard of society,
and not press for an examination until certain simple expedients
have been resorted to, and on the other hand our own professional
reputation must be considered. Although the symptoms com-
plained of may point to disease of the uterus, ovaries or contiguous
parts, yet we must always bear in mind the intimate sympathy in
nature between the functions of various organs, menorrhagia, for
instance, being a not infrequent symptom in diseases of the heart,
liver, and kidneys; and dysmenorrhoea being frequently dependent
upon so-called neuralgia, rheumatism, etc. In fact, "It may be
affirmed that no severe constitutional disorder can long continue
in a woman during the predominance of the ovarian function
without entailing disturbance in this function. And the converse
is also true, that disorder of the sexual organs cannot long con-
tinue without entailing constitutional disorder, or injuriously
Meeting the condition of other organs." (Barnes.)
The question then is, what symptoms or combination of symp-
MENORRHAGIA, ETC. 21
toms lead us to infer that some local mischief is present and neces-
sitates an examination ?
Menstruation being the most important function, any disturbance
of this will probably be the first indication to arrest our attention,
such as defect, excess, irregularity, pain, etc. As a rule in ordi-
nary cases of amenorrhoea, more especially in those associated
with chlorosis, tubercular cachexia, or ansemia from over-w^ork or
insufficient supply of nourishment, no local examination is neces-
sary ; but should the menstrual molimen recur at regular intervals,
and the patient suffer much pain and discomfort, although no dis-
charge of blood appear outwardly, we are justified in resorting to
a local examination, as the case may prove to be one of retention
of the catamenia from imperforate hymen or os uteri, and if not
relieved may prove fatal.
Where menorrhagia persists and is not influenced by ordinary
remedies, but produces marked anaemia, debility, and impairment
of the general health, an examination should always be resorted
to even whilst the haemorrhage continues, more especially if the
loss be excessive, for a polypus, fibroid tumor, or cancer may be
present.
In cases of dysmenorrhea the question of resorting to examina-
tion is often a very perplexing one. After the usual recognized
means have been tried, on the supposition of its being neuralgic
or congestive, and where the discomfort is so great as to unfit the
patient for her ordinary duties, or her general health sufifers
materially from the frequently recurring paroxysms of pain, an
examination with the view of detecting any flexion or obstruction
is clearly indicated, and should be resorted to.
In cases of leiicorrhoea in single women, it is well to try first w^hat
influence iron and aloes, with some astringent injection, or sea-
bathing, will produce ; but should the general health sufler, more
especially where there is any phthisical history, and the discharge
continue excessive, spite of all our remedies, an examination
should be made.
Where patients complain of bearing down, dragging pain in the
hips and loins, pressure upon the bladder, causing retention of
urine or frequency of micturition, and there is no habitual consti-
pation to explain the symptoms, or these persist after the former
has been remedied, an examination had better be instituted.
Having learned all that is possible from the patient's statements
as to her sufferings and symptoms, and having decided that a local
investigation is necessary to complete the diagnosis of the case,
the reasons for this should be briefly stated to the patient, and her
permission obtained. It is best to leave entirely to the patient as
a general rule, the option of her mother or friend being present
in the room during the examination. But in the case of young
unmarried girls, especially if there is the least tendency to hys-
teria, it is always a prudent precaution to insist upon the mother
or some other discreet married friend being present.
22 MEANS OF PHYSICAL DIAGNOSIS.
CHAPTER 11.
MEANS OF PHYSICAL DIAGNOSIS.
In order to arrive at a correct diagnosis, it is essential that the
student take every opportunity of educating his sense of touch, of
acquiring the " tactus eruditus," for upon this sense he will have
mainly to rely in a large number of cases. The sense of hearing
may assist him in some doubtful cases of abdominal tumors, the
sense of sight corroborate an impression that the sense of touch
has suggested, or the sense of smell even lead to the suspicion of
pregnancy, cancer, or other condition ; but it is upon the sense of
touch more particularly that he will have to depend for arriving at
a correct diagnosis in nearly all instances of uterine and pelvic
disorders.
As Gooch has ably remarked : " The faculty of observation re-
quires rather to be guided than to be sharpened ; the finger soon
gains the faculty of feeling when the mind has acquired the
knowledge of what to feel for."
It will be well to enumerate the various means at our disposal,
so that the student may see them at a glance.
Methods resorted to for Physical Diagnosis in Uterine Disorders.
1. Vaginal touch.
2. Conjoined manipulation, bimanual palpation, or abdomino-
vaginal examination.
3. Uterine exploration, utero-abdominal, -rectal, and -vaginal
exploration.
4. Inspection of the vulval outlet, and examination by the
speculum.
5. Abdominal inspection, palpation, percussion, and auscultation.
6. Rectal touch, recto-abdominal, -vaginal, -vesical, rectal ex-
ploration.
7. Dilatation of cervix uteri by means of tents.
8. The aspirator or exploring needle.
9. Examination of the secretions, discharges, or substances ex-
pelled, by the naked eye or assisted by the microscope.
10. Ansesthesia.
Management of Patient during Physical Examination. — Having pre-
viously explained to the patient the necessity for resorting to a
local investigation, our next object is to place her in such a posi-
tion as will least offend her sense of modesty, at the same time
enable us to examine the condition of the pelvic organs without
unnecessary exposure.
In England, the more usual method is to place the patient in the
left lateral position, the ordinary obstetric one. This affords per-
fect facility for digital exploration, for the passage of the sound if
THE DORSAL POSITION. . 23
requisite, as also for the employment of the speculum. The body
should lie obliquely across the couch or bed, the head being well
over to the further side, the hips close to the edge of the couch,
the shoulders on the same level as the buttocks, the knees drawn
up towards the abdomen. If the left arm be brought out behind
and the patient rolled somewhat over, so that the left shoulder
rests upon the couch, we have the semi-prone position, which
proves very convenient where we have to pass the speculum. A
folded shawl or light rug should always be employed to cover over
the lower portion of the body, both to prevent the patient getting
chilled as well as to avoid unnecessary exposure.
The dress and underclothing must now be pulled gently back
towards the buttocks, being disengaged over the knees if the dress
be at all tight, so that the examiner is not incommoded in any way.
If the practitioner be ambidexter, i e., can use either hand equally
well, the left lateral position has many advantages. If the right
index finger be employed, the sensitive pulp of the digital extremity
naturally is directed backwards, so that the posterior vaginal cul-
de-sac and the posterior portion of the pelvis can be thoroughly
explored, but as the finger-nail is turned toward the cervix uteri,
and the examiner must cross his left hand awkwardly over the right
to get at the abdomen, it is more diificult to carry out the conjoined
manipulation. The perineum in this position can, however, be
more fully retracted than when the patient is in the dorsal position.
The right side of the pelvis, including the right ovary, is most
readily explored by this arrangement.
If the left index finger be employed, the pulp of the finger being
directed forward enables us to ascertain readily the condition of the
cervix, the anterior wall of the vagina, and anterior portion of the
pelvis. The right hand is now conveniently disposed for abdomi-
nal palpation. The left portion of the pelvis, including the left
ovary, are best explored in this way. Where the left finger is em-
ployed, it is essential to place the patient nearly transversely upon
the bed or couch, the back being at right angles to the side of the
bed, and not parallel with it.
The dorsal position is that usually adopted on the Continent,
and has unquestionably many advantages over the lateral one,
inasmuch as if the patient be properly placed, the conjoined man-
ipulation is far more readily carried out, the abdominal muscles
being relaxed, and the organs occupying the position natural to
them at the time of examination, without being deflected to one
side or other, as happens when the patient lies on her side.
The right finger now serves equally well to explore both sides of
the pelvis, and the left hand is conveniently disposed for abdominal
palpation. Should it be found necessary to examine the patient
lying on the left-hand side of the bed, who may be too ill to be
transferred without unnecessary risk or trouble to the right side of
the bed, it will be more convenient to employ the left index finger
to examine internally, the right being used for abdominal palpa-
tion so as to get the conjoined manipulation. In order to obtain
24 MEANS OF PHYSICAL DIAGNOSIS.
the full advantage from our examination, the patient should either
be undressed and in bed, or should have her clothes loosened, her
corset unfastened or removed, and all tight bands round the waist
undone. If in bed, a hard, firm mattress should always be pre-
ferred to a feather bed. The patient must lie close to the edge,
fairly upon her back, her head resting upon a pillow, the knees
well drawn up and slightly abducted.
Perpendicular Examination. — This, a common method in some
countries, is seldom resorted to here, but nevertheless is often
very necessary, as in cases of hernia, displacements of the uterus,
whether version, flexion, or prolapse, where we wish to form an
accurate idea of the true state of affairs when the patient is in the
upright position. ISTo exposure is necessary, and if the object of it
be explained to the patient herself, she will seldom offer any obj ection.
Vaginal Touch. — Having placed the patient in the dorsal or lateral
position, loosen any clothes and cover her with a rug or shawl ;
the examining finger being first lubricated with olive oil, cold
cream, vaseline or lard, carbolized oil being most suitable, the
remaining fingers are flexed upon the palm and the thumb laid
upon them, the forefinger is introduced into the vulva from its
posterior aspect along the raphe of the perineum. As soon as the
sensitive pulp of the finger detects the vaginal orifice, the finger is
pressed firmly but gently against the distensible perineum, and
then passed onwards along the posterior vaginal wall, following
the curve of the sacrum. By this means the sensitive structures
near the pubes are avoided, and the patient thus saved any unnec-
essary annoyance ; besides, it is easier to gain access to the vagina
in this way than if the point of the finger be carried more forward.
The several points to be noted in the order in which they would
generally present themselves are, incidentally, any haemorrhoidal
excrescences, undue sensitiveness or laceration of the perineum,
rigidity of the hymen, hyperesthesia of the vulval orifice as indi-
cated by spasm, presence of any vascular growth of the urethra,
warts, condylomata or sores on the vulva, perviousness and capacity
of the vagina, rugosity of its walls; whether unusually dry and sen-
sitive, increased in temperature, or relaxed and bathed with muco-
purulent secretion; whether any foreign body be detected, such as
a polypus, malignant growth, or some inorganic substance intro-
duced from without; whether the rectum be loaded with faeces,
whether any induration or fulness be detected in the posterior
vaginal cul-de-sac, such as might result from a retroverted or re-
troflexed fundus uteri, a fibroid of the posterior wall of the uterus,
a prolapsed ovary, a retro-uterine hsematocele, or remains of pelvic
cellulitis. Having made these observations, we now come to the
main object, in most cases, of our examination, the cervix uteri.
ISTote the position, direction, density, size, shape, character of sur-
face as to smoothness or roughness, as well as sensitiveness. Then
ascertain the state of the os uteri, whether closed or patulous, cir-
cular or oval, incomplete from laceration of the cervix, indurated
or softened, smooth or granular, or ulcerated as in the advanced
BIMANUAL EXAMINATION.
25
brm of epithelioma, presence and character of discharge as to
|uantity, tenacity, etc.
Thus far the finger alone has been employed, but no examination
should ever be considered completed unless abdominal palpation
iias also been resorted to, the two methods, constituting the con-
loined manipulation, being invariably combined.
The passage of the whole hand into the vagina, the patient
being anaesthetised, has been practised in certain rare and obscure
cases, but should be resorted to with great care lest the vulva be
seriously injured or the vagina ruptured.
Conjoined Manipulation or Bimanual Examination is unquestion-
ibly the most important method of diagnosis at our disposal, and
should in every case be resorted to. It is of the utmost value in
determining the position and relation of the pelvic organs to one
another, and enables us to estimate correctly the bulk, sensitiveness,
mobility, position, and shape of the uterus, etc. In making a
vaginal examination with the finger the tendency is to push up
still further out of reach the organs we are attempting to explore.
Fig. 2.
Method of Bimanual Examination. (After Sims.)
To overcome this, and even, if necessary, to press the pelvic contents
still lower down, the hand should be laid upon the lower portion ot
the abdomen. The index finger of the other hand being meanwhile
in the vagina, the conjoined manipulation being carried on simul-
taneously enables us to explore seriatim the several pelvic viscera.
The dorsal position of the patient, with the knees drawn up, is
the one most suitable for the majority of cases, but the lateral one
can be resorted to where any special indication for it is discovered.
It is w^ell to have the clothes loosened, so that the hand may be
passed under them directly on the surface of the abdomen, without
the intervention of anything likely to interfere with the delicacy
of touch. It is not always necessary to uncover the abdomen, but
this should invariably be done where any unusual abdominal en-
largement can be detected.
26 MEANS OF PHYSICAL DIAGNOSIS.
If the uterus be normal in size and position, its body can usually
be detected in front of the cervix through the upper and anterior
wall of the vagina. If the ulnar edge of the left hand be now
pressed firmly but gently, first towards the sacral promontory, and
then downwards in the axis of the pelvic brim, the right index
finger internally will be enabled to appreciate the condition of the
uterus as to size, shape, density, mobility, sensitiveness, etc. By
this method any increase in size, as in early pregnancy, any ir-
regularity in outline, as in fibroid, any induration of the cervix, as
in the early stage of cancer, an}' impairment of mobility due to
cellulitis, hsematocele, etc., any increased sensitiveness, as in
metritis, may readily be detected. In order to accomplish the
conjoined manipulation properly, it is essential to have the ab-
dominal walls relaxed. The patient's shoulders should be slightly
elevated on a pillow, the knees drawn up, and she should either
be engaged in conversation so as to distract her attention, or be
encouraged to take several consecutive deep breaths, when the
hand can be sunk deeper at the end of each expiration without
causing unnecessary discomfort.
Should the patient be extremely nervous, or hysterical, or unduly
sensitive, it may be well to produce anaesthesia, more especially if
any phantom tumor be detected.
If the abdominal wall be very fat and the intestines very flatulent,
or the rectum loaded with faeces, it will be expedient to give some
brisk aperient, or administer an enema, so as to clear out any
accumulation and lessen the distention of the abdomen.
Having satisfied ourselves as to the condition of the uterus, we
should then ascertain the state of the ovaries, broad ligament, etc.,
as to the several points already indicated. The ovaries, when in
their normal position, may ot\en be felt, in thin persons, about
midway between the fundus uteri and the crest of the ilium.
When prolapsed they may more readily be detected if the patient
lies on the side. If any tumor be detected in the pelvis, its relation
to the uterus should be estimated, or its connection with the ovaries
or broad ligament determined, if possible. The means of diagno-
sing these will be fully discussed further on. Too great caution
cannot, however, be exercised in conducting the examination,
otherwise in an attempt to arrive at a correct diagnosis, we may
succeed in ruj)turing an extra-uterine cyst or ovarian abscess, or
light up fresh inflammatory mischief, supposing the case to have
been one of pelvic cellulitis.
Uterine Exploration by means of the Sound. — This should not be
resorted to as a mere matter of routine in every case, but only
when its employment is necessary to clear up some doubtful point in
the diagnosis, or is likely to afiPord some additional information that
cannot be gained by any of the ordinary methods of examination.
Before ever venturing to pass the sound, satisf}^ yourself, as far
as possible, that pregnancy does not exist; ascertain the date of
the last catamenia, and estimate by conjoined manipulation the
apparent size of the uterus. Should there be the least doubt as to
UTERINE SOUND.
27
Fig. 4.
Fig. 3.
the existence of pregnancy, avoid using the sound until after another
menstrual period has passed by. It is better to wait than to run
any risk of inducing abortion, before attempting to clear up the
diagnosis. In cases of cancer, acute metritis, pelvic peritonitis, and
other similar conditions, the sound should not be used as a rule.
The employment of the uterine sound should be resorted to with
great care and gentleness, and only when we are likely to gain
some information from its use that we cannot otherwise gain.
Several instances have been recorded Avhere the point had been
made to perforate the wall of the uterus. This accident is most
likely to happen when the organ is in a softened state, such as
.occurs during the fatty degeneration of sub-involution following
abortion or parturition, or in the ulcerative stage
of cancer. It has been suggested that the point
may have passed along a dilated Fallopian tube,
but although this may explain some few cases
where the point of the sound has been felt beneath
the abdominal wall, there is little doubt
but that in the majority of such cases
perforation of the uterine wall has
actually occurred. Although in most
instances no very serious symptoms
have followed, the accident must not
therefore be regarded as one unat-
tended by risk.
Where the sound is employed to re-
place a retro-verted or -flexed uterus,
too great care cannot be taken to avoid
all force, lest adhesions be torn through
and peritonitis ensue. The uterine
sound or probe should be made of
pure silver, or copper, plated, so as to
render it sufiiciently pliable to be bent
to any shape desired, at the same time
sufficiently firm to retain its shape
w^hile being introduced, and to replace
the uterus if required. The terminal
extremity should be slightly bulbous,
about one-eighth of an inch in diame-
ter, though for cases of stenosis it is
desirable to have it smaller even than
this. The sound should be slightly
curved, as in Fig. 3. On the concavity
of the curve, at two and a half inches
from its extremity, a slight notch is made to indi-
cate the length of the normal uterus, other similar
notches being placed at intervals of an inch, so as
to enable us to measure the length of the uterine canal when this
is elongated. It is not requisite to have a knob or shoulder on the
convexity of the curve to indicate the normal length of the uterus.
Uterine Sound.
Portable Uterine
Sound.
28 MEANS OF PHYSICAL DIAGNOSIS.
The notch on the concave side answers this purpose perfectly well,
and does not interfere with the flexibility of the sound. Ten"
inches is the usual length. A convenient form for carrying in the
pocket is one which doubles up as in Fig. 4. Having ascertained \
by digital and conjoined manipulation the apparent direction of
the uterus, the sound, properly warmed, so that it may not excite
spasm of the cervix by its coldness, and curved so that it may
enter readily the uterine cavity, is then held lightly between the
thumb and one or two fingers of the left hand. The patient lying
obliquely across the couch on her left side, with the hips close over
the edge and the knees well draAvn up, the index finger of the
right hand is introduced into the vagina, as previously directed,
and passed up to the cervix uteri. The sound, A^dth its convexity
forwards, is then glided along the palmar surface of the right fore-
finger, and its point guided into the os uteri, the handle of the
sound being held well back. As soon as the point has traversed
the canal about one inch, supposing the direction be normal, the
handle is swept round in a semicircular direction, so as to allow the
terminal portion of two and a half inches to rotate on its own axis.
The sound, with its concavity now directed forwards, with gentle
pressure finds its way into the uterine cavity, the handle being
pressed backwards if necessary, to facilitate this. IN'o force need
be employed, the sound, like the catheter in the male subject, is
allowed to find its own way. This method is the more convenient
one, especially in virgins where the vulval orifice is small, the
vagina narrow, and the perineum rigid.
Where the vagina is capacious, and the parts more relaxed, the
concavity of the sound may be directed forward from the first, the
handle being held well forward between the thighs, and gradually
carried more backwards as the sound enters the uterine cavity. If
preferred by the examiner, the left index finger may be inserted
into the vagina, the patient lying transversely across the bed, the
sound held lightly in the right hand with the concavity forward,
and so passed into the uterus. 'No force should in any case be
employed. If any flexion of the uterus exist, it may be well to
increase the curve of the sound until it will pass without difliculty.
Sims recommends his speculum to be first passed, so that the
examiner can see to pass the sound, but the disadvantage of this
method is that the pressure of the speculum may alter the position
of the uterus, and so render the evidence derived from the probe
fallacious. In case of flexion, too, we cannot assist the passage of
the sound by pressing up the fundus with the finger, as can be
done in the other method. In the case of virgins, or patients
where the vulval outlet is narrow, the passage of the speculum
causes much more inconvenience than that of the sound by the
usual method, and if the amount of flexion be great, there is less
play for the handle of the sound, and more difliculty in passing it
into the uterus. Moreover, we lose a great deal of information
imparted by the sense of touch when the sound is passed through
the speculum.
UTERO-RECTAL EXPLORATION. 29
The several points ascertained by the introduction of the sound
are, 1st, the length of the uterus. If any difficulty occur in passing
the sound the proper distance, the direction of the point must be
altered, and gentle but firm pressure exercised so as to overcome
any spasm that may be induced. There is often some little delay
in passing the internal os, due it may be to flexion, or more rarely
to stenosis. In some cases there is distinct pain or uneasiness.
"When the point reaches the fundus, which is more sensitive than
other parts of the uterus, pain is often experienced.
2. The direction of the uterus. — This is often of great importance,
as in the case of flexions, thus enabling us to differentiate them
from fibroid outgrowths. In some cases where the uterus is em-
bedded in surrounding deposit, as in hsematocele and pelvic cellu-
litis, it is essential to determine the exact position of the uterus
before resorting to aspiration or puncture.
3. The mobility of the uterus. — In many cases we can readily as-
certain the extent of mobility of the uterus by the conjoined ma-
nipulation, but where an ovarian or other tumor is in close apposi-
tion with the uterus it is very important to determine whether
the organ be intimately associated with it or independent of it.
4. The sensitiveness of the uterus. — If the sound be passed with
care into a healthy uterus, little or no inconvenience is produced,
but in case of metritis, pain is complained of the moment the
point of the sound touches the fundus.
5. The presence of any foreign body within the uterus, such as a
rejtained ovum, polypus, or fibroid tumor, can often be ascertained
by means of the sound.
TJtero-abdominal Exploration. — The employment of the sound, con-
joined with abdominal palpation, is often of great service in de-
termining the direction and size of the uterus, where, from the
presence of an abdominal tumor, conjoined manipulation fails in
detecting the position of the uterus, as also in deciding whether
the tumor springs from the uterus, is loosely attached to it, or
perfectly independent of it. The patient lying in the left lateral
position, the sound being passed in utero, is then held by the left
hand, whilst the right hand is employed for external palpation.
If the sound be now rotated so as to move the uterus, the external
hand will be enabled to detect whether the tumor moves with it, as
in the case of a fibro-cystic tumor, or is uninfluenced by the move-
ment, as would probably be the case where an ovarian tumor was
present. If any difficulty be experienced in differentiating a fibroid
polypus from an inverted fundus uteri, or even a submucous fibroid
fi'om a retroflexed fundus, the fact of being able to lift the organ
somewhat on the sound so as to feel the fundus distinctly behind
the pubes, will clear up any doubt upon the subject.
Utero-rectal Exploration. — This is of service in cases of fibroid or
other tumors growing from or connected with the posterior wall
of the uterus. The sound being introduced into the uterus, the
finger per rectum detects any irregularity of the body or cervix.
K a small ovarian tumor be situated in Douglas's pouch, this
30 MEANS OF PHYSICAL DIAGNOSIS.
method is often of great value in determining the exact nature of
the growth.
TJtero-vaginal Exploration. — This is really an extension of the
ordinary vaginal touch, the sound prolonging our sense of touch
into a cavity into which our fingers are unable to reach. The
sound being passed in uterum and the finger per vaginam, any
irregularities upon the wall of the uterus, alteration of direction
or flexion of the uterus, can thus be readily detected.
Inspection of the Vulval Outlet. — The opportunity should always
be taken of examining the external parts visually before introduc-
ing the speculum, more especially if the finger have previously
detected any suspicious irregularities or abnormalities around the
vulval outlet, as mentioned under the head of vaginal touch.
Examination by the Speculum. — It should always be remembered
that this is merely a confirmatory test, so to speak, and in fact
often resorted to more for the purposeof treatment than diagnosis.
The sense of touch should always be first appealed to, and is by
far the more important, the sense of sight by means of the specu-
lum, being only called in requisition where we have reason to
believe that granular degeneration of the cervix exists, and some
application is necessary, or in cases of cancer, etc. The field for
observation is limited, the vagina itself and the os and cervix
uteri being all that can be seen by means of the speculum. Be-
fore examining a patient, we should always take the precaution to
place her in such a position on the bed or couch that, in the event
of the speculum being needed, a good light is obtainable without
further change of position. Direct daylight is always to be pre-
ferred, the hips being placed opposite the window. Where this
cannot be well managed, an ordinary hand-glass answers the pur-
pose of reflecting the rays of light into the trumpet-shaped end
of the speculum which serves to concentrate the rays of light, or
a concave mirror similar to a laryngoscopic mirror, with rather a
larger central aperture, may be employed. If we are obliged to
depend upon artificial light, a short bit of wax candle, an ordinary
bull's-eye lantern, or one of Collin's illuminating lamps will an-
swer best.
There are numerous varieties of specula invented ; some in the
form of cylindrical tubes, others having a valvular arrangement
either bivalve or trivalve. Sims's acts more as a retractor upon the
posterior vaginal w^all. Many of them are very ingenious, but
the more elaborate the mechanism the more likely are they to get
out of order, and the more difficult to keep clean — a very impor-
tant consideration.
Fergusson's Tubular Speculum, with its trumpet-shaped entrance
for concentrating the rays of light, its reflecting surface and
bevelled extremity, which allows the cervix to be readily brought
into view, is by far the best tubular speculum invented. It is
readily cleansed, is not attacked by acids or other applications,
provided care be taken to prevent any excess running down, and
being tubular it protects the vagina perfectly from any caustics
EXAMINATION BY SPECULUM. 31
that may be intended merely for tlie os or cervix. They have
been made of toughened glass with a view to rendering them less
fragile. The speculum consists
of a tube of glass, about six
inches long, the sizes varying
in diameter from about half an
inch to two inches. This tube
is coated with quicksilver, like
an ordinary looking-glass and ^ Fergusson's Speculum.
then covered by india-rubber
or vulcanite, well varnished, to render it impervious to the vaginal
secretions. Other tubular specula are made of metal, which have
the advantage over the glass ones of not being fragile, but the
disadvantages of not reflecting the light so w^ell, and being affected
by chemical agents. Some are made of porcelain, but they are
fragile, and do not reflect the light at all. Others are made of
ivory and wood; these are chiefly serviceable for applying the
actual cautery, and are seldom employed for ordinary cases. It is
well to have some short Fergusson's specula handy, to suit special
cases where the uterus is very low or the vagina very short.
To introduce the ordinary tubular speculum, let the patient lie
in the usual obstetric position on her left side, wdth the hips close
to the edge of the bed, the left arm brought out behind her, the
body being turned in the semi-prone position. Having first oiled
the surface of the speculum, grasp it in the right hand between the
thumb and three fingers, the fore-finger being placed on the end
to assist in propelling it. Having drawn up the right buttock, and,
if necessary, separated the labia, the tip of the speculum is inserted
into the vaginal orifice, the perineum being pressed well back by
it to avoid injuring the parts in front. The axis of the speculum
is then directed backwards, and by glancing through the interior
it will be seen w^hen the, os is engaged in the orifice, the instrument
being pressed slowly and carefully backwards, and if any difiiculty
arise in finding the os, the speculum should be withdrawn a little
and then pressed in again in such a position as the previous exami-
nation suggests the cervix will be found in. Where the uterus is
much anteverted, difiiculty may be experienced in getting the os
uteri into the end of the speculum; a sound or other instrument
may then be employed to direct the os forwards or pull it down-
wards, as required. A long, straight tenaculum with a curved
hook at the extremity is often useful for the purpose. Should this
plan not succeed, it will be w^ell to place the patient in the dorsal
position, when the eftect of gravity tends to bring the axis of the
uterus more nearly into coincidence with that of the vagina, and
so facilitates exposure of the os.
If any difiiculty be experienced in getting the whole circuit of
the OS into view, the bevelled end of the speculum should be rotated
so as to bring the projecting tip anteriorly, thus pushing up the
fundus and bringing the os fully into view.
Cusco's Bivalve Sj^eculum is the most generally useful of all valvu-
32
MEANS OF PHYSICAL DIAGNOSIS.
lar specula, in that it is easy of introduction, is self-retaining, and
brings the uterus nearer to the vulval orifice rather than pushes it
away. Having previously ascertained the position of the uterus by
digital examination, the speculum, closed, is tilted obliquely side-
ways so as to avoid pressing upon the soft structures in front of
the pubes, and inserted gently within the vaginal orifice, being
pressed backwards on the perineum and passed onwards until the
extremities are about opposite the os uteri, care being exercised
Fig. 6.
Cusco's Bivalve Speculum.
that they do not pass beyond into either cul-de-sac. The blades
are then turned antero-posteriorly and opened by means of the
handles; as soon as the os uteri is fully in view, the screw^ is at
once turned, and the blades thus fixed. The fundus uteri being
pushed up by the anterior blade, the antero-posterior stretching of
the vagina tends to draw the cervix downwards and forwards, the
Fig. 7.
Modification of Cusco's Speculum.
axis of the uterus being thus brought nearly in a line with the axis
of the vagina.
The lips of the os uteri are also separated, so that the cervical
canal can be seen for some little distance.
Care must be taken in withdrawing it not to allow^ the blades to
close completely, lest the vaginal walls be pinched.
Numerous modifications of Cusco's speculum are made, but the
practitioner should select the original form, or one in which the
EXAMINATION BY SPECULUM.
33
blades are capable of being separated widely, are nearly equal in
length (about four and a half inches) * and sufficiently wide to pre-
vent the vaginal walls bulging in (about one and a half inches).
An ingenious modification is an American one (Fig. 7), the
upper blade being divided so as to increase still further the breadth
when the blades are separated.
If the anterior blade be much shorter than the posterior, it inter-
feres mth the mechanism of bringing the uterus into a slightly
retroverted position.
Barnes' 8 Speculum (Fig. 8) is a modification of H. Bennet's bivalve
Fig. 8.
Barnes's Speculum.
speculum. The objectionable complication, however, is the wooden
plug. The author himself prefers for general use Cusco's.
Sims's Speculum (Fig. 9) is more calculated to prove of service to
the operative surgeon than to the ordinary practitioner. It presents
Fig. 9.
Sims's Speculum.
such disadvantages that it is hardly likely to come into anything
like general use. It cannot be employed without an assistant, and
to be of real value a skilled assistant is necessary. For operative
procedures upon the cervix or vagina it is unquestionably of great
value, more especially in cases of vesico-vaginal fistulse, laceration
of the cervix, etc.
To employ Sims's speculum to advantage, the patient must be
undressed, or have all clothes loosened from the waist, and be
placed upon an operating-table opposite a good light, which must
be nearly horizontal. She lies in the left semi-prone position, with
the head and shoulders low, the left arm behind her, the knees
drawn up, the right in front of the left one in contact with the
table, the body rotated so that the chest nearly rests upon the
34 MEANS OF PHYSICAL DIAGNOSIS.
table. The assistant standing behind her raises the right buttock
with the left hand, the operator then having determined the
position of the cervix and the capacity of the vagina, holds open
the vulva with one or two fingers dragging upon the perineum,
and then slips the blade of the speculum in, holding it somewhat
obliquely, so as to avoid injuring the sensitive tissues in front. As
soon as the end has passed the vulva, the blade is rotated so as to
bring the back of the instrument against the perineum, which is
then retracted, and the end guided into position behind the cervix
by the aid of the finger. The instrument is then given in charge
of the assistant, w^ho by dragging upon the posterior wall of the
vagina converts this latter into a straight canal, and so discloses
the cervix to view.
If the patient has been properly placed, so that the vaginal
orifice is the highest point of the vagina, this canal becomes dis-
tended with, air and the pelvic and abdominal viscera gravitate
towards the abdomen, so drawing the anterior vaginal wall forward,
and the cervix also out of the hollow of the sacrum. When the
vagina is narrow, or when it is large and lax, the anterior vaginal
wall does not always recede, or bulges up against the speculum,
preventing the os being seen. The finger, handle of a sound, or
Fig. 10.
GriflBth's Speculum.
depressor must then be used to hold back the anterior vaginal
wall. If the cervix still slants too much backward so as to prevent
the 08 uteri being fully exposed, a small tenaculum or fine hook
may be inserted into the anterior lip of the cervix, and this latter
drawn forward so as to lie more in the axis of the vagina. But
little pain is produced, and the shank of the instrument serves to
keep back the vaginal wall as well.
Various modifications of Sims's speculum have been devised with
a view to overcoming the tendency for the anterior vaginal wall to
bulge in, by means of a depressor or lever frame attached, thus
making it really a bivalve speculum, as in Fig. 10. Some of them
even have a sacral plate affixed, so that the instrument is self-
retaining, and by attaching it to the table acts as a mechanical
assistant.
Dr. Hey wood Smith's modification of Sims's speculum (Fig. 11)
consists of three blades, any two of which can be fixed together by
two pins and slots. The duckbill portion is straight and open at
EXAMINATION BY SPECULUM.
35
the end, so that the vagina can be plugged with facility without
the end of the speculum fouling the plug during withdrawal. Two
Fig. 11.
Heywood Smith's Modification of Sims's Speculum.
of the blades can be inserted one after the other, and used as a
Keugebauer's speculum.
Nmgehauefs Speculum (Fig. 12), as modified by Barnes, and
called the crescent speculum, forms a useful instrument in some
cases. It consists of two blades, which slide one within the other,
and open out when in position. The posterior or larger blade is
first passed in a similar manner to Sims's speculum, the patient
Mng in the left semi-prone position, and guided by means of the
right index-finger behind the cervix. The anterior blade is then
slid within the edge of the posterior blade, and when the external
Fig. 12.
Neugebauer's Speculum.
ends are brought towards each other the uterine ends diverge like
two valves, stretching the roof of the vagina, and giving an excellent
view of the vaginal portion. The two blades in combination thus
form a bivalve speculum. They may be made so that the handles
clasp together in a reversed position to form a Sims's speculum, as
in Fig. 11. To withdraw the instrument, each blade is removed
separately, the anterior one first.
The instrument is self-retaining, so that the operator has his
hands free for making any application that may be necessary. It
36 MEANS OF PHYSICAL DIAGNOSIS.
is, however, inferior to Cusco's speculum in self-retaining power,
and also in enabling us to get the cervix into a line with the
vaccina.
CD
Abdominal Inspection, Palpation, Percussion, and Auscultation, are
of service onlv in those cases where conjoined manipulation has
detected the presence of some tumor rising out of the pelvis or
occupying the abdomen. It is not necessary to resort to these
methods in every case, as should invariably be done with the
bimanual examination.
Inspection. — By this we ascertain the size and shape of the abdo-
men, regular and symmetrical in case of pregnancy, irregular and
unsymmetrical generally in case of fibroids, globular and pro-
tuberant in case of ovarian tumor, flat and bulging at the sides in
case of ascites. The appearance of the skin as to the presence of
any dark abdominal line, enlarged veins, linese albicantes, protru-
sion of the umbilicus, parchmenty or corrugated condition, may
prove of service in assisting diagnosis.
As it is essential, for accuracy in description, to know the dif-
ferent regions into which the abdomen is usually divided, the ac-
companying outline figure will serve to indicate them.
Palpation enables us to estimate the character of an abdominal
tumor as to its size, shape, density, solidity or fluidity of its con-
tents, sensitiveness to pressure, mobility, or presence of foetal move-
ments.
Both hands should be employed, the fingers being directed either
upwards or downwards, as may seem most convenient to the ex-
aminer. The size of the tumor is first determined, any irregularity
of its surface, variation in consistence in diiferent parts, mobility
from side to side, or from below upwards, sensitiveness, etc., being
also noted. If fluid be suspected, the left hand should be laid flat
on one side of the tumor, and an impulse communicated to the
opposite side by means of a rapid stroke with the second finger of
the right hand, or, better still, by placing the index-finger over the
middle finger and allowing it to slip suddenlj^ oft' on to the surface
of the abdomen. If fluid be present in any quantity, a distinct
wave will be propagated, and communicated to the other hand.
To guard against a fallacy occasionally witnessed in cases of fatty
tumors, an assistant should place his hand edgewise in the centre,
with the fingers directed downwards, between the two hands of the
operator. If fluid be present, the wave will be transmitted to the
opposite hand as before, but if the tumor be solid, this will not
occur.
If the fluid be thick, or contained in small cysts which are very
tense, or grasping the tumor with the left hand, and giving a steady
but somcAvhat sudden pressure with one hand, the sensation of out-
ward pressure towards the other hand will be experienced.
If the tumor be solid, on pressing it firmly between the two
hands its density will be appreciated.
Tympanitic distention of the abdomen may mislead the unwary
into suspecting the presence of a tumor, but, apart from percussion,
ABDOMINAL INSPECTION.
37
if the patient's attention be distracted by conversation, the fingers
may often be pressed firmly down towards the spine, the sacral
promontory even being distinctly felt, thus elFectually precluding
the possibility of a tumor being present.
This subject will be found more fully entered into in speaking
of the difterential diagnosis of ovarian tumors.
Percussion should never be neglected in the case of abdominal
enlargements. Frequent mistakes are made in diagnosis, owing to
inattention to this precaution. A single tap with the finger is often
sufficient to dispel a patient's hopes of maternity, and upset the
most elaborate diagnosis that had been made without observing
this precaution. Percussion is of service in enabling us to difier-
FiG. 13.
1. Bight Hypochondriac.
4. Right Lumbar.
7. Right Inguinal.
Regions of Abdomen.
2. Epigastric.
5. UmbilicaL
8. Hypogastric.
3. Left Hypochondriac.
6. Left Lumbar.
9. Left Inguinal.
entiate flatulent distention from fluid accumulations, in mapping
out exactly the size and relation of tumors, in assisting us in diag-
nosing ovarian tumors from ascitic collections, phantom tumors
from real tumors, spurious from real pregnancy, etc. To employ
percussion, the middle finger of the left hand is placed firmly upon
the abdomen, and the second phalanx struck sharply, distinctly,
and evenly with the tip of the middle finger of the right hand. If
air be present underneath, a hollow sound is elicited ; if fluid, a
dull sound is produced ; and if the tumor be solid, in addition to
the dull note, a sense of solidity and resistance is communicated to
the finger. It is always well to get the superficial as well as the
deep percussion note, especially if the abdominal walls be very fat.
38 MEANS OF PHYSICAL DIAGNOSIS. j
Auscultation is principally of service in detecting the foetal heart
sounds or uterine circulation in cases of pregnancy, the uterine
scuffle in fibrous tumors, the borborygmi in phantom tumors, the
absence of indication of circulation in ovarian tumors, friction
sounds in respiration in these latter, and friction fremitus in case
of large hydatid cysts.
In ascites, where the abdomen is considerably distended, and dull
on percussion anteriorly and superiorly, owing to a short mesentery
holding the intestines down, or to the fact of previous peritonitis
having bound down the intestines, auscultation may save us from
making a grave error in diagnosis. , The mere fact of hearing the
air moving in the intestines at a point where, if the case were
ovarian, there should be no intestines present, would suggest at
once the nature of the case.
In extra-uterine gestation, auscultation is often of great assistance
in clearing up the nature of the tumor. A form of stethoscope
has been made for auscultating the uterus per vaginam, but is one
of those unnecessary refinements more ingenious than practically
useful. The ear, with the intervention of a thin linen covering, or
the binaural stethoscope, applied to the abdomen, answers every
purpose.
Rectal Touch. — This method of examination may be resorted to
in the case of virgins where the hymeneal aperture is very small,
the hymen intact, or Avhere atresia of the vagina exists. It is, how-
ever, generally regarded by the patient as being far more disagree-
able than vaginal exj^loration, and should therefore only be excep-
tionally employed. In ordinary cases, where the vaginal examina-
tion has led to the detection of some unusual condition posteriorly
to the uterus, the rectal touch often proves a most valuable method
of exploration. The finger cannot only be made to pass much
higher, but can explore a greater area of the body of the uterus,
sweeping over the posterior wall, as well as getting behind the
broad ligaments, feeling the ovaries, and examining the state of
Douglas's pouch. Care should be taken to ensure the rectum being
empty at the time of examination.
The left lateral position will generally be found the most con-
venient one for carrying out the rectal touch, but special cases will
necessitate the right lateral or dorsal decubitus. Before oiling the
finger, it is well to scrape the nail along a piece of soap, so as to fill
the interspace between the nail and top of the finger, and thus
prevent fsecal matter gaining access. Having then coated the index-
finger with carbolized oil, it is passed per anum, the patient being
instructed to bear down or strain a little as the finger is passing
the sphincter, so as to facilitate its entering without unnecessary
discomfort. Incidentally, we should notice whether any unusual
pain be experienced, indicating the presence of a fissure, ulcer, or,
possibly, a fistula, or whether any hsemorrhoidal protuberances,
either externally or internally, exist. The finger being passed up
along the posterior wall of the rectum, if the uterus be in its nor-
mal position, or anteverted, the first prominence encountered will
I
KECTAL EXPLORATION. 39
be the cervix uteri ; the fundus being detected if retroversion or
flexion exist. On then passing the finger to either side, the ovaries
may be felt. The examination is facilitated if the right hand be
pressed over the lower portion of the abdomen, so as to depress
the uterus somewhat, this constituting the so-called recto-abdominal
exploration. By this means the bulk, form, position, and sensi-
tiveness of the uterus, as well as of the ovaries, may be estimated.
An extra-uterine gestation, uterine fibroid, retro-uterine hsemato-
cele, induration from pelvic cellulitis, or pelvic abscess, may thus
be readily ascertained.
The recto-vaginal exploration, or double touch, is often of great
service in determining the nature of any swelling in Douglas's
pouch. There are several ways of performing this. The index-
finger of one hand may be passed per vaginam, and that of the
other per rectum ; the thumb of the same hand may be passed per
rectum ; or the index-finger passed into the vagina, and the middle
finger of the same hand into the rectum.
Of these several methods the latter is probably the best ; the
nerve supply of the two fingers being in more intimate relation,
and the sensation experienced being more accurately apprehended.
Where the two index-fingers are employed, the hands interfere
with each other, and the thumb is often too short to be of much
service. The better plan is to adopt that method which the exam-
iner finds by experience is most easy to himself, or which is most
suitable to the individual case under observation. The thumb may
be passed into the vagina, and the index-finger into the rectum,
the uterus being pushed down somewhat by the other hand over
the abdomen, or drawn down by means of tenaculum forceps
applied to the cervix. Where it is desirable to ascertain the con-
nection of retro-uterine swellings with the uterus itself, the uterine
sound may be passed into the organ, and the attachment or other-
wise of the tumor determined.
Recto-vesical exploration may be accomplished by the uterine or
vesical sound passed into the bladder, and the index-finger into the
rectum. This method is useful in cases of atresia vaginae, in deter-
mining the presence or absence of the uterus, as also in discrimin-
ating between a large pol^^us and an inverted fundus uteri. The
size of the uterus can also be ascertained by this method in cases
where the abdominal walls are so fat that we are unable to judge
of this in the usual way.
In some exceptional instances it may be deemed requisite to ex-
plore by means of the finger passed into the bladder.
Rectal Exploration should never be employed except in very rare
cases to establish some very important diagnosis as to the nature
and connections of a tumor. Thomas maintains that, except in a
very few rare cases, it should be expunged fi^om the list of explor-
ative measures in gynecology, and even then should be employed
with the greatest caution, and be regarded in the light of a serious
operative procedure. Several fatal cases have been recorded, and
permanent incontinence of fseces may result.
40 MEANS OF PHYSICAL DIAGNOSIS.
To carry out the operation the patient should be anaesthetized,
and placed in an exaggerated lithotomy position, the knees being
thrown upwards. The hand being held in form of a cone, and
well lubricated with oil, the fingers are inserted gradually within
the sphincter ani by a sort of rotatory movement until the whole
hand is cautiously introduced. The fingers are then separated and
a careful examination of the pelvic organs is made, a portion of
the forearm being passed if requisite. The danger is consider-
ably increased if several examiners succeed each other in explora-
tion.
Dilatation of the Cervix Uteri by means of Tents. — Wliere the in-
troduction of the sound leads to the belief that there is something
within the uterus that needs to be removed, as with polypi, products
of conception, granulations, fibroid tumors, etc., or where dilata-
tion of the cervix is determined on with the view to relieve me-
chanical dysmenorrhoea, the introduction of some agent mth this
object becomes requisite.
Several have been tried from time to time, such as the dried
gentian-root, slippery-elm bark, etc., but the only two that are
usually employed now are the sponge tents (Fig. 14) and the Lami-
FiG. 14.
A Sponge Tent.
naria digitata or sea-tangle (Fig. 15), both of which may be procured
at the instrument-makers. A description of the mode of preparing
sponge tents seems therefore uncalled for.
The sponge tent should taper gradually from apex to base, so as
Fig. 15.
A Laminaria Tent.
to present a uniformly conical shape, not bulging in the centre as
often made, and the string for its removal should pass completely
through the centre from one end to the other, as in Fig. 16, so as to
avoid any risk of a portion of the tent being broken oflf on attempt-
ing to withdraw it.
The hollow sea-tangle tents are to be preferred, both on account
of the facility of introducing them, and by reason of their swell-
ing more rapidly than occurs with the solid ones. In some instances
considerable pain, amounting to almost insupportable agony, is
produced during the dilatation of a laminaria tent.
A new form, the tupelo tent, has lately been introduced to notice
— the root of the tupelo tree, Nyssa muitiflora. It is light, smooth.
DILATATION OF THE CERVIX UTERI.
41
and its power of absorption is said to be greater than that of sea-
tangle. Dr. Thomas thinks that, while it will not entirely super-
sede sponge, it will in a great many cases replace it.
To introduce an ordinary sponge tent, the patient should be
placed in the usual position for examination, and a tubular specu-
lum inserted, for otherwise the sponge becomes softened and swollen
Fig.
Fig. 18.
Fig. 16.
A Sponge Tent with thread
passing through it. (After
Thomas.)
Barnes's Tent-Introducer.
Long Sponge-tent Forceps,
with slide.
before it reaches the os; and then, having fixed the tent on a
pointed stilette, curved similar to a uterine sound, or on Barnes's
tent-introducer (Fig. 17), or held by a long pair of forceps (Fig. 18),
the point is inserted in the os, the direction of the canal having
previously been ascertained by digital examination and the passage
of the uterine sound; the tent is then pressed in the direction
42
MEANS OF PHYSICAL DIAGNOSIS.
indicated, care being taken to insert it completely within the os,
otherwise it will probably be expelled before accomplishing the
object for which it was introduced ; a plug of carbolized cotton-
wool soaked in glycerin may then be placed against the os and
the speculum withdrawn, the patient being instructed to remain
perfectly quiet.
Should any difficulty arise from the uterus being pushed up and
receding before the tent, it will be advisable to draw down the an-
terior lip of the cervix by means of a tenaculum, so as to hold the
uterus firmly.
As a rule six hours are sufficiently long to leave a sponge tent in ;
it should then be withdrawn, and if the cervix be not sufficiently
dilated the vagina should be syringed out with some antiseptic
fluid and a larger sponge tent introduced, six to eight hours being
allowed before being again interfered with. If much pain or in-
convenience be caused during the process of dilatation it is always
better to give opium, or inject morphia hypodermically, or pass a
suppository of opium.
Nausea or vomiting, heats and chills, at times occur. The pulse
may increase considerably in frequency, and the temperature run
up. In this case it will be better not to persist in
Fig. 19. f^Q employment of tents, but wait until the irrita-
tion set up has subsided.
It is well to steep the sponge in carbolic acid when
the tents are prepared, so as to render them antisep-
tic. An assortment of different sizes, as in Fig. 19,
should always be at hand, as it will often be found
that a much larger one can be inserted than at first
seemed possible. If the one passed be too small, it
is apt to slip out before it has had time to expand.
Where laminaria is employed it is seldom requisite
to pass a speculum, but having duly softened and
bent the sea-weed, insert a pointed stilette in the
centre, and let it be passed much as a uterine sound
would be. If any difficulty be experienced, a Sims's
speculum may be employed if requisite, and a tenacu-
AUl 1 1 lum used to &x the cervix.
Hi After remaining in twelve hours, attempts may be
HI made to remove it by drawing on the thread attached
HI to the extremity of the tent; should this break, or
H the removal be found to be impossible, the speculum
H must be introduced, and the projecting end of the
H I tent seized by the forceps, and so withdrawn. In
H cases where the tent has been passed completely in
W ' utero, the os remaining closed over it so as to pre-
vent the extraction, if the end cannot be seized by
a properly constructed pair of forceps, and the os
sizes. dilated by pulling on the tent, it may be requisite to
incise the os slightly, or to insert another tent by the side until the
OS is sufficiently dilated to allow of its withdrawal.
Sponge Tents,
showing different
I
DANGERS AND PRECAUTIONS. 43
The advantages of using the laminaria in place of sponge tent
are thus summed up the late Dr. ^ott :
1. Where moderate dilatation is required, the laminaria is
preferable to the sponge tent.
2. If placed in warm water, just before the introduction, for a
few minutes, they become flexible, coated with mucilage, are easily
curved to suit the cervical canal, and may be inserted with the
utmost facility.
3. From their smoothness and softness they are removed without
force, and produce no abrasion or irritation.
4. They may be medicated with morphia, iodine, or anything
soluble in water, but do not absorb alcoholic solutions or glycerin.
After being so charged, they may be dried and kept for use an in-
definite time.
5. They do not become putrid, and therefore poisonous, as do
sponge tents, and may, therefore, be retained twenty-four hours or
more with impunity.
6. The laminaria will be found of great benefit in obstructive
dysmenorrhoea, if introduced a few days before the menstrual
period, and also in cases of uterine catarrh connected with con-
tracted cer\dx; they prepare the way well, too, for all intra-uterine
medication. In either case, if softened in hot water before intro-
duction, they rarely produce any pain or irritation.
7. It is better to insert several small tents than one large one, as
the small ones expand more rapidly than the large ones.
The advantage of a sponge tent is that as it dilates it insinuates
itself into the folds of the cervical mucous membrane, and thus
tends to modify its surface, entangling in its meshes any granula-
tions and causing atrophy of them, or tearing them away when
the tent is withdrawn. It is less liable to slip out as it expands,
causes less pain, and also serves as a more efficient plug in cases of
haemorrhage than a laminaria tent. The chief disadvantage of
sponge is that it becomes very offensive if retained many hours.
The laminaria tent can be made smaller than a sponge tent, and
is therefore more readily introduced ; it is smoother, and is capa-
ble of overcoming greater resistance in expansion than a sponge
tent.
Dangers and Precautions. — -Much has been written respecting the
danger of resorting to this method of investigation, and the prac-
titioner will do well to consider carefully the risks incurred before
passing a sponge tent. Several instances have been recorded of
death from peritonitis, pelvic cellulitis, tetanus, septicaemia, etc.,
due entirely to the passage of a tent, and it is very probable that
numerous other instances could be cited, were all the fatal cases
published. To avoid as far as possible these risks. Dr. Thomas
suggests that the following points should be attended to :
1. ^o force whatever should be employed; either the direc-
tion must be altered or a smaller tent made use of if any difficulty
occur.
2. The patient should always be seen at her own residence or in
44 MEANS OF PHYSICAL DIAGNOSIS.
hospital, and she should be confined strictly to bed during the pro-
cess of dilatation. Xever think of inserting a tent and then allow-
ing the patient to go home with instructions to withdraw it in so
many hours' time.
3. ^ever allow a tent to remain in the uterus longer than
twenty-four hours ; as a rule twelve hours are sufficient, and much
safer. Others can then be introduced if the cervix be not suffi-
ciently dilated.
4. Remove the tent whilst the patient is lying on her back,
and let the vagina be syringed gently, not forcibly, with a little
Condy's fluid and water, or carbolic acid, or other disinfectant.
Should any rigor, pain, or other discomfort ensue, give quinine
and opium, and keep the patient perfectly quiet in bed.
5. In any case keep the patient in bed for the first twenty-four
hours following the withdrawal of the tent, strictly prohibit any
sexual relations, and do not permit her to travel for several days
afterwards.
6. When any pre\^ous history of pehic peritonitis or pehdc
cellulitis exists, or where the uterus is already in an inflamed con-
dition, never employ a sponge tent unless after pre\dous leeching
and other precautions, and not then without explaining the risk in
doing so.
The dangers inseparable from the employment of tents to dilate
the cervix should deter any but those having special experience in
gynecology from resorting to them. A young woman in perfect
health, who suffers periodically from dysmenorrhoea, or who fails
to conceive w^ithin a twelvemonth after her marriage, has a lanii-
naria tent inserted within the cervical canal a few days before her
expected period. The tent is only allowed to remain in six or eight
hours, and yet peritonitis develops itself and proves fatal within a
few days. Such cases are most distressing, not only to the friends
but also to the practitioner. Still, there are cases where it is per-
fectly justifiable to incur the risk, such as where a patient's powers
are gradually being exliausted by severe hemorrhage, where septi-
caemia threatens from retention of a portion of an ovum and other
similar cases, where the cer\dx is not sufficiently patulous to allow
of appropriate exploration or treatment. The danger seems to be
greater in those cases where a series of tents have been employed
to eftect progressive dilatation. It is well, therefore, not to use
tents more than twice in immediate succession, and to adopt every
antiseptic precaution possible, such as syringing the vagina well with
carbolized water before inserting a tent, and again on withdrawal,
carbolizing the tent, or smearing it with carbolized oil or lard, pack-
ing the vagina with a tampon of cotton-wool soaked in carbolized
glycerin, and being extremely careful that the examining finger
and any instruments employed are thoroughly clean or disinfected.
Where serious symptoms occur, the presumption is that septic ma-
terial becomes absorbed by the lymphatics, the tent producing a
lymphangitis or angeioleucitis in the abundant network of uterine
lymphatics; the inflammation spreads rapidly along their course
THE ASPIRATOR, OR EXPLORING-NEEDLE. 45
•Q the peritoneum and pelvic areolar tissue, and peritonitis, cellu-
itis, or septicsemia results.
Mr. Tait suggests impregnating the sponge tent with oil of cloves ;
)ut even with these there is some risk. Complete immunity from
ianger may, however, be obtained by placing the tent within an
alastic capsule. He thinks that surgeons engaged in general surgi-
3al practice, involving constant attendance on suppurating surfaces,
should never undertake any operations upon the uterus.
Use of Hydrostatic Dilating-Bags. — If the cervix cannot be dilated
suihciently by tents to allow of the requisite exploration, or where
the uterus is much enlarged by a tumor projecting into its cavity,
a small ^o. 1 Barnes's bag may be introduced and distended so as
to increase the dilatation.
A^Hien the cervix is sufficiently dilated to allow of the introduc-
tion of the finger, careful exploration should be made to determine
the presence of any fungosities, remains of an ovum, polypus, or
submucous fibroid.
Mr. Lawson Tait has introduced lately to notice a method for
dilating the uterine canal by continuous elastic pressure. The ap-
paratus consists of a waist-belt, with a strap depending from it back
and front, on which a series of hooks are sewn in a line close
together, to allow of an easy gradation of the pressure employed.
The dilators are a series of conical vulcanite plugs, which screw on
ito a common stem, which is usually quite straight, though in ex-
ceptional cases it requires to be bent. In the handle of this stem
sthere are three holes, through which a single elastic thread is passed.
Fig. 20.
Lawson Tail's Apparatus for Dilating the Uterine Canal.
The point of the dilator is passed into the cervix, and the elastic
thread is then fastened to the hooks, so that by very gentle press-
ure the plug is forced into the cervix. Two rules require to be
observed : always to begin with ^o. 1 dilator, and that sufficient
force to give pain should not be used, unless there is imperative
necessity for rapid dilatation, in which case opium must be given.
The uterus may be completely dilated in four or five hours, but it
is better that twenty-four hours should be given to the process.
The Aspirator, or Exploring-Needle. — In cases where the diagnosis
is exceedingly difficult or very doubtful, more especially in circum-
scribed pelvic swellings, the employment of the aspirator proves of
great value, often enabling us to clear up the diagnosis, where
otherwise it would have been impossible, and also allowing us to
treat cases hitherto deemed incurable.
46
MEANS OF PHYSICAL DIAGNOSIS.
Dieulafoy's aspirator is one of the simplest, most reliable, and
usefal forms. A very slender, long needle, perforated by a capil-
lary tube, or a fine canula and trocar, is connected by means of
india-rubber tubing with a glass cylinder in which a piston plays
very accurately. On drawing this upwards and fixing it by slightly
rotating the handle, a vacuum is created, powerful suction is thus
exerted upon any fluid contained in a cyst penetrated by the needle,
Fig. 20a.
Dieulafoy's Aspirator.
and if it be not too viscid, a portion can thus be withdrawn for
examination.
In some cases where no aspirator is at disposal, a small quantity
of fluid may be withdrawn by means of an ordinary hypodermic
syringe.
The exploring-needle is also employed with the same object, but
ANAESTHESIA. 47
is less generally useful, as, apart from the difficulty of penetrating
cysts through the vagina, there is more risk of admitting air, and
in cases of hsematocele and pelvic abscess, this is a point of great
importance.
The range of use for the aspirator is very great. It has been
successfully employed to lessen the tension and permit of the re-
duction of an otherwise irreducible hernia ; to relieve the bladder
threatened with rupture by an impassable stricture ; to draw oif
fluid from a distended colon blocked up by extension of malignant
disease ; to reduce the bulk of the retroverted gravid uterus im-
pacted in the pelvis beneath the sacral promontory ; to arrest the
development of the ovum in an extra-uterine cyst ; to determine
the diagnosis between a retro-uterine hsematocele, an ovarian cyst,
and a pelvic abscess ; to draw off fluid from a distended abdomen
in order that, by chemical and microscopical examination, the
question might be determined whether it was ascitic, ovarian, par-
ovarian, or due to the irritation of cancer of the ovaries ; and to
lessen the risk of septicaemia w^here large quantities of menstrual
blood have accumulated from an imperforated hymen, atresia of
the vagina, or occluded os uteri.
Before employing the aspirator, some hot carbolized water should
first be passed through the apparatus to ensure its cleanliness, and
avoid all risk of infection from any foul tube or trocar.
Puncture may either be effected per rectum, per vaginam, or
through the abdomen, the position of the swelling mainly deter-
mining our choice. Care must be taken not to bend or break the
tube by twisting or forcing it too suddenly in.
Examination of Discharges, etc. — This should never be neglected,
for it often throws important light upon the nature of the case.
Any substances expelled should be carefully examined with the
naked eye, and subsequently, if necessary, with the microscope.
In cases where haemorrhage from the uterine cavity persists, and
nothing definite can be determined from the character of the dis-
charge, the curette may be employed to bring away a small por-
tion of the mucous membrane, in order to ascertain whether we
have merely uterine fangosities to deal with, whether some retained
product of conception, sarcoma, or cancer of the ftmdus, is the cause
of the discharge, or whether a portion of sponge tent has become
broken off and retained in utero, giving rise to all the symptoms
of malignant disease.
The examination, under the microscope, of fluid removed from
an accumulation in the abdomen may enable us to distinguish the
fluid of an ovarian cyst from that of a par-ovarian cyst, or from that
of ascites, fibro-cystic disease of the uterus, or from hydatid cyst.
Examination of the scrapings of the surface of suspected growths
from the cervix will often enable us to determine the question of
its malignancy or not, and consequently the advisability of its
removal or otherwise.
Anaesthesia. — In some cases of extreme hyperaesthesia of the vulva,
more especially in young unmarried girls, who may be over-sensi-
48 MEANS OF PHYSICAL DIAGNOSIS.
tive as to the expediency of an examination, but where the symp-
toms imperatively call for a strict investigation, the administration
of some aneesthetic affords the only hope of our being able to make
a proper diagnosis. In cases where the examination cannot be
properly conducted, either on account of the resistance offered by
the patient, because of the pain produced, where delirium is pres-
ent, or malingering is suspected, anaesthesia may be produced. It
should not be resorted to in the consulting-room, and never unless
a third person be present. Everything tight round the throat and
waist should be loosened, and every precaution taken to avoid any
accident occurring from its employment. In cases of spurious
pregnancy and phantom tumors, its use cannot well be dispensed
with, diagnosis being facilitated, and removal of the supposed tumor
being accomplished both at the same time.
MALFORMATIONS OF THE UTERUS. 49
CHAPTER III.
MALFORMATIONS OF THE UTERUS.
Absence or Rudimentary Development of the Uterus. — Complete ab-
sence of the uterus is exceedingly rare. There will mostly be
^found, on dissection, one or two small nodules of uterine tissue
forming a cavity lined by mucous membrane in the peritoneal
ifold behind the bladder.
We may suspect this condition where there is only a rudimentary
development of the vagina, absence of any menstrual molimen or
:flow, and where, on passing one finger into the rectum and a sound
into the bladder, we fail to detect the presence of any body corre-
sponding to the uterus between the two. In some cases it may be
justifiable to pass a finger per urethram, and with a finger of the
other hand per rectum, explore carefully the intervening space.
The ovaries may be present although the uterus be absent, so
ithat there may be distinct menstrual molimen but no menstrual flow.
Where the diagnosis can be made out pretty accurately, any at-
'tempts at treatment are uncalled for. Should the vagina be also
absent, there would be great risk of opening the peritoneal cavity
iif any attempt were made to form an artificial vagina.
Uterus bipartitus consists of a central closed cord of uterine sub-
stance, corresponding to the cervix, inserted into the roof of the
'vagina, from either side of w^hich at the upper extremity a rudi-
.mentary uterine horn proceeds. To each of these a Fallopian tube
lis attached, running outwards to the ovary.
Uterus duplex occurs when there is complete separation of the
'two parts of the uterus, each side forming a separate cavity open-
ing below by a separate orifice into a distinct and separate vagina,
there being also two external orifices.
Uterus unicornis results when the duct of Miiller becomes nor-
imally developed on one side, while that on the other is either absent
for very imperfectly developed. The uterus thus curves to one side.
Menstruation may be normal, and even pregnancy occur in the
developed horn and proceed to a natural termination. Pregnancy
is also possible in the undeveloped horn, but this generally ruptures
before mid-term, ending fatally.
Uterus bicornis results from development of both ducts, the two
uterine halves failing to coalesce completely, but being fixed together'
at their lower portion. In some cases the point of junction is near
the fundus, in others much nearer the os uteri. The cavity of the
fundus is divided, the body and neck being single.
Uterus bilocularis occurs when the womb is divided interiorly
only by a membranous wall without any external evidence upon
4
60 MALFORMATIONS OF THE UTERUS.
tlie fundus uteri of any trace of this division. It is spoken of by
some authors as uterus septus. The vagina may be normal, or divided
more or less completely into two separate canals by a continuation
of the septum.
Infantile Uterus. — It occasionally happens that the uterus is
regularly and naturally formed, but fails to undergo the usual de-
velopment at puberty, either from some congenital fault, or from
mal-nutrition about the period of puberty. This condition is char-
acterized by an extreme length of the neck relatively to the body,
the uterus being more cylindrical than pear-shaped. Amenorrhoea
is an almost constant s^Tiiptom.
In the generally ill-developed uterus the whole organ is atrophic.
It is often associated with stenosis of the external os uteri and
anteflexion.
Conception may occur in most of these instances of malformation.
In the bipartite uterus the gestation often terminates, as in tubal
gestation, by rupture, during the first half of pregnancy.
In the uterus bicornis and bilocularis, repeated gestations may
occur interchangeably, sometimes in one, sometimes in the other
uterine half, a decidual membrane forming in the non-pregnant half.
Pregnancy may also occur simultaneously in both halves ; one foetus
is usually, however, arrested in development. Some of the cases of
superfoetation may be thus explained, by pregnancy occurring in
the two halves at an interval of some months.
The ill- developed condition of the uterus and its small size in
these various malformations will account for the frequency of
rupture, abortions, and tedious labors.
Treatment. — But little can be done in these cases. We cannot
alter the form of the uterus, but may endeavor to augment its
development by every means calculated to improve the general
health, the administration of chalybeate tonics, the employment of
warm hip-baths, hot-water injections, and, where the uterus is suffi-
ciently developed, by electricity, or the insertion of small galvanic
stems, as will be found mentioned under Amenorrhoea.
Congenital Atresia Uteri is exceedingly rare. The external os
may be impervious, or the whole of the cervix may be involved.
This condition not infrequently complicates atresia vaginae.
Acquired Atresia Uteri is generally limited to some portion of
the cervical canal, and is commonly due to cicatrization following
upon granulation, ulceration, or laceration of the cervix uteri. In-
juries to the cervix from severe labors, whether instrumental or
otherwise, causing laceration or subsequent sloughing, are probably
the most frequent cause of this form of atresia. It may also result
from the application of nitric acid, potassa fusa, nitrate of silver,
or the actual cautery to the cervix uteri ; amputation of the cervix
by the knife, or galvanic ecraseur, if proper means are not resorted
to to maintain the patency of the canal during cicatrization. Seal-
ing of the OS externum or internum by a false membrane occa-
sionally also takes place during pregnancy, so that at the time of
parturition no os uteri can be felt. Advancing senile atrophy may
TREATMENT OF CONGENITAL ATRESIA OF OS UTERI. 51
produce a kind of concentric obliteration of the os uteri. In elderly
women, too, with prolapsus uteri, who suiFer from cervical catarrh,
adhesions may ensue between the granulations on opposite sides of
the canal, especially when the climacteric has been passed and there
is no longer the flow of any secretion to keep the canal patulous.
In other cases distinct ulceration of the cervix occurs from the con-
stant attrition of the band or cloth w^orn to prevent the further de-
scent of the uterus, and cicatrization not infrequently takes place,
producing atresia. This is occasionally followed by hydrometra, or
accumulation of mucous fluid within the uterus, giving rise to
much discomfort, producing symptoms similar to those observed in
cases of hcematometra, or retained menstrual blood, though seldom
to a similar extent.
Closure of the uterus may result from extrinsic causes, as from
external pressure of tumOrs, such as fibroid tumors and cancer
in the neck of the uterus; any acute flexion; plugging from clots,
polypi, membranes, etc.
The passage of the uterine sound will often enable us to differ-
entiate these conditions from true atresia.
Symptoms of occlusion, or atresia, of the os uteri are seldom pres-
ent before puberty, and in the acquired condition not until after
parturition. They w^ill be found fully mentioned under the head
I of Imperforate Hymen.
Periodical attacks of uterine colic, with pelvic pain and bearing
down, or expulsive efforts, accompanied by an absence of the men-
strual flow, will naturally suggest the possibility of retention. If,
on .examination, we detect occlusion of the os uteri with enlarge-
ment of the uterus, and the fact of pregnancy can be excluded,
we may be almost certain that the case is one of hcematometi^a, or
retention of the menstrual fluid within the distended uterus.
Diagnosis. — The condition most likely to cause diflaculty in form-
ing an opinion is that of pregnancy. Attention to the history of
the case, the mammary signs, the softening of the cervix, the
enlargement of the uterus corresponding to the length of time the
catamenia have been absent, the possibility of pregnancy, and the
other symptoms and signs usually met with as characteristics of
this condition, will enable us to recognize its presence.
In cases of hsematometra, although the mammae may be tender
or painful, we do not notice the enlargement of the follicles, dark-
ening of the areolae, and other indications of pregnancy. The
size of the distended uterus does not correspond with that of the
pregnant uterus. Symptoms of retention may have been present
for over twelve months, and yet the uterus may not be larger than
the pregnant uterus at the fifth or sixth month.
The condition of the cervix in cases of haematometra varies con-
siderably from that of pregnancy. It is more taken up into the
body of the uterus, not sofl and infundibuliform in shape, as in
pregnancy.
Treatment of Congenital Atresia of Os Uteri. — Should an imper-
forate OS uteri be detected, even when no symptoms of retention of
62 MALFORMATIONS OF THE UTERUS.
menstrual fluid are present, it will be well to make an incision in
the centre of the cervix, and take means to prevent it closing again,
by the occasional passage of bougies, or by the wearing of a glass
or vulcanite intra-uterine stem for some time afterwards.
Where there is distinct evidence of hsematometra existing, the
fluid may be drawn ofl:' in small quantities at a time by the aspirator
or trocar, with antiseptic precautions, as indicated when speaking
of the treatment of imperforate hymen, or a crucial incision may
be made at a spot corresponding to what should be the normal os
uteri, and the retained fluid allowed to escape freely, warm water
being subsequently injected carefully into the uterine cavity, to
facilitate expulsion of the treacly fluid, and also to cleanse the
csivitj of the uterus, so as to prevent decomposition of the fluid
remaining adherent to the walls.
The edges of the incision may be touched with the perchloride
of iron to prevent their uniting, to check haemorrhage, and prevent
absorption. It will be necessary to take precautions lest the aper-
ture close by cicatrization. The occasional passage of a bougie or
sound will often be suificient. The insertion of any intra-uterine
stem is contra-indicated until the uterus has contracted to its nor-
mal dimensions, and all the fluid has been expelled.
Acquired occlusion of the os uteri, from injury or other cause,
will need operative interference, as in cases of congenital occlusion,
modified according to the circumstances of each individual case.
Closure of the cervical canal from extrinsic pressure, as in cases
of flexion, fibroid tumors, etc., will have to be remedied by obvi-
ating the causal condition. This will be found under the various
headings.
Conical Cervix and Stenosis of Os Externum, is not infrequently
found as a congenital condition associated with imperfect develop-
ment of the uterus or ovaries.
The tapering cervix projects further than usual into the vagina,
and is often curved forwards, the posterior lips being lengthened
and the anterior shortened. There may be
^^' ' stenosis both of the internal as well as the
external os, but the latter is generally most
marked. The cer^dcal canal itself is fairly
normal in size between these two points. The
vagina is often smaller than usual, and there
may be an infantile form of peh^s, with ab-
sence of sexual feeling.
Symptoms. — Dysmenorrhcea is usually pres-
ent. The pain, situated chiefly in the sacral
and iliac regions, radiates to the loins, down
the inner side of the thighs, and at times
Conoidai Cervix. assumcs the character of severe forcing or
expulsive pain, unfitting the patient for the
least exertion, and compelling her to keep in bed. Pain is not,
however, an invariable symptom. Where the menstrual discharge
is scanty, and the mucous membrane becomes completely disin-
CONICAL CERVIX AND STENOSIS OF OS EXTERNUM. 53
Fig. 22.
Fig. 23.
tegrated, there may be no evidence of obstruction or pain; but
where menorrhagia results, and clots or shreds of decidua attempt
to pass, violent spasmodic pain is produced by the contractions of
the uterus in endeavoring to overcome the difficulty.
In sensitive patients the agony is often intense, causing vomiting
or retching, and even syncope, or extreme prostration bordering on
collapse, leaving her exhausted in body and de-
pressed in mind from the amount of physical
suffering she has undergone, as well as the ever-
present sense of the inevitable return of the pain
within a few weeks. The breasts are often ex-
tremely painful ; the abdomen becomes distended
and tympanitic, headache, nausea, and inability
to take food, and other sympathetic disorders,
all contribute to render the patient's condition
most distressing.
Sterility is an almost invariable accompaniment
of this stenosis of the os externum,
and in some cases is the only symp-
tom that suggests to the patient the
necessity of appealing to us for as-
sistance.
Results. — In consequence of the
impediment to the free exit of
the menstrual secretion, a certain
amount of congestion of the uterus
ensues, disposing to menorrhagia;
this, together with the efforts at
expulsion, cause spasm and colic,
and lead ultimately to hypertrophy
of the uterus.
Endometritis may be produced
by the irritation due to retention
of the menstrual secretion; ova-
rian irritation, or inflammation,
being often set up, as also pelvic
peritonitis. In some instances the
Fallopian tubes become dilated,
the menstrual fluid, unable to es-
cape freely through the cervix, is forced back
through the patulous tubes, and gives rise to
pelvic hsematocele.
In married patients the tendency to these complications is still
further increased. Should impregnation by any chance occur,
abortion is by no means infrequent, but dysmenorrhoea and sterility
are the rule.
Treatment. — Dilatation, whether by tents or instrumental dilators,
is generally unsatisfactory ; the os contracting again within a very
short time. Incision, by means of the metrotome (Fig. 22) or by
1
Kiichenmeis-
ter's Scissors.
Simpson's Metrotome.
54
ALFORMATIONS OF THE UTERUS.
a scimitar-shaped knife, or by Kiichenmeister's scissors (Fig 23), is
a better plan.
It is well to select the week after the menstrual period for the
operation. Unless the patient be very nervous, or very sensitive
to pain, it is unnecessary to produce anaesthesia. Should the os
uteri be so minute as not to admit even the point of the metrotome,
it may be well to pass a short tubular, or Sims's speculum, get the
OS well into view, and incise it by means of a bistoury or knife.
The metrotome may then be passed just up to the internal os,
and gradually expanded as it is withdrawn, so as to make the inci-
sion triangular in form, the base being at the lower portion, or
Kiichenmeister's scissors employed, and the vaginal cervix cut
through. Where the body of the uterus is nearly in the same axis
as the cer^dx, it is better to make moderate incisions bilaterally;
but if the stenosis is associated with anteflexion, it is better to divide
the posterior wall only of the cervix freely, so as to lessen the differ-
ence, as much as possible, between the axes of the cervix and the
fundus uteri.
To restrain haemorrhage, as also to prevent union by first inten-
tion, a dossil of cotton-wool or lint steeped in the perchloride of
iron should be passed just within the incisions, the speculum being
used for this purpose. A plug or two of cotton-wool, steeped in
iodized glycerin, should then be inserted up to the cervix, and the
patient kept perfectly quiet in bed for the next few days. The plugs
should be removed the next day, and the vagina
syringed out with warm water, to which a little
carbolic acid or tincture of iodine may be added.
The cotton-wool placed within the incisions may
be left until it comes away of its own accord from
the syringing. Occasionally secondary haemor-
rhage occurs when this happens, and may need
a reapplication of the iron to check it.
After the operation care must subsequently be
taken not to allow the wound to close up ; the
occasional introduction of the end of the finger
or of a large bougie may be resorted to from
time to time with this object, or an india-rubber,
glass, vulcanite, or galvanic intra-uterine stem
may be inserted, and worn until the next period
be due, when it should be removed. Where the
incision has been extensive, it is better to keep
the patient at rest for the first week or ten days,
being used daily. She should remain in bed
The Cavities of the
Uterus and Cervix as
they are during life.
(After Bennet.)
vaginal injection
during the menstrual period to guard against complications, such
as congestive hypertrophy, hsematocele, menorrhagia, etc. Men-
struation generally returns before the parts have become thoroughly
healed, while the pelvic vessels are still overcharged, in consequence
of the irritation following upon the operation, and as an accom-
paniment of the reparative process.
Stenosis of the Os Internum. — According to Bennet, the interior
STENOSIS OF THE OS INTERNUM. 55
of the uterus does not present, as is generally supposed, a single
cavity, reached by a channel or passage through the neck, but a
double cavity, one belonging to the body of the uterus, and the
other to the neck itself. At the union of the two cavities there is,
during life, a natural stricture or coarctation, w^hich closes the
cavity of the uterus, and is suiScient to prevent even a small sound
penetrating into the uterus unless considerable force be used. The
entire cervical canal is physiologically endowed with considerable
contractile power, which may be much modified, increased, or
'diminished by disease.
Barnes, Schroeder, and others regard stenosis of the internal os
'. as so rare as seldom or never to require any operative interference.
When obstruction is experienced at the os internum, Barnes finds
it almost always to be due to the flattening of the canal at this
point, caused by extreme flexion or angulation of the body of the
uterus upon the neck. The fact remains, that in many women
who sufter from dysmenorrhoea and sterility, the sound passes wdth
difliculty the internal os, and that when incision of this is prac-
tised, one or both of these conditions are relieved. The cure of
the sterility is not nearly so frequent as the cure of the dysmenor-
rhoea, but, it must be remembered, impregnation is a far more
complicated process than menstruation.
Acquired stenosis of the internal os, or of some portion of the
cervical canal, has been known to ensue from the too energetic
application of caustics, resulting in cicatricial contraction, from
injuries received in parturition, or from some operative interfer-
ence upon the cervix.
Diagnosis. — Inability to pass an ordinary-sized uterine sound be-
yond the internal os does not necessarily prove that there is stenosis
— there may be merely spasmodic contraction, w^hich will pass oiF,
and allow the sound to enter if gentle pressure be persisted in, or
the uterus itself may be acutely flexed, a far more common form
of obstruction than stenosis. A metal sound, of about one-fifth
inch diameter, gradually tapering at the point to about one-eighth
inch, is better adapted to detect any contraction at the internal os
than an ordinary uterine sound. If this can be passed readily, and
no flexion of the uterus exist, there is no necessity to resort to
operative measures.
Treatment — Two distinct methods are available, viz. : (1) Dilata-
tion by means of graduated sounds or bougies, sponge or laminaria
tents, and by expanding instruments. (2) Incision, whether by knife,
scissors, or metrotome.
Dilatation. — In some few instances the mere passage of the uterine
sound through the cervical canal, a few days before the expected
appearance of the catamenia, will serve to materially diminish the
spasm and constriction usually produced at such times. But, as a
rule, the passage of graduated bougies or metallic rods, commenc-
ing with a size that can be passed w^ith little diflftculty, will be
found requisite. If a ]^o. 4 size be passed and left in situ for a few
minutes, provided it does not cause much inconvenience, a ^o. 6
56
MALFORMATIONS OF THE UTERUS.
or 8 may then be passed, and retained in situ, for ^\q or ten minutes.
It is well to begin gradually and carefully, and not attempt to ac-
complish too much at one inter\'iew. A convenient plan is to have
a series of graduated ends, made of pure copper, electro-plated, so
as to bend easily, which fit into one handle, as in Fig. 25. The
sizes may range from a l^o. 4 up to ^o. 12. A few days after-
wards we may commence ^dth a S'o. 8, and gradually increase the
size up to No. 10 or even 12, beyond which it is seldom requisite
to go.
The best time to commence this treatment is about a week after
Fig. 25.
Fig. 26.
Fig. 27.
f
ft
I
Priestley's Portable Uterine
Sound, with movable handle.
Priestley's Uterine
Dilator.
Ellinger's Cervical Dilator.
the period has passed, persevering every few days until the next
period is due, when we shall probably find the pain usually attend-
ing the process is materially diminished. After this, the occasional
passage of a moderate-sized bougie shortly before the expected
period will serve to prevent a relapse, though, unfortunately, this
method can scarcely be regarded as one of permanent utility, un-
less, perchance, impregnation ensues, when the difficulty is at an
STENOSIS OF THE OS INTERNUM. 57
end. Dilatation by means of laminaria or sponge tents is not a
thing to be rashly undertaken. There is always a certain amount
of risk attending the process. Many cases of pelvic cellulitis, pel-
vic peritonitis, or pehdc abscess have been caused by the use of
tents, and fatal results have followed, although it seems to be such
a simple proceeding.
The dangers attending dilatation of the cervix by means of tents,
and the method of employing these latter, have been fully consid-
ered when describing their use under the head of Physical Diagnosis.
Dilatation by means of expanding instruments has been tried in
many cases successfully. Several ingenious inventions, similar to
those employed for rapid dilatation of stricture in the male, have
been devised. One of the best is probably Priestley's dilator. Fig.
26. The instrument, when closed, can be passed like an ordinary
uterine sound. When in the cervical canal the screw at the end
is turned, and dilatation accomplished. The operation is somewhat
painful, and as a rule should only be done when the patient is in
bed, as it is apt to cause a feeling of faintness. The pain rapidly
subsides. There is seldom any haemorrhage to speak of. In very
nervous patients it will be well to give a few whiffs of chloroform
before dilating, and to pass a morphia suppository either before or
immediately after the operation, the patient remaining in bed until
the following day.
A modification of Holt's stricture dilator is also used for rapid
dilatation. Ellinger's cervical dilator (Fig. 27) answers the same
purpose.
Dr. Pallen,^ in a resume read before the ITew York County
Medical Society on " Incision and Division of the Cervix Uteri for
Dysmenorrhcea and Sterility," says : " I have operated for stenosis
of the cervical canal producing obstructive dysmenorrhcea 337
times. The sections have been bilateral for straight canal w^ith
stenosis, posterior for anteflexure of the neck at or below the inter-
nal OS, anterior for retroflexion of the neck, and antero-posterior
for anteflexion of the body with retroflexion of the neck, the sig-
moid-shaped uterus.
"After a careful estimate of all these years of experience, I am
constrained to say that in properly selected cases, w^here no peri-
metritis or pelvic cellulitis exists, no procedure ofi'ers more cer-
tainty of success, more freedom from danger, than does cervical
division for obstructive dysmenorrhcea.
" Of the 337 cases upon w^hich I have operated, more than fifty
per cent, have been relieved of their dysmenorrhcea, some thirteen
or fourteen have conceived and borne children ; about one-fourth
of the number were not benefited, from inability to keep open
the canal and fi-om other causes unrecognized at the time of the
operation.
" Of pelvic cellulitis and perimetritis, I have encountered three
cases ; of eversion of the lips (ectropion of the os) only one case ;
1 American Journal of Obstetrics, vol. x, 1877, p. 385.
58
ALFORMATIONS OF THE UTERUS.
of serious hsemorrhage, either primary or secondary, not one. In
the same period of time (twelve years), that these 337 incision oper-
ations were made, some 150 patients have heen subjected to treat-
ment by tents (of sponge or laminaria), for various conditions, of
w^hich two succumbed rapidly from metro-peritonitis, fourteen had
pelvic cellulitis, and one had metritis followed by abscess of the
Fig. 28.
Fig. 29.
Fig. 30.
Peaslee's Metrotome.
Greenhalgh's Metrotome.
Civiale's Urethrotome.
posterior wall, which discharged through the rectum. In com-
]Daring the results of these cases of dilatation by cutting with dila-
tation by tents, the deductions are very unfavorable to tenting. If
the choice is presented, all conditions being equal, there is no hesi-
tancy between incision and dilatation ; the question of pain is in
favor of the cutting, and there is very much less danger than from
STENOSIS OF THE OS INTERNUM. 59
sponge or laminaria tents. The operation is to be performed upon
no case where any cellulitis exists, nor upon cervices of women
laboring under incurable affections of heart, lungs, liver, or kidneys,
not in surgical wards of large hospitals, nor by a surgeon who has
been in attendance upon erysipelatous, diphtheritic, scarlatinous, or
puerperal diseases."
Dr. Barnes also states, " We may then conclude that the use of
tents to dilate the cervix uteri is not efficient, and does not possess
the advantage of being safer than incision."
Incision of the cervix in place of dilatation by the means enu-
merated, may be accomplished in various ways.
Incision through the internal os uteri is attended by considerable
risk, as the blood-vessels enter the cervix just about this level, and
the venous canals are maintained as more or less rigid tubes. Hence
the danger of haemorrhage, as well as of inflammation and septi-
caemia. Where obstruction to the patency of the cervical canal
exists at this point, it is almost invariably due to flexion, and if this
be overcome the obstruction will at the same time be removed.
Where it is desired to di\dde the structures through the internal
OS uteri, Simpson's single-bladed metrotome (Fig. 22) may be em-
ployed, or Peaslee's (Fig. 28). I^Tumerous double metrotomes have
been invented, but their action is too mechanical, and too little
under control of sight and touch, for them to be resorted to with
safety. K any obliquity of the uterus, or variation in thickness or
density of the two sides of the cervix exist, an opening may readily
be made into the peritoneal cavity. Greenhalgh's (Fig. 29) is one
of the most ingenious of these, but it will readily be seen how soon
an accident might occur with it. In some instances where severe
pain is experienced on passing the uterine sound through the inter-
nal OS, the mere nicking of this with an instrument like Civiale's
urethrotome (Fig. 30), and the passage of a large bougie or dilator,
often proves of much service in allaying the pain and facilitating
further treatment.
Whatever form of incision be adopted, the success of the opera-
tion depends upon the after-treatment. The patient must be kept
quiet in bed for several days to avoid risk of haemorrhage. Should
this be troublesome, it is well to expose the cervix through the
speculum, clear away all clots, seize one lip with a tenaculum-hook,
so as to steady the cervix, and at the same time render the os patu-
lous, then insert a small strip of lint soaked in liq. ferri perchl. or
tinct. iodi into the incision ; packing the cul-de-sac of the vagina
mth tampons of cotton-wool, soaked in glycerin or carbolized oil.
K no haemorrhage ensue after the operation, a glass or galvanic
stem may be inserted on the following day, and allowed to remain
in for several weeks. Barnes's galvanic coil pessary has the ad-
vantage of stimulating development, and being flexible is less
likely to injure the uterus than a rigid stem. As long as this is
retained, the patient must be carefully watched and instructed to
avoid all risk of cold or over-fatigue, more especially at the men-
strual epochs, lest peritonitis or cellulitis be set up.
60 MALFORMATIONS OF THE UTERUS.
It will be necessary to wear the stem for several weeks to avoid
contraction of the cervical canal. It is well to warn the patient
that immunity from pain does not always follow the operation, or
not for some little time, lest disappointment be expressed at the
result. It often happens that before a patient will submit to opera-
tive treatment, the general health has been allowed to become con-
siderably impaired, and the tone of the nervous system very much
lowered ; this will necessitate time, and appropriate constitutional
treatment. It is comparatively rarely that entire failure results
if only the cases for operation are judiciously selected, and too
much time has not elapsed since the commencement of the symp-
toms. Dr. Barnes has pointed out that success is in proportion to
the earliness of treatment. The important point is to operate
before secondary changes in the uterus and ovaries have been
established.
NORMAL POSITION OF UTERUS. 61
CHAPTER lY.
DISPLACEMENTS OF THE UTERUS. — ASCENT AND DESCENT OF THE
UTERUS.
The uterus naturally possesses a considerable amount of mobility;
still, there are limits to this, and Avhen these are exceeded, either
from sudden or repeated or continuous application of undue force,
we get displacement of the organ.
Considerable diiference of opinion still exists as to the frequency
and importance, and even the reality, of displacements. ]N^o sub-
ject probably has given rise to keener controversy, some contend-
ing that displacements of the uterus are due to chronic hyper?emia,
inflammation, or h^-perplasia ; others that these conditions depend
upon the displacements. The question is one of great practical
importance to determine, as upon an intelligent appreciation of
the subject will depend our mode of treatment, which is the all-
important consideration for the patient.
Fortunately, w^e can often solve the question practically, for
even if the displacement in the first instance be the consequence of
hyper?emia or inflammation, it unquestionably tends to keep up or
increase the condition which first caused it ; therefore, if marked
prolapse or retroversion of a congested or inflamed uterus occur,
we are perfectly justified in inserting a pessary, pro^dded it is tol-
erated and does not increase the discomfort already existing, at
the same time that we adopt measures to lessen the congestion or
inflammation.
Where, however, the displacement is slight, and the congestion
or inflammation marked, we should first endeavor to relieve this
by appropriate treatment, before resorting to any mechanical appli-
ances that might tend to increase the congestion, even though they
obviated the displacement. This especially applies to the treat-
ment of anteflexions by the insertion of intra-uterine stems.
Where the uterus is displaced and fixed by inflammatory adhe-
sions or deposits, no attempt at replacement or introduction of a
pessary, as a rule, should be thought of until the inflammatory
mischief has subsided, and the uterus again become mobile.
Normal Position of Uterus. — The healthy unimpregnated uterus
is suspended about midway in the pelvic cavity (see Fig. 31). A
line drawn from the upper margin of the symphysis pubis to the
lumbo-sacral articulation just touches the fundus uteri, another
line drawn from the lower margin of the symphysis to the articu-
lation between the fourth and fifth sacral vertebrae passing over
the lower portion of the cervix.
The uterus is suspended or held in position partly by its relation
62
DISPLACEMENTS OF THE UTERUS.
to the contiguous organs — ^the rectum and "bladder — its attachment
to the vagina and Fallopian tubes, hut chiefly by the folds of peri-
toneum inclosing muscular tissue constituting the ligaments of the
uterus.
The Broad Ligaments extend from the borders of the uterus to
the sides of the pelvis, forming a kind of septum which divides
the pelvis into two parts, allowing the uterus to move freely back-
wards or forwards in accordance with the varying distention of
the bladder or rectum.
The Round Ligaments are really continuations of uterine mus-
cular tissue, and are 'enclosed within the folds of the peritoneum
constituting the broad ligaments.
The Utero-sacral Ligaments extend from the lower part of the
Fig. 31.
Longitudinal Section of Pelvic Organs.
1. Body of Uterus; 2. Its Cavity; 3. Vaginal Portion of Cervix; 4. Canal of Cervix:
5. Os Uteri Externum ; 6. The Vagina; 7. Orifice of Vagina; 8. Interior of Bladder; 9. Urethra :
10. Vesico-vaginal Septum; 11. Rectum; 12. Its Cavity; 13. Anus; 14. Recto-vaginal Septum:
15. Perineum ; 16. Vesico-uterine Fossa of Peritoneum ; 17. Recto-vaginal or Douglas's Fossa
of Peritoneum; 18. Os pubis; 19. Labium Minus; 20. Labium Majus; 21. Perineal Body.
body of the uterus to the outer sides of the sacrum, their inner
concave borders passing on to the sides of the rectum. They serve
to attach the uterus posteriorly, preventing it being driven for-
wards on the bladder or downwards towards the vulva.
The TJtero-vesical Ligaments consist of two lateral folds of
peritoneum running off from the posterior portion of the bladder
containing bundles of fibrous tissue, and join the uterus just at
the junction of the body with the cervix.
The uterus possesses naturally a considerable range and variety
of motion, its position being influenced by the ever-var^dng dis-
tention of the bladder or rectum, the fact of standing or sitting,
coughing or straining.
ASCENT OF THE UTERUS. 63
The fundus is more mobile than the cervical portion, and is in-
fluenced in position by the superincumbent weight of the intes-
tines, being generally kept in a state of slight anteversion, the
axis of the uterus being coincident with that of the pelvic brim.
Besides the forward, backward, and lateral movements of the
uterus, the organ may also be moved in an upward or downward
direction, or become bent upon its own axis, giving rise to flexion.
We have thus ascent, descent, or prolapsus, anteversion and flex-
ion, retroversion and flexion, lateroversion and flexion, inversion.
Causation of Displacements in genjBial. — Any influence which tends
to increase the bulk and weight of the uterus, to weaken its sup-
ports, or to push or drag it out of its natural position, will cause
displacement.
Increase of bulk and weight may be due to congestion, preg-
nancy, fibroid tumors, subinvolution, hyperplasia or hypertrophy
of the cervix.
Weakening of the uterine supports may arise from defective
nutrition, not only of the tissues locally, but from the general
health being enfeebled.
Pregnancy and parturition exert a most important influence in
the production of uterine displacements. During pregnancy the
various ligaments become considerably stretched. After parturi-
tion they remain relaxed for many weeks before regaining their
proper tone. The vagina also, from the excessive amount of dis-
tention it has undergone, becomes weakened, not only from its
own relaxation, but also frequently from rupture of the peri-
neum. When, in addition to these, the patient gets about too
early, or sustains any prolonged exertion shortly after delivery,
before the uterus has had time to undergo the process of involution,
the natural result of the increased weight of the organ, combined
with the weakened and relaxed condition of its supports, is to
produce serious displacement, generally in the form of prolapsus,
or retroversion, or both conjoined.
The influences tending to push the uterus out of place are tight-
lacing, the suspension of heav}^ skirts from the waist, distention of
the bladder, abdominal tumors, prolonged exertion in the erect
position — as noticed chiefly in laundresses, milk^^omen, and those
who carry heavy burdens on their heads, repeated efl:brts, as in
chronic cough, or straining in habitual constipation. Any inflam-
matory deposits in the pelvis, as noticed in pelvic cellulitis and
peritonitis, tend either to push the uterus out of place or, by the
contraction of adhesions, to drag it from its normal position.
Ascent of the Uterus.
This does not occur as an original condition. In pregnancy,
about the fourth month, the uterus commences to leave the pelvis,
rising into the abdomen on account of its increased volume. Fi-
broid or fibro-cystic tumor of the uterus may likewise occasion a
similar ascent.
64
DISPLACEMENTS OF THE UTERUS.
An ovarian tumor may drag the uterus upwards, or it may be
pushed up by pelvic tumors or collections of effused matter, as seen
in cases of hsematocele, pelvic abscess, or even ovarian tumors im-
pacted in the pelvis. The ascent of the uterus is, however, only
an evidence of some other primary condition, and does not call for
treatment on account of the upward displacement simply.
As the uterus is drawn upwards the vagina becomes elongated
or stretched, and the rug?e smoothed out or obliterated. The cervix
also becomes elongated and attenuated, and has been known to be
actually separated from the body of the uterus.
Descent or Prolapse of the Uterus.
Descent or settling down of the uterus varies in degree. For
practical purposes it will be sufficient to describe three stages : the
Diagram illustrating successive stages of Prolapsus of Uterus, and the attendant degrees
of Retroversion (after Barnes). A,B. Axis of Brim of Pelvis; C,D. Axis of Outlet; B,E
Curve of Carus, or Curvilinear Axis of Pelvis. 1, 2, 3. Stages of Prolapsus; 4. Procidentia.
The Uterus, tethered to the Symphysis, revolves round it in descent.
(It would probably be more correct to regard 1 as the normal position of the uterus, and 2,
3, and 4 as the three stages of prolapse.)
first, in which the uterus remains entirely within the vulva ; the
second, in which it passes partially outside ; the third, in which
the whole uterus is extruded.
The first two stages are usually spoken of as incomplete prolap-
sus, or falling of the womb ; the third as procidentia, or complete
extrusion of the womb.
In its descent the uterus follows the curved axis of. the pelvis, the
fundus becoming more and more retroverted the lower it descends,
the cervix following the course of the vagina, until at length it
passes out of the vulval orifice.
DESCENT OR PROLAPSE OF THE UTERUS. 65
Prolapsus uteri is an aiFection to which women, especially in the
lower classes, are exceedingly liable, occasioning much inconven-
ience and distress, interfering not only with comfort but with health
and usefulness. The close coimection and intimate attachment of
the uterus with the bladder and anterior vaginal wall necessarily
involves the displacement of these when the uterus is prolapsed, so
that in speaking of prolapse of the uterus, prolapse of the vagina
with cystocele, or prolapse of the posterior wall of the bladder,
. must be regarded as an associated condition.
H\q3ertrophic elongation of the cervix may occur in consequence
of prolapse, or may arise independently, and ultimately lead to
prolapse of the body of the uterus. In these cases the cervix is
elongated out of all proportion to its breadth, and is often markedly
, attenuated in structure.
Causation. — The predisposing causes are child-bearing, laborious
i occupations, habitual constipation, and advanced age.
The exciting causes are, as we have already seen, any condition
tending to increase the weight of the uterus, to weaken its supports,
to force the uterus downwards by excessive intra-abdominal press-
ure, or to drag 'it down by traction from below.
In a large majority of instances, parturition is the starting-point.
The bulky, subinvoluted uterus dragging upon the already relaxed
and weakened supports, becomes partially prolapsed. Hypersemia
i of the organ is a natural consequence. This may run on to inflam-
mation ; in any case, the increased weight causes still further pro-
lapsus with retroversion. Hypertrophy or hyperplasia of the uterus
often ensues, and thus we have every condition requisite for per-
manent displacement of the uterus downwards.
It will be well for the practitioner to bear in mind the several
steps thus indicated, as many cases of prolapsus may readily be
prevented, and many more arrested, by resorting to appropriate
treatment in the early and most curable stages of the malady. We
have here a combination of the two most important factors in the
production of displacements — increased weight of the uterus, and
weakening of the supports which ordinarily keep it in position.
!N'ot only is the vagina relaxed and feeble from its recent distention,
but the perineum is often ruptured and the uterine ligaments very
much stretched. It is little to be wondered at that the frequency of
prolapsus is generally in a direct ratio to the number of pregnancies.
Prolapsus does occur in women who have never borne children,
but comparatively rarely. In these cases there is often a history of
prolonged leucorrhcea, chronic cough, or constipation.
An abnormally capacious pelvis, with alteration of the ordinary
spinal curve, the weight of the superincumbent intestines falling
directly on the axis of the pelvic brim, in place of as usual upon
the posterior surface of the symphysis pubis, unquestionably favors
a tendency to prolapsus. Where, in addition to these conditions,
the patients have to stand for many consecutive hours, or to carry
hea\y burdens, or to sustain prolonged muscular efforts, prolapsus
uteri is not infrequent.
5
66 DISPLACEMENTS OF THE UTERUS.
Prolapsus irom senile atrophy results not only from the relaxed
state of the vagina, but also from the absorption of the padding of
fat that usually is found in the pelvis, as well as in the omentum
and abdominal walls. The retentive power of the abdomen is thu^
weakened.
Owing to the general decrepitude of old age, or the muscular
debility from disease and old age combined, the figure alters in
shape. The spine, in place of being more or less sigmoid in form,
becomes semicircular, the shoulders pressing forward, thus bring-
ing the axis of the pelvis more in a line with the axis of the trunk.
The intestines thus descend more into the pelvis, pressing upon the
uterus, in place of, as normally, striking upon the posterior surface
of the pubes. The uterus is ^no longer sheltered under the prom-
ontory of the sacrum. The vaginal walls being very relaxed,
become prolapsed, and exert traction upon the uterus, which does
not descend in consequence of its bulk, being often atrophied, and
lighter even than when it retained its proper place.
Symptoms. — These chiefly consist of a sense of dragging or bear-
ing down, aggravated on standing, walking, coughing, or straining.
The uterus, increased in bulk, drags upon the utero-sacral and
broad ligaments, stretching and elongating these, giving rise to
dragging pain in the back and lower abdomen. There is usually
increased tendency to still further prolapse, when the patient has
to strain in emptpng the bladder or rectum, the uterus acting as a
foreign body by exciting reflex irritation.
There is generally marked prolapse of the anterior vaginal wall
with the base of the bladder, constituting cystocele, giving rise to
diflficulty and frequency of micturition, often attended by tenesmus,
and not infrequently cystitis ensues from decomposition of the urine
retained in the pouch.
The patient experiences a sensation of weakness in the parts,
with inability to stand for long at a time, or to undergo any pro-
longed exertion. She suflfers from considerable fatigue on walk-
ing, and feels quite unable to lift or carry ordinary weights.
Although leucorrhoea is generally present to a greater or less
extent, menstruation is not invariably interfered with; still, where
the uterus is much congested, menorrhagia is not infrequent.
Physical Signs. — If the symptoms point to prolapsus, but the
displacement is only slight, it is better to examine the patient
standing, first explaining to her the necessity of resorting to this
somewhat unusual method of investigation. The cer^dx will then
be found lower down in the pehds than normal, and on coughing
the uterus will be felt to descend still more. Anteversion or flexion
is not infrequently present at this stage.
In prolapse of the second degree the os uteri will be found pre-
senting at the vaginal orifice, the fundus being retroverted, the
anterior vaginal wall often bulging extern alty.
In the third degree, the uterus is found to be completely ex-
truded beyond the vulval aperture, the fundus retroverted. The
finger per rectum <3an be passed beyond the ftmdus, or this latter
DESCENT OR PROLAPSE OF THE UTERUS. 67
may even be distinguished externally lying in the inverted vagina.
A certain amount of cystocele and rectocele are usually present.
The uterine sound in these . cases passes directly backwards and
downwards, generally in excess of the normal length.
Differentiation. — If only ordinary intelligence and care be exer-
cised, it is difficult to mistake a case of prolapsus uteri. The con-
ditions most liable to lead to error are inversion of the uterus,
fibroid pol}^us, and hypertrophic elongation of the cervix.
From inversion, prolapsus may be distinguished by the cervix
with the central os being felt or seen, and by the absence of any
symptoms or history of inversion.
From pol}^ius, by the shape of the protruding mass and the de-
tection of the OS uteri in the centre, together with the absence of
symptoms of polypus.
Hj^iertrophic elongation of the cervix is at once recognized by
the length of the cervix, the uterine sound often passing in several
inches beyond the normal standard, even after the cervix has been
pushed up as far as it will go without using violence. It is impos-
sible, however, to replace the elongated cervix, as can be done in
cases of prolapsus.
Consequences. — When prolapsus is marked, or of long standing,
even if only to the second degree, the uterus becomes congested,
its tissues softened and relaxed. Inflammation, either of a chronic
form from the persistent congestion and exposure to cold, or of an
acute character from violence or injury from the employment of
ill-adjusted pessaries, is not infrequent. Hyperplasia or hyper-
trophy of the organ naturally results, the cervix being specially
liable to hypertrophic elongation.
As the uterus increases in bulk and weight, it becomes more and
more prolapsed, until in due course it becomes extruded through
the vulva, inverting the vagina, which in time changes its char-
acter and appearance from that of a moist mucous membrane to
that of smooth, dry epidermis. This is often ulcerated in patches
from the effects of exposure or friction, though ulceration is not
infrequent in the posterior fold of the vagina, where the effects of
friction are less obvious, which is frequently overlooked. A kind
of scab forms on these ulcerated patches, giving rise to haemor-
rhage should the scab by any means become detached.
The rugpe of the vagina generally disappear where the case is
one of long standing. The cervix uteri becomes obliterated from
the stretching of the vagina, which also causes eversion or ectro-
pion of the cervix, the os uteri being pulled open, the cervical
canal being rolled out as it were, so that the os internum takes the
place of the os externum, which has disappeared by expansion.
Prolapse of the posterior vaginal wall, dragging with it the an-
terior wall of the rectum, constituting rectocele, which is often
present in the early stages, increases as the uterus becomes ex-
tended, the whole of Douglas's pouch descending externally, often
containing one or both ovaries, and in rare cases coils of small
intestine. After prolonged exertion in the upright posture, gan-
68 DISPLACEMENTS OF THE UTERUS.
grene has been known to occur from the mass becoming strangu-
lated at the vulva, leading to extensive and even fatal sloughing.
Rupture or laceration of the vagina may take place from forcible
attempts to return the procident uterus. Occlusion of the cervical
canal, after the menopause, has also been observed in some cases.
Hydronephrosis, with dilatation of the ureters and enlargement
of the bladder, may result from the displacement of the base of
the bladder.
Sudden or acute Prolapsus Uteri may occur from any violent mus-
cular efforts, even in nulliparae. It has been observed in cases of
epilepsy, severe fits of coughing, forcible straining at stool, at-
tempting to lift heavy weights, and other similar conditions. Where
the uterus is enlarged by subinvolution, or pregnancy in the early
stage, or from the presence of fibroid tumors or polypus, or from
hyperplasia, especially if the vagina be lax, and the uterine sup-
ports weakened from pre\dous stretching, sudden prolapsus is still
more liable to occur.
The patient feels that something has given way wdthin her.
There is generally more or less shock, with severe pain over the
abdomen, tenesmus, or bearing down, with irritation of the bladder
and rectum. Peritonitis is very apt to occur in consequence.
Treatment — Our first effort will naturally be to replace the uterus
in its normal position, our next to keep it there.
Methods of replacing the Uterus. — Where prolapsus exists only in
the first or second degree, there is seldom much difiiculty expe-
rienced in accomplishing the reduction. Resorting to the semi-
prone or genu-pectoral position, and allowing the air to gain access
to the vagina, so as to gain the advantage of atmospheric pressure,
vs\\\ often be sufficient. Gentle, but steady pressure upwards, by
means of one or two fingers passed per vaginam, may be resorted
to if requisite. It is always well to secure a thorough evacuation
of the bowel and also of the bladder beforehand.
Where prolapsus of the third degree, or procidentia, exists, the
protruding mass must first be well lubricated with oil. It is then
grasped firmly in the hand, compressing it if necessary, for a short
time, so as to reduce its bulk, and then pressed gently and steadily
upwards in the direction first of the pelvic outlet, then in that of
the cavity, endeavoring to return first the upper portion which
was the last to be prolapsed.
If any difficulty be experienced, further efforts should be de-
sisted from at present ; the patient being kept at rest in bed for a
day or two and enjoined to resort frequently to the genu-pectoral
position ; a perineal bandage being employed to keep up gentle
pressure, and cooling evaporating lotions being used, so as to
lessen the congestion and reduce the bulk.
Pressure by means of strapping or elastic bandages has been
suggested, but it is seldom that it will be requisite to resort to
this expedient.
After a few days the mass will be found to have diminished con-
siderably in bulk, and can then be readily returned.
METHODS OF SUSTAINING THE UTERUS. 69
IN'o excessive force should ever be attempted, as laceration or
rupture of the vagina might occur and prove fatal. Where much
difficulty is experienced in completing the reduction, it will gen-
erally be found that, owing to the length of time the prolapsus has
existed, considerable hypertrophy of the uterus has taken place, or
there may be adhesions in the pelvis from previous inflammation
which tend to fix the uterus more or less in its abnormal position.
In long-standing and difficult cases reduction will be accom-
plished with much greater safety and certainty by steady, gentle,
continuous pressure than by any sudden or forcible attempts. Oc-
casionally it happens that the mass, for the time being, is irreduci-
ble. In this case we must desist from making any farther efforts
at reduction, and content ourselves with suggesting a suspensory
bandage which will have the effect of supporting the mass, prevent-
ing farther displacement, and by exercising steady, gradual pres-
sure tend to reduce not only the bulk but also the prolapsus itself.
Ulcerations of the surface of the procident mass need not deter
us from attempting reduction ; they will heal far sooner after re-
placement, when the vagina has recovered its natural moist condi-
tion, and the circulation can take place more naturally, provided
attention be given to cleanliness, and an astringent lotion be em-
ployed, than if we allow the procident mass to remain externally
and attempt to heal the ulcerations by local applications of caustics
or other agents.
Methods of Sustaining the Uterus. — Having reduced the displace-
ment of the uterus, we should not be in too great a hurry to apply
a pessary. For the first few days at least, the patient should be
kept quiet in bed, the bowels carefully regulated, the bladder
emptied regularly every six or eight hours, an astringent vaginal
injection used twice daily, the hips should be elevated, either by
means of a pillow when the patient is lying in the dorsal position,
or better still by resorting frequently to the semi-prone or genu-
pectoral position.
Any complications that exist, such as hypersemia, inflammation,
hypertrophy, or ulceration, must be attended to. In every case
we should endeavor to ascertain, as far as possible, the cause of
the prolapse and obviate this, trusting to the secondary results
disappearing when the primary cause has been removed.
In almost all instances of prolapsus before the menopause, the
uterus is increased in bulk. This we must attempt to remedy.
The mere fact of keeping the uterus in its normal position tends
to diminish this condition by allowing the circulation to go on nat-
urally. When prolapse exists, the venous circulation is considera-
bly interfered with, the vessels become bent at a more or less acute
angle, varicose, and often unduly distended; serous infiltration of
the tissues ensues, increasing any already existing hypertrophy,
and interfering materially with a healthy state of the organ.
In cases where the uterus is so bulky that it will not remain in
its normal position even whilst the patient retains the recumbent
posture, or where from any reason she is unable to rest up, much
70 DISPLACEMENTS OF THE UTERUS.
good may be attained by the insertion in the vagina of a large
tampon. This may be made of tow, oakum, or marine lint, or better
still, of sheep's wool, which, in place of becoming compressed by
moisture like cotton-wool, retains its elasticity, and thus keeps up
pressure, if a perineal bandage be worn at the same time.
In order to lessen hypereemia and to exercise a constringing
influence upon the vagina, it is well to soak the tampon in a mix-
ture of the glyc. acid, carbol. (1 part), glyc acid, tannici (4 parts),
and glycerin pur. (7 parts). This effectually prevents any decom-
position taking place, produces a considerable amount of watery
discharge, and enables us to retain the tampon in situ for a day or
two at a time, without the necessity of removing it or the fear of
setting up any unpleasant discharge.
Where ulceration had been noticed pre\dous to the return of the
procident mass, astringent injections will facilitate their healing, or
nitrate of silver may be employed. Touching the surface over
lightly two or three times a week with the lunar caustic, or painting
^^-ith a solution (3j-5ss ad Sj aq.), will exj^edite the healing process.
Where the prolapsus is of comparatively recent occurrence, the
vagina only moderately relaxed, the uterus not hypertrophied, the
perineum uninjured, and the general health not greatly debilitated,
rest in the horizontal position, the insertion of a tampon, and after-
wards the employment of strong astringent injections, may be suffi-
cient to restore the parts to a natural condition' and thus prevent
any subsequent prolapse.
The uterus being replaced in its natural position not only tends
to recover its original size, but the strain upon the ligaments which
ordinarily support it being removed, an opportunity is given them
of recovering to a great extent their proper tone.
The vagina also becomes corrugated, and in time contracted, by
the astringent injections, and thus aids materially in affording sup-
port to the uterus. The vulva at the same time regains somewhat
of its natural resiliency, and thus the several factors that tended to
produce or keep up the prolapsed condition are gradually eliminated
or at least diminished.
During the time the patient is resting up, careful attention must
be given to the regular daily evacuation of the bowels so as to avoid
all straining or pressure. The bladder also should never be allowed
to become distended to any extent. Where any tendency to cysto-
cele exists, the patient should be instructed to pass water in the
knee-shoulder position, or the pouch should be pressed up at the
time so as to ensure complete emptying of the viscus each time.
At the recurrence of each menstrual period, the recumbent position
should be enforced as far as possible, as the uterus is always hea^^.er
at these times.
Every means should be resorted to to improve the general health
and tonicity. Tonics, such as iron and quinine, strychnia, ergot,
bark, and acid, should be administered. Sea-bathing, where it can
be indulged in, not only acts very beneficially locally, but also im-
proves the state of the general health.
PESSARIES. 71
The best astringents for vaginal injections are strong solutions
'of alum, sulphate of zinc, iron alum, and tannin. These may be
used morning and evening, two or three pints of cold water having
first been injected. The strength of the solutions may gradually
be increased from 5j ad .Sj to as much as 5iij or iv ad 5j. Cold hip-
baths, injections of salt- or sea-water, are also of service.
Another and a very effectual method of applying astringents to
the vagina is by wrapping up a teaspoonful or two of powdered
alum or other astringent in a piece of prepared cotton-wool or small
muslin bag, and inserting this into the vagina. This can readih^
be done by the patient herself, either directly or by means of the
suppository tube. Injections of cold water must then be employed.
Prepared wool saturated with alum, tannin, etc., can be procured
at many of the leading chemists, and when made into plugs with a
piece of twine, answer the purpose very well.
Tannin and other suppositories may be employed at bedtime or
when the patient remains lying down; but they are not so cleanly
as the plugs, and should only be used where, for any reason, the
patient objects to the latter.
There are certain means adapted to obviate downward pressure
which are too often neglected, but which assist materially both in
the prevention as well as the relief of prolapsus uteri. The em-
ployment of skirt suspenders, by means of straps passing over the
shoulders, enables the patient to sustain the whole weight of the
underclothing from the shoulders, in place of allowing the constant
dragging upon and compression of the lower abdomen by the gar-
me^its, as is too frequently the case.
A carefully adjusted abdominal belt that does not extend too
high up, may assist in lifting the abdominal viscera and preventing
them pressing unduly on the pelvis.
All tight-lacing, or employment of corsets that compress the
thorax and press the viscera downwards, should be strictly for-
bidden.
Whilst the patient remains in bed it is a good plan to elevate the
foot of it six inches, so as to favor the return of venous blood, and
thus lessen congestion of the pelvic viscera.
Pessaries. — We have already indicated the steps that should first
be taken in replacing the uterus and encouraging a healthier action
of the pelvic organs, before resorting to any mechanical appliances
to retain the uterus in situ.
The term of pessary is an example of the change that takes place
in the meaning of a word, until it no longer signifies the thing it
stood for. Pessary, from •n-icffw to soften, originally meant a soluble
substance placed in the vagina, as a suppository is in the rectum.
Dr. Barnes suggests a far more appropriate term, Hysterophores
(uffTspa, womb, and (pipw, I bear), for instruments employed in
retaining the uterus in position.
Objections have been raised to their employment on the plea that
they are unscientific, that their usefulness is only palliative and
temporary. Whatever objections, however, may be urged, there is
72 DISPLACEMENTS OF THE UTERUS.
little doubt that they offer a valuable method of relief for a large
number of cases of prolapsus, as well as for other forms of dis-
placement.
It will generally be found that those who are most opposed tc
their employment have seldom if ever tried them, or only sc
rarely that they have never acquired the requisite experience tc
ensure a successful result.
The practical advantage, however, that is gained far outweighs
any amount of theory. Even granted that the usefulness of pes-
saries is only palliative and temporary, that is no reason why we
should discard them. As well might we object to the application
of splints to a fractured limb, or of a truss for a hernia, or of any
orthopaedic instrument for the cure of deformity.
The object of a pessary or hysterophore is to support and retain
the uterus in its normal position in the pelvis without unduly dis-
tending the vagina or setting up any irritation. In the large ma-
jority of cases of prolapsus in the first and second degree, a Meigs's
oval elastic ring, or a Hodge's lever pessary, variously shaped to
meet the requirements of each case, will answer the purpose, pro-
vided the perineum has not been seriously ruptured.
As long as the vagina retains any amount of contractility, we
must be careful not to destroy or diminish this property, but make
use of it.
Hodge's Pessary is the one of all others that offers the greatest
number of advantages with the fewest drawbacks. It is made of
various materials — vulcanite, copper wire covered
^^â– ^1 with gutta-percha, pliable metal, etc. The two
^^^^k latter are as a general rule more serviceable in
£^ m that they can be moulded by the practitioner at
m 'm the time, to suit the requirements of each indi-
â– M vidual case, or can be altered in shape from time
â– ^k to time should it be found requisite.
^B M The best form for general purposes is a sigmoid
^w M shape, the upper or sacral end being somewhat
M ^M wider and flatter than the lower or pubic limb
^I^HH^^r (Fig. 33). Having formed an approximate idea of
Hod e's Pessarv ^^ length and capacity of the vagina, we should
select a Hodge of such a size that the upper limb
will fit into the posterior cul-de-sac, and the lower limb rest behind
the symphysis pubis above the meatus urinarius. Too large an in-
strument must not be inserted, otherwise its action as a lever is
interfered with, the vagina is unduly stretched, its elasticity im-
paired, and inflammation or ulceration very liable to occur.
It is essential that the Hodge should be freely movable, merely
held in the vagina, floating as it were in the pelvis, and not taking
any bearings upon the walls themselves.
Its action is that of a lever ; the fulcrum being a transverse axis,
nearly through its centre, upon Avhich the Hodge revolves when
grasped by the vaginal walls; the power is the pressure of the
anterior vaginal wall upon the lower limb, increasing during in-
hodge's pessary.
73
spiration, or exertion, or by any expulsive effort, when the intes-
tines are driven down upon the uterus and bladder, causing the
anterior vaginal wall to descend ; the weight or resistance is the
fundus uteri, which is pushed up by the posterior limb as it rises
in the opposite direction, lifting the roof of the vagina and the
uterus, tilting the fundus somewhat forwards.
To Inti'oduce a Hodge's Pessary. — Having first replaced the uterus,
the patient lying in the semi-prone position, with the hips close to
the edge of the couch, the thighs well flexed upon the abdomen,
the feet resting one upon the other, the pessary being well oiled, is
taken in the right hand. The index-finger being pressed firmly
against the inner surface of the upper or sacral extremity, the con-
cavity of which should look forward, is opposed by the thumb, so
Fig. 34.
Hodge in situ j Uterus slightly retroverted.
as to hold the pessary securely edgewise. The perineum being re-
tracted by the left index-finger, the instrument is guided into the
vagina in an oblique direction, so as not to press upon the sensitive
structures anteriorly in the arch of the pubes, and is then directed
quickly and firmly along the posterior wall of the vagina until the
whole of the pessary is within the passage. The instrument as it
passes up is rotated somewhat, so that the concavity of the upper
or sacral curve looks forward. This should be guided behind the
cervix into the posterior cul-de-sac or fornix of the vagina.
If the sacral curve be great, the tendency is for this to pass up
in front of the cervix. Should this happen, the index-finger of the
right hand passing through the pessary, presses or hooks the upper
limb backward behind the cervix, at the same time pushing it up-
wards into the posterior cul-de-sac. The cervix then occupies the
central space, the anterior or pubic extremity of the instrument rest-
74 DISPLACEMENTS OF THE UTERUS.
ing upon the anterior wall of the vagina behind the pubic arch, with
its convex surface facing forwards, sloping as it were, under the
pubes.
It is not always necessary to retract the perineum by the left
index-iinger. The pressure of the instrument alone is often suf-
ficient, and we gain the further advantage of the perineum replac-
ing the thumb, so that the extended index-finger can carry the
pessary up rapidly along the posterior vaginal wall, without the
thumb ofiering any obstruction to its progress.
When properly adjusted, the instrument should cause no dis-
comfort. Should it do so, it is probably too large or not suitable,
and should at once be removed, and a smaller or a difterent-shaped
one inserted.
As a rule, it is necessary to wear the instrument continuously for
many weeks or months; but it should invariably be insisted upon,
that the patient present herself within a few days, or a week at
most, aft:er it has been inserted, in order that we may determine
whether it is likely to answer the requirements of the case, as also
to satisfy ourselves that it is not causing any undue pressure likely
to lead to ulceration or other mischief. It is ad^dsable to remove
the instrument every few months in order to see whether it has
produced any chafing of the vagina, and to ascertain how far im-
provement has taken place. As long as it is worn, the patient
should make use daily of vaginal injections, a combination of
astringent and antiseptic agents being desirable.
The patient should be cautioned to attend to the proper regula-
tion of the bowels ; not to pass water in the ordinary squatting
position, but to make use of the bed-chair ; to avoid all unneces-
sary straining or violent exertion ; to relieve the bladder regularly
at least thrice daily ; and to rest in the recumbent posture as much
as possible at the menstrual periods.
She must be instructed not to interfere with the instrument in the
way of removing it, unless it should cause inconvenience, and it is
always well to explain, in the case of married patients, that the pres-
ence of the instrument does not necessitate their leading a single life.
In cases of patients living at a distance, instruction may be given
how to remove and replace it at stated intervals, but it is compara-
tively seldom that we find a patient who wdll trust her own powers
of adjusting it properly.
After having worn the support for several months, and having
employed astringent injections, and other remedies calculated to
improve the general health, it mil be well to remove the instru-
ment for a time, to see if the uterine ligaments have recovered their
tone, and whether the uterus will remain in its normal position.
In many cases, it will be found that the instrument may be changed
for a smaller one after a few weeks' interval, when the parts are
less relaxed and the uterus itself less bulky.
It is not always that we can succeed in adjusting a Hodge satis-
factorily at first, but we must not be deterred from making further
attempts because we happen to fail with the first one. The shape
75
of the Hodge can be altered to suit the requirements of individual
3ases. The pubic curve may be lessened, and the end made broader,
so as to rest behind the arch of the pubes and give support to the
base of the bladder.
In place of the Hodge being bent in the ordinary sigmoid form,
it may be made into a semicircle, as suggested by Dr. Galabin
'Fig. '35). The anterior limb then rests high above the pubic arch,
distending the anterior vaginal wall, with the base of the bladder,
into a pouch, and does not press against the rami of the pubes at
all. This form is specially suitable in those cases where the vagi-
nal vault is much relaxed. It fails if the vaginal cer\ix be so
atroi)liied that it does not retain the
posterior limb of the pessary behind Fig. 35.
it in the posterior cul-de-sac. ^
It is somewhat less easy to intro-
duce than an ordinary Hodge, owing
to the difficulty experienced in hook-
I ing the posterior limb backsvard over
(the cervix into the posterior cul-de-
f-sac. In proportion to this difficulty
lis the security of its retention.
Hodge's pessaries are made of
various materials, of which the prin-
cipal are vulcanite, gutta-percha,
block tin, pliable metal composed of GalaWn's Pessary.
tin and lead, or of copper mre covered
with india-rubber tubing. They can also be made of aluminium,
^silver, or copper tubing plated, and celluloid or coralin.
Vulcanite is by far the best material, being light and durable,
retaining its smooth polished surface even after many years' wear,
ilts chief disadvantage is that it is difficult to alter the shape origi-
nally given to the pessary, so that unless w^e have a considerable
number to select from, much delay occurs should it be requisite to
modify the shape in any way. This may be done by placing the
pessary for a few minutes in boiling water, extracting it by the aid
of a pair of forceps, and then making the necessary alteration in
shape by bending it with the fingers, holding it, if necessary, in a
thin cloth to avoid injuring the fingers. It is then plunged into
cold water, and held there until it is again hard, which takes place
in about a minute or two.
Another plan is to lay the pessary close to a bright fire for a few
minutes, until it becomes pliable, when it may be moulded as de-
sired, and set firm by holding it for a minute in cold water as before.
If only a slight alteration of shape be needed, the surface of the
pessary may be oiled, and the instrument moved rapidly backw^ards
and forwards through the flame of a spirit-lamp until it be suffi-
ciently pliable. Care will be needed to avoid burning the surface,
and so spoiling the polish.
Celluloid or coralin has recently been employed in the manu-
facture of Hodge's pessaries. It is similar in many respects to
76 DISPLACEMENTS OF THE UTERUS.
vulcanite as to hardness and lightness, and can be moulded b
placing it in boiling water. It is of a pretty coral-like color.
Copper wire covered wdth gutta-percha, so that the thicknes
corresponds to about one-third of an inch in diameter, forms
useful material for ordinary purposes. AVlien slightly warmed, o
even at the ordinary temperature of the room, the pessary can b
readily altered in shape, shortened or lengthened, curved or straighi.
ened, to suit the requirements of the case. If the least crack occu
in the gutta-percha, a heated knitting-needle and a small scrap c
fi^esh gutta-percha are all that are needed to make good the defeci
taking care to smooth the surface well before adjusting the pessary
Even after remaining in the vagina for a twelvemonth or longei
provided injections for the sake of cleanliness have been employee
the pessary will be found to be as perfect as the day it was insertec
Copper or other wire, covered with india-rubber tubing, is ofte:
employed in the manufacture of Hodge's pessaries. It is mor
Fig. 36. Fig. 37.
Dr. Greenhalgh's Elastic Spring Pessary, with india-rubber transverse bands.
liable to become sodden with the secretions, and thus set up irrita
tion, than is the case with gutta-percha, but still forms a usefu
material for the construction of the annular rings and other elasti
forms of pessaries, and is useful where an elastic end is preferred
Flexible white-metal is now often employed for pessaries. It i
somewhat heavier than vulcanite, and is liable to become corrodet
after long wear, especially at the part where the tubing is joined
They can be easily moulded into any required form. Should it b
requisite to persist in the wearing of a pessary for any considerabl
length of time, it can be either electro-gilt or nickel-plated, or
fac-simile of it made of aluminium, platinum, or silver tubing
thus ensuring lightness, cleanliness, and durability.
Where cystocele forms a marked feature in cases of prolapse, ;
barred Hodge, with strips of india-rubber passing across, is often o
much service in preventing prolapse of the vaginal wall. Dr. Green
halgh's modifications, with elastic end, answers well (Figs. 36 and 37)
Where the uterus is very bulky, the vagina very relaxed, an(
the perineum injured, a Hodge's pessary is seldom retained so a
to be of any service. An elastic ring pessary, composed of spira
spring, covered with india-rubber, mil often succeed in these cases
"Wlien compressed, as indicated in Fig. 38, it can be readily intro
duced, and has the advantage over the. ordinary sigmoid Hodge'
pessary, in that the elastic ring may be removed and reintroduce(
CUP AND STEM PESSARY.
77
)y the patient herself without much fear of it assuming a wrong
)Osition owing to its flatness, the posterior portion passing natu-
ally behind the cervix and not in front, as too often happens with
lodge's pessary.
Where the prolapsus is of the third degree, or the vagina so lax,
)r the perineum so torn, that the ordinary ring or lever pessaries
Fig. 38.
Fig. 39.
Annular Ring Pessary.
Barnes's Stem Pessary.
ire not retained, we have still other forms of support that may be
rried before resorting to some plastic operation.
The cup and stem pessary (Fig. 39), in cases where the vagina is
contractile, is often self-retaining. It consists of a somewhat taper-
iing hollow cylinder made of vulcanite, curved to correspond with
â– he pelvic or vaginal axis, and an upper expanded portion or cup.
Fig. 40.
Fig. 41.
Cup and Stem Pessary in siitu.
Duffin's Pessary,
When the vagina is sufficiently contractile to grasp this, the tendency
is to carry the cone upwards, and so exert pressure upon the cervix.
It is only, however, in a limited number of cases that this form
of pessary will be retained without external support. This is best
accomplished by attaching the lower end of the cylinder to an
oblong-shaped piece of stout india-rubber. Elastic bands formed
of india-rubber tubing are attached to the margins of this, thus
78
DISPLACEMENTS OF THE UTERUS.
enabling them to lie in the groove at each side of the labia, and
not produce chafing by crossing directly from the end of the cjlindei
as represented in Fig. 40.
The stem may be either straight or curved, but if there be an}-
FiG. 42.
Fig. 43.
Cutter's Cup and Stern Pessary.
Cutter's Ring Pessary.
tendency to retroversion the former is preferable, as it tends to
correct the displacement by pushing the cervix backward.
The advantage of this form of pessary is that it can be applied,
by the patient herself. It does not stretch the vagina, and being
sustained by elastic supports, these yield at every inspiration, thus
permitting the natural ascent and descent of the uterus, and also
Fig. 44.
Cutter's Pessary in situ.
ob\Hating the effects of concussion or violence which rigid external
supports would be likely to cause. To introduce it, insert the left
forefinger just within the vaginal outlet, press the perineum back-
wards, and then pass the cup edd of the stem in a direction back-
OBJECTIONABLE FORMS OF PESSARIES.
79
wards and upwards, being careful to avoid allowing it to press
against the symphysis pubis. It should be removed every night
at bedtime, and an astringent injection employed. The elastic
bands will need renewal from time to time, as they tend to lose
their elasticity. It is well to adjust the stem before rising, before
the uterus has had time to become prolapsed. This form of pes-
sary is specially serviceable in elderly women where the parts have
'become atrophied, the vagina having lost its contractility and the
tpadding of fat having become absorbed.
Dujffin^ s Pessary (Â¥\g. 41) is a useful form in some cases of prolapsus
in elderly females. It consists of a boxwood stem and cup, working
in an ivory ball-socket on a shield which is kept approximated to
ithe vulval aperture by means of a napkin worn in the usual way.
Gutter's Pessary (Fig. 42) consists of a cup and stem which curves
Ibackward over the perineum, a piece of india-rubber tubing being
continued from this and attached to a belt surrounding the abdo-
men by means of a strap. It has been spoken very favorably of
iby Thomas, and may be tried w4iere others fail. It is more liable
I to get displaced than the other form of cup and stem pessary, and
Ithe perineal tube often sets up irritation. Another form of this
pessary is where the stem passes anteriorly over the symphysis
pubis. This is less convenient in practice than the former variety.
If the cup-shaped form be objected to, the ring modification (Fig.
43) may be employed.
There are certain objectionable forms of pessaries which it will
be well to indicate. These are the globular boxwood pessary. Fig.
46,' the large circular disk-shaped pessary. Fig. 45, and all the
countless modifications of these which depend for
their efiicacy upon their bulk. By constantly dis-
tending the vagina they destroy any remaining con-
tractility that may exist, and often set up a consid-
'Crable amount of inflammation or ulceration, with
offensive purulent or sanguineous
discharges. They are still em-
ployed by many old-fashioned pa-
tients, who wear them for a num-
ber of years consecutively without
removal. When, however, they
attempt to accomplish this latter,
they find the vulval orifice has be-
come so contracted, as well as rigid,
that it is impossible to w^ithdraw
the pessary. Under these circum-
stances we may be applied to for assistance. In the
case of the circular or oval boxwood pessary, we
may sometimes succeed in removing it, by passing
one or two fingers of the left hand per rectum and
pressing the mass downwards, assisting meanwhile
by counter-pressure with the right forefinger on the anterior por-
tion of the globe.
Fig. 46.
Fig. 45.
Elastic Gum Ring
Pessary.
Globular Box-
wood Pessary.
80 DISPLACEMENTS OF THE UTERUS.
Where this manoeuvre does not succeed, a pair of large ovum
forceps may be introduced per vaginam, and attempts made to grip
the pessary and withdraw it, assistance being given if requisite by
the finger passed per rectum as before. It may be necessary to in-
cise the margins of the vulva before we succeed, but this plan is
better than using violence.
The same difficulty is often encountered with the large circular
disks. They have been known to find their way, by ulceration,
wholly or in part into the rectum or bladder. The cervix uteri
has also in some cases become incarcerated in the central ap-
erture.
The only form of pessary that acts by distending the vagina in
order to retain the uterus in position, to be recommended, is Gariel's
air pessary, made of india-rubber prepared so as to resist moisture.
It can be introduced in a state of collapse by the patient herself,
and then inflated by means of a small air-pump, being retained
during the day and removed at night.
ZwancWs Pessary (Fig. 47), or as modified by Dr. Godson (Fig.
48), acts by distending the upper portion of the vagina laterally,
Fig. 48.
Fig. 47.
Zwanck's Pessary. Godson's Modification of Zwank's Pessary.
preventing the cervix protruding externally. The expanded wings,
with their narrow margins, often exert such an amount of pressure
upon the vagina as to produce ulceration, and not infrequently be-
come buried in the tissues. Granulations occur, which, projecting
through the circular holes, often unite and form a band, which in-
carcerates the pessary, and renders its rem.oval a work of much
difficulty.
It is an unscientific instrument, and should never be employed
where other more rational measures can be adopted. Among hos-
pital patients, who are unable to rest up, or unwilling to undergo
any operation for the cure of prolapsus, where a Hodge is not re-
tained, the employment of a Zwanck's pessary aftbrds in many
instances the only means of relief at our disposal. It should
always be removed at night and replaced in the morning before
the uterus has had the opportunity of descending.
To introduce it, the click at the end is unfastened, so as to en-
able the two wings of the pessary to be closely approximated to
SURGICAL TREATMENT.
81
Fig. 49.
each other. The right forefinger is then placed on the hinge be-
tvN^een the two halves of the stem, and the pessary inserted by
pressing obliquely on the perineum, guiding the wings upwards
towards the hollow of the sacrum. When the tips of the mngs
have reached the cer\dx, the two halves of the stem are brought
together and the wings thus expanded, the ends being secured by
the click.
Where the parts are very relaxed, and the uterus bulky, it is
often ad\dsable for the patient to wear a cloth or perineal band-
age, to prevent the stem descending or causing inconvenience on
sitting.
Where the original Zwanck's pessary is employed, the screw is
turned so as to approximate the wings. The pessary is then in-
serted as above directed, and the screw turned so as to expand the
wings. Three different sizes are sold, so that a suitable one may
be selected for each case.
Removal is effected by reversing the above movements and pull-
ing the stem downwards and forwards.
Duncan's Stem and Disk Pessary (Fig. 49) is still more liable than
Zwanck's to set up ulceration unless carefully watched. The vagina
contracting firmly round the disk, this latter either becomes im-
bedded in the walls, or in any case the escape of secretions from
the upper part of the vagina is prevented. Decomposition of these
takes place, and may cause considerable con-
stitutional disturbance.
Simpson's Shelf-pessary has perforations in
the disk which allow the secretions to pass,
and thus ob\dates the defect of Duncan's.
Utero-abdominal supporters, consisting of
a perineal pad attached by straps, passing
before and behind, to an abdominal belt, are
in some instances of service in affording sup-
port by pressing the posterior vaginal wall
against the anterior, and so preventing the
descent of the uterus. They are fitted with
either a sacral or pubic padded metallic plate,
the pressure of which relieves the sympa-
thetic pains so often complained of.
Abdominal belts, as previously suggested,
often afibrd marked relief by taking oft' the superincumbent press-
ure of the intestines, and so lessening the tendency to prolapse.
Surgical Treatment — Where pessaries or hysterophores fail in
supporting the uterus in its normal position, or where a more radi-
cal mode of treatment be indicated, there are several operative
procedures that may be resorted to with a fair prospect of suc-
cess.
Rupture of the perineum during parturition, being a frequent
starting-point in the production of prolapse of the uterus, it is es-
sential to remedy this defect whenever it is found to exist. This
must be done in the ordinary way, by paring the edges, and bring-
Dunoan's Stem and Disk
Pessary.
82 DISPLACEMENTS OF THE UTERUS.
ing them together by means of sutures, so as to obtain adhesion
between the freshened surfaces, care being taken to restore, as far
as possible, the perineal body. This alone mil not always be suffi-
cient to effect a permanent cure, as the perineum will again dilate
if the uterus be allowed to press downwards. A Hodge's, or other
appropriate pessary, will still be needed, and will now be retained,
where before it was readily expelled.
The integrity of the vagina being restored, and this being one of
the chief supports of the uterus, the tendency to prolapse is there-
by lessened, but time will be needed to remove other factors that
may have been present, as tending to produce prolapse or have arisen
in consequence. Restoration of the perineum may prevent the
complete expulsion of the uterus externally, but does not sustain
the uterus in situ. It is important to bear this in mind, otherwise
disappo-intment will ensue. The operation of perineorrhaphy can
hardly be regarded as a radical method of cure, or even a perma-
nent one. It should be undertaken more with the view of facili-
tating treatment, by enabling the vagina to retain a properly ad-
justed pessary, which will keep the uterus suspended at its normal
level, and thus favor reduction of bulk, and enable the ligaments
to recover their tone to a great extent.
IS'umerous operations, haN-ing for their object the narrowing or
constriction of the vaginal canal, have been resorted to by various
operators. Sims and Emmet adopt the plan of anterior colpoiThaphy
or elytrorrhaphy , of narrowing the anterior wall of the vagina, by
removing a triangular portion of mucous membrane near the cer-
^nx, so as to strengthen or brace up the vagina near the junction of
the cervix uteri with the bladder. Sims removes a Y-shaped por-
tion by means of curved scissors, and then brings the edges to-
gether by silver sutures, the cervix fitting into the pouch thus
formed above.
Emmet closes the pouch by running a denuded strip, as a base to
the triangle, across in front of the cervix uteri. Owdng to the diffi-
culties experienced in completing this operation, he has since sim-
plified it by denuding two surfaces, about half an inch square, on
either side of the cervix, and a little behind the line of its anterior
lip, then removing a strip from the vaginal surface, in front of the
uterus, about one inch long by half an inch wide, and bringing
together these three points, with the effect of forming a fold in
front of the cervix. Schroeder freshens an oval portion, and se-
cures adhesion by alternately deep and^ superficial sutures.
Huguier's operation consists in removing the whole of the cervix,
and a portion even of the body of the uterus, by incision, slanting
from without inwards, as well as the upper extremity of the vagina.
It is a very formidable operation, and apparently is contra-indi-
cated, according to Huguier, in the very cases which most demand
relief.
The operation of j^osterior colporrkaphy or removal of a more or
less considerable portion of the posterior wall, with the object of
CHOICE OF OPERATION. 83
thus contracting the vagina, has been advocated by Simon, Baker
Brown, Hegar, and others.
Simon freshens a pentagonal surface, two and a quarter inches
wide at the vaginal outlet, the posterior halves of the labia majora
being included, the incision extending two and a quarter inches up
i the vagina, narrowing slightly towards the upper extremity, which
is completed by two incisions meeting above at a very obtuse angle.
The opposite edges of the wound are then brought together by alter-
nate deep and superficial silk sutures. By the junction of the labia
.majora, the perineum is greatly lengthened, and additional support
Tthus obtained. A pouch is thus formed in which the cervix rests,
I opposing a firm barrier to the exit of the uterus at the point toward
^ which that organ naturally gravitates, the vagina being made
narrower and more rigid. A perfect and permanent cure is thus
effected, union taking place throughout the whole extent, a firm,
dense, cicatricial band being obtained, running almost the whole
length of the posterior vaginal wall.
Hegar narrows the vagina by the removal of a Y-shaped piece of
i mucous membrane from the posterior vaginal wall, the apex being
' carried up nearly to the cervix, the base ending at the vulva, which
it includes, as in the operation for ruptured perineum, thus narrow^-
ing the vagina, and making a firm perineum.
Where there is marked hypertrophic elongation of the cer\dx, it
will be necessary to remove a portion of this by means of amputation ;
i at the same time remove a triangular piece of the mucous membrane
just in front of the cervix, the base of the triangle merging in the stump
of the cervix, and bring the sides of the triangle together by sutures.
The operation of JEpisiorrhaphy (iitiasm, the labium, and pdcpri,
suture), or closure of the vaginal outlet by uniting the posterior
three-fourths of the labia majora, has been practised in cases of
elderly w^omen, w^here patency of the vagina is no longer necessary.
The edges of the labia majora are pared, the labia minora removed,
and the vivified surfaces united by silver sutures.
Le Fort recommended making a longitudinal septum by uniting
the anterior with the posterior vaginal wall, thus producing an arti-
ficial duplex vagina.
Choice of operation. — This will depend materially on the nature
of the individual case. Before resorting to any plastic operation,
it is always advisable to enjoin rest in the recumbent posture, the
foot of the bed being elevated, or the genu-pectoral position as-
sumed from time to time, in order to diminish the bulk of the
uterus, allow^ any ulceration of its surface to heal, and ensure a
healthier condition of the vagina. If the perineum be ruptured,
the perineal body should first be restored before any further opera-
tion be performed. K the cervix be elongated, it will be w^ell to
remove a portion of this at the same time that some plastic opera-
tion be done. If the uterus be prolapsed without marked elonga-
tion of the cervix, rupture of the perineum, or e\4dent rectocele
dragging down the uterus, the better plan is to perform anterior
colporrhaphy, after the manner of Sims or Emmet.
84 DISPLACEMENTS OF THE UTERUS.
If rectocele exist to any great extent, or the perineum be much
dilated or ruptured, posterior colporrhaphy, together with perineor-
rhaphy, will be indicated.
If there be a combination of these several conditions, it may be
necessary to perform more than one operation at successive inter-
vals.
Various devices have been tried to procure contraction of the
vagina without resorting to incisions, by means of the actual cau-
tery, mineral acids, escharotics, ulceration created by galvanic
pessaries, and sloughing produced by pressure by forceps and
clamps. They have the disadvantages of proving excessively pain-
ful, more tedious and uncertain in their results, as well as being
more unmanageable, and are therefore not to be recommended.
ANTEVERSION OF THE UTERUS.
85
CHAPTER V.
DISPLACEMENTS OF THE UTERUS — Continued.
Anteversion and Anteflexion.
Anteversion of the TTterus. — The normal position of the uterus
(Corresponds with the axis of the pelvic brim,^and is therefore one
• of anteversion. This is represented by a line *drawn from the um-
bilicus to the coccyx. The uterus occupies as near as possible
the centre of the upper part of the pelvic cavity, being suspended
between the rectum and the bladder, about midway betw^een the
symphysis pubis and the sacrum. It will thus be readily under-
stood that the position of the uterus may vary considerably, depend-
ing upon the distention of either of these hollow viscera, and
whether the patient be lying down or standing up. It is only
Fig. 50.
The degrees of Retroversion and Anteversion (after Galabin). The dotted outlines show
the various stages of Retroversion ; the plain outlines those of Anteversion.
when the axis of the uterus is persistently altered from its normal
direction, the fundus falling forwards, that the condition becomes
pathological, and is spoken of as anteversion. It very rarely
happens that the angle of deviation exceeds that of a right angle,
or 90°; the symphysis pubis generally prevents any further dis-
placement of the fundus forwards, whereas retroversion, in extreme
cases, may amount to as much as double this, or an angle of 180°
(Fig. 50). In some extreme cases the fundus may fall behind the
pubes almost parallel with the axis of the vagina.
Causation. — Any condition tending to increase the weight of the
86 DISPLACEMENTS OF THE UTJjRUS.
uterus, such as congestion, early pregnancy, the presence of a fibroid
tumor in the wall of the uterus, areolar hyperplasia of the body of
the uterus, or subinvolution, may produce anteversion.
Any excessive intra-abdominal pressure, when the uterus is re-
tained at its normal level, may lead to this, displacement, such as
violent muscular efforts, tight-lacing, wearing hea^^ clothing, the
pressure of abdominal tumors, and other similar conditions.
The presence of cystocele not only deprives the uterus of sup-
port in front, but also tends to produce anteversion by the traction
exerted when the prolapsed pouch of the bladder becomes distended
with urine. Excessive inclination of the pehas disposes to ante-
version. Coitus itself may produce the displacement in those cases
where the vaginal portion of the cervix is driven backwards and
upwards.
Symptoms. — ^But little inconvenience may be occasioned by a
moderate degree of anteversion. Where, however, the uterus is
enlarged, and the displacement well-marked, the uterus lying hori-
zontally across the pelvis, the functions of the bladder and rectum
become interfered with. Frequent desire to pass water without
any feeling of relief afterwards, dysuria and even retention, are
prominent symptoms. These would probably be more often noticed
were it not for the fundus falling obliquely over to one or other
side, and thus avoiding the neck of the bladder.
The cervix pressing against the posterior vaginal wall, dysmenor-
rhoea and sterility are induced. Pressure on the rectum tends to
produce irritability of the bowel, constipation, diarrhoea, tenesmus,
or pain on defsecation.
Leucorrhoea, menorrhagia, dysmenorrhcea, and dyspareunia are
generally marked symptoms. Discomfort on standing or walking,
or even inability to get about, is occasionally witnessed, but not so
often as in cases of retroversion.
Diagnosis — Examination per vaginam detects the os uteri facing
backwards, high up in the hollow of the sacrum, occasionally so
high as to be reached with difficulty. The body of the uterus is
found lying across the pelvis in the antero-posterior diameter, the
fundus of the uterus resting on the symphysis pubis.
On conjoined manipulation the fundus is not discovered in its
normal position, but immediately behind the pubes, occasionally
below the level of this. The uterus can generally be felt to move
between the two hands. Rectal touch makes the position of the
cervix still more evident, especially if the bimanual method be
employed. The use of the sound is seldom requisite either for
diagnosis or treatment. It should never be employed where there
is a possibility of pregnancy being the cause of the anteversion.
The only cases where its employment is indicated are those where
it is desirable to ascertain the exact size of the uterus or to deter-
mine the presence of a small fibroid tumor. There is no other
condition likely to be mistaken for anteversion if an ordinary
amount of care be taken.
Treatment — It is comparatively seldom that well-marked ante-
anTeversion. 87
version, giving rise to troublesome symptoms, and necessitating
treatment, occurs, unless there be some morbid condition of the
uterus, such as subinvolution, hyperplasia, or the presence of a
small fibroid.
Our first efforts then should be directed towards obviating the
cause that led to the displacement.
The same preliminary treatment as indicated when speaking of
retroversion, such as leeching, scarifying, hot-water vaginal injec-
tions, glycerin plugs, etc., should first be carried out, the patient
meanwhile reclining in the dorsal position, and being instructed to
hold her water for as long an interval as possible, so as to allow
the hydrostatic pressure exerted by the distended bladder to press
the fundus backwards.
If the external os uteri be small, and the uterus much congested,
advantage will be gained by resorting to bilateral incision of the
cervix. The depletion lessens the congestion, and the more patent
orifice allows a more ready exit to the secretions, and thus lessens
the tendency to future engorgements.
All abdominal pressure should be removed as far as practicable.
If the abdominal walls be lax or the abdomen pendulous, much
good will be derived by a carefully applied abdominal belt, with a
pubic pad. This pushes the fundus backwards, and at the same
time takes off* the superincumbent weight of the intestines. All
compression of the thorax by tight-lacing, or dragging of heavy
clothing, should be avoided. Pessaries, or hysterophores, for the
support of the displaced fundus, are far more difficult to adjust in
the case of ante- than of retroversion. The natural tendency is
for the anterior or upper limb to slip behind the cervix. Even
when an anteversion pessary remains in situ, it often produces in-
jury to the base of the bladder, and is seldom tolerated as well as
a retroversion pessary. For this reason it will need to be very
carefully watched at first. A patient should never be allow^ed to
go away from observation wearing an instrument, unless she has
been previously instructed how^ to withdraw it, which should be
done at once on the occurrence of the least discomfort. In any
case it will be prudent to rest up for a few days and avoid all exer-
tion, or risk of injury from coitus. Frequent examinations should
be made to see that no injury results from undue pressure, and that
the pessary does not become displaced.
Mere elevation of the uterus by means of an ordinary Hodge's
pessary wall sometimes afford marked relief, though it does not in
any w^ay lessen the anteversion.
]!^umerous instruments have been devised for the cure of ante-
version, some acting on the principle of pushing up the fundus
through the anterior vaginal wall, which being arched is thus short-
ened, and so brings into play another principle, drawing the cervix
forward by pulling upon the vaginal portion, the uterus being re-
garded as a lever which rotates upon its axis of suspension.
Graily Hewitt's Ch^adle Pessary (Fig. 51) answ^ers very well in many
cases. The large ring rests posteriorly, and thus gives the pressure
88
DISPLACEMENTS OF THE UTERUS.
Fig. 52.
on the uterus higher and more anteriorly than when the crutch-
shaped portion of the instrument rests in front, as dehneated in
the third edition of his work.
Fig. 52 represents the pessary in position. Of late a cross-har
has been added to the instrument, which prevents the cervix being
caught between the two projecting arms of the
Fig. 51. instrument, and makes its use more tolerable
^^^^ in certain cases. Undue compression of the
f^f^k cer^dx may occasion troublesome sickness. To
M V ^k introduce the instrument, pass the larger ring
^f ^^l ^(ak in somewhat obliquely, pushing it inwards and
^^^^f^^^^^k backwards a short distance ; pressure is then
^B^^^^l^ made on the middle saddle of the instrument,
Graiiy Hewitt's Cradle which thus passcs close Under the mcatus uri-
Peseary. narius, and shoots into its place. The lower
end is then gently pushed a little upwards,
and the operation is completed. The upright projecting saddle
part must look upwards and forwards. The combined use of the
sound and the cradle pessary is to be recom-
mended in the majority of chronic cases.
Thomas's Anteversion Pessary (Fig. 53) con-
sists of a Hodge's pessary, to the anterior
aspect of which a movable horseshoe lever
is attached. This, when left to itself, rises
at an angle to the Hodge, and presses up in
the anterior cul-de-sac in front of the cervix.
To introduce it, press the two curved ends
together and pass them into the vagina in
the same way as an ordinary Hodge. The
ends being carried as far as, and just under
the cervix, the anterior arm or bow is thrown
forward by the index-finger; the cervix falls
behind it, the fundus upon it, the posterior
bow going behind the cervix.
It requires some little practice to insert it properly. One great
advantage of this instrument is that the patient can readily remove
it by hooking the finger in the lower end and drawing it down,
when the bow flaps back of itself against the base of the pessary.
The practitioner should be careful to select one where^ the movable
bow closes up to the upper and not to the lower limb, otherwise,
though it may be easy of introduction, it will be difi3.cult to remove
it. Another form of this is Fig. 54.
Galahin's Anteversion Pessary (Fig. 55) has been " devised with
the object of extending to the treatment of anteversion and of cor-
poreal anteflexion the principle of leverage which is so useful in
posterior displacements.
" The instrument resembles a thick Hodge's pessary, with its
anterior lipib replaced by a broad arch directed upwards, and
nearly square at its summit.
" By its shape alone, without any leverage, it elevates the ante-
Cradle Pessary in situ.
ANTEVERSION PESSARIES. 89
rior vaginal wall in considerable degree, but it will be found in
practice that the lower corners do not lie against the posterior
vaginal wall, but the whole of the anterior extremity is tilted
somewhat upwards in consequence of the tension of the posterior
cul-de-sac.
" In introducing the instrument, it is first passed entirely within
the vulva, with the upper limb in front of the cervix; the index-
finger is then passed through it and hooks the upper limb back-
ward over the cervix and into the posterior cul-de-sac. It is with-
drawn by hooking the index-finger over one of the lower angles,
and making traction upon that. Since it occupies a higher posi-
FiG. 53. Fig. 54. Fig. 55.
Thomas's Anteversion Thomas's Hinged Galabin's Anteversion
Pessary. Pessary. Pessary.
tion in the vagina than even a Hodge's pessary, it can be worn
without discomfort by married women. It is not suitable for vir-
gins, or cases in which the vaginal outlet is narrow."
Where an internal pessary cannot be tolerated, where antever-
sion is combined with partial prolapse, where married women ob-
ject to the wearing of a pessary constantly, or where sustaining the
uterus in its normal position requires more force than is prudent,
the fundus may be elevated by means of a Cutter's pessary. The
vaginal portion having a more considerable curve, with the con-
cavity forwards, than the retroflexion pessary, allows the summit
to rest in front of the cer^dx.
The patient, when properly instructed, can remove it at bedtime,
and replace it before rising in the morning. When the parts are
so sensitive that the hard bulb causes pain, an india-rubber cushion
or piece of sponge may be afiixed to the extremity, until the parts
become less sensitive, or until a pouch has been formed in front of
the cervix which will allow an internal support to be adjusted.
We should not rely merely upon mechanical treatment alone.
Having relieved any local congestion or inflammation by appro-
priate measures, any granular degeneration of the cervical canal
should be treated by the application of carbolic acid, nitrate of
silver, iodine, or other agent. The general health should be looked
to — tonics, such as iron and quinine, strychnia, or cinchona with
90
DISPLACEMENTS OF THE UTERUS.
acids, prescribed ; vaginal injections, astringent or simple, employed.
The patient should on no account be confined to bed, or even to
the couch, for any length of time, but encouraged to take regular
daily outdoor exercise, either driving or short walks. In some
cases the iodide of potassium or of iron internally, together with
iodized cotton or tampons Siiturated with glycerin and iodine in-
serted up to the cervix uteri, have a beneficial action in reducing
the bulk of the uterus.
Anteflexion of the Uterus,
This consists in bending of the body of the uterus at an angle
to the cervix, the conca^'ity being forwards. The normal condition
of the uterus is one of slight anterior curvature, scarcely amount-
ing to flexion. When this, however, is exaggerated to the extent
of 15° or 20° it becomes pathological.
It may seem to some an unnecessary refinement to speak of thi\ v
Fig. 56.
Anteflexion of Uterns.
different varieties of flexion, but inasmuch as the treatment varies
somewhat, depending upon the exact nature of the flexion, it will
be well to adhere to the varieties mentioned by Thomas. These
are:
1. Corporeal flexion, where the body is flexed, the cervix main-
taining its normal position (Fig. 57).
2. Cervical flexion, where the cervix is flexed, the body remain-
ing in the normal direction (Fig. 58).
3. Cervico-corporeal, where both body and cervix are flexed for-
wards (Fig. 59).
ANTEFLEXION.
91
:\. rare form of anteflexion occurs occasionally, when the cervix
is flexed forwards and the body of the uterus backwards on its
central axis.
- Causation. — Flexions may be primary or congenital, or secondary
or acquired. During early childhood the uterus is naturally more
anteflexed than is the case in the adult. Should this condition
persist or become exaggerated after puberty the condition becomes
pathological. Ordinarily, the walls of the uterus about the time
of puberty become thicker, denser, and consequently stronger. If
the development take place symmetrically, an equilibrium is es-
tablished between the two walls, the uterus straightens itself, its
anterior concavity disappears. But if the posterior wall develop
more rapidly than the anterior wall, appropriating, as it were, an
excess of nutrition, the congenital curve not only persists, but be-
comes exaggerated, the anterior wall undergoing a certain amount
of atrophy, and so increasing the already existing disproportion.
Congenital anteflexion is of much more frequent occurrence than
cons^enital retroflexion.
We generally find in these cases of congenital anteflexion that
the anterior lip of the cervix is shorter than normal; the uterus
Fig. 57.
Fia. 58.
Fig. 59.
Corporeal Flexion.
Ceryioal Flexion.
Cervico-corporeal Flexion.
itself ill-developed, small; the cervix conical, and the external os
also small.
In many cases there is evidence of imperfect development of the
ovaries, and even of the bony pelvis itself. The vagina is often
small, the anterior w^all short — the whole sexual apparatus defec-
tive, often associated with entire absence of sexual feeling.
Secondary or acquired anteflexion frequently occurs from un-
usual softness of the uterine tissues, such as met with in delicate,
ill-nourished girls about the time of puberty. Tight-lacing, the
suspension of heavy skirts from the loins, and other improprieties
in dress, tend to force the intestines downwards and backwards.
These pressing upon the posterior wall of the uterus carry the
fundus downwards and forwards, anteversion and subsequently
anteflexion occurring in consequence. Endometritis may produce
92 DISPLACEMENTS OF THE UTERUS.
flexion by creating an inward growth of the utricular glands into
the submucous connective tissue near the os internum. This in
consequence undergoes atrophy and enfeeblement, or the cervical
glands, undergoing cystic degeneration, burst, and thereby cause
a collapse of tissue in the formerly dense framework of the uterus,
leaving in its place a flaccid net-like areolar tissue incapable of
sustaining the organ in its normal position. A small fibroid de-
veloping in the wall of the fundus may cause flexion. Contraction
of the utera-sacral ligaments from antecedent pelvic peritonitis or
cellulitis may produce flexion by dragging the uterus backwards
at its angle of suspension.
Habitual constipation from atony of the muscular coat of the
intestine, associated as it frequently is with defective nutrition of
the tissues generally, and softening of the uterine walls, is not
infrequently productive of flexion.
In some cases, doubtless, anteflexion may be more or less sud-
denly produced from falls and other accidents, but in the large
majority of instances the displacement is gradual. It may happen
that anteversion passes by slow degrees into one of flexion.
It is comparatively rarely that we witness extreme cases of cer-
vico-corporeal anteflexion, where the fundus is bent completely
down upon the cervix, so that it is impossible even for the finger to
pass into the angle of flexion, the uterus being simply doubled up.
" In cases of corporeal flexion the uterus is often high up in the
pelvis, while in that of cervical form it is almost invariably low
down. The cervical and cervico-corporeal varieties preponderate
in frequency over the corporeal form in nulliparous women, this
latter condition being generally met with in multiparous women."
(Thomas).
The angle of flexion is generally most acute at the internal os,
the cervical canal being flattened, and therefore obstructed, in
cases of acquired anteflexion, whereas in primary or congenital
anteflexion the curve is generally more uniform, omng to the
tissue of the uterus being firmer, so that the cervical canal is less
flattened, and consequently there is less obstruction to the passage
of the secretions, although there may be difficulty in passing the
uterine sound. As soon as flexion becomes marked, the circular
tion in the uterus becomes impeded. " The incompressible arteries
still carry blood to the body, but the compressible veins fail to
return it to the general circulation, and the consequences are con-
gestion, oedema, and in time hjqDergenesis of tissue."
Symi^toms. — Primary or congenital anteflexion is not infrequently
associated with amenorrhoea, or with such scanty menstruation
that symptoms of dysmenorrhoea are not produced. Where, how-
ever, the flexion is acute and the menstrual flow profuse, dys-
menorrhoea is often one of the most distressing evidences of the
displacement. It is usually synchronous with the first appearance
of the catamenia, gradually increasing in severity with each suc-
cessive period, as the uterus becomes more congested from the
obstruction to the circulation. Patients who have experienced but
ANTEFLEXION. 93
little inconvenience during their maiden career, after marriage
often suffer severely at their periods, partly from the hypersemia,
the result of increased functional activity, and partly from a certain
amount of inflammatory mischief being set up from mechanical
violence, owing to the shortness of the vagina. The menstrual fluid
being also increased in quantity after marriage, clotting of it is more
liable to occur, and obstruction to its exit thereby increased, not
only from the bending of the cervical canal but also from the fact
of the smallness of the external os. In some instances this coagula-
tion of the menstrual fluid leads to more or less perfect occlusion
of the cervical canal, a clot becomes impacted, which effectually
prevents the further exit of fluid, or coagulation may take place
behind the seat of flexion, which, as we have seen, is generally at
the internal os. The body of the uterus thus becomes gradually
distended with the constantly increasing accumulation of fluid,
giving rise to severe uterine tenesmus, often accompanied by most
distressing nausea and even syncope and symptoms of collapse,
the patient rolling in agony upon the floor. With the increasing
distention of the body of the uterus, the axis of this latter grad-
ually rises until it becomes more in a direct line w^ith the axis of
the cer\dcal canal. A gush of pent-up menstrual fluid then occurs
with marked relief to the patient, the fundus again falls forward,
and another accumulation of fluid goes on witln similar symptoms
and a like ending. This may be repeated on and off* for several
days. Such patients often describe the flow as intermittent. They
sufler considerably before it commences, then gain sudden relief
as ^' the flow comes on all of a rush." This ceases, almost or alto-
gether, for a day or so, and then comes on again suddenly and often
unexpectedly. In some cases patients describe their periods as
being horribly offensive, so much so that they are ashamed to go
into society at those times. This almost invariably results from
acute flexion, more commonly ante- than retroflexion.
In rare instances we meet with septic metritis or peritonitis as
a consequence on the one hand of retention and decomposition of
the menstrual fluid, on the other from reflux through the Fallo-
pian tubes of some of the fluid into the peritoneal cavity. There
is little doubt but that many severe cases of so-called dysmenor-
rhoea, attended by feverish symptoms, are really due to limited
pelvic peritonitis, the result of effusion of menstrual fluid into the
peritoneal cavity occurring in consequence of acute anteflexion.
Apart, however, from dysmenorrhcea, patients complain of pain
in the hypogastrium, with frequent desire to pass water ; aching
in the groins ; pain on standing or walking, often so distressing
as to compel them to keep mainly to the couch or bed ; a sense of
depression or sinking at the epigastrium, with more or less de-
spondency ; neuralgia and other nervous symptoms. Leucorrhoea
is generally present.
In married patients, in addition to these symptoms, there is dys-
pareunia; occasionally menorrhagia, though not nearly so fre-
94 DISPLACEMENTS OF THE UTERUS.
quently as in retroflexion ; sterility as a rule, though if conception
occur, abortion is not infrequent.
Diagnosis. — On inserting the finger into the vagina, if the case
be one of corporeal anteflexion, the cervix will be found much in
its normal position. On pressing the finger upwards in the an-
terior cul-de-sac, the fundus uteri will be felt almost on a level
with the OS. On conjoined manipulation the fundus can often be
pressed down still more on to the examining finger, and felt to
move conjointly with the cer^dx, the angle of flexion being readily
felt. In case of cervical anteflexion, the os uteri is found looking
forwards, the cervix directed backwards, as in an ordinary case of
retroversion. On conjoined manipulation the fundus, however, is
detected in its normal position, and not pressing on the rectum, as
is the case in retroversion.
In cervico-corporeal anteflexion, the cervix is directed back-
wards as in the last case ; but the fundus is flexed and can often
be felt in front on conjoined manipulation. The angle of flexion
is often so acute that it is impossible to insert the finger between
the fundus and the cervix. Impulse is communicated directly
from the external hand to the finger behind the cervix, the double
thickness of the ftmdus and cervix being felt between. In order
to determine whether the rounded solid body in front of the cervix
be the fundus uteri or a small fibroid of the anterior wall, the
uterine sound, curved in accordance with the apparent amount of
flexion, should be gently inserted, with its concavity directed back-
wards or forwards, as may be found most convenient, depending
upon the direction of the cervix, as far as the internal os. Having
reached this point, the handle of the sound is then made to describe
a large semicircle, if it have been passed thus far with the con-
cavity backsvards, as will be most convenient where the cervix is
flexed, so that the point is directed forwards. Pressing the handle
well back towards the perineum, and, if possible, pushing up the
fundus by the finger in the vagina, the sound is then passed be-
yond the internal os by gently pulling first upon the angle of
flexion, and then pushing the point of the sound until it at length
enters the cavity of the body of the uterus. Having eftected this,
the handle is then brought forwards so as to elevate the fundus.
If, on examination now, the round solid body that was previously
felt low down in front of the cervix has disappeared, and can be
felt by the hand pressed in above the symphysis pubis resting on
the point of the sound, we may be pretty certain that the case is
one of anteflexion, and not of fibroid. By moving the sound
gently in various directions we can also gain information as to the
mobility, sensitiveness, bulk, shape, and relations of the uterus.
In case of fibroid of the anterior wall the sound will probably
pass in the normal direction, behind the tumor. The finger in the
vagina will then be able to detect the increased thickness due to
the fibroid, the hardness, irregularity, want of symmetry, and
increased bulk of the uterus. Bimanual examination will still
further assist us in coming to a conclusion. Other conditions oc-
ANTEFLEXION.
95
Fig. 60.
casionally simulating anteflexion are pregnancy, cellulitis, haemato-
cele, tumors, or calculi in the bladder. In case of pregnancy, the
liistory, softening of the cervix, increased bulk of the fundus, and
disappearance of the tumor in front of the cervix when the patient
is placed in the dorsal position, will generally enable us to dis-
tinguish it. If any doubt exist, it will be better to wait until the
evidence is more distinct. The uterine sound should on no account
be passed.
Swellings due to cellulitis or haematocele are generally fixed,
irregular in outline, and have some special history. Tumor or
calculus in the bladder would be recognized by
passing the bladder-sound and feeling the mass
between the sound and the finger in the vagina.
[If necessary, the urethra might be rapidly di-
lated and the finger passed into the bladder.
The uterine sound, in the three last-mentioned
conditions, passed into the uterus, will gen-
erally clear up the diagnosis.
Treatment. — The cure of anteflexions is one
demanding much patience, perseverance, skill,
and experience. S'ot only will each individual
case require some special plan of treatment,
but what may seem to be the same identical
condition in two different patients will often
require essentially dififerent management. A
congenitally anteflexed uterus, where the organ
lis only moderately developed but extremely
frigid, may require more active and prolonged treatment than an
acquired flexion, where the uterus is softer, bulkier, more con-
gested, or more prone to inflammatory mischief
Corporeal anteflexion may often be remedied by measures quite
unfitted for treating a case of cervical flexion. It may be well
here to mention that it is not every case of anteflexion that neces-
sitates active treatment. Only such cases should be dealt with
where the symptoms are plainly referable to the existing displace-
ment. Under any circumstances we must first determine by ten-
tative measures, such as passing the uterine sound, whether the
uterus will tolerate interference, and not think of passing an intra-
! uterine stem until we have previously ascertained the probability
y of its presence being tolerated.
If any peri-uterine inflammation exist at the time of observation,
•or there is a history of such a condition having previously oc-
curred, we should be extremely careful how we proceed, lest in
our endeavor to overcome one evil we set iip a greater, or rekindle
into activity an inflammatory process that would otherwise have
ultimately died out. The mere passage of the uterine sound has
not infrequently given rise to an attack of pelvic peritonitis which
has proved fatal. We should therefore endeavor carefully to esti-
mate not only the position of the uterus as regards flexion, but also
its condition in regard to congestion, inflammation, adhesions, etc.,
Fibroid in Anterior
Wall of the Uterus simu-
lating Anteflexion.
96 DISPLACEMENTS OF THE UTERUS.
as well as the condition of the ovaries, the presence of any sur-
rounding tumefaction, or other condition likely to influence our
treatment of the case. A patient who has been more or less con-
fined to the couch, unable to take exercise, whose appetite is im-
paired, and general health much deteriorated, in consequence of a
long-standing flexion of the uterus, will probably bear treatment
far worse than another in whom the anteflexion has been acci-
dentally discovered when examining to ascertain the cause of ster-
ility, where there has been almost an entire absence of symptoms
due to the flexion itself, beyond the sterility for which we are
consulted.
In cases of primary or congenital corporeal anteflexion, and in
acquired flexions of long standing, where the uterus is more or less
rigid, we may first try what the occasional passage of the uterine
sound will accomplish. The best time to commence treatment is
shortly after menstrual period, within a few days. The sound
having been passed into the cervix as far as it will go without diffi-
culty, generally to the internal os, the point is gently insinuated
beyond the angle of flexion by pressing the handle of the sound
well back towards the sacrum, and alternately pulling and pushing
the point over the seat of obstruction. Having succeeded in pass-
ing the point of the sound as far as the fundus, if much pain bo
thereby produced, it will be well to refrain from doing more than
allowing the sound to remain in for a minute or two, and then
withdrawing it. Should, however, its presence cause little or no
inconvenience, the handle of the sound may be carried forward,
the finger in the vagina pressing up at the same time the anterior
cul-de-sac, so as to elevate the fundus uteri. By rotating the han-
dle of the sound by a tour de mmtre, and then bringing it again for-
ward, the fundus may be held back for a short time in a position
of slight retroflexion. This movement may be assisted by the
hand pressing externally on the abdomen just above the pubes.
If no marked inconvenience arise, the passage of the sound may
be repeated at intervals of three or four days, to within a week of
the expected return of the catamenia. Should the pain usually
experienced at this period be much lessened, the occasional passage
of the sound about once a week, for a short time, although it will
not cure the anteflexion, will often prove sufficient to relieve urgent
symptoms. If it be deemed expedient to attempt more, we may
proceed to dilate the cervical canal by means of graduated bougies,
increasing the size each time, until a ^N'o. 10 or 12 will pass readily.
This will have the eflfect of stimulating the development of the
uterus, at the same time overcoming the constriction at the inter-
nal OS.
Chalybeate tonics, such as the citrate of quinine and iron with
strychnia; a pill containing phosphorus, iron, and nux vomica, or
other suitable form; should at the same time be given, so as to im-
prove the tone of the general health.
Another method of accomplishing the same object is, by insert-
ing a small laminaria tent within the canal of the uterus, and
ANTEVERSION PESSARY. 97
illowing it to remain in for eight or ten hours. This produces
•softening of the wall of the uterus, straightens out the flexion, and
stimulates the development of the uterus. It is, however, not un-
ittended by risk, and should never be resorted to until we have
previously ascertained whether the uterus is tolerant of interfer-
ence. The safest time to attempt it is a week or so after the men-
strual period. The better plan is to pass the tent between the
iiours of 9 and 11 a.m., the patient remaining in bed. The tent
should then be withdrawn between 6 and 9 p.m. A morphia sup-
pository may be employed if much nausea or pain be produced.
The following day the patient should be confined to the couch
until the uterus has had time to contract again. She should keep
lying on the back, and allow the bladder to remain distended as
much as possible. If no inconvenience arise, the patient may re-
sume her ordinary duties after this. The same process may be re-
peated again in ten days' or a fortnight's time. It is not a prudent
plan to insert a tent whilst in the consulting-room, and then allow
the patient to return home. It should invariably be done at her
residence when she is in bed.
In single women the dysmenorrhcea, irritability of the bladder,
and other symptoms are often thereby much improved, and in
the case of married women, impregnation not infrequently takes
place.
Galabin's, Thomas's, Hewitt's, or other appropriate form of An-
teversion Pessary may be inserted into the vagina with a view of
supplementing the other measures adopted for straightening out
the, uterus, but as a rule they only tend to cause the uterus to re-
volve upon its axis of suspension, and do not succeed in straighten-
ing out the flexion. It is difficult to exert any power upon the
displaced fundus, and there are no natural forces called into
play tending to accomplish this object, as in the case of retro-
flexion.
A Hodge's pessary is here as a rule of little avail, since the upper
limb naturally inclines to the posterior cul-de-sac of the vagina. In
some instances, in virgins, where the vaginal canal is small, it is
possible to adjust a Hodge so that the upper limb rests on the an-
terior cul-de-sac, the fundus resting upon the end, the cervix pass-
ing through the instrument, the lower limb lying parallel with the
posterior wall of the vagina. A long, narrow pessary, well curved
at its upper extremity, should be selected. Hewitt's Cradle Pes-
sary (Fig. 51), according to the author, answers the purpose per-
fectly of supporting the uterus in the state of rest required.
Dr. Fancourt Barnes has devised an ingenious combination of
Dr. Graily Hewitt's Cradle Pessary, with the ordinary Hodge's
pessary as used in retroflexion and retroversion of the uterus (Fig.
62). The cradle portion is capable of limited movement, being
attached to the Hodge's portion by watch-springs. The pessary
is introduced and placed in situ in the same way as in a Hodge's
pessary. The advantages claimed are that the Hodge portion
forms a ^rm point d' apimi for the cradle portion — which when used
7
98 DISPLACEMENTS OF THE UTERUS.
alone often Leeomes displaced — and that the cradle portion i
unable to become displaced behind the os uteri.
Where it is found that the uterus does not resent interference,
and that the advantage gained by occasional dilatation of the cer-
vical canal is merely temporary, the dysmenorrhoea, or the steril-
ity, or both remaining uncured, we may try the effect of introduc-
FiG. 61.
Fig. 63.
India-rubber Stem
Anteflexion of Uterus, showing essary.
position of Hodge's Pessary.
ing a pliable india-rubber stem (Fig. 63). Those usually met with
are far too thick, the diameter of the stem should not exceed one-
sixth of an inch. They are made of white, red, and pure black
india-rubber. The black is the most durable, and should be
chosen by preference.
A bulging projection near the extremity assists in retaining
them in situ. Those having the shield perforated are to be pre-
ferred. Although soft, elastic, and easily bent while out of the
uterus, it becomes sufficiently firm when pressed equally on all
sides by the canal of the cervix to gradually overcome all flexions,
except in cases where the uterus is bound down to the surround-
ing parts. When the stem has been Avorn for some time, the en-
larged and firm uterus becomes greatly reduced in size, and so
soft as closely to resemble that organ in the early stage of subin-
volution, effects probably due to the freer exit of the secretions
and the mucous discharge, which usually persists during the re-
tention of the stem. It may be readily introduced on the end of
an ordinary uterine sound, a Playfair's probe, or other similar in-
strument, which by elongating the stem somewhat obliterates the
projection for the time being, and allows the stem to pass.
It is not necessary to dilate the cer^nx by a tent before introduc-
ing the stem, though the passage of a ^o. 8 sound will facilitate
its introduction. As a rule, it is quite self-retaining. Should there
be an}' tendency to slip out, a plug of cotton-wool saturated with
glycerin may be pressed up against the shield so as to keep the
stem in situ.
Where the vagina is very small, the elastic stem is passed with
far greater facility than any of the ordinary stems with a large
GALVANIC STEM PESSARIES.
99
Fig. 64.
solid shield, and owing to its bending slightly when in situ, it is
far less liable to be shot out, as not infrequently occurs with the
solid stem.
Galvanic Stem Pessaries (Fig. 64), consisting of alternate coils of
copper and zinc wire, so as to render the stem somewhat pliable,
are useful in many cases of flexion. They are
not so rigid as to counteract entirely the flex-
ion, but by setting up a kind of a chemical,
more than electrical stimulus, owing to the
constant slow production of chloride of zinc,
they tend to stimulate the development of the
uterus, increasing the menstrual flow as well as
the secretion of mucus.
To introduce one of these where the vagina
is small is often diflacult. Having previously
dilated the cervical canal sufl3.ciently by means
of graduated bougies, the patient lying in the
left lateral, or semi-prone position, the right
forefinger is introduced into the vagina. The
stem, supported on a tent-introducer, Playfair's
probe, or uterine sound, is then passed along-
side the finger until the disk impinges on the
perineum, the extremity of the stem is mean-
while guided into the os uteri by the finger.
AVhen this is effected, the finger is partially
withdrawn and made to press back the per-
ineum, so that the disk may pass the vulval
outlet, when, if the point had previously been
directed into the os, the stem can then be passed along the cervical
canal, until the disk approaches the cervix. The finger in the
vagina, pressing up the fundus uteri in the an-
terior cul-de-sac, will assist the introduction of
the stem. If much difiiculty be experienced
in passing the disk into the vagina, as not in-
frequently happens, it may be necessary to em-
ploy a small Sims's speculum to retract the per-
ineum and expose the os uteri, so that the stem
may be passed by sight instead of by touch.
The disk or bulb attached to these galvanic
stems is usually made far too large for practical
purposes. It may with advantage be lessened
considerably. Should the stem show any dis-
position to slip out, a tampon of cotton-wool
saturated in carbolized glycerin, or a small Hodge covered over
with thin india-rubber (Fig. 65), may be inserted into the vagina
so as to retain the stem in situ. Owing to the chemical action set
up in the stem by the secretions, it becomes corroded and rough-
ened, so that it is better to remove it every few weeks to see
that no mischief arises, and to avoid any risk of the stem beiHg
broken.
Barnes's Galvanic Stem
Pessary.
Fig. 65.
Pessary with perfo-
rated septum and spiral
wire between extremi-
ties.
100
DISPLACEMENTS OF THE UTERUS.
Fig. 68.
Galvanic stems are also made of alternate pieces of zinc and
copper in various forms, which are rigid. These are more liable
to produce mischief, unless closely watched. Peas-
lee's stem (Fig 66) is a good form to use.
Slightly curved vulcanite stems, hollow in the
centre, and perforated as in Fig. 67, with a shield
or disk at the lower end, are often of service where
a rigid stem is preferred to an elastic one. Its
length should be at least a quarter to half an inch
less than the length of the uterine canal as meas-
ured by the sound, so as not to impinge upon the
fundus. Wliere the flexion is acute or of long
standing, there is a great tendency for the stem
to be forced out beyond the angle of flexion, the
Fig. 67.
Fig. 66.
Peaslee's Stem Pessary.
Vulcanite Stem Pessary.
WW.
Wright's Intra
uterine Stem
Pessary.
upper part of the stem remaining in the cervical
canal. To obviate this, a plug of cotton-wool, as
previously directed, may be inserted, or a covered
Hodge as suggested by Dr. Wynn Williams.
AÂ¥here the uterus, however, is thrown into a posi-
tion of anteversion on the insertion of the stem,
the disk impinges on the posterior vaginal wall, and
is thus prevented from slipping. A perfectly straight
stem, whether of metal, vulcanite, or glass, should not as a rule be
employed, since the natural form of the uterus is slightly curved.
Expanding stems will sometimes be retained when the ordinary
straight stems are forced out. There are several varieties of these.
As good a one as any is Wright's (Fi^. 68), or Chambers's modifi-
cation of it in vulcanite. The expanding branches of the stem are
held together by the hollow cylinder of the introducer, which slides
over them during insertion. They spring open as soon as the in-
troducer is withdrawn, and thus make the stem self-retaining.
The disadvantage is that the diverging points tend to press on
the interior of the sides of the uterus, and so set up irritation, more
especially as the weight of the fundus is sustained on the two pro-
jecting points. Other expanding stems, consisting of a hollow stem
INTEA-UTERINE STEM. 101
^iwith diverging branches, are also employed. The great disad-
vantage of nearly all these is, that the diameter of the stem is
too large for the majority of the cases in which their employment
is necessitated.
In all cases where evidence of inflammatory mischief exists, this
-must be first remedied before thinking of resorting to any me-
chanical treatment. The application of a few leeches, puncture
with the scarifier, injections of hot water into the vagina, the appli-
cation of plugs of cotton- wool morning and evening, saturated with
glycerin or with glycerin and iodine, rest in bed for a few days,
saline aperients, and other appropriate remedies, must first be tried.
- The sound may then be passed, in order to ascertain whether the
- uterus will tolerate interference. If no severe pain or constitu-
tional disturbance ensue, the same measures may cautiously be
adopted as previously described. Commencing with the mere
passage of the sound, we may gradually proceed to restoring the
position of the fundus, dilating the canal by graduated bougies or
a laminaria tent, inserting an elastic, expanding, or vulcanite stem;
watchipg carefully lest any symptoms of mischief arise, desisting
from further treatment the moment there is any evidence of intol-
erance of it. Where there is a marked history of previous gonor-
rhceal infection, pelvic peritonitis, or cellulitis, we should, as a rule,
avoid resorting to mechanical interference.
After the introduction of an intra-uterine stem, it is better to
i keep the patient in bed for the first few days, and see her daily.
If any febrile symptoms occur, the stem should at once be with-
â– drawn. When these have subsided the stem may again be passed,
• but the patient must be carefully watched. She should always be
either within reach, or be able to withdraw the stem by a string
attached to it. It should, as a rule, be removed during the period
of menstruation, until we have ascertained that the uterus tolerates
' its presence without inflammatory mischief ensuing, when it may
' be allowed to remain in during the periods. In the case of married
patients it is well to avoid all risks by enjoining abstinence for a
time, at least, as well as prohibiting all unnecessary exertion of any
kind. There is always a certain amount of congestion, with in-
â– creased secretion, as long as the stem is worn. On its removal,
however, this soon subsides, and a process analogous to involution
takes place. Impregnation not infrequently occurs within a few
months. Even after parturition there is a great tendency for the
flexion to recur, which may need treatment before impregnation
again takes place. Flexions are generally of gradual production,
not sudden, as is the case often with versions, so that we must be
prepared to allow many months to elapse before expecting to
straighten the uterine axis by means of a stem.
In those cases where difficulty is experienced in retaining a stem
in situ, it may be necessary to resort to a combined intra-uterine
stem and a vaginal support ; but they should never be made in one
piece, otherwise the mobility of the uterus is seriously interfered
with, and the patient is exposed to danger from shocks. Still, cases
will be met with that test our ingenuity and tax our patience to
102
DISPLACEMENTS OF THE UTERUS.
Thomas's Anteflexion
Pessary.
the utmost, and, as these generally occur in patients determined to
be cured, we need to have no end of devices to overcome the diffi-
culties that beset us, and for this reason it may
^^^ ^!l_:. ^® ^^^^^ ^^ mention a few of those most calculated
^|Pi|fc to be of service.
iff m Thomas's Anteflexion Pessary (Fig. 69) consists
^T M of two parts : a stem of solid glass or vulcanite,
^l^pl^^^L tv\"0 to two and a half inches long, ending below
^^^^^^^1 in a rounded bulb. This being introduced into
^^^^â– ^^^X the uterus is supported by an ordinary anteflexion
^^^^^^^^^ pessary, between the branches of which a shallow
^H^^^^^ vulcanite cup has been fixed, with a small hole in
^St^^ it for drainage. The fundus is thus supported
partly by the pessary, and not entirely by the
intra-uterine stem.
If the flexion be acute, and the cervical canal contracted, a lami-
naria tent may first be employed to straighten and dilate the canal.
Fig 70 ^^^ Stem IS then inserted, and subsequently the
^ ' * pessary. The patient should remain in bed for
% three or four days, being watched carefully lest
% symptoms of irritation ensue. A small hole
% being drilled just above the shoulder of the
%^^^ stem, a silk thread is secured to the instrument,
^^i^^^m so that upon the first symptoms of mischief the
^^DtB^ patient can withdraw it by exercising traction
^â– ^^^^ upon the silk thread.
^^^1 The instrument should be removed during
ll menstruation, and also if pain, chilliness, or feel-
II ing of general languor or discomfort arise. The
i' patient should never be allowed to go beyond
the reach of help whilst wearing one of these.
Hewitt's Anteflexion Stem Pessary consists of an
intra-uterine stem, one and a half inches long,
which is retained in situ by means of an oval
disk of gutta-percha, similar in shape to a Hodge's
pessary, covered over one-half by india-rubber
sheeting. This disk is perforated so as to admit
the lower end of the stem. The two pieces are
introduced separately, and, as a rule, should not
be worn during the menstrual periods.
Wynn Williams's Stem Pessary is constructed
on the same principle : an intra-uterine stem
being supported on a Hodge, covered with a dia-
phragm of perforated india-rubber, the bulb
resting in a kind of socket or perforated cup
(Fig. 70). The stem is first passed into the
uterus on the end of a stilette or tent-introducer ;
the pessary, previously passed over the end of the rod, is then
guided up into its place, the end of the stem being fitted into the cup.
There are several varieties of these combined instruments, each
of which possesses different advantages as well as disadvantages.
Wynn Williams's
Stem Pessary and
Introducer.
ANTEFLEXION.
103
Fig. 71.
Cervical anteflexion will require a different plan of treatment to
that suggested for corporeal anteflexion.
The better plan is to incise the posterior wall of the cervix, from
the external os as far back almost as the junction of the vagina,
A, so as to make the axis of the uterine canal
almost continuous with the axis of the vagina
(Fig. 71). The posterior lip of the cervix is first
divided as far up as is prudent towards the vagi-
nal cul-de-sac. The point of the scissors moving
in the arc of a circle, a b, will thus leave a trian-
gular portion, a b c, to be divided by means of a
metrotome, ball and socket knife, or bistoury,
passed along a probe as a guide.
Apart from this advantage, this single incision
posteriorly is preferable to the bilateral incision,
as sometimes recommended, as the edges do not
gape or roll out so much after they have healed,
the flaps being kept sufficiently in contact by the
lateral walls of the vagina ; there is less risk of
haemorrhage proving troublesome, and there is
also less risk of cellulitis ensuing.
The operation should be performed either with
Kiichenmeister's scissors (Fig. 23), or with slightly curved, long-
handled scissors (Fig. 72), the cervix being steadied by means of a
tenaculum. A dossil of cotton-wool, steeped in liq. ferri perchl..
Fig. 72,
Lines of Incision
in Flexion of the
Cervix. (After Em-
met.)
is inserted between the lips of the incision, to arrest haemorrhage
and keep the edges separate, so that they may not unite by first
intention. The fundus vaginae is then packed with oakum or cot-
ton-wool steeped in carbolized glycerin, and the patient kept at
rest in bed. The operation has been already described when speak-
ing of stenosis of the external os.
Where the flexion is very acute, and the vaginal junction lower
than usual, after having divided the posterior wall of the cervix by
means of the scissors, it may be necessary to extend the incision
still further backwards by passing the blade of the ball and socket
knife, mth its cutting edge backwards, into the canal, and dividing
the triangular portion that remains between the extremity of the
first incision and the canal of the cervix.
Some authors recommend excising a strip of tissue, a quarter of
an inch or more wide, from the posterior wall of the cervix, so as to
ob\date the possibility of the incision cicatrizing up again. Others
have suggested removing the entire posterior wall of the cer^dx.
104 DISPLACEMENTS OP THE UTERUS.
CHAPTER VI.
DISPLACEMENTS OF THE UTERUS — Continued.
Retroversion and Retroflexion.
Retroversion of the Uterus. — Definition. — When the uterus, i
place of being suspended in the axis of the pelvic brim, becom^c
tilted backwards, so that the fundus is directed towards the sacrum,
and the os points forward towards the pubes, it is spoken of as
being retro verted. The displacement may vary in degree from an
angle of 90° to as much as 180° from the normal axis, the fundll^
being carried downwards until it rests upon the perineum.
Frequency. — Retroversion is not of frequent occurrence as am
idiopathic primarj^ lesion in t\\Q unmarried, nor is it common in
those who have not borne a child.
Causation. — The predisposing causes are similar to those already;
mentioned when speaking of displacements in general.
The exciting causes are any influences tending to increase the
weight of the uterus, such as congestion, pregnancy, subinvolu-
tion, fibroids, or hyperplasia. Weakening of the uterine supports,
as met with in pregnancy, rupture of the perineum, and prolapse
of the vagina, often give rise to prolapsus, with which retrover-
sion is frequently associated.
The uterus may be retroverted by being forcibly displaced, as
witnessed in cases of extreme distention of the bladder, any severe
muscular efibrts, blows or falls, tight-lacing or tight-bandaging
after parturition, or the pressure of tumors.
The uterus may also be dragged out of place by adhesions re-
sulting from pelvic peritonitis or cellulitis, or from retro-uterine
hsematocele.
Retroversion seldom occurs when the uterus is in a healthy con-
dition. There is usually some antecedent pathological state, such
as hyperaemia, enlargement of the body of the uterus, as in early
pregnancy and subinvolution, especially if associated with prolapse
of the vagina or rupture of the perineum.
We have seen that, as the uterus becomes prolapsed, it tends to
become more and more retroverted, the cervix follomng the direc-
tion of the vagina, which is that of least resistance.
In the puerperal state, the uterus being greatly enlarged, the
ligaments weakened from stretching, the vagina lax, the perineum
often ruptured, the bladder allowed to become unusually dis-
tended, the patient being kept lying constantly on her back, and
the abdominal binder being firmly applied, all tend to produce
retroversion, which often persists even after the process of involu-
tion is completed.
RETROVERSION. 105
Si/mjytoms. — These will vary considerably, depending upon
r whether the displacement occurs suddenly, or, as is far more
vQSual, gradually.
During menstruation, prolonged standing or walking, or any
!den exertion or succussion, may force the fundus backwards
1 1 give rise to urgent symptoms of acute retroversion, such as drag-
,ging sensations or pain from the stretching of the uterine sup-
ports, irritation of the bladder and rectum, with occasionally
retention of urine and faeces, or tenesmus. There are often symp-
{im\s of shock, the agony in some cases being great, the patient
i)c'ing unable to stand. The uterus, omng to the displacement and
[\\c obstruction to the circulation, becomes still more congested.
Throbbing pain, with bearing down, a feeling of weight and dis-
3omfort, and even expulsive pains if the uterus be much depressed,
ire experienced. Constitutional disturbances, with hysteria or
Dther nervous phenomena, may also be present.
When retroversion occurs gradually, there may be few^ symp-
Doms to indicate its occurrence beyond those which already existed
is evidence of uterine disorder, with wdiich this displacement is
asually associated. There may be more or less discomfort in
svalking, standing, prolonged sitting, or on defsecation, pain in the
^acral region, dragging sensations in the groins, frequent desire to
micturate from pressure of the cervix against the neck of the
•jladder, together with vesical tenesmus.
Obstinate constipation, with sickening pain on defgecation, if the
iterus be inflamed, rectal tenesmus, w^ith excessive secretion of
^liniy mucus from the rectum, are often produced by pressure of
he fundus uteri on the bowel. Dyspareunia is generally marked.
Vlenorrhagia is occasionally but not invariably present. Acquired
iterilit}^ is the rule. ^\niere conception occurs, abortion during
he first half of pregnancy not infrequently takes place.
In cases of retroversion of the gravid uterus, impaction in the
^elvis often occurs, causing retention of urine, interfering with
:he passage of faeces, and producing much local distress as well
is constitutional disturbance if the condition be not detected and
-elieved.
Diagnosis:- — On passing the finger into the vagina, the cervix, in
ilace of being detected near the centre of the pelvis, is found to
oe pushed over to the front, behind the symphysis pubis; the fun-
lus is tilted backwards towards the concavity of the sacrum, often
n an oblique direction, the fundus pointing somewhat to one or
)ther sacro-iliac synchondrosis. The uterus is generally more or
ess tender on pressure. On conjoined manipulation, the hand
oressing externally fails to detect the fundus in its normal position,
md in cases where the abdominal w^alls are very lax, the fingers
)ressed w^ell down behind the pubes may often be felt by the finger
n the vagina. On passing the finger into the rectum the fundus can
generally be felt very distinctly projecting on to the bowel, the
inger passed up sufficiently high mapping out the contour of the
undus.
106 DISPLACEMENTS OF THE UTERUS.
If any doubt exist, provided utero-gestation be not present, the
uterine sound may be introduced in a back\\^ard and downwan
direction, when, if it be a case of retroversion, the sound will entei
two and one-half inches or more, until it impinges on the innei
surface of the fundus, when pain is almost invariably complainec
of. If the uterus be mobile, it may be redressed by making th(
handle of the sound describe a semicircle, the intra-uterine portior
revolving as near as may be on its own axis, the handle being a"
the same time pressed backwards, so as to guide the fimdus uter
forwards to its normal position, when it may be felt by pressing
the hand externally over the pubes, the mass that had preyiousb
been detected posteriorly ha\dng meanwhile disappeared. Grea
care must be exercised not to use any force, lest adhesions exis
binding dow^n the fundus.
The conditions most likely to mislead us ar« :
1. Fibroid tumor of the posterior wall of the uterus.
2. Eetro-uterine hsematocele or pelvic cellulitis.
3. A small ovarian tumor in Douglas's pouch.
4. Hardened scybalae in the rectum.
In the first case, the uterine sound passes in the normal direc
tion, the fundus being felt anteriorly by pressure above the pubes
and the sense of touch discriminates the increased bulk of th»
tissue intervening between the sound in utero and the finger ii
the rectum, or even in the vagina.
In the second case, the uterus is generally more or less fijxed, th'
fundus in its normal position is ascertained by the sound, and tin
history of the case will also throw light upon it.
In the third case, the sound enters in the normal direction, th'
tumor is less hard and resisting than the fundus uteri, and is oftei
capable of being moved independently of the uterus.
In the fourth case, the uterus is found to be in its normal posi
tion, the mass posteriorly can be indented by firm pressure wdth th'
finger, and may at once be diagnosed by examination per rectum.
Prognosis. — If adliesions exist binding down the fundus uter
posteriorly, whether as the result of pelvic peritonitis, cellulitis
or retro-uterine hsematocele, a guarded prognosis should be given
as treatment may be contra-indicated, at least for some time.
If fibroid tumor be detected in the posterior w^all, the prognosi
will depend upon our being able to remove this.
Where the vaginal portion of the cervix is exceedingly short
great difficulty will be experienced in adjusting any pessary, an(
our prospects of relieving the patient will thus be slight.
As a result of the displacement we often find more or less activ'
hypersemia or inflammation, which ultimately leads to hj3)erplasia
Pressure upon the neighboring structures may induce cystitis, o
lead to the production of haemorrhoids. Dysmenorrhoea and ster
ility, menorrhagia or leucorrhcea, are also often noted as complica
tions.
Treatment — The first indication is to restore the uterus to it
normal position, provided there are no adhesions binding it down
GENU-PECTORAL POSITION.
107
^and so preventing replacement. This may generally be most
li-eadily effected by placing the patient in the semi-prone position,
bis adopted when using Sims's speculum, or still better by resort-
f ing to the genu-pectoral position. The index-finger is then intro-
; iuced per vaginam, and the posterior wall of this passage pulled
* backward, so as to allow atmospheric pressure to come into play.
This alone may be sufficient to reduce the displacement.
Wlien the patient is placed in the genu-pectoral position, the
thighs being directly vertical or perpendicular to the surface on
Fig, 73.
Retroversion. Genu-pectoral Position. (After Campbell.)
Avvhich she kneels, the body inclined at an angle of about 45° to
(he horizon, we get the most complete reversal of the bearings of
3^ravity of which the human body is capable, the inlet of the pelvis
ooks nearly vertically downwards.
The abdominal muscles being relaxed, we gain an additional ad-
FiG. 74.
Replacement of Uterus by Genu-pectoral Position. (After Campbell.)
v^antage in the draught of the viscera, and when air is admitted to the
v^agina, the atmospheric pressure enables the uterus to recede, and
:hus regain its normal position. Should, however, reduction not
rake place, the finger may be employed to press the fundus down-
kvards and forwards during a prolonged expiration.
108 DISPLACEMENTS OF THE UTERUS.
In some cases where the uterus is very bulky, as in instances o .
the gravid uterus about the third, or fourth month, the insertion 0:1
two fingers of the left hand per rectum, so as to press the funduti
downwards and slightly to one side, in order to avoid the promon- i
torj of the sacrum, whilst the index-finger of the right hand ir :
the vagina hooks or pulls the cervix backwards, will enable us tc
replace the uterus when other methods completely fail. The ad-
vantages of the postural method, both for purposes of diagnosis
and treatment, have been ably set forth by Dr. H. F. Campbell, o:1
Augusta, Georgia, in a pamphlet on " Pneumatic Self-replacemenv
of the Uterus."
Under no circumstances should an}^ considerable amount of forc(
be employed. If reduction be not readily effected by this method
the presumption is that adhesions exist which prevent the replace-
ment of the uterus. Further efforts should be desisted from foi
the time being, the patient being required to resort to the genu-
pectoral position occasionally. This will lessen any congestion 0:
the uterus that may be present, and also tend to stretch graduallj
any adliesions that may exist, and so favor ultimate replacement oi
the uterus. Steady hydrostatic pressure by means of an india-rub-
ber bag or colpeuryuter, inserted per vaginam or per rectum, and
distended mth Avater, may be employed for a few hours daily witV
a similar object.
In some cases the insertion of a Hodge's pessary, with a view tc
stretching the adhesions, may be indicated, thus accomplishino
gradual reduction of the displacement, where more rapid efforts
would prove dangerous.
A method frequently resorted to to replace the uterus when retro
verted is that by means of the uterine sound. This requires caution
and should not be attempted by those who do not possess the requi-
site skill or dexterity in manipulation, as mischief may readily be
done in a few moments that may require weeks to recover from.
The patient l^ang in the lateral or semi-prone position, the uter-
ine sound is introduced as far as the fundus, the handle of the
sound being first carried well forward between the legs. The shafi
of the sound being steadied by the fingers of the other hand neai
the centre, so as to form a fulcrum, the handle is then gradually
drawn back posteriorly, the sound forming a lever of the first order.
The fundus is thus lifted away from the sacrum, care being taker
to direct the uterus slightly to one side, so as to avoid the promon-
tory of the sacrum. The intra-uterine portion of the sound being
now made to revolve on its own axis by making the handle of the
sound describe a large semicircle, the sound is pressed well back-
wards again and the uterus thus anteverted.
If much resistance be experienced, or pain produced, indicating
the presence of adhesions, all further efforts at reduction should al
once be abandoned, as otherwise the point of the sound may pene-
trate the uterus, and peritonitis ensue.
Sims's uterine repositor may be employed with safety in simple
cases. The intra-uterine portion can be made to describe a half
MECHANICAL SUPPORTS.
109
Fig. 75.
Inrcle by withdrawing the stop-rod running through the shaft,
vhich is projected by a concealed spring. All complicated instru-
nents are liable, however, to get out of order, and encumber need-
essly the armamentaria of the gynecologist. It possesses no
;pecial advantages over the sound in the hands of an experienced
nanipulator.
Having replaced the uterus in its normal position, our next
bbject is to retain it there by some mechanical support until the
-iterine ligaments have recovered their tone and the natural sup-
jjorts are again available. Retroversion seldom occurs where the
iterus is in a normal condition. There is generally some antece-
flent congestion, inflammation, or hypertrophy. The
question will naturally arise. Shall we attempt to cure
r-he coincident condition before replacing the uterus,
i)Y shall we re'place the uterus first, and then endeavor
1^0 relieve congestion, etc.? As a general rule it will
H)e found that by replacing the uterus in its normal
position we facilitate treatment, and are more likely
â– 0 be successful in curing the displacement as well as
-1 he condition which induced it. But should the ute-
- us be too tender to tolerate a pessary sufficiently large
ro keep it in position, it may be necessary to resort to
. preparatory course of treatment by the application
1'f a few leeches; the employment of the syringe night
1 nd morning, with as hot water as can comfortably be
jorne ; resort to the semi-prone or genu-pectoral posi-
â– \on ^t frequent intervals ; replacement of the uterus
rom time to time, and keeping it there by means of
ampons of cotton-wool or oakum saturated with glyc-
rin, medicated with iodine or carbolic acid, if thought
esirable. A tampon, as large as a bantam's egg, is
irst pressed up in the posterior cul-de-sac behind the
ervix. Another tampon is then placed below the
ervix, and pushed up so as to elevate the uterus, and
P possible, keep it slightly anteverted. Rest in the
emi-prone position will favor this treatment, but the
•atient may be allowed to get up for a few hours each
ay. It mil be necessary to change the tampons at
3ast every other day.
In some cases a modification of Cutter's pessary,
dth a soft egg-sponge or inflated air-ball attached to
he extremity in place of the bulb, will serve to main-
lin the uterus in position, and to lessen congestion,
nd enable a Hodge's pessary to be borne later on.
^ A Hodge's pessary, or some modification of it, even
: the uterus be tender, will, however, generally be tolerated. Too
irge a one must not be employed at first, except in those cases
•here it is difficult to keep the uterus in place by a moderate-sized
ne, for fear of producing ulceration of the vagina by pressure,
'he instrument should be sufficiently long for the upper extremity
Sims's Uterinf
Repositor.
110 DISPLACEMENTS OF THE UTERUS.
to pass well up the posterior cul-de-sac behind the cervix, while th
lower extremity is concealed behind the arch of the pubes, ik
descending low enough to interfere with the urethra, but restin
against the anterior wall of the vagina.
When an appropriate one is adjusted, the patient is often m
conscious of its presence. Under no circumstances should it b
retained if pain or discomfort be complained of. A smaller on
should be inserted, or any local congestion or inflammation fir& J
relieved.
The variety of shapes of so-called Hodge's pessaries are innri
merable, and vary frequently with each instrument-maker. Th i
original closed lever pessary suggested by Professor Hodge (Fh *
76), consisted of a more or less square-shaped ring, having a coi
siderable upper or sacral curve, and a very slight low^er or pubi
curve, with the corners well rounded, just sufiicient to distribut
the pressure equally over the anterior vaginal wall without ei
croaching upon the rami of the pubes. The lower end, thus res
ing behind and above the arch of the pubes, does not interfei
with coitus.
In some cases the original Hodge's pessary is found to be to
square-shaped, the pubic extremity pressing against the rami of th
Fig. 76.
Fig. 77.
IloJge's Pessary. Albert Smith's Pessary.
pubes, and causing much discomfort. Under these circumstance
the Albert Smith Pessari/ (Fig. 77), which is longer and more pointe
at its lower extremity, rests between the rami of the pubes and ^
borne more readily.
Thomas's Retroversion Pessary is of somewhat similar shape, tt
upper or sacral end being ver}^ thick, so as to afford a broad ba.^
of support to the fundus. The lower end being curved well dowi
wards, and pointed, rests between the rami of the pubes withoi
interfering; with the urethra, and thus prevents its rotation in tl:
pelvis (Fig. 78).
The disadvantage possessed by all the modifications of Hodge
pessary ha^dng narrow pubic extremities, is that being wedg'
shaped they are more likely to be driven out beyond the pube
The pubic curve being increased also renders the pessary moi
liable to cause obstruction in married life.
Greenhalgh's Pessary (Fig. 79), where the bar in front is made (^
Ill
t^oft india-rubber tubing, was intended to ob\'iate this difficulty.
^ Being made of elastic wire covered with india-rubber, the broad
3nd can thus be compressed so as to facilitate its introduction, and
?>vhen in situ offers little or no impediment to the introduction of
l:he speculum or to coitus.
; Practically, it will be found that when the tubing corresponding
^ the lower bar of the pessary becomes soft in the vagina, the
isomers occasionally press injuriously upon the tissues, and often
^\^ause ulceration.
The beneficial action of a Hodge's pessary is promoted by mod-
rarate exercise. The lower limb of the instrument being carried
Hown as the anterior vaginal wall descends during the act of in-
spiration, the upper limb ascends in the posterior cul-de-sac, rais-
ing the fundus uteri and also pushing it forward. In time, it will
Fig. 79.
Fig. 78.
Thomas's Retroversion Pessary. Greenhalgh's Pessary.
fee found that the congestion usually accompan^dng retroversion
iliminishes as the uterus is kept in its proper position, and thus the
-endency to retroversion is lessened.
The uterine ligaments meanwhile have an opportunity of recov-
ering their tone, and if measures be adopted to improve the general
lealth, as well as to relieve any local disorder, the patient will in
ime be enabled to dispense with wearing the support.
The bowels must be carefully regulated, so as to avoid all risk of
iccumulation of faeces or the necessity for straining occurring. A
dttle confection of senna, pulv. glycyrrhizee co. (Ph. Pr.), Hunyadi
anos water, or other simple aperient, will often prove sufficient.
Any undue congestion of the uterus must be relieved by the ap-
i)lication of a few leeches just after the menstrual period is over,
>r by puncturing the cervix with the lancet-shaped scarifier, or by
he regular daily employment of the hot-water vaginal douche.
Che insertion of a plug of cotton-wool saturated in glycerin,
iiedicated with tannin, alum, iodine, etc., if deemed requisite, will
:eep up a continuous drain, and so serve to deplete the uterus and
essen materially its bulk.
If there be abrasion or granular degeneration of the cervix, or
ervical catarrh, these conditions must be relieved by appropriate
reatment, such as the application of the nitrate of silver, carbolic
cid, or other suitable agent. Astringent vaginal injections to
trengthen the vagina will generally be needed. In any case, for
112 DISPLACEMENTS OF THE UTERUS.
cleanliness' sake, it will be necessary to employ some form of vagi
nal injection as long as the patient continues to wear a pessary.
She should farther he instructed not to pass water in the usua
manner, sitting low on the chamber utensil, but to employ th^
night commode or w. c, so as to avoid any bearing down, whic]:
must inevitably happen when the patient squats in the way indi \
cated.
In many cases of retroversion some form of Hodge's pessary ij
a sine qua non, but it should not be regarded as the only expedient
requisite. ^
Reclining in the semi-prone, or resorting to the knee-shoulde i
position from time to time, will assist the action of the pessar '
materially, and often enable a patient to tolerate it when otherwis
it could not be done. Just before, during, and for some few day ^
after each menstrual period, when the uterus is naturally heavie j
than usual, great care must be taken not to stand too long at
time, or to undertake any prolonged or severe exertion, the patioi
reclining whenever opportunity serves.
In some cases retroversion is complicated by prolapse of one <
both ovaries in the posterior cul-de-sac of the vagina. They ar
often so tender as to effectually preclude any ordinary pessar
being tolerated, so much discomfort, nausea, faintness, or inten>
agony being produced if a Hodge be inserted, that its immediat
removal is necessitated. The postural treatment, in these cases, "
often all that can be borne in the first instance. Local depleti(»
by means of leeches may prove of service. The administration *
scruple doses of the bromide of potassium, with or without bell;
donna, often relieves the ovarian congestion and renders the orgar ti
more tolerant of pressure. |
Belladonna, or morphia and atropine pessaries, should be trie*
or they may be used as suppositories. K we can succeed in o<
justing a Hodge's pessary so as to restore the fundus to a moi :i
natural position, the ovaries are then drawn up as well. j
This may often be effected by employing a somewhat larg€ I
Hodge than would otherwise be prudent, so as to render tl
vagina tense, and enable the posterior limb to rest between tl
ftmdus and the ovary. j
Greenhalgh's pessary (Fig. 79), reversed, the soft india-rubbej
tubing being placed posteriorly, behind the cervix, is sometim(^
tolerated in these cases, and may be tried.
K a little patience be exercised, and a few days' preliminary
rest be enjoined, we shall generally be able to adjust some fori
of Hodge's pessary that will be tolerated.
Shultze's pessary, resembling a figure of eight doubled upo â–
itself, the smaller loop encircling the cer^^ix, is sometimes of servii
in these cases, especially if the posterior cul-de-sac be short, or th
cervix be held forward l)y congenital shortness of the anteric
vaginal wall.
Bpiegelberg's pessary engages the cervix in a ring at the e:
tremity of a retroversion pessary, forcing it backwards and uj
ji-
RETROFLEXION.
113
yards. This may be accomplished also by merely arranging a
â– 3ross-bar near the upper part of one of the retroversion pessaries.
Meigs's elastic ring pessary answers well in cases where very
ittle pressure is exerted by the retroverted body, and where a cer-
ain amount of prolapsus also exists. Being elastic, it assumes any
â–º ^hape required by the pelvis, but it is more liable to cut through
he vaginal walls than almost any other variety of pessary.
- "Wliere the uterus is so bulky, or the vagina so lax, that no form
>f internal support succeeds in keeping the uterus in position,
Thomas's modification of Cutter's pessary, wdth a bulb sufficiently
arge to rest behind the displaced fundus and make this fall for-
wards by displacement and not by pressure, may be tried. It
^^hould be removed every night and reinserted every morning.
K the perineum be torn and rectocele be marked, it may be
lecessary to perform the operation of perineorrhaphy as indicated
>vvhen speaking of prolapsus.
Retroflexion of the Uterus,
When the axis of the uterus is bent upon itself, the fundus being
irched backwards, it is spoken of as retroflexion. There is gen-
erally a certain amount of retroversion associated with it, so that
Fig. 80.
Retroflexion of Uterus.
the cervix does not always retain its normal axis in the pelvis, but
is tilted somewhat backwards, the os uteri looking forwards. In
some cases of primary or congenital retroflexion the cervix is found
to be just the reverse of this, being tilted forwards, the os looking
backwards.
In recent cases the wall of the uterus on the convex side is
thinned from stretching. In cases of long standing, however, the
114 DISPLACEMENTS OF THE UTERUS.
tissues at the angle of flexion on the concave side are found to b-
attenuated. The explanation of this is that it may he due to some
congenital defect of development either of the anterior or posterio: l
wall. Or it may he due to the continuous pressure producing}
atrophy of the muscular tissue. ^
Retroflexion is more often met with than retroversion indepen
dently of prolapsus.
Causation. — Retroflexion occurs as a primary or congenital con
dition in some cases from defective development of the posterio i
uterine wall. 'Bo symptoms are developed, as a rule, until the tim« ^
of puberty.
In by far the larger number of cases retroflexion is secondary o i
acquired, the result of abortion or parturition.
During the process of involution the tissues are soft and pliable ^
the uterus is not only bulkier but also heavier, the uterine sup
ports, including the vagina, lax and feeble. A certain amount o
prolapsus with retroversion occurs, favored doubtless by the pa
tient lying constantly on her back. The intestines descending \\
front of the fundus uteri tend, under the influence of the abdoni
inal pressure, to push the fundus still further backr^^ard. Owin;
to the soft and pliable condition of the tissues retroflexion is thii
readily produced. The presence of any clot within the uteru
retards involution, and often excites expulsive efforts. The ab
dominal muscles being thus called into play press the intestine
down upon the anterior wall of the uterus, causing an increase(
amount of retroversion and ultimately retroflexion. A fibroic
tumor of the posterior uterine wall has a similar effect in produc
ing retroflexion. The pressure of an ovarian tumor may produc«i
retroflexion in some cases.
Symptoms. — Retroflexion generally produces a much greate
amount of discomfort than occurs in cases of retroversion. Ii
consequence of the vessels being bent at a more or less acute angle J
venous congestion almost invariably ensues. The natural resul *
of this is that leucorrhoea, menorrhagia, and metrorrhagia ar
prominent symptoms. Owing to the cer\dcal canal being con
stricted at the seat of flexion, the escape of the menstrual an(
mucous secretions is impeded, giving rise to dysmenorrhcea, o
uterine colic and tenesmus.
The retroflexed fundus pressing backv^^ards interferes mth th^
calibre of the rectum; the passage of hardened faeces over th<
tender and often inflamed fundus causes so much pain and distress
that the patient instinctively postpones the act of defsecation fo
as long a time as possible. The straining efforts to overcome th<
obstruction increase the congestion as well as the flexion. Ii
some cases the fundus acts like a ball-valve, almost occluding th<
bowel, the faeces being flattened or ribbon-like. Obstinate con
stipation thus results, often associated with an increased secretioi
of slimy mucus from the rectum, together with tenesmus and sen8<
of bearing down.
Dyspareunia, or pain on coitus, results not only from mechanica
RETROFLEXION. 115
violence applied to the flexed and congested fundus, but also to
the ovaries, which are often prolapsed and congested as well.
Localized pain in the sacral region is generally present, increased
on defsecation, and also by standing or walking. Just preceding
the menstrual flow, the pain is often spoken of as agonizing and
almost unbearable, extending down tJie thighs, radiating to the
groins, and producing considerable malaise. The pain in the
lower part of the spine is sometimes so intense and persistent
as to lead to the idea that spinal disease exists. Tenderness
on pressure over one &xed spot, a sense of numbness or want
of power, especially of inability to w^alk, and even in extreme
^ cases, paraplegia, all tend to confirm the supposition that spinal
disease is present. In former years many patients were con-
fined to bed or the couch, made to recline on bare boards,
cupped, blistered, and otherwise actively treated for supposed
spinal complaints, due in reality to symptomatic disturbance from
a retroflexed uterus.
Reflex nervous manifestations are often well marked. " The
nervous centres respond to the slightest impressions. Hysteria
breaks out in all its manifold eccentricities ; neuralgia appears in one
or more of its various forms, as sciatica, lumbago, tic-douloureux;
rheumatism, headache, and a disposition to vertigo or syncope
frequently recur; emotional, moral, and intellectual disturbance,
as manifested in irritability, despondency, melancholy, loss of
I command over feeling and thought, are often developed. The
congested displaced organ is a constant source of nervous irrita-
tion and exhaustion; it is constantly pressing upon the sacral
plexus; it is constantly sending painful impressions to the nervous
centres; constantly using up in a morbid direction the nerve-force
which is wanted for the performance of healthy function." (Barnes.)
Besults. — In addition to dysmenorrhcBa, endometritis from reten-
tion of the secretions setting up irritation is not infrequent. The
obstruction to the normal circulation induces congestion, which is
still further increased by the obstruction to the escape of the secre-
tions. The uterine contractions excited to expel the retained
secretions produce retrograde dilatation of the Fallopian tubes,
and not infrequently reflux of the menstrual fluid occurs, and
peritonitis is set up in consequence. The walls of the uterus be-
come hypertrophied from the contractions excited to overcome
the obstruction, and thus the bulk of the uterus in time is greatly
increased.
In some cases an accumulation of mucus takes place in the
uterus, which at length gives rise to efforts at expulsion attended
by severe colic. This is often spoken of by the patient as " gather-
ing" in the womb, which bursts and gives vent to a quantity of
discharge. It is the condition described as hydrometra.
Sterility is not infrequent, but is less common than in cases of
anteflexion. Should pregnancy occur when the uterus is retro-
flexed, or retroflexion take place during the early months of utero-
gestation, and the uterus become impacted in the pelvis, the fundus
116 DISPLACEMENTS OF THE UTERUS.
being incarcerated below the promontory of the sacrum, abortioi
ahnost invariably occurs. The fact of frequent miscarriages at th*
third or fourth month should always lead to a careful examinatioi
as to the position of the uterus. If retention of urine occur aboui
this period it will generally be found to be due to retroflexion.
The obstinate constipatk)n resulting from the pressure of the
retroflexed fundus upon the rectum, in time leads to considerable
disturbance of the digestive functions; flatulent distention of the
intestines, nausea, anorexia, headache, and other symptoms of dys-
pepsia occur. "Coprsemia" is the term Dr. Barnes suggests foi
the form of blood-poisoning produced by absorption of some o:
the elements of decomposition resulting from retention of th(
excreta in the large intestine, as evidenced by the sallow, dirtj
hue of the skin, and the unpleasant exhalations from it.
Diagnosis, — On vaginal examination with the finger, the cervis
is not infrequently found to occupy nearly its normal position ir
the centre of the pelvis, the os uteri looking downwards in the
axis of the vagina instead of pointing somewhat backwards, a^'
occurs when the uterus is in a normal state, or forwards as met
with in cases of retroversion.
On carrying the finger in front of the cervix, there is an absence
of the usual resistance, due to the presence of the body of the
uterus, whereas on sweeping the finger round to the posterior cul-
de-sac, it detects a firm, globular, uniform rounded tumor contin-
uous with the ridge of the cervix, but with a distinct sulcus oi
concavity between the two. This is the retroflexed fundus. It
may be felt to move conjointly with the cervix. If the abdominaJ
walls be moderately lax and not over-rigid or thickened by the
presence of adipose tissue, and there be no ovarian tumor or in-
flammatory swelling to interfere with bimanual examination, we
shall be able to detect the absence of the fundus from its norma]
position. This examination should always be made with the pa-
tient lying on her back, the knees well drawn up.
Rectal examination by means of the finger will generally enable
us to map out more carefully the displaced fundus than was possi-
ble per vaginam. This may also be combined with the bimanuar
examination, when the contour of the uterus can often be accurate!}
determined. Should any doubt still remain as to the presence of s
retroflexion, it may be necessary to employ the uterine sound. Thif
should not, however, be passed as a mere matter of routine, for ij
the uterus be inflamed as well as flexed, a considerable amount o^
pain may be caused and the symptoms much aggravated, and iJ
there be the least probability of pregnancy existing, the use of the
sound is counter-indicated. Acquired sterility is the rule in these
cases, so that if the menstrual period has been regular, even though
the bulk of the uterus be greater than normal, the presumption is
that pregnancy does not exist.
In cases of primary or congenital retroflexion, the os uteri is
often found to be very small, and tilted more forwards than is.
usually the case in acquired retroflexion.
RETROFLEXION. 117
Having bent the sound to a curve corresponding to that of the
( rine axis, as ascertained by previous examination, the patient
iiig in the left lateral or serai-prone position, the point is intro-
iiiced within the cervix, with the concavity forward, as far as the
internal os if possible. The handle of the sound is then made to
k'scribe the arc of a large circle, the intra-uterine portion revolv-
liiii' almost on its own axis, so that the point of the sound is directed
l)ackwards. If the handle be now carried well forwards, whilst
I he finger in the vagina presses up the retroflexed fundus, the sound
w ill generally enter without diiSculty, and the point may be pushed
r in a backward and downward direction until it reaches the fundus,
|where it may be felt by the examining finger.
J To ascertain whether the fundus be mobile the handle of the
sound is now pressed gently in a backw^ard direction so as to raise
the fundus. If no adhesions exist this will readily be accomplished.
The handle of the sound is then again made to describe the arc of
a large circle, so as to bring the concavity forwards by what is
termed the tour-de-mditre, in a similar manner to passing a silver
catheter under the pubic arch. The handle being then pressed
- backwards, the point of the sound carries the fundus forwards into
the position of anteversion. The fundus may now be detected by
conjoined manipulation to be in its normal position, and the tumor
'- that was originally felt posterior to the cervix to have disappeared.
In effecting this reduction of the displaced fundus, care must be
i taken to direct it to the left of the promontory of the sacrum, espe-
cially if the uterus be enlarged and tender. This is done by direct-
ing the point of the sound in a proper direction, assisted by the finger.
Differentiation. — The conditions most liable to be confounded with
: retroflexion of the uterus are a small fibroid tumor in the posterior
fwall of the uterus, retro-uterine heematocele or pelvic cellulitis, pro-
i'l lapsed and enlarged ovary, and accumulation of faeces.
The detection of the fundus uteri behind the symphysis pubis by
â– conjoined manipulation, the passage of the uterine sound in the
normal direction, the tumor behind the cervix being still felt by the
â– finger, will serve to distinguish a fibroid from retroflexion. The
same remarks apply to the other conditions. In addition, the his-
tory and other prominent symptoms will assist us in forming a
diagnosis. In retro-uterine hsematocele the uterus is pushed for-
vvards behind the pubes, the cervix being more or less compressed.
In cellulitis the swelling is not only felt posteriorly, but gen-
erally surrounds the uterus, fixing it in the pelvis. The history of
its invasion, mostly following parturition, the febrile disturbance,
pain, etc., will point clearly to the nature of the aflfection.
Prolapse of a moderately enlarged and infiamed ovary, where
intercurrent pelvic peritonitis has caused adhesions fixing the ovary
behind the uterus, is sometimes very difficult to distinguish from a
retroflexed fundus at first. The passage of the uterine sound in the
normal direction, and the somewhat elastic, tense, semi-fluctuating
feel of the ovary, serve to distinguish it from retroflexion on the
one hand, or from a small fibroid on the other.
118 DISPLACEMENTS OF THE UTERUS.
Accumulation of faeces may mislead the unwary ; an examina-
tion per rectum will at once disclose the nature of the affection.
A movable kidney has been known to descend into the pelvic
cavity, behind the uterus, and might occasion some difficulty in
diagnosis. It is, however, a very rare complication, the mere men-
tion of which will be sufficient to place us on our guard.
Treatment. — Our first object will generally be to replace the.
uterus and endeavor to restore the continuity of the axes of the
uterine and cervical canals, so that the secretions from the body:
of the uterus may gain ready exit through the cervix.
K, as frequently happens, the uterus is not only retroflexed but
also enlarged, inflamed, and tender, the patient experiencing much
discomfort on even a digital examination, it will be better to enjoin
a few days' rest in bed before commencing active treatment. The
patient, however, must be instructed not to remain constantly lyin^ .
on her back, but on her left side in the semi-prone position, the
left arm being brought out behind the back, the body turned ovei
on the chest, the head low, the knees drawn up towards the ab-
domen, as indicated when describing the employment of Sims'e
speculum.
This posture alone favors the return of the fundus to a more
normal position. If in addition to this the index-finger be employe*
to press the fundus gently forwards and downwards so as to sweej
it under the promontory of the sacrum, taking the opportunity oJ
allowing air to enter the vagina by pressing the posterior w^all o:
the vagina well backwards, the uterus will thus be replaced, al-
though the flexion will not be straightened out.
Where the uterus is very much increased in bulk, it may be
necessary to resort to the knee-shoulder posture, as indicated wher.
speaking of the treatment of retroversion. The pressure of the ab-
dominal organs is thus removed. The draught of the viscera falling
forwards and downwards, exerts a suction force, which, when air i^
admitted by the vagina, secures the effect of atmospheric pressure
and allows the influence of gravity to come into play, so that w^
get what Campbell describes as pneumatic self-replacement of th(
uterus.
Having reduced the dislocation of the uterus in this way, th(
patient should let herself gently down into the semi-prone posture
and remain there as long as may be convenient.
If deemed requisite, a few leeches may be applied from time tc
time, or blood abstracted from the cervix by puncturing with the
scarifier. Depletion of the swollen organ will still further be en
couraged by the injection of hot water per vaginam, and the sub-
sequent insertion of plugs of cotton-wool saturated in glycerin.
The engorgement of the uterus being thus materially diminished,
with the diminution of bulk we get also a corresponding improve-
ment as regards the flexion. Pressure being removed from the
rectum, the bowels are thus enabled to act without pain or strain-
ing, and thus an important symptom — obstinate constipation — ^i^
not only removed, but the evil effects of straining and the passage
hodge's pessary. 119
of hardened faeces over the inflamed organ avoided. If necessary,
the action of the bowels may be assisted by means of small enemata,
or saline or other simple aperients.
Having thus relieved the painful inflammatory condition of the
? uterus by these means, a Hodge's pessary, carefully adjusted to
meet the requirements of the individual case, may now be tried.
The mode of introduction has been already described.
The great advantage of this form of pessary is that the posterior
limb stretches the posterior vaginal cul-de-sac backwards and up-
wards, tilting the ftmdus forwards and drawing the cervix back-
wards, so that the patient can be allowed to get up. The weight
of the uterus itself, in the standing position, tends to remedy and
not to aggravate the displacement, and the intestines, being again
enabled to descend into the retro-uterine fossa, press upon the pos-
terior surface of the uterus, and thus tend gradually to reduce the
retroflexion. The patient should not be allowed to stand or w^alk
too much for some little time after the introduction of the pessary.
In selecting a Hodge, our choice should be guided by the capacity
and tonicity of the vagina, the bulk or tenderness of the uterus, the
presence or absence of a prolapsed ovary, and the experience gained
in each individual case as to the tolerance of a foreign body in the
vagina. A moderate-sized one, with a well-marked posterior curve,
! that reaches well up behind the cervix, should first be tried. The
patient should rest up from timt* to time and be seen daily, until
,â– we are satisfied that it fits properly and does not press unduly on
the soft parts. The vagina should be syringed out once or twice a
day with some appropriate lotion as long as the instrument is re-
* tained. It may be worn for several consecutive months without
i removal, as long as opportunity be taken, now and again, to ex-
: amine carefully in order to ascertain that it is not setting up any
mischief. It does not interfere with coitus if properly adjusted; in
; fact, impregnation is more likely to occur whilst the instrument is
being worn than it was before. Should conception occur, frequent
resort to the semi-prone or genu-pectoral position should be enjoined
until the uterus has risen above the pelvic brim, which occurs about
the fourth month, when the Hodge may be removed. The risk of
abortion or of impaction of the gravid uterus in the pelvis is thus
materially lessened. A difl3.culty not infrequently experienced is
that the posterior limb of the Hodge fits into the concavity caused
by the retroflexion of the uterus, the fundus remaining flexed over
the pessary. In other cases the pessary, although it does not raise
the fundus, still causes so much distress from pressure upon it, that
it will be requisite to remove the pessary until the congestion of
the uterus has been relieved and the beneficial eflfects of postural
treatment have rendered the uterus less sensitive. In each of these
cases some little care will be required in finding an appropriate-
shaped Hodge. Sometimes we find that one which stretches the
vagina tightly causes less irritation than another which apparently
is a much better fit. The posterior limb should be sufficiently
bulky not to fit into the angle of flexion, as in Thomaa's Retroflexion
120 DISPLACEMENTS OF THE UTERUS.
Pessary (Fig. 82). Occasionally a Hodge, with india-rubber tubing
in place of the solid posterior limb, will be tolerated vnih less ir:
convenience than an ordinary Hodge. Even the same instrumei i
differently shaped will sometimes make a great difference as regards
the comfort with which it is worn.
Frequent resort to the semi-prone or knee-shoulder posture, in
jection of hot water, regulation of the bowels, rest at the menstrua,
epochs, and avoidance of all causes of excitement or fatigue, should
still be observed.
Any granular degeneration of the cervical mucous membrane,
or endometritis, should be treated by appropriate remedies, so as tf
remove all sources of irritation. Tampons of oakum or cotton-
wool saturated with glycerin, or mth carbolized or iodized glyc-
erin, may still be employed to lessen the bulk of the uterus.
The employment of skirt-supporters or garment-suspenders, the .
avoidance of tight-lacing, lifting heavy weights, or prolonged ex-
ertion, should be insisted upon, and every other precaution taken
to aid the mechanical treatment.
Fig. 81.
Fig. 82.
Hodge's Pessary for Retroversion. Thomas's Retroflexion Pessary. '
Medical treatment should not be forgotten, but carried out con-
jointly with surgical aid.
In many of the cases of acute retroflexion associated with me- i
tritis, the administration of the liquor, hyd. perchlor 5j, pot. iod.
gr. iij-v, tinct. nucis vom. tt^^x, tinct. cinch, co. t^^xx, with inf. aur. -
CO. or aqu. chlorof. proves very beneficial. In others a combina- j
tion of the pot. bromid. gr. x-xx, with ext. ergot, liq. tt^xv-xx, and {
cinchona, serves to allay the nervous disturbance and reduce the j
bulk of the uterus. Iron, as a rule, should not be given, as it tends j
to increase the congestion of the uterus and produce constipation.
But where the patient is very ansemic from the menorrhagia, and
the uterus has been restored to its projDer position and the conges-
tion diminished, some of the lighter forms, such as the acetate,
citrate, phosphate, or tartrate may be given, or the arseniate, sac-
charated, carbonate, iodide, or reduced iron, if preferred.
Local pain or discomfort may be relieved by means of morphia,
morphia and atropine, conium, belladonna, or other form of sup-
pository or pessary. A small enema of starch and laudanum often
proves as efficacious as an;)i:hing.
Posture should always be tried first. Dull, heavy, aching pain
PESSARY FOR RETROFLEXION.
121
Thomas's Modification of Cutter's Pessary.
in the back or sacrum, with sense of dragging, bearing down, or
other form of discomfort, may often be effectually relieved by re-
sorting to the genu-pectoral or
semi-prone position. This es- ^^g- 83.
pecially applies to cases where
distress is complained of after
insertion of a Hodge's pes-
sary.
Primary or congenital retro-
flexion is commonly associated
with stenosis of the external os
uteri. This in single women
aggravates considerably the
dysmenorrhoea, and in married
patients conduces to the pro-
duction of dyspareunia and
sterility. Bilateral incision of
the cervix is generally indi-
cated, and should be performed
in the manner described when
speaking of malformations of the uterus. The treatment for the
flexion will be similar to that suggested for the secondary form :
posture, replacement, a Hodge's pessary, etc.
Cutter's Pessary for Retroflexion (Fig. 83), as modified by Thomas,
may sometimes be found of service in cases where the vagina is so
relaxed that an ordinary Hodge cannot be retained, or where the
posterior cul-de-sac is very shallow. The curved stem passes over
the perineum, and is attached to a waistband. It is less dangerous
than any of the forms of intra-uterine stems connected with ex-
ternal supports, but is still not free from risk, in that shocks are
readily communicated to the fundus when the patient sits down,
or from jolting in driving, etc.
Some care will be needed in teaching the patient how to insert
it, so that the upper portion passes behind the cervix. It should
be removed at bedtime and replaced in the morning.
After wearing one of these for a few weeks, the posterior cul-
de-sac often becomes sufficiently stretched to allow of a Hodge
being retained in situ.
Intra- Uterine Pessaries or stems will rarely be required in cases
of retroflexion, if only a moderate amount of skill and patience
be exercised in carrying out the indications suggested.
Still there will occasionally be found cases so intractable, more
especially of the congenital form, where the os is very small, the
vaginal cervix so short, the posterior cul-de-sac so shallow, or the
vagina so lax, that an ordinary Hodge's pessary cannot be retained,
and the flexion persists, spite of all our eflforts to the contrary.
As we have considered at length the indications for the employ-
ment of intra-uterine stems, the precautions requisite to be ob-
served, and other matters pertaining to this subject, when speaking
of anteflexion, the reader is referred to this for further details.
122 DISPLACEMENTS OF THE UTERUS.
A simple vulcanite or silver stem, or a self-retaining one, such
as Wright's, or Chambers's modification of it, may be inserted,
and thus convert a case of retroflexion into one of retroversion.
If a Hodge's lever pessary be now introduced, the fundus will be
carried upwards and forwards. Both the flexion and version are
thus overcome, without exposing the patient to unnecessary risk.
as too often happens when the intra-
^^^' ^^' uterine stem forms part of a vaginal or
H external pessary.
â– Numerous ingenious contrivanci^
â– have been devised to overcome the
I difficulty often experienced of keeping
I the uterus straight and the fundus ele-
â– vated. Meudows's Vulcanite Stem and^
I Support (Fig. 84) consists of an intra-
I uterine stem attached to a kind of
^â– ^^^ ^t Hodge's pessary. To insert it the stem
W^ ^^^^HIH^^^ ^^^ ^^ drawn down in a line with the
^^^^^^^^^^^^^ Hodge, and is fitted on to a long probe
^^^^^- or sound, which guides the stem into-
Meadows's Vulcanite Stem and ^^^ utcrUS. On withdrawal of the SOUud,.
^^^^^ ' the elastic band pulls the stem at right
angles to the pessary, elevating and straightening the body of the
uterus. The rounded extremity of the vaginal pessary is directed
backwards towards the sacrum. The patient should be carefully '
watched whilst wearing it, lest mischief arise from undue pressure.
To withdraw it the finger must be passed into the rounded ex-.:
tremity, and traction exerted downwards.
INVERSION OF THE UTERUS.
123
CHAPTER YII.
DISPLACEMENTS OF THE UTERUS — COUtimted.
Inversion of the Uterus.
Inversion. — This form of displacement is fortunately not of fre-
|, quent occurrence. "When complete, the uterus is simply turned
^ inside out, so that the inner surface becomes the outer, the normal
intra-uterine cavity disappearing and another cavity forming above
ffrom depression of the fundus, so that the external surface of the
' normal uterus becomes the internal surface of the inverted uterus.
The cavity above contains a portion of the Fallopian tubes and
of the round ligaments, which are dragged in by the descent of the
â– fundus uteri. In cases of acute inversion following parturition, the
' ovaries may be drawn into the cavity and even coils of intestine ;
i but after involution of the uterus has taken place and the case be-
A comes chronic, this complication is not met with.
Varieties. — The displacement may be either partial or complete.
â– i Crosse speaks of three degrees.
J 1. Depression, where the fundus or placental site falls inwards,
}| projecting in the cavity of the uterus.
:: 2. Introversion or intussusception, the fundus not reaching be-
^ yond the os uteri (Fig. 85).
f 3. Perversion, where the fundus passes through the os uteri (Fig.
J 86), the cervix and os being inverted in extreme cases, so that not
I' even a groove remains between the inverted cervix and the vaginal
Introversion. Perversion.
Illustrating the Degrees of Inversion of the Uterus. (From Crosse.) a. The Inverted
Fundus, b. The Natural Cavity, c. The Vagina, d. The Upper Margin of the Cup formed
by the Inverted Fundus Uteri.
vault. This condition may be complicated by extrusion of the in-
verted fundus beyond the vulva.
Inversion may be acute or chronic, or sudden or gradual. The
acute form, where the fundus becomes rapidly inverted at the time
124 DISPLACEMENTS OF THE UTERUS.
of parturition, endsVith the completion of involution of the uterus,
and belongs more to obstetrics. The chronic form dating from the
completion of involution, or occurring independently of parturi-
tion, is that which will be considered now.
Causation. — In order that inversion can take place, there must
be relaxation and inertia of the uterine walls, with considerable
enlargement of the cavity combined with downward traction or
pressure on the fundus. At the time of parturition, traction upon
the funis when the placenta is adherent, or immoderate pressure
upon the fundus uteri by the hand externally, through the abdo-
minal walls, or the mere weight of the placenta itself, will gen-
erally be found to be the exciting cause. When the uterus is re- ^
laxed, as occurs shortly after parturition, the mere act of sneezing,,;
coughing, or any muscular effort, may be sufficient to produce in-
version.
In the non-puerperal state, the presence of a submucous fibroid
or fibroid polypus may exert traction upon the fundus, depressing
this until the uterus, stimulated by the foreign body, endeavors to"
expel this, and so causes a still greater amount of inversion.
Symptoms. — When acute or sudden inversion occurs at the time
of parturition, there is generally evidence of severe shock with col-
lapse, alarming distress, vomiting, clammy sweats, restlessness,
frequently attended by sudden and profuse haemorrhage with a
sensation as of "her inside coming out." The uterus is discovered
occupying the vagina, or even protruded beyond the vulva, covered
by the placenta.
K the nature of the case be not discovered at the time, the proc-
ess of involution may occur, the uterus gradually diminishing in
size until it retreats within the vagina, and it then constitutes
chronic inversion.
The symptoms of chronic inversion are menorrhagia, or more
or less constant haemorrhage mucopurulent leucorrhoea, dragging
pains in the back and loins, rectal or vesical tenesmus, bearing
down, difiiculty in locomotion, and a general state of anaemia.
Results. — As long as the tumor remains within the vagina, it gen-
erally gives rise to explosive efforts. The inverted mucous mem-
brane becomes inflamed or even abraded, profuse leucorrhoeal dis-
charge and often haemorrhage resulting. Wlien. forced beyond
the vulva, chronic inflammation with induration of the parts en-
sues, the surface becomes dry from exposure, often ulcerated, and
occasionally sloughing of the mass ensues.
With the progressive senile atrophy which occurs after the cli-
macteric period, all acute symptoms may subside and toleration
become established.
Diagnosis. — This is not so easy as at first sight might appear.
The recently inverted uterus has been torn away by the attendant,
and even forceps applied to drag it away on the supposition that it
was the head of a second foetus. In the chronic stage, when the
inversion is more or less complete, it has frequently been mistaken
for a polypus and removal attempted.
POLYPUS AND INVERSION.
125
In recent or acute inversion, the history of sudden shock or col-
lapse following parturition, the presence of the uterus at or beyond
the vulva, the absence of the fundus behind the pubes, the detection
of a circular ring or pit in place of the firm round ball usually felt,
will generally indicate the nature of the case. The inverted uterus,
about the size of a foetal head, is painful to the touch, has a vascular
velvety surface, bleeding readily on the slightest touch ; alt'ernate
contractions and relaxations may frequently be noted, inducing
characteristic changes of size and consistence, such as can only
occur in the case of the uterus.
In the chronic stage, the following are the points of difference
|between polypus and inversion :
Polypus.
The uterine sound passes 2^ inches
t)or more beyond the edge of the cervix.
Fig. 87.
Polypus.
Tumor pyriform in shape, neck nar-
row.
Size varies much.
No cords felt.
On conjoined manipulation, fundus
uteri detected.
On rectal examination, finger reaches
only up to body of uterus ; the fundus
can be felt by pressing over lower ab-
domen.
Growth non-sensitive, even on rough
manipulation ; may be removed without
causing pain.
Inversion.
Sound seldom passes beyond an inch,
generally arrested at neck.
Fig.
Inversion.
Tumor flattened anteriorly and pos-
teriorly, largest point is lowest, neck
comparatively large, encircled by a thick-
ened ring or ridge if inversion com-
plete.
Size scarcely larger, and often smaller,
than in natural state.
The stretched round ligaments may
be felt within the tumor.
A cup-shaped depression or ring de-
tected if abdominal walls lax.
Finger can be passed above the tumor.
Tumor very sensitive, especia% if a
ligature be applied to its neck with a
view to removal.
126
DISPLACEMENTS OF THE UTERUS.
By introducing a male catheter into the bladder and directing
its end downwards and backwards, in case of inversion the point,
carrying the coats of the bladder before it, w^ill enter the peritoneal
cul-de-sac formed by the inversion, and be felt by the finger in the
vagina through the coats of the inverted organ. Again, by a simi-
lar method, the end of the catheter may be directed backwards, s(
as to bring it to project in the rectum, where a finger w^ill feel v
with only the coats of the rectum and bladder intervening in cas>
of inversion ; but if the firm-resisting uterus be there, as in case oi
polypus, the end of the catheter will not be felt.
If doubt as to the nature of the vaginal tumor still exists, an?e^;
thesia may be produced, and rectal exploration by insertion of t]](
hand carried out, so as to map out the contour of the uterus.
In rare instances adhesion between the pedicle of a polypus ano
the cervical canal may take place, preventing the passage of the
sound, and so leading to the belief of inversion being present.
When inversion is produced by a polypus attached near the fun
dus, it may be exceedingly difficult to diagnose the complication, oi
to decide where the polypus commences and the uterine wall ends.
Partial or incomplete inversion may be difficult to diagnose froir
a submucous fibroid growth. Attention to the following points^
will generally enable a diagnosis to be made :
Fibroid.
Inversion.
Sound passes normal length or even
more.
Sound passes less than normal d
tance.
Fig. 89.
Fig. 90.
Submucous Fibroid of Uterus.
Conjoined manipulation detects fun-
dus uteri in normal position and of nor-
mal shape.
Growth insensible to touch.
Historj^ of gradual development.
May occur in nullipara.
Partial Inversion of Uterus.
Depression of fundus detected, od
conjoined manipulation.
Tumor sensitive to touch.
More sudden development.
Generally follows parturition.
From prolapsus uteri inversion may readily be distinguished
by the os uteri being detected at the lowest point of the tumor,
through which the uterine sound may be passed the normal distance
or more in case of prolapsus.
aveling's uterine eepositor. 127
Prognosis. — This is at all times serious. One-third of the cases
reported have proved fatal within one month. Death may result
ifrom prolonged haemorrhage, exhaustion, sloughing, or gangrene.
The difficulty of forming a correct diagnosis is an element of
t danger ; rupture of the vagina from forcible attempts at reduction
[ is another ; and removal by the ecraseur, on the supposition that
^ the tumor is a polypus, is also to be borne in mind.
Owing to the improved methods of treatment lately devised" for
the relief of inversion, a much more favorable expectation of reduc-
tion, with a corresponding decrease in the mortalit}^ may fairly be
'looked forward to.
Treatment. — If acute inversion occur immediately or shortly after
rlabor, the placenta remaining attached, peel this off rapidly but
carefully, apply counterpressure above the pubes to avoid rupturing
the vagina, then press the fist or the fingers formed into a cone
upon the lowest portion of the fundus, and press steadily upwards,
Lbackwards, and to one side, so as to avoid the sacral promontory.
? Where uterine action is present and the cervix and os are con-
stringing the inverted portion, we must then endeavor to replace
. that part first which came down last, by grasping the upper portion
Briof the mass and pressing steadily upwards, forwards, and to one side.
Chloroform may be administered if uterine action be strong,
Tiand the patient should be placed in the semi-prone position. It
will be useless now endeavoring to indent the fundus, as we there-
] by double the thickness of the uterine wall that has to be passed
.through the constriction.
In chronic inversion, where the process of involution has been
! completed, we must not attempt immediate reduction by forcible
taxis, or we shall run great risk of rupturing the vagina. Pro-
longed elastic pressure by suitable mechanical contrivances must
now be tried. This may be combined with the taxis at appropriate
intervals, or to complete the reduction.
An air-ball pessary inflated and passed into the vagina supported
Iby a perineal bandage, may first be tried. Where this fails, or only
] partially succeeds, efforts at digital compression, for short intervals
at a time, may be resorted to, continuous elastic pressure being
persevered with steadily in the meantime.
The most ingenious and successful apparatus is Aveling's Uterine
Eepositor (Fig. 91) with a compensating perineal, and a pelvic curve.
The cup-shaped disk is applied to the inverted fundus, the lower
end of the repositor is secured by four elastic bands which are at-
itached to a waist-belt, held in place by shoulder-straps. The
amount and direction of the pressure are regulated by adjusting the
straps, the fundus being pressed upwards and forwards in a direct
line with the axis of the uterus and the pelvic inlet.
When reduction has been partially accomplished by this process,
a smaller disk must be applied which will pass readily through the
08 uteri.
It is better to keep the patient in bed, and if much distress be
occasioned, employ morphia injections subcutaneously, or morphia
128
DISPLACEMENTS OF THE UTERUS.
1 U
Fig. 91.
suppositories, to enable her to tolerate the pressure. Eeductior
usually accomplished within forty-eight hours.
Pressure may also be applied by means of a vaginal stem Avitl
a cup- or bulb-shaped extremity, to which ;
small india-rubber disk pessary has beei
cemented, similar to those employed in case^
of procidentia. A Cutter's pessary answers
the purpose. An ordinary stethoscope with
a perineal band to support it may be em
ployed if no other suitable instrument b*
at hand.
Dr. Barnes has devised an elastic pessary
consisting of a fixed stem made to fit the
pelvic curve and surmounted with a cup-
shaped disk of hollow rubber which receivee
the inverted uterus.
Strong rubber bands are attached to the
end of the stem which projects beyond thf
vulva, similar to Aveling's (Fig. 91). These
bands can be tightened or relaxed so as tc
regulate the pressure to a nicety and give ii
the exact direction required. Counterpress
ure is exerted by pads applied to the al)
domen, supported by a firm binder.
Once a day, or every other day, the instru
ment may be removed, and under chloro-
form, an attempt at reduction by taxis b(
made until fatigue or the condition of the patient warn us to desist
when the elastic pessary is readjusted.
During all this time the patient must be watched, and care taker
that the sustained elastic pressure does not occasion unusual dis
tress. At times this is severe, and may necessitate intermitting
our efforts, or resorting to chloral or morphia hypodermically tc
allay the pain produced. In many instances of long standing wt
shall need to persevere steadily for many successive days ; as man\
as eighteen have been necessary.
Reduction often takes place suddenly with a jerk at last. Adhe
sions are extremely rare, and for all practical purposes the possi
bility of their presence may be ignored.
Where constriction of the external os ofifers considerable resist
ance to attempts at reduction, the method of Dr. Hicks may h
tried. This consists in distending the vaginal vault by means of t
hollow annular elastic pessary, used in conjunction with direci
pressure on the fundus, so as to stretch open the os.
Dr. ^oeggerath suggests compressing the uterine body opposii
to each horn by means of the finger, so as to indent one of these
and thus offer to the cervical canal a wedge, which passes up anc
is followed rapidly by the other horn, and the whole body. Thie
method is specially applicable when the fundus has been carriec
up within the os but resists farther reduction.
Aveling's Uterine Repositor.
FORCIBLE TAXIS. 129
Dr. Barnes, after trying continuous elastic pressure with occa-
|,ional attempts by taxis, draws down the tumor to the vulva by
I )assing a sling noose of tape round it, thus putting the neck on
I he stretch, then makes two incisions about a third of an inch
i leep, one on each side, in a longitudinal direction across the fibres
V)f the cervical sphincter. Then compressing the uterus with the
i eft hand, and supporting the os uteri by the fingers of the right
^land, through the abdominal wall, the uterus is replaced. He
.Suggests that this method should only be resorted to after a ftill
i rial of continual elastic pressure with occasional attempts by taxis,
.^ nd that the reinversion should be trusted to sustained elastic
|)ressure.
p In practice it will be found that this latter process, if only prop-
jf^rly directed, is sufiicient to overcome the most chronic inversion.
Or. Aveling'8 double-curved uterine repositor has proved most sat-
isfactory, and should always be employed.
r Forcibly taxis, by endeavoring to overcome resistance by sheer
Lwce rapidly applied, is attended by far too great risk to be con-
^"idered as a justifiable operation in the majority of instances,
-i It is impossible to restrict the amount of force within safe limits,
'i.nd the parts will not sustain more than a certain amount of vio-
rence without laceration. Death has frequently resulted from a
-esort to this method. The experience of late years as to the
afety and efiacacy of persistent elastic pressure should encourage
s to confine our efifbrts to wearing out resistance by gentle, long-
sustained pressure, and not to attempt forcible reduction.
Barrier eftected reduction by grasping the inverted uterus in the
iand, pressing the thumb against the fundus, and forcing the neck
gainst the curve of the sacrum as a point of resistance.
Courty recommended passing two fingers up the rectum, dipping
hem into the cervical ring, and thus gaining a point of resistance.
Thomas has twice tried opening the abdomen, dilating the cer-
ix from above, by a kind of glove-stretcher, and reinverting the
=}andus; but the operation seems to be more dangerous even than
imputation, and at present can scarcely be recommended.
White constructed a uterine repositor having a spiral spring of
teel wire at the outer end. The uterine extremity is expanded
;nd hollowed to receive the fundus, and is tipped with soft rubber.
Phis is supported on a stem of wood slightly curved.
The hand being passed into the vagina, the uterine cup of the
apositor is then adapted to the fundus, where it is held by the
and. The spring is then placed against the breast of the opera-
)r, keeping up a pressure of eight or ten pounds. Counterpressure
) prevent too great strain upon the vagina is made by the hand
iutside, so that the fingers dip into the inverted uterus.
Amputation of the inverted uterus has been recommended and
ractised, but cannot be regarded as a scientific proceeding, nor
'ith the improved methods of accomplishing reduction by means
f continuous elastic pressure, can it now be regarded as a justifi-
ble proceeding except in very rare cases where efibrts at reduction
9
130 DISPLACEMENTS OF THE UTERUS.
have been tried by some competent operator and failed, and th
patient's life is threatened.
The operation itself is attended by risk, first of hsemorrhag.
then of shock, and as a direct communication is established with tL
peritoneal cavity, acute peritonitis is not infrequent. It shouL
never be undertaken until return of the displacement has beei
proved to be impossible, nor even then unless every appliance witl-
competent assistance be at hand in the event of hsemorrhage oc ^
curring.
Having drawn down the tumor and passed a ligature throug] ;
the base so as to retain full control over the stump, the galvanic o
the wire ecraseur is then applied and gradually tightened until th â–
lower portion is removed. If haemorrhage occur this must b
arrested by the actual cautery, styptics, or sutures passed througl
the divided edges of the cervix so as to secure the bleeding vessels
M'Clintock has tried strangulating the neck by means of a liga
ture, left on for a few days, and then removing the uterus belovs
by the chain ecraseur; this lessens the risk of haemorrhage con
siderably, and is a mode of operation which may safely be recom
mended.
Where reduction cannot be accomplished, and amputation is n
resorted to for various reasons, we may be called upon to an\
the haemorrhage that is generally the chief symptom. This ma^
best be done by steeping a narrow bandage, half an inch broad, ii ,
some strong styptic solution, such as alum 1 in 12, sulphate of zin(^
1 in 2, perchloride or persulphate of iron 1 in 2; tannin 1 in d
(glycerin); and then wrapping it tightly round the inverted organ .
If this remain within the vagina, strong astringent injections may
be employed. K this be insufficient, the surface may be paintec ^
over with the solid nitrate of silver, strong carbolic acid, potas8£^
fusa, or the actual cautery, so as to alter profoundly the structur(
of the mucous membrane and restrain further haemorrhage.
MENSTRUATION. 131
CHAPTER VIII.
MENSTRUATION AND VASCULAR DISORDERS OF THE UTERUS.
Ijefore entering upon the consideration of the vascular disorders
of the uterus, it is essential to understand the normal functions of
I the organ.
Menstruation. — Menstruation consists in a periodic discharge of a
T^sanguineous fluid from the mucous memhrane lining the body of
the uterus, recurring at regular intervals of about a month, during
the period of sexual activity in women, except during pregnancy
and lactation.
The terms catamenia, the name given by Aristotle, the monthly
iperiod, the menses, the courses, etc., are also employed to designate
'â– the menstrual flow. The flow has been regarded as a secretion and
lias a simple haemorrhage. It is, however, a secretion only in so far
las it contains mucus, and it is something more than a simple
Jhsemorrhage. According to John Williams, immediately before
^menstruation is about to take place, the inner surface of the body
iiof the uterus is found to be soft, pulpy, and swollen. This is due
ito the presence of a membrane known as the decidua menstrualis,
lining the cavity. The decidua just before menstruation is pulpy
in consistence. It is applied directly to the muscular wall of the
iiuterus, without the intervention of a layer of connective tissue,
; though there is an abrupt distinction between the two at their line
t'of union.
The decidua is thickest at the fundus and the upper ]3arts of the
^anterior and posterior walls of the uterus, where it measures one-
fourth of an inch, and sometimes more, in depth; it is thinnest
along the borders of the organ, in the cornua, and just above the
'OS internum. It is composed of a superficial layer of columnar
epithelium, tubular glands lined by ciliated columnar epithelium,
blood-vessels, nerves, and lymphatics, embedded in a soft tissue,
which again is formed of round and fusiform cells lying in atrans-
; parent structureless matrix. The glands do not terminate at the
line of union of the decidua and muscularis, but penetrate deeply
into the latter structure. The decidua attains the highest develop-
ment of which it is capable in the unimpregnated uterus just before
a menstrual flow. At this time its elements, matrix, cells, walls of
blood-vessels, etc., undergo fatty degeneration. In consequence of
this degeneration, and of the contraction of the uterine wall, the
decidua becomes greatly congested, the walls of its blood-vessels
yield, and blood becomes efiused into its superficial layer. After
this has taken place, the whole of the membrane undergoes rapid
disintegration and dissolution, and is ultimately carried away as
Mhris in the menstrual fluid. By this process all the vessels of the
132 VASCULAR DISORDERS OF THE UTERUS.
decidua, which run more or less perpendicularly to the inner sui-
face of the uterus — both arteries and veins — are laid open, an^
haemorrhage — the haemorrhage of menstruation — follows.
Menstruation is not, therefore, a separation of blood, or of blood
and mucus simply, from the body by the uterus, but the moleculai
removal of a tissue which has become useless; and the haemor-
rhage is the result of the destructive process by which the useles-
material is removed from the body. It is the terminal change ol
a cycle, beginning with the development of a new decidua and
ending with its destruction. Aveling describes this as a process ot
denidation, as it is the carrying away of a nidus prepared for the
reception of an impregnated ovum ; while the process of growtlj
by which a decidua is formed during every intermenstrual interval
is called nidation.
It has generally been believed that menstruation was the result
of an ovarian influence, and that this influence emanated from the
maturation and rupture of a Graafian follicle ; and in accordance
w^ith this \dew it was long maintained that a Graafian vesicle rup-
tured with every menstrual epoch. It cannot be doubted that an
ovum is discharged, in the great majority of cases, in connection
with menstruation ; at the same time it must be stated that a con-
siderable number of cases have been recorded in which menstrua-
tion had taken place unaccompanied by maturation and rupture of
an ovarian vesicle, and these cases are sufficient to show that men-
struation is independent of the discharge of ova.
It was, and is still, generally maintained that in the absence of
the ovaries menstruation is impossible, but since ovariotomy has
been so ^^ddely practised, several cases have been observed in which
both ovaries have been removed, and yet menstruation has con-
tinued to recur regularly for years. Still, it may be affirmed as a
general law that when the ovaries are extirpated or become atro-
phied, menstruation does not reappear. In Avomen whose ovaries
are not developed, or where they have been removed before puberty,
menstruation does not occur. This may be explained by the fact
that a stimulus to the nervous system originating in the ovaries is
requisite for the establishment of menstruation, and the recurrence
of this function after removal of the ovaries is due to the habit of
periodicity acquired during the ovarian activity.
Facts have been observed proving that ovulation may occur with-
out menstruation, and equally that menstruation may take place
without any evidence of ovulation on the most careful examination
2wst mortem. Women who have never menstruated have conceived,
and even conception during lactation, whilst menstruation is sus-
pended, is not uncommon.
The association of ovulation with menstruation, although by no
means an invariable, is still the general rule. The maturation of
ova, and most frequently their dehiscence, although revealed gen-
erally by the appearance of the catamenia, may still occur in the
intermenstrual intervals, certain conditions accelerating or retard-
ing their development. The influence of the hyperaemia induced
MENSTRUATION. 133
iby coitus may hasten the maturation of ova, and especially their
escape from the ovary. Conception is possible at any stage of the
intermenstrual period, though menstruation being the natural epoch
ifor the escape of ova, conception is most likely to occur about this
rtime.
The first appearance of the catamenia generally takes place be-
tween the thirteenth and fifteenth year in temperate climates. It
may, however, appear as early as the ninth or tenth year, or be
delayed until the twentieth year, or even later. It appears earlier
in warm than in cold climates, in the inhabitants of towns than in
f those of the country, in brunettes than in blondes, and in certain
I races than others. The exact time of its advent in any given in-
Tstance depends on the state of the general health, the development
:of the system generally, and the organs of generation particularly,
luxurious living and libidinous excitement tending to tbrestall the
ordinary period, whilst the contrary conditions of hard living and
r^freedom from sexual emotion tend to postpone it.
^ Coincidently with the appearance of the catamenia we have other
^indications of puberty, such as development of the mammae, hair
upon the pubes, and well-marked changes in the mental condition
as well as the disposition and bearing of the girl. Precocious men-
struation is occasionally witnessed in very young girls and even
infants, the pelvis and breasts being unusually developed, and the
stature stunted . Premature menstruation is not infrequent, children
lias young as eight and ten years having before now borne living
children at full term. In premature menstruation the groAvth of
the 'body is not usually interfered with.
. The first appearance may vary between the age of thirteen and
^sixteen and a half years, the extremes being eight to twenty-five.
H The cessation of menstruation, which is generally spoken of as
^the climacteric period, the menopause, or change of life, generally
'Occurs about forty-five, the average of menstrual life being usually
thirty years. A healthy woman, living the full span of her life, is
so organized that the condition necessary for continuing the race
recurs with her nearly four hundred times during the years of her
full strength. The menopause not unfrequently occurs in women
who present no other signs of ill-health as early as twenty-five or
thirty, and instances are recorded w^here women have been regular
up to sixty and even later. The earlier menstruation commences
the later is it likely to be prolonged, the ovarian activity in these
cases being often well-marked. The converse also holds good. In
cases of superinvolution following parturition, the uterus becomes
atrophied, and thus induces premature senility. Instances of preg-
nancy occurring late in life are not uncommon, but " the law^s of
physiology, the experience of mankind, and the decision of courts
of law justify a medical man in declaring that a woman over fifty-
five years of age is past the period of childbearing."
The source of the menstrual blood is mainly from the cavity of
the body of the uterus, that portion of the internal surface of the
w^omb which is lined with the decidual membrane. Dr. Barnes
134 VASCULAR DISORDERS OF THE UTERUS.
states : " This intense vascular engorgement involves the ovaries
and Fallopian tubes as well as the uterus ; and there is no doubt
that blood is effused from the Avhole tract of the tubo-uterine
mucous membrane."
The cer^dcal mucous membrane remains intact during menstrua-
tion, and does not normally contribute in any way to the discharge
of blood. The average period of flow is from three to five days,
but it may be prolonged to seven or eight without being abnormal.
It continues longer, as a rule, in women w^ho reside in towns than
in those who live in the country ; longer in small, delicate, nervous
women than in those who are tall, rol)ust, and of a sanguine tem-
perament ; longer also in those who lead a sedentary, easy, volup-
tuous life, than in those w^ho follow active occupations, whose diet
is conducive to health, and whose manners are regular.
The t^^ical periodicity is every twenty-eight days, but varies
from three to five weeks.
The amount lost varies in different women, and even at different
seasons of the year, or under varying conditions of health. It is
estimated that the average loss is from three to four ounces, though
six to eight ounces is no unusual amount is some women. The
influence of exercise, and especially of coitus, in increasing the
discharge is oflen noticed. Englishwomen often suffer from menor-
rhagia as long as they reside in India, the flow diminishing mate-
rially on their return to their native country. Some periods are
naturally profuse, others scanty ; there is no invariable uniformity.
The menstrual discharge consists of blood, the debris of the de-
cidua, mucus, and epithelium from the uterus and vagina. Mixture
with the acid vaginal secretion prevents coagulation as a rule, but
if the flow be excessive, or retention within the uterus, from sten-
osis or flexion, occur, clots are found. ISTormally there should be
neither shreds nor clots.
Menstruation being normally a physiological process, little or
no discomfort is experienced by women in a state of health ; but
where the condition of the general health is deteriorated, or the
nervous system very impressionable, certain premonitory symptoms
are not unusual. These are know^n as molimina menstiixationis, and
consist of a sensation of weight and fulness in the pelvis, bearing
down or dragging, a feeling of weariness or aching in the loins,
radiating downwards to the perineum and occasionally extending
down the thighs. There is slight tenderness over the hypogastric
and inguinal regions, Avith not infrequently a burning sensation.
In some instances there is irritability of the bladder, frequency of
micturition, or even retention. The regularity of the bowels is
often interfered with, constipation or diarrhoea being not uncom-
mon. The appetite fails, nausea or sickness is occasionally experi-
enced, and the patient complains of feeling " unwell." The breasts
become hard and tender, and in some instances severe neuralgic
pains are experienced in them. Dr. Barnes has pointed out that
menstruation, and probably ovulation also, are, like pregnancy,
preceded and accompanied by increased central nerve irritability
I
FLUXION. 135
and increased vascular tension. Fretfalness, irritability of temper,
hand increased tendency to attacks of hysteria, migraine, or epilepsy,
^^are often noticed when any predisposition exists.
Vascular Disorders of Uterus. — The uterus is an organ peculiarly
liable to alterations in its vascular supply. Its tissue being to a
certain extent erectile, and the organ being surrounded by a mass
of blood-vessels passing in every direction through the loose con-
fnective tissue of the pelvis, it is directly affected by any increase
or diminution in the neighboring circulation. Dr. Barnes distin-
guishes four grades or conditions characterized by excessive blood-
supply, viz. : 1. Fluxion, or simple determination of blood. 2.
Hyperemia. 3. Congestion or engorgement. 4. Inflammation,
which may be regarded as the climax of the first three conditions.
iDr. Barnes, in his clinical history of diseases of women, has dis-
cussed these several conditions most fully, and in a way that no
other modern author has attempted. The following observations
ias to the causes and symptoms of hypersemia are almost entirely
.condensed from this source.
Fluxion is merely a transient hypersemia, or flow of blood to the
; parts, analogous to that witnessed in the rush of blood to the cheeks
under the emotions of shame or anger. It is purely a physiological
[process, and if it occurs in healthy organs entails no ill efl^ects,
unless it be artificially and inordinately stimulated. Instances of
fluxion are witnessed in the determination of blood to the uterus
t as a result of ovulation at the menstrual periods, from sexual excite-
rment, from reflex irritation, as when the child is put to the breast,
rand in the vascular falness determined by the developmental at-
^traction of pregnancy, the growth of fibroid tumors or polypi, and
veven of cancer. The tendency to fluxion is increased where the
^ ovaries or uterus are in an abnormal condition, whether from con-
Igestion, inflammation, displacement, or from being the seat of new
1 formations.
The symptoms are mostly subjective, the patient experiencing a
sensation of local heat and falness, depending upon the turgidity
of the organs affected, and the tension of the plexuses and erectile
; portions of the vascular system. If varicose veins exist in the legs,
thighs, or groins, the efltect of fluxion is seen in a marked manner
at the menstrual periods. The veins visibly swell, become tumid,
'â– deeper-colored ; oedema sometimes occurs. When fluxion occurs
in morbid structures, the symptoms are commonly more severe.
'Pain is more marked; the sense of fulness, of weight, is more op-
pressive ; dragging pain is felt in the loins and groins ; and often
sharp colic spasms in the stomach in the region of the umbilicus.
The vascular tension seeks relief in discharges ; these present them-
selves as hsemorrhage, leucorrhceal or mucous discharges, and es-
cape from the mucous membrane of the uterus, vagina, bladder, or
rectum.
Certain general symptoms precede and attend the local phe-
nomena. There is a state of tension, marked by a chill or even by
a rigor, by spasm, vague nervous phenomena, irritability or depres-
136 VASCULAR DISORDERS OF THE UTERUS.
sion of temper, restlessness, perhaps hysteria. The objective signs
are: distention of the hypogastrium, increase of heat, and shght
development of pain on pressure. The vagina is relaxed, the uterus
increased in bulk, lower in the pelvis, and is tender to the touch,
the cervix soft and smaller.
Hypermmia consists in a continuous or chronic fulness of the ves-
sels of a part, which does not necessarily imply morbid action in
that part, but which at most leads to languid, passive changes. It
occurs especially in connection with excessive menstrual conges-
tion; the uterus is full of blood, dark-red, swollen, softened; the
mucous membrane is injected, red, swollen, with a spongy, iioccu-
lent aspect, from the development of its uterine tubular glands,
softened and bleeding.
Hypereemia of the uterine mucous membrane occurs in the course
of typhus, cholera, typhoid, the exanthemata, and scurvy.
The uterus becomes hypersemic and swollen when the pelvic sys-
tem of veins is overloaded, and especially when flexions or displace-
ments of the organ exist.
New formations cause and keep up hypersemia, sometimes more
marked in the uterine substance, sometimes in the mucous mem-
brane. It also occurs in heart disease, from obstruction to the re-
turn of blood through the vena cava.
Persisting h^^er^emia leads to persistent secretion of mucus, and
to hypertrophy of the uterus, commonly of the eccentric form;
to hypertrophy of the vaginal portion, with predominance of the
connective tissue; and thence to induration, the so-called infarctus.
Hypersemia disposes to oedema of the tissues, and to haemorrhage
mostly due to portal obstruction, and to the general want of vascu-
lar tone arising from obesity and want of exercise. There is often
a chronic pelvic hypersemia in aged women, leading to haemorrhage.
There is a sense of weight and heat, often some degree of pro-
lapsus, and also a troublesome form of pruritus.
Dr. Galabin has directed attention to the fact that among the
wealthy passive hypersemia is apt to be promoted by the excessive
use of the dorsal reclining position in cushioned chairs or sofes, as
opposed to the recumbent posture, and by the use of feather-beds
instead of firm mattresses. He observes that in the dorsal reclin-
ing position the pelvic brim is rendered nearly horizontal, instead
of being inclined about 55° to the horizon, as it should be in the
upright position. The pelvis is thus exposed to the full weight of
the abdominal viscera, and the return of venous blood from it is
at the greatest disadvantage, while any tendency to retroversion or
retroflexion is promoted by gravity. At the same time the use of
soft cushions obviates the natural tendency which persons resting
on a harder seat have to change their position frequently, and to
assist, in an important degree, the venous circulation. In lying on
a feather-bed, also, the pelvis sinks in and becomes the lowest part
of the body, whereas upon a hard couch, in consequence of the
greater width of the hips, the pelvis is somewhat higher than the
shoulders.
CONGESTION OF UTERUS AND OVARIES. 137
Congestion or Engorgement of the Uterus and Ovaries. — This con-
dition implies, according to Dr. Barnes, a more prolonged fulness
of the vessels than mere fluxion ; it rarely exists without some
J amount of retardation of the blood in the vessels, that is, hyper-
femia ; and this retardation almost certainly entails more or less
: eftusion of the serous or aqueous elements of the blood into the
tissues of the organs affected. This implies swelling or tumefac-
tion. Once set up, this condition is extremely liable to persist.
i Congestion may arise from many causes. If the organs are
^caught whilst under the influence of physiological fluxion by con-
^stitutional shock, by exposure to cold, or protracted fatigue, fluxion
j'raay pass into congestion.
-' Congestion of the uterus very frequently takes its rise in the
state of imperfect contraction and involution following pregnancy
and labor. The relaxed tissues and dilated vessels form a ready
receptacle for the blood, and the want of tone and contractility
;- obviously favors its retention. Congestion is soon aggravated
vb}^ displacement of the womb, the organ almost invariably sink-
ing lower in the pelvis, or becoming ante- or retro-verted or
flexed. The vessels thus becoming twisted, distorted, or com-
pressed at the point of entry and exit, blood can still enter the
uterus by virtue of the propelling vis a tergo through the ar-
teries ; but the veins, thin-walled, flaccid, and valveless, rendered
ttortuous and compressed, aflford but a diflficult return.
\ Uterine congestion complicates, or plays an important part, in a
Marge proportion of cases of uterine disease. It constitutes one of
the, most serious obstacles to their cure. It tends by its very con-
;^ditions to perpetuate itself. It exhibits little or no tendency towards
spontaneous recovery. The organ in which it occurs is rendered
(Permanently larger, its tissues are infiltrated with serum or semi-
plastic extravasations, its contractile force and the tonicity of its
vessels are impaired ; the blood brought to the uterus either by the
ordinary distribution or by intermittent fluxions is delayed ; a kind
of hsemostasis is induced ; and these conditions are aggravated by
time, by the increasing mechanical impediment to the course of
the pelvic circulation, which displacement of the uterus in relation
â– to the broad ligament induces.
Uterine congestion may be primary, and for an indefinite time
constitute the chief morbid condition. It rarely exists long with-
â– out inducing displacement or prolapse of the uterus ; and sooner
or later it is likely to lead to other evils, as hypertrophy and in-
!flammation.
It may be secondary upon other conditions. Fixing of the
uterus almost infallibly induces congestion, whether this be from
perimetric madhesions, from compression of tumors, from pressure
against the symphysis pubis by retro-uterine hsematocele, or other
cause. But the most frequent cause is retroflexion with locking
of the fundus beneath the sacral promontory.
The symptoms are essentially the same as those wMiich mark the
combination of fluxion and hypersemia; the diagnostic test being
138 VASCULAR DISORDERS OF THE UTERUS.
the persistence of the symptoms, and the accidental intermittent
character of the fluxions which may or may not comphcate this
congestion. There is also more pain than in hypersemia. The
enlarged uterus, hy its proximity to the bladder and rectum, irri-
tates these organs, and thus keeps up hypersemia in the surround-
ing pelvic tissues. The reflex irritation causes frequent desire to
void urine, and dysuria. Dysmenorrhcea is a frequent consequence
of congestion, especially if displacement of the uterus be also pres-
ent. The difficulty which congestion occasions to the uterus in
the performance of its functions becomes a source of aggravation
of the congestion. Menstruation becomes disordered, occasionally
scanty, frequently irregular.
Leucorrhcea is an almost constant effect of congestion: the
gorged vessels of the uterus seek relief by secretion of mucus,
the glands undergoing enormous development.
The local signs are the increased bulk and weight of the organ,
involving diminished mobility and more or less displacement —
generally prolapsus or retroversion or flexion. The vaginal por-
tion of the cervix is seen to be swollen and red, and bleeds readily
on examination.
Treatment — For simple fluxion rest is very important. The
observance of hygienic precautions calculated to obviate or avert
the irregular fluxions provoked by accidental, emotional, and local
irritation should be attended to as far as possible. They cannot
always be foreseen or guarded against, but familiarity with the
idiosyncrasy and surroundings of the patient will often enable us
to avert some of these irritations.
There is one very effective agent in turning away the fluxion
from the organ predestined to be its seat, which it is almost hope-
less to recommend at the present time, and that is venesection.
The doctrine of revulsion teaches that we may divert the torrent
of the circulation from an organ towards which irritation conducts
it, by setting up an artificial fluxion to another part. A small
bleeding from the arm, timely practised, may not only save a
greater eftusion, by turning aside the current from the morbid
surface, but by lessening the vascular activity in the diseased organ
may check the jDrogress of the disease. This mode of revulsion
is especially useful in young plethoric persons, and when the fluxion
is recent or only impending.
Another form of revulsive treatment, less powerful, consists in
causing derivation to the skin or intestinal canal. By epispastics,
by blisters, or fomentations, we can excite some degree of local
afflux to a distant part of the body. By purgatives we can cause
a derivation to the intestine, and take off some degree of vascular
tension by drawing off a portion of the watery element of the
blood.
A revulsive recommended by Hippocrates is the application of
dry-cupping to the breasts.
Certain medicines possess the valuable property of allaying and
regulating vascular excitation. Of these the most useful are the
REMEDIES. 139
^acetate of ammonia, nitrate of potash, tartarated antimony, aconite,
^digitalis, veratrum, salicylic acid.
^ X very useful formula is '^i liq. ammon. acet. 5iij, potass, nitrat.
XV, vini antim. Tt\^xv, infusi digitalis 5ij, aqu?e Siij, to be taken
c\ery three or four hours. It determines to the skin and intes-
ttinal canal; it may possibly provoke nausea or vomiting, but this
thas a powerful influence in checking haemorrhage.
: Ergot, strychnia, digitalis, bromide of potassium and ammonium,
vare the drugs most to be relied upon in influencing hypersemia and
icongestion. Ergot in the form of ext. ergotse liq. 5s8, given with
Hinct. cinch, co. tt|^xx, in the form of a mixture, thrice daily, exerts
5a very beneficial influence upon the muscular walls of the uterus,
sas well as in contracting the arteries and so lessening any tendency
ido haemorrhage.
Strychnia exercises a similar eflect and is a valuable tonic as
well. Digitalis in some instances seems to strengthen the heart's
:^action and diminish general venous pressure, and may be given in
conjunction with either of the others.
Bromide of potassium is one of our most reliable sedatives for
ijlthe sexual system, acting at the same time as a general vascular
and nervous sedative. Owing to its general depressant effect, it is
well to combine it with some tonic. Twenty to thirty grains given
^.^\vith liq. arsenicalis n]^v, thrice daily, produces all the beneficial
efi*ects, and is less likely to cause bromic acne in susceptible sub-
t.jects.
Where the catamenia are suppressed or scanty it may be well to
.;2rivG the syr. ferri bromid. 5j , in water, thrice daily, as the bromide
lalone tends to diminish the quantity of the menstrual flow and
•lengthen the intervals.
• Where hyperaemia is dependent upon ovarian irritation, the
iodide of potassium is very useful combined with the bromide.
The general health must be considered. The diet should be
light and unstimulating, alcohol being avoided or given in very
small quantities. The bowels must be carefully regulated, so as
to preclude all risk of venous obstruction from faecal accumulation.
iThe Hunyadi Janos or Ptillna water, a wineglassful with the same
:quantity of. hot water, taken in the early morning, acts very well
lin most cases. Any of the saline aperients, such as the sulphate
'Of soda or magnesia, may be given, alone or combined with tonics,
in half to one drachm doses twice or thrice daily. A cold hip-bath
of a morning, when the season permits, or a bath at a temperature
of 60° F. in winter, will exercise a stimulating influence upon the
general circulation and lessen the tendency to hyperaemia.
All prolonged standing, sedentary occupations, and lying con-
stantly on the back should be avoided, the patient being encouraged
to assume the lateral or semi-prone position from time to time on
a flat couch, and not allowed to sit propped up in easy-chairs.
Any displacement of the uterus must at once be remedied by a
suitable form of pessary, more especially any flexion or prolapse.
Care must be taken before the advent of the menstrual period to
140 VASCULAR DISORDERS OF THE UTERUS.
avoid all risk of cold, prolonged exertion, or other exciting cause
of hjpersemia.
Local Depletion. — This will often he requisite where the con-
gestion is accompanied hy intense pain and sense
of weight, the hulk of the uterus being sensibly in- ^^^' ^^"
creased. If the congestion be liable to periodical ag-
gravation, especially if attended by haemorrhage, the
principle of derivation and revulsion should be in-
voked.
The methods usually adopted for depleting the uterus
are puncturing the cervix, scarification, and leeches.
Puncturing is by far the simplest and most effectual
method of relieving congestion, and has the advantage
of not encouraging a renewed determination of blood to
the uterus, as not infrequently happens from the suction
of leeches. The cleanliest and most con-
venient mode of depleting by this means
is to pass an ordinary cylindrical Fergus-
son's speculum so as to expose the cervix,
the patient lying in the left lateral or
semi-prone position. Two or three punc-
tures are then made with a lance-headed
scarificator having a long handle (Fig. 93),
a spear-headed needle (Fig. 92), a trian-
gular surgical needle held in a pair of
torsion-forceps, or a sharp-pointed bis-
toury. It will depend upon the condition
of the cervix, and the amount of blood
desired to be withdrawn, how many and
how deep the punctures shall be.
It is well at first to puncture the left
side of the cervix in two or three places,
an eighth to a quarter of an inch in depth,
and be guided by the rapidity and the
quantity of the flow whether we repeat
the punctures on the upper or right side
of the cervix. By this plan the surface is
not obscured by the blood, as would be
Spear-beaded Nee- the CaSC if WC IDUUCtured indiscriminatclv- I^a°°«-beaded
die for Puncturing, a n • j? i i i • bcanficator.
Liuriug. ^ gjj^all piece of sponge, held m a mop-
holder, soaked in hot water, may be used from time to time to
remove the clots from the punctures, and so encourage the bleed-
ing, or if necessary, a stream of hot water may be injected along
the speculum with the same object. If suflacient blood be not
extracted, fresh punctures may be made until one or two ounces,
or as much as deemed requisite, has been obtained. If the lance-
shaped scarificator be employed, the punctures should radiate from
the centre, the edge of the instrument being directed towards the
OS uteri. A plug of cotton saturated in glycerin, with a string
attached, is then passed up to the cervix and the speculum with-
APPLICATION OF LEECHES. 141
drawn, the plug being removed the following morning, when the
syringe should be employed.
Should haemorrhage persist longer than is wished from any one
of the punctures, the end of a knitting-needle heated in a flame
may be inserted into the orifice, or a saturated solution of alum
; injected up to the cervix.
Scarification is more useful w^hen marked granular degeneration
J of the cervical mucous membrane exists. A cylindrical speculum
I having been passed, as just described in speaking of puncturing,
a spatula-shaped knife, or bistoury, or scarificator curved like a
S\ nie's knife, is carried just wdthin the os uteri, and draw^n across
the face of the cervix several times, thus severing the superficial
- vessels, and so aftbrding exit to the blood. In some cases where
the OS is pinhole and tends to keep up the congested condition by
preventing free exit of discharges, the curved scarificator is of
much service in enlarging the os by a series of incisions radiating
;from the centre.
In cases where the endometrium of the cervix is specially in-
vvolved, scarification by means of linear incisions often proves very
[Serviceable.
A glycerin plug should then be inserted and allowed to remain
i in from twelve to twenty-four hours, so as to assist and prolong the
i process of depletion.
Leeches, although frequently applied with the object of depleting
i the uterus, are really of more service in cases of amenorrhoea, as
! they tend by their suction to encourage a temporary fluxion, and
r^ so attract blood to the pelvic organs. The vascular system of the
; pelvis has been likened, not inaptly, to a sponge. The free anasta-
moses between the branches of the internal iliac and the valveless
^ veins, w^ith the numerous plexiform structures, constitute a peculiar
' formation unfavorable to local bleeding by exhaustion. If we draw
' blood from any one part it is immediately replaced by a new sup-
ply, the vessels can hardly be emptied, so that any local engorge-
ment is but little diminished. Dr. Barnes remarks, " I now resort
'to this practice wdth very great circumspection." Regarded from
la practical point of view% the application of leeches to the cervix
uteri is not. only unsatisfactory, tedious, and troublesome, but also
I very uncertain in its results. Occasionally they cause severe pain,
.4 amounting to agony, especially if one crawls into the uterine cav-
ity and attaches itself there. Urticaria not unfrequently results.
Sometimes it is dififtcult to get them to bite, at others to arrest the
bleeding, and the quantity abstracted is always uncertain. If their
application be entrusted to a nurse, considerable inconvenience
may be caused by the prolonged unscientific attempts to get the
cervix into the field of the speculum, and more harm done to a
tender, inflamed uterus than any good likely to be derived from
the depletion. For these reasons I very rarely employ them now,
but resort to puncture in preference, as being more certain, less
troublesome, and much safer.
However, if it be decided to apply leeches to the cervix, the best
142 VASCULAR DISORDERS OF THE UTERUS.
way of doing so is to pass as large a Fergusson's speculum as tli
vagina will accommodate, and get the cervix well in view. Witl i
a mop of cotton wipe the cervix perfectly clean, plug the os mth j |
small piece of cotton to which a thread is attached for its removal |
and then puncture or scarify the cervix lightly so as to draw a fev
drops of blood. Four to six leeches will generally be sufficient
Having dried them, place them in the speculum and press them u]
towards the cervix by a plug of cotton-wool, or apply each one sep
arately by means of leeching-forceps, keeping the speculum pressec j
firmly against the roof of the vagina, so that the leeches canno |
insinuate themselves between the speculum and the vaginal walls!
The lower end of the speculum will need to be carefully watchec j
for a quarter of an hour or so, until the leeches have taken an( j
fallen off, as otherwise they may refuse to bite and attempt to worn â–
their way out most insidiously between the wool-plug and the specu -
lum, and to escape without being noticed. At the end of twenty^
minutes the cotton-plug may be removed, and any leeches that hav
filled and fallen oft" removed, any still remaining being removed b;
a pair of forceps. The usual plan is to place the leeches in a platt
or saucer, and sprinkle salt over them to make them disgorge thei
contents. They should never be used a second time.
Should by any possibility a leech enter the cavity of the utern .
through a patulous os, and attach itself there, becoming so dis-
tended with blood as to preclude its return, severe uterine coliu
may be produced, haemorrhage may persist, or metritis even be sc t
up. As a rule, the leech is soon expelled by uterine contractions
Should the haemorrhage prove excessive or prolonged, the cervi:^
may be plugged. If the pain be severe, opium should be admin
istered.
When the leeches have been removed, a stream of hot wate:a
should be injected into the speculum to wash away all clots, a plu^ '
soaked in glycerin passed up to the cervix, and the patient kep
lying down for the remainder of the day. Should haemorrhage
persist, and the injection of cold water fail to arrest it, the bette;
plan will be at once to pass the speculum again, cleanse the vagina
and apply a dossil of cotton-wool soaked in alum or the perchlorid<-
of iron to the bite, or a plug soaked in a strong solution of alun -
may be pressed up against the cervix, other plugs being packet
behind it so as to ensure pressure as well.
If these means fail, the point of a knitting-needle heated in n
flame may be passed into the leech-bite, when the bleeding will a -^
once be arrested.
As a general rule, leeches should not be applied in the consult
ing-room, but only when the patient is in bed, where she can remair
as long as necessary. Apart from their application often proving
very tedious, if the patient be allowed to walk or drive home shorth
afterwards, the risk of prolonged haemorrhage is thereby increased
and there is also danger of the patient catching cold.
The proper time to apply leeches, as regards the menstrual period
will vary, depending upon the nature of the case. It is, however
HOT-WATER VAGINAL DOUCHE. 143
i seldom prudent to apply them within a week of the expected cata-
^ menia, unless the pain and discomfort attending the flow are
S marked. Where the catamenia are scanty and there is much dis-
comfort following the cessation, depletion immediately following
5 the flow is frequently indicated.
I The process of depletion will generally need to be repeated at
' intervals of a fortnight or so until the condition necessitating such
I treatment has disappeared.
I The employment of the hot- water vaginal douche, as elsewhere
lindicated, will often obviate the necessity of resorting to any local
: depletion, or may prove a useful adjunct. Another extremely useful
J and convenient method of depleting the uterine vessels is by means
r- of the glycerin plug. A tampon of cotton-wool, with a string at-
;:;tached, sufficiently large to soak up at least half an ounce of glyc-
erin, is passed up to the cervix and allowed to remain there from
I twelve to twenty-four hours. A copious watery discharge from the
-cervix and vagina is thus produced, thereby relieving the congestion
land preventing our having to resort to more direct depletion.
144 INFLAMMATION OF THE UTERUS.
CHAPTEE IX.
INFLAMMATION OF THE UTERUS.
Inflammation of the Uterus. — This may be acute or chronic, lim-
ited to the cervix or to the body, or affecting both conjointly. The
parenchyma of the uterus may be chiefly involved, or the linino
membrane mainly affected.
The term metritis is applied to inflammation of the substance oi
parenchyma of the uterus ; endometritis to inflammation of the lin- -
ing mucous membrane. This is a somewhat arbitrary distinction, -
for the inflammatory process is never entirely confined to one oi
other structure, but involves both to a greater or less extent. In
the very acute form of inflammation the whole of the tissues, both
of the body and cervix, are involved. It will be convenient, there-
fore, to consider acute metritis and acute endometritis conjointly.
When the inflammation is of a less acute character and chronic
in its duration, it may be limited more to one or other portion oi
the uterus, the body or cervix, or to the parenchyma or lining,
mucous membrane, though, as before observed, both structures are
generally implicated. Most mucous membranes are separated from
the structures lying beneath them by a layer of loose areolar tissue;
the mucous membrane of the uterus, however, is itself of a dense
character, consisting mainly of closely-packed round or slightly
elongated cells, and is intimately connected with the muscular wall,
without any intervening areolar tissue. The extremities of the
glands even dip more or less into the muscular layer, and it is
probable that a considerable proportion of the thickness of the
uterine wall really corresponds in development to the muscularis
mucosae, so that if endometritis exist it is not likely to be strictly
limited to the mucous membrane, but will affect the uterine walls
to some depth.
Acute Metritis and Acute Endometritis. — This latter condition is
sometimes spoken of as uterine leucorrhoea or catarrh. It often
runs a rapid course, and is overlooked until it has subsided into
the more chronic form.
Causation. — There are practically three grades of acute inflam-
mation affecting the entire uterus. The first, most intense, and
rarest form, is that due to septic absorption as witnessed in cases
of abortion and parturition, operations upon the uterus, such as
enucleation of fibroid tumors or evacuation of retained menstrual
fluid, or even from the use of sponge-tents, or mere division of the
cervix.
The inflammatory process generally extends to the peritoneum
and surrounding cellular tissue, involving the broad ligaments.
ACUTE METRITIS AND ENDOMETRITIS. 145
The next occurs for the most part independently of the puerperal
- state, and seldom runs so severe a course as the former. It is gen-
â– : erally dependent upon some traumatic injury, such as the applica-
tion of powerful styptics or caustics to the interior of the uterus,
whether by swabbing or as intra-uterine injections, the wearing of
Hntra-uterine stem pessaries, etc., the absorption of septic material
' in some cases being more than probably a complicating condition.
The third variety, where though the majority of the tissues are
implicated, the inflammatory process is rarely so intense as in the
two former, occurs mostly from exposure to cold during menstrua-
tion, the extension of gonorrhceal or other acute inflammation from
:.the vagina, injury from intemperate or immoderate coitus, and de-
r composition of retained menstrual fluid in consequence of flexion
or stenosis. As a sequela of the exanthemata, endometritis is not
^at all infrequent.
The mere passage of the uterine sound in some cases may prove
suflicient to set up acute metritis.
Pathology. — In the severe acute stage we have infiltration and
i softening of the uterine tissue, especially in the layers subjacent
.^to the mucous membrane, with intense and acute hypersemia of the
mucous lining itself, which is red, swollen, oedematous, and soft-
ened. Ecch^mioses are not infrequent, and even small collections
of pus may be noticed between the muscular fibres, in the uterine
veins, or in those of the broad ligaments, but abscesses of any size
are exceedingly rare in the wall of the uterus. The inflammation
not infrequently extends from the uterine mucous membrane along
the ^ Fallopian tubes to the peritoneum, causing salpingitis and
purulent peritonitis, with pelvic cellulitis and even abscess of the
ovary, the intensity of these latter symptoms often preponderating
over those of the primary disease.
Symptoms. — In the septic and traumatic varieties of metritis the
onset of the attack is usually evidenced by a rigor, acceleration
of pulse, elevation of temperature, and other well-marked febrile
symptoms. The patient complains of a feeling of heat and fulness;
bearing down or dragging in the pelvis ; pains in the back radiating
to the groins and thighs; tenderness over the lower abdomen,
which is more or less tympanitic ; tenesmus of the bladder and
rectum, and not infrequently of the uterus as well. The pulse
3oon becomes very rapid, small, and compressible. Where peri-
tonitis is marked, the abdomen becomes very tympanitic, the
breathing often hurried, the breath having the peculiar sweetish
odor so characteristic of septicaemia.
Where septic metritis ensues as a consequence of abortion or
parturition, the discharge or lochia becomes arrested. In some
3a8es of traumatic injury, such as occurs when a piece of solid
nitrate of silver is inserted or falls into the uterine cavity, a pro-
ftise h?emorrhagic discharge arises, constituting the " metritis
bsemorrhagica " of West.
Where the inflammation is chiefly confined to the lining mem-
brane of the uterus and to the subjacent muscular tissue, the peri-
10
146 INFLAMMATION OF THE UTERUS.
toneum and surrounding cellular tissue not being involved — acut
endometritis proper — the symptoms are not so urgent. Tlie patiei
experiences throbbing, with a sense of weight or bearing dowi
irritation of the bladder, pain and tenderness on movement c
pressure. The pain in some instances is paroxysmal from uteri ii
tenesmus, and may last for an hour or two at a time, exhaustin
the patient to an extreme degree. The bowels are usually const
pated, but occasional attacks of diarrhoea from reflex irritation c^
the rectal nerves at times occur.
The discharge in the first instance is generally very slight an-^
of a serous nature ; after a few days it becomes more profuse au'
muco-purulent, often tinged with blood. It is more or less acric
and of an offensive odor, setting up intense irritation if allowed t
come in contact with the surrounding parts, and may produce es.
coriation with pruritus of a most troublesome character.
Physical Signs. — On examination the vagina is found to the toucJ
to be hot and dry, the uterus bulky, tender, and softened; the o
uteri gaping, the cervix swollen, very sensitive to pressure, an«*
lower than normal in the pelvis.
By the aid of the speculum the cervix may be seen to be oedeiDi
atous, enlarged, and of a livid hue. i
The discharge exuding from the os may be either clear and a
buminous, muco-purulent, or viscid, hanging out in a long string
Xo attempt should be made to pass the uterine sound for fear c1
aggravating the already existing mischief, and even the speculurl
must be passed with the greatest care, as considerable pain is pre
duced by pressing on the uterus.
Differentiation. — The slighter degrees of acute metritis and endc
metritis, uncomplicated by peritonitis or pelvic cellulitis, may b'«
recognized by the increased bulk and tenderness of the uterus O]-;
conjoined manipulation, and its mobility. The conditions mos '
liable to be confounded with acute metritis or endometritis, ar
pelvic peritonitis and cellulitis, and possibly acute vaginitis.
The constitutional symptoms of the two former are generall;
more marked than in the disease we are now considering. Th
initiatory rigor, rapidity of pulse, and elevation of temperatur
will often point to the nature of the inflammation. The immo
bility of the uterus from surrounding deposit, without any unusua
increase of uterine discharge, will also assist us in forming ai
opinion. In vaginitis the constitutional disturbance is often lee
marked, the situation of the pain somewhat different, and the dis
charge from the vagina characteristic.
Prognosis. — The simpler forms may end in recovery within fiv<
or six weeks without having attracted much attention, or ma;^
merge into the chronic form, relapses not infrequently taking plac(
at successive menstrual periods.
In the septic form, whether puerperal or traumatic, the prog
nosis is always grave, the inflammation extending to the perito
neum, and setting up purulent peritonitis, which proves rapidh
fatal.
ICE-WATER CAP. 147
Treatment. — It is important to distinguish the different varieties,
as the management of the case will vary, depending upon the se-
verity of the attack.
In septic metritis, the symptoms from the first are often of
; an adynamic type. Any portion of retained placenta or ovum,
blot, decomposing tumor, or debris^ should at once be removed if
i possible. A stream of carbolized or iodized water should first be
injected, or allowed to gravitate into the uterus, so as to wash away
-any debris or decomposing matter. K the cervix be sufiiciently
dilated the finger may then be introduced, and the cavity of the
^mterus carefully explored. Should this be found impracticable,
Ffansesthesia may be induced, and then the finger pushed carefully
Hin, or we may dilate the cervix by means of a sponge-tent, and
then explore the interior. If no debris be detected, it may still be
advisable to wash out the cavity of the uterus at least twice a day,
Dftener if the discharge be very ofl:ensive, as the system may be
t-3nabled to withstand a moderate dose of the poisonous material,
j»but prove quite unable to tolerate the continuous or intermittent
?i mbibition of fresh doses of septic matter.
Internally quinine proves most valuable, given in 10, 15, or 20
^rain doses every four hours, until the temperature comes down or
i ntolerance of the drug is established. If the patient's stomach is
^ rritable and such doses cannot be retained, the kinate of quinine
n less quantity may be injected subcutaneously. A solution of
lifteen grains to the drachm of water is made, and the injection
-epeated at short intervals. Warburg's tincture in half-ounce
loses every three or four hours for two or three doses will some-
imes be retained by the stomach when quinine itself fails to be so.
Turpentine in Tn>xv-xx doses, given in mucilage, occasionally acts
^ IS a useful stimulant, where much tympanitis is present.
Opium in some form will generally be requisite to allay pain and
;[uiet nervous disturbance. A pill of quinine gr. ij, with extract
)pii gr. ss-j, answers well, given every three or four hours if nec-
essary. Morphia, as suppository or hypodermically, may be tried.
The liquor opii sed. in n\^xv-xxx doses proves very useful in some
3ases.
An enema of starch and laudanum (Tri,xx-xxx) frequently re-
peated, or a suppository of morphia (gr. J-J), may be given with
^ood effect.
Where the temperature runs high and threatens life by its per-
dstent elevation, efforts should be made to reduce this by the ap-
)hcation of cold. This may be effected by means of Thornton's
ce- water cap, which consists of coils of india-rubber tubing, through
vhich a continuous stream of ice-cold water can be made to circu-
late round the head. Another method is to employ a water-bed,
ind change the water repeatedly, or continuously by an improved
nethod whereby cold water runs in at one extremity and passes
)ut by another tube at the other extremity of the bed. Small
vater-cushions, filled with ice-cold water, may be packed around
he patient, and thus serve to diminish the temperature. In some
148 INFLAMMATION OF THE UTERUS.
cases small doses of tincture of aconite or of tincture of veratrum
viride frequently repeated may prove of service.
'No aperient medicine should be prescribed ; if any accumulation
be present, an enema of olive oil will accomplish all that is requisite.
Some authors still recommend calomel and opium in the early
stage ; 1 gr. of the former with J gr. of the latter, given in form
of pill every four, six, or eight hours for the first forty-eight hours,
being careful to stop short of salivation ; but in cases of severe
septic metritis it is of the first importance not to lower still farther
the vital powers. Opium alone should be regarded as our sheet-
anchor, and given sufficiently often to keep the patient free from
pain.
Leeches are seldom indicated, and only annoy the patient.
Locally, a poultice of crushed linseed covered by oil-silk should
be placed over the hypogastrium, and changed only morning and
evening. Where even the weight of this proves too much for the
patient, the surface of the abdomen may be smeared over with a
mixture of the extract of belladonna (Sss) and glycerin (Siijss), and
then covered over mth a thick layer of cotton-wool and oil-silk
externally. This often affords considerable relief.
Hot fomentations with laudanum or turpentine may be employed
where the pain is very severe, or the inflammation has spread to
the surrounding structures.
The patient's strength in the meantime must be supported by
means of milk, beef-tea, jellies, eggs, and other similar forms of
nourishment, administered at short intervals.
Alcohol in some form will generally be found requisite, brandy
or whiskey being the best forms. If the patient is unable to re-
tain nourishment on her stomach, nutrient enemata must be given. .
Two ounces of good beef-tea with a like quantity of warm milk,
one tablespoonful of brandy, and tt\^xx of liq. opii sed., injected
every eight hours, will be sufficiently often.
In the simple form of acute metritis and endometritis, uncom-
plicated by peri-uterine inflammation, the patient must be kept
perfectly at rest in bed. After the diagnosis has once been made,
all further examinations, employment of speculum or internal ap-
plications of any kind, should be avoided. If the case be very
severe and it be deemed prudent to apply leeches, they will prove
equally serviceable if applied round the anus or over the pubes.
From six to ten w^ill generally be sufficient. Hot fomentations, =
with or without laudanum or turpentine, should be regularly ap-
plied to the lower abdomen, or glycerin and belladonna, as before
indicated, covered by cotton-wool and oil-silk. Dr. Barnes recom-
mends a plasma consisting of one drachm of extract of belladonna
mixed with half an ounce of mild blue ointment and two ounces
of simple cerate, spread in a thin layer upon a piece of lint and
covered with cotton-wool.
Pain must be alleviated by means of opium or morphia given
as suppository, subcutaneously, or in form of pill, or in combina-v
tion with salines. The only injections likely to prove serviceable
VAGINAL INJECTIONS. 149
are copious streams of warm water into the vagina as soon as there
J is any muco-purulent discharge, medicated with a little carbolic
acid, 1 in 40, or made soothing with laudanum, 5j ad Oj aquam,
infusion of bran, linseed, or starch. Warm hip-baths may also be
employed, care being taken to allow the water to gain access to
the vagina either by means of the bath-speculum or by employing
ithe syringe.
] Later on, saline aperients prove of service. The Hunyadi Janos,
!' Piillna, or other natural waters answer well.
- Hot-water vaginal injections have lately been strongly advocated
J by Emmet and others as proving an invaluable aid in the treat-
ment of all conditions of uterine disease. To be effectual the
patient should recline in the dorsal position, with the hips elevated,
and at least half a gallon or more of water at a temperature of
100° to 110° F. be allowed to flow into the vagina in a continuous
stream. This may at first sight seem difficult to accomplish in
private practice, but is really very simple, and only needs a little
, practice and perseverance on the part of the patient to accomplish
(the object satisfactorily.
! An ordinary can, such as is used for holding bath-water, capable
) of holding one or two gallons of hot water, is placed upon a table
' or chest of drawers near the bed or couch upon which the patient
Hies. Three to six feet of india-rubber tubing of about half to
! three-quarters of an inch bore, having a leaden weight, perforated
' in the centre, at one end, so as to prevent the tube falling out of
â– the can, and a vaginal tube with stopcock or tap at the other end,
sis then inserted through the spout of the can. The stopcock being
^ opened the tube is immersed, all but about six or eight inches, in
' the water so as to fill it ; the tap being now turned, the tube is
t drawn out all but the lower twelve or eighteen inches. When the
vaginal end is held at a lower level than that of the water and the
I tap turned, the natural law of gravitation comes into play, and we
-ihave the syphon action produced, whereby a continuous steady
-stream of water can be made to flow into the vagina without any
effort on the part of the patient, and without the intervention of
any skilled nurse, servant, or other assistant. By regulating the
height at which the can is placed and the calibre of the tube, we
can modify the force and size of the jet at pleasure. To prevent
' the tube collapsing as it hangs out of the spout of the can, it is
necessary to have a coil of wire inserted in the final two feet of the
'tubing.
Another method is to pro\dde a bath-can, a small tub, or other
vessel capable of holding about two gallons of hot water. I^ear
'the bottom of this is inserted a tap or spigot, to which five or six
? feet of india-rubber tubing is attached, a tap and vaginal nozzle
being added so as to enable the patient to use it herself. Dr. Per-
cival has also invented a syphon uterine douche.
It is impracticable for a patient to use a syringe herself whilst
reclining on the back ; but this, if necessary, can be entrusted to a
nurse.
150 INFLAMMATION OF THE UTERUS. .
A certain amount of benefit may doubtless be derived by the j
patient employing a syringe with hot water whilst sitting over a ]
bidet or other arrangement, but we do not secure the advantages, 1
claimed by Dr. Emmet, gained by his method of injection. j
Having overcome this difficulty, our next will be in carrying off i
the water as it flows from the patient without wetting the bed or \
soiling the patient's linen. To accomplish this the simplest method J
to adopt is for the patient to lie crosswise upon the bed, or at the ^
end of a couch, with the hips at the edge, a pillow under the back =
so as to elevate the hips somewhat, and her feet resting upon chairs. I
A piece of mackintosh about one yard square is placed over the j
pillow so as to protect this from getting wet, and the other end is j
draped into a tub or foot-pan below, so that the water falls into ;i
this. It is well for the patient to be undressed ready for bed, but
care must be taken that the body is properly covered to protect .
her from cold, the legs also being covered by a couple of shawls
or small blankets.
Another plan is to place a properly constructed bed-pan under*J
the hips, and to employ the douche whilst lying in bed. This is '
especially useful in cases of serous inflammation, where it is desir-
FiG. 94.
Improved Uterine Douche.
able to avoid lifting or moving the patient more than is absolutely
necessary.
An ordinary slipper bed-pan is of no use, as it holds so little that
it would necessitate constant emptying ; but if a tube be attached
to the large end so that the water can flow freely away into a tub
or foot-pan below, the difficulty is overcome.
Various devices have been resorted to to obviate the necessity of
employing a bed-pan or other similar arrangement. They, how-
ever, necessitate the assistance of a second person, and this is in
many cases objectionable, for the mere fact of having some one at
hand who will save the patient all personal trouble, seems in some
cases to remove that healthy stimulus to self-exertion which is at
times such an important adjuvant in the case of uterine disorders.
Still, there are other cases Avhere it would be out of the question
for the patient herself to administer a continuous injection of hot
water, and for such the cup or shield apparatus as indicated above
may prove of service.
HOT-WATER INJECTIONS. 151
To obviate the risk of the water being injected directly into the
i uterine cavity, the nozzle must be directed along the recto- vaginal
f wall until it has reached the posterior vaginal cul-de-sac and the
stream allowed to flow gently at first until the vagina has become
; distended. Still, in some cases where the cervix is lacerated or the
•cervical canal dilated, there is great risk of the nozzle being passed
directly into the cervix and the Avater forcibly injected into, the
uterus. Such an accident would set up violent uterine contraction,
-severe pain, and even collapse. Should the fluid be forced up
^through the Fallopian tubes, acute pelvic peritonitis, with death as
5 a consequence, might ensue. To prevent this, Thomas suggests
â– the employment of a nozzle with a reverse current, the water
flowing back towards the outlet of the vagina, and not directly
^forwards, as occurs with an ordinary nozzle.
The immediate effect of the hot water is to cause relaxation, and
to increase the congestion of the parts ; but if its application be
prolonged, reaction ensues and contraction takes place. The capil-
laries are excited to increased action, the tonic effect extends to the
coats of the larger vessels, their calibre in turn becomes lessened,
and with this approach to healthy action the congestion is dimin-
ished. The blood being thus driven from the local parts, the
weight of the uterus and its appendages is reduced, the tenderness
• due to congestion is removed, and when inflammation is present it
i is relieved. The absorption of products of inflammation is assisted,
and the normal mobility and elasticity of the tissues is restored.
Emmet thus describes the effect of hot- water injections. The
f mucous membrane is found blanched in appearance, and the usual
size of the canal lessened in calibre, as after the use of a strong
astringent injection. As the patient lies on her back, with her
hips elevated, the action of gravity will be brought into play, by
which the veins will be rapidly emptied, sufficiently to relieve the
over-distention.
Then, in this position also, the vagina will become fully distended
+by the weight of water, and kept so, since only the surplus amount
can run off into the bed-pan beneath. The hot water will then be
in contact with every portion of the mucous membrane, under
which the capillaries lie. The vessels going to and from the cervix
and body of the uterus pass along the pelvis on each side of the
•vagina, and their branches inclose the vagina iu a complete net-
\work. The vessels of the fundus, through the veins of which the
blood flows to the liver and back into the general circulation, com-
' municate freely by anastomosis with the vessels distributed to the
body and cervix below. If, then, we are able to cause the vessels
of the vagina to contract, through the stimulus of the hot water,
we can, directly or indirectly, influence the whole pelvic circulation,
and thus reduce it almost to a natural condition. He finds the
best mode of all is to have the injections given while the patient is
placed on her knees and elbows or chest. But this position is a
difficult one to assume, since those who are in the greatest need of
hot water have not the strength to remain in this posture long
162 INFLAMMATION OF THE UTERUS.
enough to accomplish the purpose ; and considerable difficulty is
also experienced in keeping the patient dry. The hour of bedtime
is generally the best in which to seek for the beneficial effects of
hot water on the reflex system in allaying the local irritation ; for
prolonged vaginal injection at a high temperature will often act
with more promptness than an anodyne in allaying the nervousness
and sleeplessness of an hysterical woman. :
In rare instances cases are met with where a sense of weight and'
an uncomfortable feeling are experienced about the pelvis after an
injection of water at the usual temperature.
CHRONIC CERVICAL ENDOMETRITIS. 153
CHAPTER X.
CHRONIC CERVICAL ENDOMETRITIS*
Chronic Cervical Endometritis. — This term has been applied to
chronic inflammation of the mucous membrane of the cervix, or
that portion extending between the os internum and the os exter-
num. Other names — such as endo-cervicitis, cervical catarrh, or
leucorrhoea — have been employed to designate this condition.
It is probably the most frequent of all diseases of the uterus,
judging from the fact that it is almost universally present in the
majority of patients seeking advice for uterine disorders.
Pathology. — To understand properly the pathology of this affec-
tion, we must call to mind the minute anatomy of the mucous
membrane lining the cervix. This is disposed in folds and ridges,
constituting the arbor vit?e, is covered over by cylindrical and cili-
ated epithelium, and studded with numerous villi. Between the
folds are countless mucous glands, the so-called glands or follicles
of Xaboth, the number of which has been estimated as being at
least 10,000. When this membrane becomes inflamed it is found
to be swollen and hypereemic, the mucous glands being especially
involved, pouring out a glairy, viscid mucus, which fills up the
cervical canal in the form of a tenacious plug.
The cervix itself is more or less swollen and softened. The villi
or papillae on the vaginal face of the cervix become hypertrophied,
giving rise to an appearance termed granular degeneration.
Later on the mucous membrane itself becomes hypertrophied,
and we get eversion of the os and lower portion of the canal.
In those cases following on parturition, where the whole thick-
ness of the cer\ix becomes inflamed, especially if laceration has
taken place, areolar hyperplasia with induration generally occurs.
Causation. — In virgins and nulliparae we meet with a form of
chronic cervical endometritis, due chiefly to catarrhal inflamma-
tion of the lining mucous membrane, where the tissue of the cervix
is only moderately involved. The causes predisposing to this con-
dition are natural feebleness of constitution, especially if there be
any scrofulous or tuberculous tendency, want of fresh air and exer-
cise, insufficient nourishment, and other similar influences. The
chief exciting causes will generally be found to be the effect of cold,
extension of vaginitis, whether simple or specific, uterine displace-
ments, excessive or intemperate intercourse, and the employment
of intra-uterine stems.
In married women who have had one or more children, the
whole thickness of the cervix is apt to become infiamed, as a result
of the bruising or laceration during parturition. Here the lining
154 CHRONIC CERVICAL ENDOMETRITIS.
membrane of the cervix not only becomes inflamed, but hyper-
plasia and induration of the tissue of the cervix ensues. In addi-
tion to the causes already mentioned as predisposing to endome-
tritis, frequent parturition, subinvolution, and excessive lactation
may also be mentioned. The exciting cause in the majority of
cases will be the bruising of the cervix during parturition, more
especially where laceration also occurs. Acute puerperal endo-
metritis may terminate in this way.
Symiotoms. — Owing to the slight amount of sensibility possessed
by the cervix, inflammation may be present without attracting the
patient's attention ; even the presence of abundant leucorrhoeal dis-
charge may pass unnoticed, although on examination with the
speculum the canal of the cervix is found to be filled with a glairy,
viscid, mucous secretion.
This leucorrhoea is often the first symptom leading the patient to
believe anything is amiss. She then begins to experience dragging
sensations about the pelvis, bearing down and pain in the back,
aggravated on standing or walking, and generally worse towards
the menstrual periods, which latter become altered in character,
often painful, and irregular as to frequency and quantity.
The discharge is at first of the nature of boiled starch, thick,
viscid, albuminous. K villous erosion complicates the cer^dcal en-
dometritis, the discharge is more muco-purulent, tinged with blood,
acrid in character, producing considerable irritation in the vagina
and vulva, and even setting up inflammation.
As the disease becomes established, constitutional symptoms be-
come more marked. The nutrition becomes impaired, owing to
diminished appetite and enfeebled digestion ; nausea and vomiting
are not infrequent. The patient becomes nervous and hysterical,
despondent and fretful ; complains of vertical headache, intercostal
neuralgia, and other anomalous aches and pains. The abdomen is
often distended, the bowels confined, the urine turbid, micturition
painful or diflicult, the bladder irritable from pressure w^here hyper-
plasia with ante- or retro-version exists, cystitis itself being not
infrequent.
Where hyperplasia of the cervix complicates endometritis, there
is often dull aching pain complained of on sexual intercourse, and
haemorrhage as well if any villous erosion be present.
Physical Signs. — On digital examination we may fail to detect any
well-marked evidence of any existing disease ; the uterus may not
be increased in bulk, nor tender to the touch, unless pressure
be applied so as to push up the uterus somewhat. The os uteri
may be enlarged, the lips sw^ollen or roughened if any granular de-
generation exists, or we may find a perfectly normal os. If now
the speculum be passed and the cervix exposed, we shall generally
find the canal filled with a tough, tenacious, mucous plug, resem-
bling unboiled white of Qgg, which resists all ordinary attempts at
removal. On extracting this by twisting it round a Playfair's probe
coated with cotton-wool, there may be no marked evidence of dis-
ease, the glands alone being affected, and no granular degeneration
MEDICAL REMEDIES. 155
present ; or there may be found an intensely red and inflamed con-
dition of the canal, due to removal of the epithelium and excessive
hypertrophy of the villi. If the bivalve, or Sims's, speculum be
employed, this condition is more readily observed. Where cervical
endometritis occurs as a result of injury during abortion or par-
turition, there is usually marked hyperplasia of the cervix, with
irregularity of the surface from lacerations of the tissue.
Prognosis. — Cervical endometritis as a rule shows little tendency
to spontaneous cure; it is a most obstinate disorder, and if un-
checked often induces hyperplasia, with consequent displacement
and other troubles. The less viscid and the less in quantity the
mucous discharge is, the more favorable is the prognosis. WTiere,
however, the granular disease is slight, and the amount of thick,
tenacious mucus blocking up the cervical canal considerable, the
prognosis is much less hopeful. Destruction of the diseased glands
by some radical method here offers the only hope of relief. Treat-
ment is at all times very tedious, and relapses are very liable
to occur.
Treatment — Although chronic cervical endometritis may be re-
garded as a local disorder, the judicious combination of constitu-
tional remedies with local treatment w^ill be indispensable to secure
relief from such an intractable disorder. The general health must
be carefully looked to, the bowels regulated by some simple saline
or chalybeate aperient, of which the sulphate of magnesia, the
double tartrate of soda and potash, Carlsbad salts, and other simi-
lar preparations in combination with some form of iron prove most
serviceable.
For this purpose a mixture as follows may be prescribed :
;^J. Ferri tartratae oss, sodse tartratse Sj-iss, acid tartarici 5j-iss,
syr. zingib. 5j, aquae ad 5vj. — M. Two tablespoonfuls added to half
a tumblerful of warm water, to be taken every morning the first
thing, and repeated during the day if necessary.
A less palatable but still useful mixture is: ^, Magn. sulph.
5j-iss, ferri sulph. gr. xii, acid, sulph. dil. 5ss-j, syr. zingib. oj,
aqu?e ad Svj. Dose as above.
If pills be preferred, a useful combination consists of ext. aloes
aquosse gr. xij, ext. nucis vom. gr. iij (vel extract, belladon. gr. iij);
pil. rhei co. gr. xxiv. — M., et. div. in pil. xij. One to be taken
every night at bedtime.
A mild, unstimulating, nutritious diet, regular daily exercise,
short of fatigue, plenty of fresh air, massage, and everything con-
ducive to health should be enjoined. Occasional warm baths,
friction, and wearing of flannel should be resorted to, in order to
keep the skin in a healthy condition. To improve the appetite
and promote digestion a mixture as follows may be prescribed :
I^. Acid. nitr. hydrochl. dil. 5iij, liq. strychnise 5j (vel tinct. nucis
vom. oij-iij) tinct. cinch, co. .^ss, tinct. chlorof co. 5iij, syr. aurantii
Siss, aqu8e ad Svj. One tablespoonful in a wineglassful of water
twice or thrice daily, after meals.
156 CHRONIC CERVICAL ENDOMETRITIS.
In some cases preparations of bismuth, pepsine, etc., are indi-
cated, and should be prescribed.
Bromide of potassium proves very useful where much nervous
disturbance co-exists, but should not be given for too long a time
continuously.
A\Tiere any doubt of syphilitic infection being present exists, a
combination of the hydr. perchl. with pot. iod. often proves emi-
nently serviceable.
Local Treatment. — Where the external os is contracted, it will be
better at once to ob^'iate this by making a crucial incision, either
with the scissors or scarifier, so as to divide freely the external
fibres of the os, touching the raw edges with the liq. ferri perchl.,
so as to prevent union again taking place. This will enable us to
command more thoroughly the cervical canal for the application
of remedies, and will also permit the ready exit of discharges. In
cases where the cervix is acutely painfiil or tender, this crucial
incision allows a certain amount of blood to flow, and so lessens
the engorgement of the cer\dx, or this may be still further encour-
aged by stabbing or scarifying the cervix as elsewhere indicated.
Where the cervical glands are much enlarged, we may accomplish
a certain amount of local depletion as well as obliteration of the
diseased glands by scarifying freely the lining membrane of the
cervical canal by means of a narrow-bladed knife drawn in parallel
lines along tlie inner surface of the canal.
K the external os be already sufficiently dilated, and local de-
pletion be not deemed necessary, we may proceed at once to the
application of remedies.
Treatment should always be commenced shortly after a men-
strual period if possible, as there is then less risk of setting up
mischief by interference.
It will be prudent to limit our applications at first to the canal
of the cer\dx alone, not carrnng them up beyond the internal os.
as even when the body of the uterus is implicated, if the inflam-
mation of the cervix be cured, that of the body often disappear^
in consequence; but should this not happen, treatment can sub-
sequently be directed to this. Before applying any of our remedies,
the cer\acal canal must be thoroughly cleansed of all inspissated
mucus. This may readily be efiected by passing a Playfair's probe
coated with cotton-wool, slightly curved, up the canal, and then
tAvisting the probe round so as to entangle the \dscid mucus and
then withdraw it. K this fail, a small piece of sponge, the size of
a raspberry, fixed in a holder, or held in long dressing-forceps,
may be passed up and twisted round, the sponge being then thrown
away. A long-nozzled syringe has been invented for this special
object, but either of the methods just mentioned will generally
prove sufficient.
Should the method indicated still fail in removing the tenacious
plug of mucus, it will be well to pass the probe saturated with
carbolic acid, or whichever remedy we intend applying, and twist
this round several times; this mil effectually overcome the diffi-
I
playfair's probe. 157
culty. A second application should then be made so as to ensure
thorough cauterization of the diseased surface, the probe being
left in sufficiently long so as to irritate the uterus into contracting
upon the probe and squeezing out the fluid.
In some cases it is a prudent plan to pass a sponge-tent up as
far as the internal os uteri, and allow it to remain in for a few
hours, and then make the application on its removal.
By this means we unfold the countless convolutions and Fig. 95.
rugae of the arbor vitae, and allow the caustic to come
into direct contact with the entire surface.
Vaginal injections of warm water, borax, etc., night
and morning, should always be resorted to, if for no
other purpose than to cleanse the passage from all secre-
tions, which otherwise keep up irritation.
Mode of applying Caustics to the Cervical Canal. — Having
enlarged the external os if necessary, punctured the cer-
vix, or scarified it, to produce local depletion, if requi-
site, and removed the plug of inspissated mucus gener-
ally found blocking up the cervical canal, we have now
to consider how best to apply our remedies.
These may be employed either in a liquid form or in
form of crayons or pencils. The more usual and prob-
ably the most eflacacious method is in the form of strong
solutions,
j A Playfair^s Probe (Fig. 95), the terminal three inches
of which is made of aluminium, so as to resist the effect
of ,acids, is first coated with a thin layer of cotton-wool,
the probe being roughened, and having a slight bulb at
the terminal extremity so as to prevent the cotton slip-
ping oft'. Absorbent cotton or jeweller's cotton should
be employed, as, being chemically cleaned, it takes up
fluid more readily, and the fibre being long and fine the
cotton is less likely to become detached.
A thin layer, triangular in shape, about three inches
long, is held lightly between the finger and thumb of
the left hand, the point of the probe is placed at one
angle of this, and then twisted round and round so as
to dispose the cotton firmly and evenly over the probe.
This requires some little practice to accomplish. Having
placed the patient in the left lateral position, ascertained
the direction of the canal by means of the uterine sound,
and passed a Fergusson's speculum, the probe is then ""pro'be'
dipped for about two inches in the solution we intend
to employ, any superfluity being carefully squeezed out against
the neck of the bottle.
The OS being well in view, the probe is then passed within as
far as the internal os, and allowed to remain for a few seconds, or
even for a minute, until the cervix contracts upon the probe and
thus secures the complete action of the remedy. The probe is
then gently rotated and gradually withdrawn, any excess that may
Playfair's
158 CHRONIC CERVICAL ENDOMETRITIS.
have run down into the vaginal cul-de-sac is carefully mopped up,
a plug of cotton-wool, with string attached, saturated in glycerin,
is then passed up to the cervix, held there by a sound or other in-
strument until the speculum is withdrawn, when the operation is
completed. If this treatment he resorted to in the consulting-room,
the patient should as a rule drive home and remain quiet for the
rest of the day. The plug may he removed at bedtime, when the
syringe is employed for vaginal injection, or left until the follow-
ing morning.
If nitric acid be employed it is well to inject a little saturated
solution of carbonate of soda into the vaginal cul-de-sac, so as to
preclude any of the acid running down and irritating the vagina;
any excess of the acid must also be carefully neutralized by the
same agent.
In every case the probe should be accurately curved to corre-
spond with the direction of the cervical canal ; no force should be
employed, lest the tissue of the cervix be injured. To remove the
cotton-wool from the probe, with a pair of scissors cut along the
convexity of the curve, then dip the end in water and again use
the scissors until all the wool be displaced.
Sims devised an instrument by means of which a roll of cotton
soaked in any medicated solution may be left within the cervical
canal by sliding it off on withdrawal of the probe, similar in con-
struction to Barnes's tent-introducer.
We can thus leave the agent employed longer in contact with
the diseased surface, and so ensure a more thorough and lasting
application of it. A string attached to the cotton enables the
patient to withdraw it in the event of the uterine contractions not
expelling it within the course of a few hours.
The same object may be attained, if the operator be an adept,
by rolling the cotton lightly on a smooth probe, and reversing this
latter as soon as the canal contracts upon it, so as to loosen the
hold of the cotton and allow it to remain within the cervix.
The agents most useful in modifying the condition of the cer-
vical canal when affected by endometritis are : Carbolic acid,
kept liquid by adding 5j of glycerin to 5j of the pure crystallized
acid, liquefied by heat (a few grains of camphor added to this pre-
vents solidification again, even at a freezing temperature); carbolic
acid, liquefied as above, with equal parts of linimentum or liquor
iodi; liquor ferri perchlorid. fortior, alone or diluted with an equal
quantity of glycerin; acid, nitric, fortior; nitrate of silver solu-
tion 5j ad 5j aquam ; chromic acid 5j ad 5j aquam ; linimentum
iodi ; glacial acetic acid ; acid nitrate of mercury.
Frequency of Application. — As a general rule it will be necessary
to repeat the application of most of the agents employed about
once a week, changing them from time to time. It is always well
to begin with carbolic acid, as being less powerful than some of
the others mentioned, and less likely to produce contraction or
occlusion of the os. Moreover it exerts a marked local ansestheti*
eftect, and so proves less painful to the patient. It is an extremeh
. APPLICATION OF CAUSTICS. 159
I useful agent, and in the majority of simple cases will alone prove
^ sufficient to effect a cure. It may be applied within a few days of
the cessation of the menstrual period, then again within a week,
and a third time a week after, thus leaving a clear interval of ten
days before the expected appearance of the next catamenia.
Iodine, whether in the form of liquor iodi (1 in 24), linimentum
iodi (1 in 9), iodized phenol (iodine 5ss, crystallized carbolic acid
5ij, water 5ij = 1 in 5), or linimentum iodi and carbolic acid in
equal parts, is a most valuable application. It is not only a local
stimulant, but also a powerful alterative, stimulating the absorb-
ents, and being taken up into the general circulation and so pro-
ducing a double action.
Patients will often detect the taste of iodine within a very short
time of its application.
It has the advantage also of not losing its efficacy by frequent
employment, and acts promptly in causing contraction of all the
blood-vessels within range of its influence.
If carefully used, the combination of the linimentum iodi with
liquefied carbolic acid is the most efficacious, and may be safely
' employed.
Nitric Acid should never be applied to the cer\dcal canal until
' other remedies have first been employed to test the toleration of
caustics, as it sometimes produces a considerable amount of pain
with reflex nervous symptoms which may last for some days. It
should be reserved for very severe and intractable cases, where
• other remedies have been tried and failed, and then only applied
once shortly after a period, other agents, as a rule, being employed
; in the interval. If necessary the acid may again be used after the
next period, and so on, once a month, for two or three months.
It is well to state that the acid causes destruction of tissues and
may lead to contraction of the cervix or occlusion of the os uteri.
I have met with instances where retention of the menstrual fluid
— hsematometra — has ensued and an operation been requisite to
restore the patency of the os uteri.
In appropriate cases, when properly applied and not repeated
too frequently, it is unquestionably a very useful application, but
should never be employed by those who are not thoroughly famil-
iar with the practice of gynecology.
Liquor Ferri Perchloridi fortior is a very powerful styptic, and in
cases where the endometrium is seen to be in a state of extensive
granular degeneration, may be applied with benefit, but not too
often. It is well to inject a little saturated solution of carbonate
of soda into the cul-de-sac of the vagina previously to applying the
iron, so as to neutralize any excess that may run down, as it has a
very irritating effect upon the vagina.
The acid nitrate of mercury offers no advantages over the nitric
acid, and is liable to produce salivation if the patient be at all sus-
ceptible.
Chromic acid is even more painful and irritating in its effect
than nitric acid, and is less generally applicable.
160 CHRONIC CERVICAL ENDOMETRITIS.
Grlacial acetic acid has been recommended as a painless applica-
tion in these cases.
Crayons or pencils made of the following substances have been
recommended for insertion into the cervical canal either by means
of a porte-cra^^on, Barnes's tube, or by the aid of a speculum and
forceps :
Mtrate of silver alone, or reduced by admixture with equal parts
of nitrate of potash, fused into moulds. Sulphate of zinc fused, so
as to make zinc points. Tannin, one drop of glycerin added to
ten grains of tannin, rolled out into a crayon. Iodoform gr. xv,
pulv. acaciie and mucilage quantum suf. made into a cylinder IJ
inch long.
In special cases crayons may be indicated, but they are far less
generally useful than the liquid caustics.
The application of the solid nitrate of silver, either by passing
the caustic in a holder up the canal or by leaving a small piece to
dissolve there, is not to be recommended ; the former method is
quite inefficient, the latter not unattended by danger, and in any
case liable to set up considerable irritation as the dissolved caustic
runs down into the vagina. K the case be really one of chronic
cervical endometritis, such as we are now considering, the only
applications at all likely to be brought into contact with any extent
of the lining membrane of the cervix are those in a fluid form,
applied by means of a Play fair's probe coated with cotton-wool,
sufficiently bulky to distend the canal somewhat and to secure a
thorough application of the remedy.
In practice the method of fusing nitrate of silver in a small cup
over a spirit-lamp, and then coating a specially constructed probe
with it, proves far too tedious to be of anything more than excep-
tional service.
In very intractable cases of endometritis, where the mucous
glands are severely affected, and nitric acid even fails to cure, our
only resort is to proceed to the destruction of the glands by still
more powerful measures.
The galvano-cautery, as well as the actual cautery, have been
employed in these cases, and with success, but there is always a
risk of subsequent contraction of the cervix.
Potassa fusa and potassa cum calce are liable to the same ob-
jection.
"Where the careful application of the nitric or chromic acid fails
in destroying the glands, the only way of effecting a cure is by re-
moval of the glands by means of the sharp steel curette.
A second operation may be necessary at some few weeks' inter-
val. It should be undertaken shortly after a period, and the pa-
tient confined to bed for a few days, precautions being taken as in
any other operation upon the cervix.
CHRONIC CORPOREAL ENDOMETRITIS. 161
CHAPTER XL
CHRONIC CORPOREAL ENDOMETRITIS.
Chronic Corporeal Endometritis. — This is the term commonly em-
ployed to express inflammation of the mucous membrane of the
body of the uterus. This latter has been described as being thin,
soft, pale, smooth, glandular, and closely adherent to the subjacent
tissues. It varies at diiferent periods in thickness, consistence,
and vascularity, and may be even absent. Dr. John Williams
thinks the mucous membrane of the uterus is of great thickness,
a considerable portion of the muscular wall of the organ being
formed by muscularis mucosae, which corresponds to the stratum
of muscular fibre-cells resting upon a layer of areolar tissue, termed
" submucous," in ordinary mucous membranes.
Pathology. — Bearing these anatomical details in mind, it wdll
readily be understood that the inflammatory process is not con-
fined to the mucous lining of the uterus, but extends to a greater
or less extent into the actual substance of the organ. The term
endometritis is limited to those cases where the inflammation pre-
ponderates in the mucous membrane, that of chronic metritis to
those cases where the parenchyma of the uterus is chiefly aifected.
In the early stage the mucous membrane is found to be swollen
and congested, the uterine wall thickened, and the bulk of the
uterus consequently increased. The secretion consists of an alka-
line, thin mucous fluid, or when the case is more severe it is
muco-purulent, rusty, or sanguinolent. Partial exfoliation of the
mucous membrane often occurs, the subjacent tissue being ele-
vated in the form of granulations or villous proliferations, which
bleed readity, constituting the disease known as fungoid or villous
endometritis. Later on, especially where the inflammation in-
volves the parenchyma of the organ, the mucous membrane be-
comes atrophied, the utricular glands obliterated, the epithelial
covering lost, or the cylindrical or ciliated epithelium replaced by
pavement epithelium.
Causation. — The predisposing causes most liable to give rise to
chronic endometritis are the strumous diathesis, general debility,
exhaustion from parturition or lactation, and prolonged mental
depression. Syphilis, in that it interferes materially with the de-
velopment of the uterine mucous membrane in early pregnancy,
must be regarded as an important predisposing cause. Abortion
frequently ensues and the membrane remains diseased.
Among the exciting causes may be mentioned exposure to cold
during menstruation, with consequent sudden arrest of the flow;
extention of the vaginitis, whether simple or specific; cervical
11
162 CHRONIC CORPOREAL ENDOMETRITIS.
endometritis, acute endometritis and metritis, puerperal or not;
retention of portions of decidua, clots, or placenta following abor-
tion or parturition; obstructions to the escape of secretions from
flexions or stenosis of the cervical canal ; congestions from dis- 1
placements or the presence of uterine fibroids or polypi, or from \
the abuse of sexual intercourse; mechanical injuries from passage
of the uterine sound, wearing of intra-uterine pessaries, or from
attempts to induce abortion; the exanthemata; phthisis.
Sudden arrest of the menstrual flow from exposure to cold dur-
ing menstruation, at a time when the uterus is in a state of intense I
hypereemia, would naturally tend to produce acute endometritis
terminating in the chronic affection.
The extension of vaginitis, more especially when of a specific
nature, is often witnessed in the newly married, the inflammation
extending not only to the cervix and body of the uterus, but also
to the Fallopian tubes, involving even the ovaries and setting up "
acute peritonitis. Dr. J^oeggerath has shown that a latent gonor- ]
rhoea or gleet in the husband may infect the newly-married wife -
with a low grade of inflammation, the s^nnptoms of which are not â–
sufficiently acute in the early stage to attract much attention, buti
which nevertheless eventuate in chronic endometritis and conse- "
quent sterility. Abuse of sexual intercourse may in some cas*
aggravate any lurking uterine disorder and account for the pro-
duction of endometritis. The acute inflammatory conditions in-^
place of ending in complete recovery may terminate in the more '
chronic affection.
Retention of portions of the placenta, of the decidua, or of clots,
and their subsequent decomposition, may lead to acute septicsemic
metritis, which, if the patient survive the attack, may terminate in
chronic endometritis, the body of the uterus being chiefly affected. ,
Obstruction to the escape of secretions from the uterus, whether ;
menstrual or othermse, from flexion or stenosis of the cervical
canal, is probably one of the most frequent causes of endometritis
among those who have never been pregnant, as also in virgins. It
is in these cases that the mischief is more especially limited to the
fundus, the cervix in many cases not being involved. Under ordi-
nary circumstances, when the menstrual blood escapes freely from
the uterus, coagulation is prevented by admixture with the acid
vaginal mucus, but if retained for smj length of time, or in any
considerable quantity, in the uterine cavity, it very soon becomes
clotted. These clots are unable to pass the constricted cervix; the
uterine cavity thus becomes distended; expulsive pains described
as spasms or colic are induced. The accumulation meanwhile
undergoing more or less decomposition sets up irritation and in-
flammation of the lining membrane of the body. When expulsion
is at length effected, it is apt to occur with a rush, the patient
perhaps stating that an abscess or gathering in her inside suddenly
burst, after which the pain subsided.
In membranous dysmenorrhoea, ivhere the lining membrane of
the body of the uterus is expelled in one piece, or in shreds, the
CHRONIC CORPOREAL ENDOMETRITIS. 163
menstrual decidua not undergoing complete disintegration, \'iolent
expulsive pains are often induced, similar to those we are now
considering.
In cases of flexion or stenosis the discharges are not infrequently
^ exceedingly oflfensive, causing much irritation in their passage over
the vagina and vulva, in some cases setting up a blenorrhagic dis-
charge in the wall and leading to the supposition of unchastity in
the female.
Cases of septic peritonitis or septicaemia are occasionally wit-
;nessed from escape of the decomposing secretions through the
? Fallopian tubes into the peritoneal cavity.
Mechanical injuries are too often responsible for attacks of endo-
F metritis, more especially if any tendency to inflammation previously
:: existed.
Si/mjytoms. — These vary very considerably. In some instances
they are so slight, or so masked and obscure, as not even to excite
the suspicion of the patient, or her medical attendant, of anything
i being amiss. Sometimes the disease may exist for years, the only
evidence of it being leucorrhcea, menstrual disorders, and nervous
derangements; at others displacement, with dysmenorrhoea, dys-
pareunia, pruritus vulvae, and serious inconvenience may result,
! rendering the patient's life one of continued discomfort.
The most prominent and most frequent symptom of corporeal
endometritis is leucorrhcea. This is either a profuse glairy mucus,
much less viscid than that occurring in cervical endometritis, or an
acrid muco-purulent secretion which irritates the passages and gives
rise to the most troublesome pruritus vulvae. A peculiarity of the
discharge is that it is often stained with blood and resembles the
' rusty sputa so characteristic of pneumonia, more especially shortly
, after a menstrual period, leading the patient to regard it as a pro-
' longation of the catamenia.
In elderly women who have passed the climacteric, the discharge
is more of a watery or creamy purulent character. It is in these
cases, when stenosis of the cervix occurs, that accumulations of
' fluid in the interior of the uterus take place— hydrometra. In some
instances the pent-up secretion suddenly escaping gives rise to the
supposition that an abscess has burst.
Menstrual disorders, such as menorrhagia, dysmenorrhoea, or
f irregularity are commonly noticed in the early stages. In the fun-
.goid variety of endometritis, profuse and often intractable haemor-
rhage is often the prominent symptom. Dysmenorrhoea is fre-
quently more marked in the latter stages, when induration of the
uterine tissue and degeneration of the mucous membrane have
taken place, menstruation being scanty and not infrequently ceas-
ing prematurely. In some cases exfoliation of the entire Ihiing
membrane of the uterus occurs, the so-called dysmenorrhoeal mem-
brane.
Sterility is an almost invariable result of endometritis, in many
cases being the only symptom that has induced the patient to sub-
mit to a local investigation. This is partly due to the leucorrhoeal
164 CHRONIC CORPOREAL ENDOMETRITIS.
discharge proving inimical to the life of the spermatozoa, an*
partly to the diseased condition of the lining membrane precludini
the normal development of the ovum.
Pain is almost invariably present, its intensity, varying in differ-
ent patients, depending upon their susceptibility to its influence at .
well as upon the extent of the uterine tissues involved. Dragging '
pain in the back, groins, and hypogastrium, often extending down-^
the inner sides of the thigh, is usually experienced, worse on stand- =
ing, walking, or coitus. In the large majority of cases the pain is^
worse on the left side, the reason of which is difficult to explain,
unless it be the distention of the rectum pressing upon the tendci
and often inflamed ovary.
The uterus itself is generally tender on pressure, much distres^
being often experienced fi"om the bearing-down efforts made when
the bladder or rectum is relieved, as well as from the passage oi-
hardened faeces through the rectum pressing upon the inflamed^
uterus.
Dysuria, frequent micturition, and even cystitis are not infre-
quently observed. As a rule the bowels are constipated, but diar-
rhoea may alternate with this condition.
Xervous disturbances of one kind or another are almost invari-
ably present in cases of chronic uterine catarrh. Headache, lim-.-
ited more or less to the vertex, of a neuralgic character, is almost^^
characteristic of this condition. The patient becomes fretful, de-,
spondent, and hysterical, crying upon very slight provocation, and
is quite incapable of concentrating her attention or of undergoing
any prolonged mental effort. In severe cases, where any heredi-
tary tendency to such affections exists, hystero-epilepsy, epilepsy,
or melancholia may ensue.
Minor neuralgic pains are often experienced, along the edge ol
the false ribs extending up to the shoulder ; in the right hypochon-
driac region, leading to the supposition of the liver being affected;
under the left mamma ; down the inner side of the thighs ; in the
soles of the feet, and in other unexpected positions.
Disorders of nutrition are generally well marked ; the appetite
becomes impaired, capricious, and even entirely wanting, the patient
loathing the sight of food ; nausea, vomiting, eructation, gastralgia,
flatulent distention of the abdomen — meteorism — with dyspepsia,
are often most distressing, in some cases leading to the supposition
of pregnancy — pseudo-cyesis or spurious pregnancy. The urine
frequently becomes turbid, loaded with phosphates or lithates. The
bowels are generally confined, occasional attacks of diarrhoea alter-
nating with this condition. In some cases, owing to the constant
discharge and impaired nutrition, the body becomes more or less
emaciated, dark areolae form around the orbits, the complexion
becomes muddy or sallow, the countenance dull and apathetic, and
the so-called /ac/f 6' uterina developed.
Disorders of the skin and its appendages are not infrequently
observed, such as pigmentation on the forehead or abdomen, around
the orbits or the nipples ; eczema and acne are often very trouble-
CHRONIC ENDOMETRITIS. 165
" some. Hyperaesthesia of the skin and mucous membrane is occa-
sionally noticed in the form of pruritus vulvae and vaginae. The
hair of the head also is apt to fall out and become very thin.
Certain reflex neuroses have been observed as complicating
: chronic endometritis, such as asthma, bronchitis, amaurosis from
1 chronic optic neuritis, partial or complete paraplegia.
Diagnosis, — In cases of uterine leucorrhoea it is important to dis-
tinguish cervical endometritis proper from corporeal endometritis,
as also to determine whether the two affections are present at the
same time, the treatment of the two conditions varying in many
important particulars.
In corporeal endometritis the discharge is more of a mucoid or
muco-purulent character, and not infrequently of a rusty tint. The
uterus is increased in size, the sound entering beyond the normal
distance producing pain on reaching the fundus and slight haemor-
rhage on withdrawal. On conjoined manipulation the uterus is
found to be bulky and very tender. Menstrual disorders are fre-
quent.
In cervical endometritis the. discharge is thick, glairy, tenacious,
adhering to the cervical canal ; there is little or no pain or tender-
ness of the body of the uterus. Menstrual irregularities are seldom
marked, and nervous disturbances are far less frequent than in the
former affection.
Prognosis. — Chronic endometritis, if recognized early and treated
); actively, may possibly end in recovery, but in b}^ far the larger
number of cases, although some partial improvement may take
place, the disease is practically incurable and resists every plan of
! treatment.
The prognosis is more favorable in recent cases, where the dis-
charge consists chiefly of mucus and is not purulent, where no dis-
placement of the uterus exists, where the patient is naturally of a
strong constitution and the general health has not been broken
down. Where, however, the case is one of long standing, the dis-
charge is muco-purulent, displacement of the uterus exists, the
cavity is increased in size, the constitution is naturally feeble or
the general health has been shattered by prolonged suftering, there
is very little hope of improvement, and relapses are very liable to
occur.
Treatment — Chronic endometritis is one of the most obstinate
and intractable disorders we are called upon to treat. Before at-
tempting any active or heroic treatment we should first familiarize
ourselves with all the details as to the history, apparent cause,
duration, severity, complications, toleration of interference, and
an}i:hing at all calculated to assist us in our management of the
individual case.
K there be evidence of previous attacks of peritonitis or cellulitis,
if the patient be unable to rest up and take proper care of herself,
or if there has been hitherto marked intolerance of interference,
we should be extremely careful in resorting to active treatment.
Every possible complication calculated to keep up or aggravate the
166 CHRONIC CORPOREAL ENDOMETRITIS.
condition should, as far as practicable, be removed. If any granu-
lar degeneration of the cervix be present, this must first be attended
to in the manner described. If cervical endometritis exist, appro-
priate treatment must be resorted to. If the os uteri be constricted,
this should be enlarged by a crucial incision.
K any marked displacement be detected, more especially if it be i
retroversion or retroflexion of the uterus or prolapse of this organ,
a vaginal pessary should be inserted as soon as it is considered
probable that it will be tolerated. Any inflammation or engorge- J
ment of the uterus should first be relieved by local depletion, rest '
in the recumbent position, the hot-water douche, glycerin tampon >
the administration of saline aperients, bromide or iodide of potas-
sium, and other appropriate drugs.
The general health should be improved as much as possible by
attention to diet, exercise, recreation, regulation of the secretions, .
and everything likely to conduce to the end in view. The diet
should be simple and nutritious, at the same time not too restricted,
as the aiDpetite is generally deficient or capricious. Alcohol, in :
strict moderation, may prove of service in assisting digestion if -
taken at meal times, but should never be allowed to replace foodF
or to be taken at odd times if the patient feels low or sinking. In
many cases it will be found better to limit the quantity very strictly
or to enjoin total abstinence, at least for a time, if, as not infre-
quently happens, there is a marked predisposition to abuse the
employment of stimulants.
As treatment, to be eftectual, will occupy several months at least,
the patient should on no account be confined to bed or to the couch,
nor even to the house. Regular exercise, short of fatigue, should
always be enjoined — walking, driving, or riding, according to cir-
cumstances. It is prudent even to intermit treatment for a time
and let the patient go to the seaside or to the country for a change,
or in some instances to one or other of the spas where she can take
the mineral waters containing iodine, bromine, iron, etc. It is not
absolutely necessary to compel our patient, if married, to lead a
single life, but it is well to suggest extreme prudence in this par-
ticular, more especially during the time active treatment is being
pursued. Every efibrt should be made to distract the patient's .
attention from herself, and to encourage her to look at the bright
side of things. The practitioner who can not only inspire confi-
dence but encourage hope of ultimate recovery is far more likely
to succeed than another who regards it as a foregone conclusion
that no treatment will be of any avail.
Medicinal tonics are often of service in improving the appetite,
such as the nitro-hydrochloric acid, with nux vomica and cinchona;
the hydrobromate of quinine, arsenic, strychnia, and other similar
agents. Iron is seldom tolerated if much local tenderness be present
or the tongue be coated, showing the liver is not acting well, nntil
these conditions have been relieved ; but where the general health
is much deteriorated the citrate of iron and quinine or other prep-
aration sometimes proves of much service.
TONICS. 167
Basham's mixture of liq. amm. acet. Siss, acid. acet. dil. 5s8,
tinct. ferri perchl. 5ij, syrupi Siss, aquarn ad .5vj, is a very agree-
able and efficacious combination. One tablespoonful with two of
water thrice daily.
Another useful form is mag. sulphat. Sss, acid, sulph. dil. 5j,
:- tinct. ferri perchl. 5ij, tinct. nucis vom. 5ij, syr. zingib. Siss, aquam
ad 5vj. Dose, Sss in water thrice daity.
r Some prefer liq. amm. cit. .5iss, acid, phosph. dil. Siij, tinct. ferri
perchl. 5ij, syrupi limonis Siss, aquam ad 5^. Dose, Sss in water
thrice daily. This makes a very pleasant mixture.
Bland's pills have been highly extolled by Meineyer. They
[ consist of pulv. ferri sulph. exsic, pot. carb. purge, aa 5ij, syrupi,
q. s. — ^Fiat mass ; div. in pil. xlviii. Dose, one pill after each meal,
h gradually increased to three after each meal.
Where endometritis follows parturition and a certain amount of
subinvolution co-exists, it will be well to give ergot in combination
- with bromide of potassium, etc. Ext. ergot, liq. Sss, pot. bromid.
5ss, tinct. cinch, co. Sss, tinct. chlor. co. Sij, syr. aurantii Siss,
i aquam ad 5vj. Dose, Sss in water thrice daily.
This will tend to check any menorrhagia and produce a healthier
' condition of the organ.
Arsenic in some cases acts very beneficially as a nervine tonic.
Strychnia is one of our best tonics, and in many cases may
replace ergot.
I Where any specific history be detected, it will be well to admin-
ister some such mixture as the following : Liq. hydrarg. perchl.
Sj-'iss, potass, iodid. 5ss-j, potassii bromid. 5ij-iv, spr. amm. arom.
Sss, glycer. purif. Sj-iss, aquam ad Svj. Dose, .Sss in water thrice
daily after meals.
It is of great importance to secure regular relief to the bowels.
Where attention to diet proves inadequate, there are various
methods we may resort to for this purpose. Half a tumblerful of
cold w^ater, a wineglassfnl of the Hunyadi Janos, Friedrichshall, or
other mineral water, with the same amount of warm water, taken
on first rising, or half a teaspoonful of Carlsbad salts, a Seidlitz
powder, or an appropriate dose of- any of the saline aperients, may
first be tried, but should not be taken too frequently.
The compound liquorice powder of the Prussian Pharmacopoeia
proves invaluable in many cases, and has the great advantage of
not losing its effect by repetition. It is composed of pulv. glycyrrh.
rad., pulv. sennee, aa .Sss; sulphur, sublim., pulv. foeniculi, aa 5ij ;
sacchar. purif. Siss. One teaspoonful in half a teacup of milk or
water at bedtime acts as a gentle aperient.
Pills are often preferred by patients. A very useful form is
Ext. aloes aquosse gr. xii, ext. bellad. gr. iij, pil. rhei co. gr. xxiv.
— M., div. in pil. xii, cap. j, pro re nata. Another rather stronger
is Ext. aloes Socrot. gr. xii, ext. nucis vom. gr. iij. pil. colocy. et
hyoscy. gr. xxiv. — M., et div. in pil. xii. The pil. aloes et assafoetidae,
aloes et myrrhse, rhei co., etc., are often useful. The confection
of senna or of sulphur acts well in some cases.
168 CHRONIC CORPOREAL ENDOMETRITIS.
The habit of indulging in tea, so prevalent among some patients,
aggravates materially the tendency to constipation, and should
therefore be restricted.
Enemata of cold water are often of more ser\ice than even
aperient medicine in securing a daily evacuation. Warm water is
less efficacious. Soap and water is more stimulating, but plain
water is generally suificient.
Where pain is a prominent symptom, the menstrual periods
being attended by great discomfort, much inconvenience being
caused by local applications, or the patient is restless at night and
unable to procure sleep, we must be prepared to suggest some effi-
cient relief.
It is well to avoid as far as possible resorting to the employment
of opiates until other methods have first been tried.
A warm hip-bath at bedtime has often a very soothing influence,
its effect being materially increased by combining with it the hot
vaginal douche. By means of a syringe, syphon, or irrigator, a
continuous stream of hot water, commencing at a temperature of
95° F. and gradually increasing this up to 110° F., may be injected
into the vagina continuously for ten or fifteen minutes. This not
only allays nervousness and restlessness, but produces contraction
of the vessels and promotes absorption, thereby diminishing the
bulk of the uterus.
In some cases a tablespoonful or two of mustard diffused in the
bath-water increases the soothing eftect of the hip-bath and tends
to promote sleep.
As sedatives proper we have a long list to choose from, and it is
well to have several to fall back upon, inasmuch as some patients
are intolerant of one remedy, but can take another readily. By
constant repetition one drug may lose its beneficial influence, and
will therefore need to be changed from time to time.
Bromide of potassium in scruple doses twice or thrice daily,
given in some aromatic infiision, such as the inf. aurantii co.,
calumbse, caryophylli, chirate, gentianse co., etc., proves most
valuable in all cases of nervous disturbance due to uterine irri-
tation.
Bromide of ammonium in scruple doses acts in a similar manner,
and is especially indicated where headache is a prominent system.
Bromide of camphor in four-grain doses three or four times a
day has been strongly recommended. It may be made into pills
with the ext. taraxaci, or Dr. Clin's capsules, which contain four
grains in each, may be given.
Belladonna is a pow^erful narcotic. Given in one-quarter grain
doses of the extract, twice or thrice daily, gradually increasing the
dose, as suppository containing one to two grains, or applied to the
abdomen in the form of the extract rubbed down with glycerin, it
proves very useful. It acts specially upon the sympathetic system,
and is indicated whenever there is any vesical tenesmus.
Camphor in five to ten grain doses, dissolved in rectified spirit
or ether and given on a lump of sugar or in milk, exerts a valuable
SEDATIVES. 169
sedative as well as anaphrodisiac effect, promoting diaphoresis and
allaying nervous irritation. Some patients prefer keeping a small
lump in their pocket and nibbling it from time to time.
Chloral in scruple doses at bedtime, or combined with camphor
or bromide of potassium, is very useful in procuring sleep.
Cannabis Indica in quarter-grain doses of the extract, gradually
increased to one grain, in the form of pill, or as a mixture contain-
ing five to fifteen or twenty minims of the tincture with mucilage,
often agrees when opium is not tolerated. It acts as a soporific or
hypnotic in conciliating sleep, as an anodyne in calming irritation,
as well as a nervine stimulant in removing languor and anxiety.
It has no constipating tendency and leaves no unpleasant after-
effects, as too often happens with opium. It exerts a special influ-
â– :. ence in cases of neuralgia and headache, as well as being a general
sedative.
Conium is a powerftil narcotic and anodyne, as well as a sedative
^ to the sexual organs. The succus conii in 5j-ij doses is the best
i mode of administering the drug, but it may also be given in the
t form of the extract as suppository or as pill.
Hyoscyamus is intermediate in its action between opium and
belladonna, acting as a narcotic and exerting an influence upon
the sympathetic nervous system secondary only to that possessed
! by belladonna itself. It increases the hypnotic action of opium,
. and also prevents the constipating effects of the latter. It may be
t given in the form of pill in doses of two or three grains of the
> extract, either alone or combined with camphor or opium.
Opium in some form or another in many cases will be found to
rbe requisite. At first we should try suppositories either of the
• extract, opii (gr. ss-j); morphia (gr. J-j); morphia (gr. J) and
atropin (gr. -^ir--^); or tinct. opii (tt\^xx-5J) and starch enema. A
drachm of laudanum with twice the quantity of glycerin may be
used to saturate a tampon, which is then passed up the vagina as
far as the cervix.
The hypodermic injection of morphia (gr. j. ad ti\,vJ), two to
three minims of the solution being suflicient to commence with,
may be used; but its employment should never be commenced
unless the practitioner is prepared to go on with it regularly, the
patient soon becoming so dependent upon it as to make the injec-
tion at stated intervals a very irksome duty.
The stomach should never be employed as the vehicle for the
•administration of opium until other methods have been exhausted.
A pill of quinine (gr. j-ij) and opium (gr. ^1 of the extract) with
ext. belladon. (gr. J-J) to obviate constipation, is a useful form ;
'Dover's Powder (gr. x = gr. j. of opium) ; liq. opii sed. (n]^xv-xxx)
*with spir. aeth. sulph. ("ixxx-lx) in form of a draught, or any of
the numerous combinations found useful under special circum-
stances, may be given. The practitioner will need to vary his
prescriptions, and may try in turn, fomentations, lotions, linaments,
ointments, pills, draughts, plasters, and suppositories.
Counter-irritation will generally be found of service in relieving
170 CHRONIC CORPOREAL ENDOMETRITIS.
pain, as also in allaying vomiting and checking tympanitic disten-
tion.
Mustard poultices and turpentine stupes to the abdomen, lini-
mentum ammonise, camphorae, crotonis, saponis co., or terehin-
thinse, rubbed in over the seat of pain, and a poultice subsequently
applied, or sprinkled on spongio-piline and kept applied for six or
eight hours, will often be of service.
The liquor epispasticus may be painted over a surface as large
as a five-shilling piece, so as to produce a flying blister, and re-
peated when necessary. The linimentum aconiti c. opio, bella-
donnse, chloroformi, or the tw^o latter in equal proportions, will
often produce a marked sedative effect. Patients often derive
great comfort from plasters applied to the back, kept on for
several consecutive weeks, or renewed as often as necessary. Of
these the emplastrum belladonn?e, calefaciens, or roborans are
generally most serviceable. The direct application of counter-irri-
tation to the cervix uteri by means of linimentum iodi or even
strong caustics, in many cases proves even more eflacacious than
when applied externally.
Intra-uterine Medication. — This should never be undertaken unad--
visedly, as it is by no means unattended by risk. Dr. Thomas, of
New York, in his last edition says : ^' Observation and experience.,
have so changed my own practice, that I find myself very rarely
resorting at present to applications above the os internum uteri."
The various methods employed are : 1, swabbing the interior ol
the uterus with strong solutions of caustic ; 2, passing ointments
up into the ca\aty and allowing them to melt there; 3, injecting
fluids into the cavity of the uterus ; 4, passing solid caustics into
the uterus and allowing them to dissolve there.
The first method, viz., swabbing out the interior of the uterus^
with strong solutions of caustic, is that most usually followed, be-
ing the most convenient, and attended by less risks than injecting
fluids into the cavity.
Preliminary treatment, to lessen congestion, remove constriction,
and secure patulousness of the cervical canal, should always first
be resorted to. In cases where cervical endometritis is marked,
but the symptoms lead to the conclusion that the body of the
uterus is also affected, it may be well to commence treatment bj
passing a Playfair's probe properly coated and charged, rapidlj
through the cervix, lea^dng it in sufficiently long for the uterus tc
contract upon, and squeeze out the fluid, so that it may come in
contact with the interior. Where, however, the mischief is chieflj
confined to the body of the uterus, the cer^dx not being involved
or already cured by previous treatment, it will be necessary to
protect this latter canal by means of a delicate cervical speculum
or intra-uterine canula, so as to prevent the fluid being squeezed
out in passing, and also to prevent the cervix contracting foreiblj
on the probe, and so shutting off the channel of exit for the fluid.
The speculum may be made of platinum or vulcanite; a long
handle should be attached to this so as to hold it in position when
INTRA-UTERINE MEDICATION.
171
Atthill's Canula for Intra-uterine Medication.
Fig. 97.
The same, showing canula and stilette separated.
inserted. Its introduction will be facilitated by having a guide as
well. The patient being placed in the semi-prone position, and
Sims's or a short cylindrical
speculum employed, the cer- ^^g. 96.
vix is cleansed if necessary,
and the canula inserted. Any
further accumulation of mu-
cus is then removed by a long
probe coated with cotton-
wool, and Playfair's probe,
duly coated and charged, is then inserted through the canula, and
the interior of the body of the uterus swabbed over. The canula
is then withdrawn, any excess
of the agent carefully neutral-
ized, and a tampon soaked in
glycerin passed up to the va-
ginal cul-de-sac. The fluids best
calculated to alter the condi-
tion of the endometrium and
to cure the disorder are :
Acid, carbolic, either saturated solution or diluted with an
equal quantity of glycerin.
Iodine, in form of strong tincture or liquor iodi.
A combination of equal parts of the liquor iodi and carbolic acid.
Solution of nitrate of silver, 3j-5ij to 5J of water.
Solution of chromic acid, 5j to the .^j of water.
Tincture of the perchloride of iron, alone, or with equal parts
of glycerin.
Liquor ferri perchloridi fortior, alone, or diluted as above.
Acid, nitric, fortior.
The relative merits of these various agents have already been
considered when speaking of cervical endometritis.
Carbolic acid is probably the safest and most reliable agent in
ordinary cases. Iron is most serviceable in cases of haemorrhage.
Citric acid has been strongly recommended in severe cases, more
especially where the haemorrhage is very profuse, the discharge
purulent or muco-purulent, and other remedies have failed to afford
relief Its application, however, should never be lightly under-
taken, as in unskilled hands it is liable to produce most serious
symptoms. Under any circumstances it should only be employed
shortly after a menstrual period, and not repeated until every trace
of irritation set up has subsided. In cases where the application
of the acid is indicated, the cervical canal is sufficiently patulous
without having to resort to artificial dilatation by means of tents,
a procedure alwa^^s to be avoided where possible.
Another method of applying astringents, caustics, solvents, or
alteratives to the interior of the uterus, is in the form of ointment
or pasma. In this way almost any substance may be applied.
Where grease is objectionable as a vehicle, a pasma of suitable
consistence maybe made by glycerin, vaseline, or other substances.
172 CHRONIC CORPOREAL ENDOMETRITIS.
In this form we may use remedies which cannot easily be applied
in any other way. For instance, we can hardly use bromide, or
iodine, or mercury in a solid shape.
The uterine ointment^positor consists of a long silver, nickel, or J
vulcanite catheter, having two long eyelet-holes at the end, and a ]
conical, well-fitting piston or rod. It is charged by dipping the I
end into the ointment, any superfluity being wiped oW. It is then J
passed through the os uteri without the aid of the speculum, the 3
piston is pushed home, and the ointment thus deposited in the in- ^
terior of the uterus. Ointments composed of iodide of mercury ?
or lead ; nitrate of silver 5ij, ext. bellad. 5j, ung. cetacei 5j ; acetate
of lead 5ij, morphia gr. iv, ung. cetacei 5j ; bismuthi 5ij, ung. zinci
5j, or any other agent desired, may thus be employed.
Intra-uterine injections should be restricted within the narrowest
limits on account of the danger of the fluid finding its way along .
the Fallopian tubes and so causing death by shock or peritonitis.
Numerous fatal cases have been recorded. "Many of our leading
men rarely employ them now, except in cases of urgent danger
from metrorrhagia. Although, in experienced hands, when proper
precautions are taken, the danger may be slight, yet in careless,
inexperienced, or unskilful hands, the perils are very great. The
operation should therefore never be undertaken by any one who
is not thoroughly familiar with the details, only acquired by much
practice, of the treatment of uterine disorders. Dr. Bennet be-
lieves that serious accidents would be far more common " were it
not that the natural coarctation of the os internum must have
generally prevented the fluid injected from penetrating into the
uterine cavity."
The danger of employing intra-uterine injections consists gen-
erally in the fluid finding its way along the Fallopian tubes, either
from the force with which the fluid is injected or from the spas-
modic contraction of the uterus closing the channel of exit around
the tube and thus driving the fluid onward. Where the tubes are in
a healthy condition the entrance of fluids is resisted, but where thej
are unduly dilated, as occurs from salpingitis, fluid readily enters.
The general conclusion arrived at by most gynecologists is that
uterine injections should not be resorted to except in cases of un-
controllable haemorrhage, their employment being likely to cause
very dangerous symptoms, such as severe uterine colic, collapse,
and peritonitis. In severe, obstinate, and protracted cases of en-
dometritis, more especially where menorrhagia is a prominent
symptom, we are, however, compelled occasionally to resort to
this method of treatment, inasmuch as the cavity being enlarged
the swab cannot be applied to the whole of the surface, nor can
sufficient quantity of the agent employed be inserted into the uterus
to arrest the haemorrhage.
To lessen the risks of danger as much as possible, the following
points should be attended to :
Avoid injecting unless the cervix be well dilated, either nat-
urally or artificially, so that the fluid can escape readily. A double
INJECTION OF FLUIDS. 173
(.'iiiiula, SO as to secure a return current, is advisable, though this
does not absohitelj guarantee safety, inasmuch as the aperture
intended to serve for the return current may become blocked by
clot or coagulated albumen.
N^ever inject when a menstrual period is pending or present, nor
if there be evidence of recent pelvi-peritonitis or cellulitis.
[n cases of marked flexion this must be first reduced, and care
taken that the canal is patulous at the angle of flexion, the fluid
being again withdrawn into the syringe within a short period from
its injection.
Before using strong solutions, wash out the cavity of the uterus
: first with warm water, slowly and carefully injected, taking special
precaution to exclude any air from the syringe, so as to test the
tolerance of the uterus.
The solution selected must be injected by an appropriate instru-
ment, in graduated quantities, very gently and slowly.
The solutions employed are chiefly the following:
Tincture of iodine diluted with equal parts of w^ater, or stronger,
ias in Churchill's tincture (iodin. 5j, pot. iod. gr. xii, alcohol. 5j).
I This acts as a stimulant, alterative, counter-irritant, caustic, and
I hsemostatic.
Acid, carbolic, crystallized, dissolved in equal quantity of glyc-
erin or diluted still further with water.
It does not cause pain, nor does it cauterize or destroy tissue.
Sulphate of zinc gr. x ad oj aquam.
Tinct. ferri perchlor. 5ij-iv ad 5j aquam.
Acid, chromic. 5j-ij ad .^j aquam.
Acid, nitric, after other remedies have been tried and failed has
been employed, but is safer w^hen used with the swab.
E'itrate of silver should not be used for intra-uterine injections,
as even in weak solutions it gives rise to violent uterine colic, often
of long duration.
The method of injecting fluids into the cavity of the uterus is
as follows : A small india-rubber ball syringe with a pointed
nozzle is fitted on to a long gum-elastic catheter, about iSo. 8 or
!10 size, with several small openings at the distal end. This is
carefully filled with warm water, the end of the tube held upper-
most and every particle of air expelled, the ball being completely
t filled before using it. Having inserted the end of the catheter
within the uterus, the water is very gently and slowly injected.
If any severe pain or colic be induced, the water is at once sucked
up again, or the catheter withdrawn and the fluid allowed to follow,
or the ball removed, the tube remaining in to facilitate expulsion of
the fluid.
Molesworth's double canula and bulb syringe is a very conveni-
ent instrument for this purpose.
A small glass syringe attached by means of a piece of tubing
to a long tube or catheter answers the purpose.
Where strong solutions are employed, ten or twelve drops are
quite sufi&cient.
174 CHRONIC CORPOREAL ENDOMETRITIS.
Injections into the uterus should never be attempted unless
the patient be in bed, where she should remain until all risk
from the operation has passed over.
If any pain be produced, give opium, ^^g- 99.
The hypodermic injection of morphia re-
lieves any uterine colic more certainly and
more rapidly than any other method.
The first injection should be given a few
days after the menstrual period, warm water
. being first tried to test the tolerance of the
uterus. If strong solutions be employed
they should not be repeated for a week or
ten da^^s, and, as a rule, only twice during
the intermenstrual period.
The fourth method, of passing solid caus-
tics into the uterus and allowing them to
dissolve there is not one to be recom-
mended. Mtrate of silver has been thus
employed; it often gives rise to intense
agony and haemorrhage. When reduced
by fusing it in moulds with equal parts of
nitrate of potash, it is less dangerous. The "
sulphate of zinc points have been employed
in a similar manner. Persulphate of iron,
tannin, alum, chlorate of potash, and other
agents may also be used, made into crayons
with mucilage or glycerin.
A long tube with a piston, open at the
extremity, is employed to deposit these
A within the uterus without the aid of the
speculum. Simpson's port e-causti que or
Barnes's canula is used for this purpose.
A long probe roughened at the extremity
and coated with fused nitrate of silver may
be tried, but it is a tedious process and
very inferior to strong solution.
Vulcanite Intra- Fungold 01 Vlllous Endometritis is really a Simpson'
"'^llTnTvInt'ltTeam. scvcrc form of chrouic endometritis, result- ^^qH'^^
ing from shedding of the superficial layers
of mucous membrane of the uterus, and by irregular proliferatioi
villous or polypoid masses are developed. Under the head o
uterine fungosities Thomas includes these fungous projections fron
the endometrium, the result of prolonged congestion from auA
cause, or of the organization of portions of placenta remaining
attached to the surface. As the symptoms and treatment of th(
two conditions are identical, and there is no means of difterentiat
ing one from the other, we think it better for practical purposes
to consider them together. He speaks of the affection as one o
great frequency, one which plays the part of an important facto-
in menorrhagia and metrorrhagia, and which often saps the healtl
REMOVAL OF GROWTHS. 175
of patients in whom its existence remains for jesirs unsuspected.
When resulting from prolonged congestion, they are found to con-
sist of hypertrophied elements of the mucous membrane, dilated fol-
licles, enlarged blood-vessels, and exaggerated cell-growth. Emmet
states that the favorite seat for these is in one or both cornua of the
uterus, from which cause their presence is frequently overlooked.
Causation. — Any condition which keeps up engorgement of the
uterine lining membrane tends to produce them, such as endome-
tritis, laceration of the cervix, subinvolution, displacements, or the
presence of submucous or interstitial fibromata. Where abortion
or parturition at full term precedes their appearance, they are gen-
erally traceable to retained portions of adherent placenta.
Symptoms. — Uterine haemorrhage is the chief and often the only
symptom. There may be also some uterine leucorrhoea, and inci-
dentally spansemia and sterility. In some cases the fungosities are
thrown off during menstruation, but generally remain, neither in-
creasing nor diminishing for years, annoying and weakening the
patient until the menopause.
Treatment. — Removal of the growths by means of the blunt wire
curette can be readily effected, provided the cervix be patulous
enough to admit it. Recamier's sharp curette is too dangerous an
instrument to be employed. The copper wire loop, slightly flat-
'tened at its edges, devised by Thomas, is a far safer instrument.
It removes the growths by looping them off, not by cutting or
ftearing the endometrium. The operation is a very simple one ;
lit is not usually necessary to produce anaesthesia, but the patient
^;>hould remain perfectly quiet in bed for three or four days in order
tto avoid any risk of secondary haemorrhage, peritonitis, or pelvic
oellulitis. Simpson employed a scoop, as in Fig. 99. Emmet pre-
|fers a pair of forceps with cutting edges. The great advantage of
'he instrument is that it can remove only what projects above the
;ommon level. This it crushes off' sufiiciently close, without drag-
^ng upon or injuring the surrounding tissues. As a rule the cer-
vical canal is sufficiently patulous to admit of the passage of the
curette forceps, but if further dilatation be required, the judicious
ise of the forceps themselves will frequently accomplish it. Before
ntroducing the forceps, the uterus must be gently drawn down
aear the outlet by means of a tenaculum caught in the anterior
]ip. The forceps having then been introduced, the blades are to
)e gently separated, then closed firmly together, and withdrawn,
he operation being repeated until the whole surface has been
ystematically passed over. The canal is then gently washed out,
as to remove all the debris, and a free application of iodine to
.be fundus made to excite contraction of the uterus.
In cases where the cervical canal is not sufficiently patulous, a
ponge-tent may be passed. This serves as a temporary plug to
rrest haemorrhage, often destroys the growths by entangling them
ti the meshes of the sponge, and in any case facilitates further
reatment, if necessary, by means of the curette or the application
f nitric acid or other strong caustic.
I
176 CHRONIC METRITIS.
CHAPTER XII.
SUBINVOLUTION, HYPERTROPHY, ANB HYPERPLASIA OF THE UTERUS, OP
CHRONIC METRITIS.
Subinvolution, H3rpertrophy, and Hyperplasia of the Uterus, or Chronic
Metritis. — In thus grouping together what may at first sight appea]
to be distinct and separate conditions, it will be found as we pro
ceed that they are in reality but stages of the same affection anc
will be best considered together, not only td' avoid needless repeti
tion, but also to prevent confusion.
Subinvolution is the initiatory stage of a large majority of th*
cases w^here on examination a congested, voluminous, tender, dis
placed uterus is found, a condition hitherto generally described a
chronic metritis.
Pathological Anatomy. — In the early stages of subinvolution fol
lowing parturition, hypertrophy of the muscular structure equal!,
with that of the connective tissue may be found, but later on, iii
the large majority of cases, on microscopic examination, the amoun .
of fibrous tissue preponderates over that of the muscular fibre. Thi
condition is due almost invariably to interference with the retrc
grade metamorphosis occurring in the puerperal uterus. Withi: ^
a few days of parturition the fully-developed muscular fibre-
undergo a fatty degeneration, the fatty globules being absorbec 1
and the uterus thus rapidly diminishes in size and w^eight. Shoul :
any untoward influences retard or check this process, and th
organ remain flabby and large, we get what is termed a conditio -
of subinvolution, or arrested retrograde evolution. At first thi
tissue is softer than normal, owing to infiltration with serum, bii
as Thomas points out, " in process of time the uterine walls dimiiii-
in size, their tissue grows less vascular, the blood-vessels becom-
smaller, and the uterine cavity assumes smaller dimensions. Bv y
the organ does not assume its original size ; it remains large, dens
firm, and sensitive ; for years presenting the characteristic appea
ances of the so-called chronic parenchymatous metritis." Tli
condition may arise without any evidence whatever of any prectM
ing inflammatory process. Gallard even speaks of the commenc
ment of chronic metritis as being so insidious that it is often difl
cult to determine its date in each particular case, this acute sta^
often passing unnoticed among the sequelae of labor.
IIow^ much more reasonable to look upon this condition as d
pending upon arrest of involution of the puerperal uterus than '
regard it as the termination of a latent, undemonstrative, acute i
flammation, the symptoms of which were so obscure as not even
have been observed.
WEIGHT OF UTERUS. 177
Dr. Thomas has directed special attention to this condition, de-
' scribed by him as areolar hyperplasia, and which until very recently
was regarded as chronic parenchymatous metritis, but, as he justly
observes, " cases which w^ere formerly regarded as instances of in-
flammation, on account of the existence of enlargement, congestion,
• and tenderness upon pressure, the microscope now proves to have
been instances of excessive growth of the connective tissue of the
uterus, w^ith congestion and resulting hyperaesthesia of its nerves."
The tendency of modern pathologists is evidently to regard the
K. subject from a similar standpoint.
f Klob asserts that " diffuse growth of connective tissue constitutes
^the so-called induration, hitherto considered as a result of paren-
chymatous inflammation of the uterus, and that it arises from over-
;^ excitation of the vaso-motor and excito-nutritive nerves, a forma-
i tive irritation as it w^ere." Even when increase of the muscular
substance occurs, that of the connective tissue considerably pre-
^ dominates.
Causation. — The uterus is more liable to alteration in size, within
- strict physiological limits, than any other organ in the body. From
; a normal weight of little more than an ounce in the virgin state, it
becomes developed during pregnancy to such an enormous size as
] to weigh as much as twenty-eight ounces, returning again after par-
\i turition to almost its normal size within six or eight wrecks, in a
â– ^ate of health. Should any circumstances interfere wdth this proc-
of involution, this retrograde metamorphosis of the puerperal
uterus, we then have the condition termed subinvolution, which is
an. occurrence of very great frequency, and constitutes the chief
cause of all chronic uterine disorders.
In order that the process of involution may proceed naturally it
is requisite that the supply of blood to the organ should be mate-
; rially diminished, and that the process of absorption should go on
1 1 actively. Anything that interferes wath either of these conditions
will therefore predispose to subinvolution. If the general health
be much depreciated, whether from constitutional ^veakness, tend-
ency to scrofula or tubercle, prolonged nervous depression, fre-
quent parturition, or other similar causes, the tone of the muscular
>ystem is lowered, and the usual rhythmical contractions of the
uterus are too feeble or too infrequent to effectually diminish the
blood-supply to the organ. If lactation be not performed this de-
tect is still further increased, the application of the child to the
l^reasts producing w^ell-marked contractions of the uterus by reflex
stimulation.
It is essential also for the process of absorption that the body be in
a state of health; where the system is enfeebled by constitutional
k'bility or other depressing causes, nutrition and the due inter-
change of waste and repair do not occur as actively as in health.
Apart from these predisposing causes, other exciting causes are
'ften present, such as retention of a portion of the placenta, mem-
anes, or clots, which keeps up a state of active hypersemia and so
avors subinvolution.
12
178 CHRONIC METRITIS.
Laceration or bruising of the cervix during parturition, inflam-
matory conditions of the uterus or adjacent tissues following par-
turition, will also prove exciting causes.
The mere act of getting up too soon after delivery, at a time
when the uterus is excessively bulky and the ligaments that should
support it are relaxed, favors prolapse of the organ, and so induces
passive hypersemia, which thus interfere with involution. This will
of couse be aggravated by prolonged standing or severe muscular
efforts. It is not a good plan, however, to keep the patient reclin-
ing on the back for too long a period and to apply a pad and tight
binder, as the uterus becomes thus retroverted or retroflexed, and
therefore necessarily congested. The presence of any cardiac mis-
chief, a fibroid of the uterus, or the pressure of any abdominal
tumor, mil also tend to keep up passive hypersemia and so favor
subinvolution.
Abortion has a still greater influence in the production of sub-
involution than even parturition at full term. This is readily
explained by the fact that the dehiscence of the decidua at an earl}
stage of pregnancy is often imperfect, owing to the close attach-
ment to the uterine mucous membrane, the unpreparedness of the
uterus to tlirow off the ovum, and the frequent occurrence of some
morbid process which determines the abortion. The stimulus of
lactation is absent, the patient generally gets about again too soon,
and not only favors congestion of the uterus by connubial inter-
course, but incurs the risk of another pregnancy before the process
of involution has had time to take place.
Abortions being apt to occur in patients who are the subjects of
some cachexia or constitutional weakness, the process of absorption
is also interfered with.
Thomas considers that " the woman who has never been preg-
nant is much less liable to areolar hyperplasia than she whose
uterus has undergone the tissue-changes of utero-gestation ; nulli-
parity securing, to a very great extent, an immunity from the dis-
ease, and multiparity constituting a most important predisposing
cause. Still, the uterus may become considerably enlarged inde-
pendently of pregnancy, as in cases of stenosis, or flexion of the
uterus, the muscular tissue becoming hypertrophied from the violent
efforts made to expel the contents. Moreover, it must be remem-
bered that the uterus is constantly undergoing changes from puberty
until the menopause, its vascularity and functional activity being
increased by emotional influences as well as by the ever-recurring
menstrual congestion. Any alteration in these conditions may
give rise to hypertrophy or hyperplasia. And here it may be well
to note that hypertrophy signifies excessive growth of the elements
of a tissue already existing ; hyperplasia signifies the development
of new tissue."
Varieties. — Hyperplasia may be limited to either body or cerA^ix,
or may affect both conjointly, but of all forms of the affection, the
cervical variety is the most frequent. This is explained by the fact
of the cervix being particularly exposed to mechanical injury
PHYSICAL SIGNS. 179
during parturition, by its liability to laceration at this time, and by
the greater risk of injury from friction, coition, cold, etc.
When involution is retarded, but at length is accomplished, it
sometimes takes place in the body but fails to do so in the neck,
from the exposure to injurious influences.
Cervical endometritis, which in multiparous women proves a not
infrequent source of the disorder, is more common than the kindred
aftection of the body.
Symptoms. — Those of subinvolution are chiefly a feeling of weight,
discomfort, or bearing down or dragging in the pelvis. As lacera-
tion or granular degeneration of the cervix frequently complicates
subinvolution, we have in addition the presence of leucorrhoea,
haemorrhage on coitu, the recurrence of menstruation even during
lactation, irritability of the bladder, pain in the back and loins,
and other evidence of local discomfort. The general health suiFers,
the appetite is capricious or defective, nausea is not infrequent, the
bowels are confined, the digestion disordered, and the spirits often
very depressed. Owing to the increased w^eight of the uterus, and
the softness of its tissue at this stage, displacement is pretty sure
to occur; partial prolapse, retro-version, or -flexion taking place,
when fresh symptoms arise and call for attention. There is difli-
culty in getting about, a sense of pressure on the bladder or rectum,
nausea on first putting the feet to the ground in the morning, ina-
bility to stand for long, or even to sit upright, the patient feeling
< as if her back would break. Besides the leucorrhoea, there is often
:2l continuous sanguineo-purulent discharge, which weakens the
j patient still more.
When the subinvolution has passed into the stage of areolar
i hyperplasia the symptoms may be less acute, but nevertheless well
; marked, being naturally more prominent in those cases where the
body of the uterus is mainly affected. There is a constant sense
of a dull, heavy, dragging pain through the pehas, increased on
standing or walking, pressure on the rectum and bladder, often
accompanied by tenesmus, pain on defsecation and coition, dull,
! heavy pain before and during menstruation, pain in the mammae
! being not infrequent at these times, the flow being generally ex-
cessive, except in the advanced stage, when, owing to the degen-
leration of the endometrium, the amount is considerably lessened.
Owing to the patient being unable to take a proper amount of
. exercise the bowels often become very confined, the appetite dimin-
ished, dyspepsia with headache, languor, sleeplessness, and other
' distressing nervous symptoms arise, and the patient becomes a con-
1 firmed invalid. She not infrequently imagines that she is pregnant,
the nausea, bearing down, pain in the breasts, darkening of the
1 areolae, etc., seeming to support this hypothesis.
Physical Signs. — AVhere the cervix is chiefly involved, it will be
found to be large, swollen, and painful, the os patulous. On con-
joined manipulation the cervix is found to be unduly sensitive,
more especially if it be lifted up by the finger. There is usually
some amount of laceration or granular degeneration present.
160 CHRONIC METRITIS.
In the early stage of subinvolution there is a softness of the
tissues, which is less noticeable in the more advanced forms of
hyperplasia.
In corporeal hyperplasia, on conjoined manipulation, the body of
the uterus is found to be much enlarged, the thickening of the
walls being greater than the increase in length of the uterus. The
organ is lower in the pelvis, and less mobile than normal from its
intrinsic bulk ; more sensitive to pressure than in health.
Differentiation. — Subinvolution, Avhen the uterus is very bulky, is
often very difficult to distinguish from early pregnancy, more espe-
cially if the patient be suckling at the time, and no information
can be gained by the absence of the catamenia. The points most
likely to assist us in forming an opinion will be that in early preg-
nancy the uterus is more globular, of a softer consistence, and
gives to the sense of touch on conjoined manipulation the feeling
of being tense, as if the contents were of a fluid nature. If pressure
be carefully but steadily maintained, the consistence of the organ
will be found to vary, owing to the rhythmical contractions and
relaxations which take place in the pregnant uterus, and less ten-
derness will be observed than if the case were one of subinvolution.
The subjective symptoms, such as nausea, pressure upon the neck
of the bladder, irritation of the breasts, etc., are often as well
marked in the one condition as in the other, and will not therefore
help us much. Even the recurrence about once a month of a
sanguineous discharge, simulating menstruation, may be due to a
granular condition of the cervix allowing of passive haemorrhage
during the early months of utero-gestation.
Fibroid tumor of the uterus, especially if it be imbedded in the
uterine wall or bulge internally, may occasion more or less symmet-
rical enlargement of the uterus closely simulating areolar hyper-
plasia. The only method of diiFerentiating the two conditions is
to dilate the cervix by means of a. laminaria tent, and explore the
interior of the uterus with the sound and finger, assisted by the
bimanual exploration. In cases of fibroid there is more likely to
be a history of menorrhagia being a prominent sj-mptom. The
difficulty of diagnosing is often very great.
In the later stage of areolar hyperplasia, when the cervix is
chiefly aflected, and the tissues have become dense and firm — the
so-called sclerosis — it is often difficult to discriminate between thi-
and scirrhous cancer of the cer\dx. The mistake has unquestion-
ably frequently been made.
In hyperplasia, the history is often one of long standing (follow-
ing parturition) ; the condition is not at all infrequent. The cervix
is movable, unless fixed by surrounding deposit from previous pel-
vic inflammation ; it feels dense, but at the same time there is a
feeling of elasticity about it, and the mucous membrane can be
made to glide over the surface. If a sponge-tent be passed, the
cer\dx softens and dilates ; the body of the uterus is generally im-
plicated. Menstruation is usually scanty, the pain being worse at
these times. Thei^ is no cachexia.
PROPHYLACTIC OR PREVENTIVE. 181
In scirrhus of the cervix, the history is seldom of many months'
duration ; it is comparatively rare. The cervix soon becomes fixed ;
it is very hard, like cartilage or wet india-rubber, the hardness ex-
tending to the very surface. A sponge-tent has no effect in soften-
ing or dilating the cervix ; the body of the uterus is seldom impli-
cated. Menorrhagia is a common symptom, and is apt to occur
at irregular times, the pain being relieved by the haemorrhage.
Cachexia is soon manifested.
Prognosis. — "Where the body alone, or the entire uterus, is af-
fected, the probability of curing the disorder is very remote,
although much may be done to relieve symptoms and promote the
patient's comfort. Where the cervix is alone involved, being a
much less sensitive and important part of the organism, and also
being much more accessible to local treatment, the prognosis is
more favorable, if the patient will only persevere sufficiently long
with treatment. Towards the menopause the probabilities of the
symptoms becoming less urgent, or even of atrophy of the uterus
occurring, should be borne in mind, though there is no certainty
of either.
The possibility of hyperplasia of the cervix degenerating into
malignant disease is apparently very slight.
]^umerous complications may be met with, such as displace-
ments, endometritis, cellulitis, menorrhagia, etc., which will in-
fluence the prognosis.
Treatmemt. — Bearing in mind that arrest of involution of the
puerperal uterus is an occurrence of very great frequency, and
coiistitutes the chief cause of all chronic uterine disorders (Thomas),
we cannot be too careful in doing everything in our power to pro-
mote the normal physiological involution of the uterus following
delivery. We may therefore divide our remarks into the prophy-
lactic or preventive, and the curative treatment.
Prophylactic. — The mere fact of allowing a patient to expend her
efforts in fruitless attempts to expel her offspring, thereby exhaust-
ing the nerve-force and wearing out the muscular energy of the
uterus, so that it is with difficulty sufficient contraction of the
organ is excited to expel the placenta or prevent subsequent relax-
ation, may prove sufficient to interfere materially with the process
of involution, and thus sow the seed of much future discomfort.
Much may be done to obviate uterine disorders by a little timely
assistance in the lying-in room. The application of the forceps in
a case of tedious labor may prevent the necessity of resorting
to subsequent treatment for subinvolution, retroflexion, and other
uterine disorders.
Care should be taken to secure efficient contraction of the uterus
after the expulsion of the placenta; any clots that may have
formed should be removed, the vagina syringed out twice daily
with tepid water, containing a little Condy's fluid or carbolic acid,
the patient allowed to sit up for a few moments daily even from
the first so as to allow any clots in the vagina to be expelled ; the
child should be put to the breast at stated intervals for at least the
182 CHRONIC METRITIS.
first month or six weeks, involution proceeding much more rapidly
if lactation be performed. The patient should not keep too rigor-
ously to the dorsal position, but be encouraged to turn on her side
from time to time. For the first month jt is well to avoid standing or
walking as far as possible. The general health should be attended
to, fresh air and daylight being freely admitted to the room, all
soiled linen immediately removed, the bowels regulated, the appe-
tite seen to, and sleep secured. If lactation be not resorted to, a
mixture of ergot and cinchona, or nux vomica and quinine should
be administered for the first month or six weeks, to promote uter-
ine contraction.
K there be the least suspicion of the placenta not ha\dng been
completely and entirely expelled, or of any portion of the mem-
branes being retained, or of a clot having formed in the uterus,
this should at once be seen to, the uterus being washed out regu-
larly if necessary, so as to avoid the least risk of septic absorption.
If the lochia are offensive, it is a prudent plan to wash out the
interior of the uterus w^ith some antiseptic solution.
Before concluding his attendance the practitioner should take
some opportunity of examining to see whether the cervix be gran-
ular or lacerated, the organ misplaced, or any condition present
necessitating local treatment.
Curative. — In the event of these preventive measures not having
been attended to, and the uterus is found to be considerably larger
than normal, some months after abortion or parturition, our first
object should be to ascertain, as far as possible, whether any por-
tion of the placenta has been left in utero. If haemorrhage has
been a prominent symptom, and the os uteri remains unduly open,
this supposition will generally prove to be correct. If the os be
not sufficiently patulous to admit the finger, the cervix should be
dilated by laminaria tents. If the patient be very nervous or sen-
sitive, or the vagina unusually small or lengthened, it will be well
to produce anaesthesia, as the operation is often a tedious and diffi-
cult one.
The bladder having been emptied, the patient's hips brought
well to the edge of the bed, the dorsal position, with the knees
drawn up, being generally the most convenient one, the left fore-
finger is passed into the vagina and so into the cervix uteri. The
fundus being then depressed by the right hand externally pressing
over the lower abdomen, the forefinger is enabled to explore the
fundus, and ascertain if any projecting portion be present. If this
can be detected it may be scraped off with the finger-nail, or, in
some cases, a pair of ovum forceps, having a catch at the handles,
may be passed up and the portion of placenta extracted. The
finger is by far the better instrument to employ, as a rule, and if
the fundus be well depressed the finger will generally prove suffi-
cient ; should this not prove to be the case, the ovum forceps, or
dull wire curette, may be employed. Ergot should then be ad-
ministered, and the patient kept perfectly quiet. The vagina should
be washed out daily, and should the discharge from the uterus
COMPLICATIONS. 183
'^become in tlie least offensive, or the temperature become elevated,
' it will be well to wash out the cavity of the uterus with some anti-
septic injection of carbolic acid or iodine. A mixture of bark
and acid with ergot will generally prove of service in favoring
H involution.
Abortions are even a more frequent cause of subinvolution than
parturition at full term. Care must be taken that the whole of
the ovum be removed, when it is not expelled entire ; the cause
that produced the abortion should be inquired into and obviated if
possible, any retroflexion being remedied by a Hodge's pessary and
appropriate position. Strict rest should be enjoined for the first
week or ten days, and the patient should not return to the marital
-couch, nor to her usual occupations, for at least a month. A mix-
iture of ergot and cinchona wdll favor the process of involution.
Jf the cervix be granular, suitable applications should be resorted
'to. Where the habit of abortion has been established, it is of
-great importance to allow time for the uterus to recover perfectly
before incurring the risk of further conception.
Thomas lays special stress upon examining for, and removing if
* discovered, the five following complications which very often ac-
company areolar hyperplasia, and establish symptoms which greatly
i increase the evils attending it :
1. Laceration of the cervix uteri, which creates intense nervous
'i irritation, both immediate and reflex, and consequent uterine con-
gestion and neuralgia.
2. Displacement of the uterus, which results in vascular engorge-
iment, dragging upon uterine ligaments, mechanical interference
'with surrounding parts, and diflSculty in locomotion.
3. Fungoid degeneration of the endometrium, which results in
i profuse leucorrhoeal and bloody discharges.
4. Granular and cystic degeneration of the cervix, which pro-
' duces nervous and vascular derangement of the uterus, leucorrhoea,
and menorrhagia.
5. Vaginitis, which is excited by the discharge dependent upon
engorgement of the endometrium.
In some cases the benefit derived from an appropriate pessary
will be the chief, perhaps the only, relief which' we can bestow,
and even where we cannot cure the disease, we may render life
much more tolerable by the alleviation of discomfort. Relief of
displacement favors free venous return, and prevents congestion,
which feeds and perpetuates hyperplasia.
General Treat)nen.t. — Everything conducive to improvement of the
general health, removal of any obvious exciting cause of uterine
disorder, and attention to the ordinary requirements of the system,
'must be carefully attended to. The diet should be simple and
nutritious, stimulants taken in strict moderation or entirely for-
bidden, the action of the skin encouraged by warm baths or sea-
bathing, the bowels regulated by suitable aperients, mental de-
pression obviated by cheerful society, change of air, or a stay at
the sea-side. If possible, a resort to one of the spas or mineral
184
CHRONIC METRITIS.
Fig.
Fig. 101.
t
watering-places, such as Kreuznach, in Germany, where the water
contains bromide of magnesium, should be encouraged. Failing
this, a visit to a well-conducted hydropathic establishment, where
pure air, plain and nutritious food, and agreeable society can be
obtained, often proves of great service.
Ferruginous tonics, combined with saline aperients, will be indi-
cated where anaemia exists. In the early stages ergot, nux vomica,
and cinchona given continuously for many weeks or months, exer-
cise a beneficial influence in exciting contraction of the uterine
tissue, thus diminishing hyperemia and so lessening the bulk of
the uterus. The bromide of potassium alone, or in combination
with ergot, etc., is also useful in these cases.
Rest in the recumbent position, either continuously or for many
consecutive hours each day, has generally been resorted to by the
patient herself before applying for assistance from the physician.
This will, however, need to be regulated according
to the nature of the case. Absolute rest is seldom
requisite, the general health becoming much dete-
riorated where this is enforced. The patient should
go out daily for health's sake, driving if
she cannot walk, but in any case getting
out w^hen the weather permits. An ab-
dominal belt may prove of service in
taking off the superincumbent weight of
the intestines. Skirt-supporters and other
arrangements to prevent the clothing
pressing unduly upon the lower abdo-
men will also assist; the corset being
strictly forbidden.
If much sense of bearing down or
dragging be experienced, or if the uterus
be displaced, a well-adjusted Hodge's pes-
sary will afford marked relief, by insuring
rest and preventing congestion.
Physiological rest, coitus being either
interdicted or permitted but rarely, should
be enjoined.
Depletion. — ^ATiere the uterus is not
only excessively bulky but also tender,
and the periodical menstrual discharge
proves inadequate to relieve the conges-
tion of the organ, the abstraction of an
ounce or two of blood by means of punc-
ture or scarification will be indicated.
Leeches often produce much pain, are at all times troublesome of
application, and are not adapted for cases of hyperplasia. Three
or four stabs are made with a small spear-pointed scarificator (Fig.
101), or an ordinary three-sided surgical needle, the number of in-
cisions being increased if requisite, and Avhen sufiicient blood has
been allowed to flow, a glycerin plug is inserted close up to the
Barnes's Vulcanite
Tampon Introducer.
Spear-pointed
Scarificator.
LOCAL APPLICATIONS. 185
cervix, and allowed to remain for the next twelve hours or so, the
patient meanwhile retaining the recumbent position. Another
plan is to pass a bistoury up as far as the os internum, cutting
through the mucous membrane as the blade is withdrawn through
the OS externum. In advanced cases of hyperplasia depletion is not
often successful — either as to the amount of blood extracted or as
to the benefit derived.
Glycerin applied to the cervix uteri on plugs of cotton-woor(Fig.
102) to which a string is attached, is a valuable method of depleting
the uterus, the watery discharge induced serving to diminish ma-
terially the bulk of the uterus. Barnes's Tampon Introducer (Fig.
100) may be employed to enable the patient to introduce them
night and morning. Vaginal injections of hot water, morning and
evening, by means of the siphon douche, as described later on, is
of much service in allaying pain, remo\dng discharges, controlling
the pelvic circulation, and promoting absorption. To be of any
real service the injection must be continued for at least a quarter
of an hour, and repeated regularly and systematically for several
consecutive weeks, or months, as the case may be.
Local Applications. — Much may be accomplished in reducing the
bulk of the uterus by the persistent employment of various agents
to the vaginal portion of the cervix, or, in some cases even, when
endometritis exists, to the cervical canal. Of these, iodine in some
form generally proves most useful. The liquor iodi ( = 1 in 24),
or in very chronic cases, the linimentum ioli ( = 1 in 9) may be
applied by means of a Playfair's probe coated with cotton-wool to
the cervical canal, as well as to the whole of the vaginal cervix. A
plug of cotton-wool saturated with glycerin is then passed up to the
cervix, and allowed to remain m situ for twelve hours, when it is with-
drawn by the aid of the string, and the hot-water douche applied.
This application may be repeated once a week, or oftener — avoiding
any risk of setting up irritation j ust before the menstrual period is due.
Observation has led to the conclusion that hyperplasia associated
with erosion of the cervix is more amenable to treatment than when
no such complication exists. Following up this
hint, various methods have been resorted to for ^ig. 102.
the production of artificial erosion. The appli-
cation of vesicating collodion — which is a com-
pound of ordinary collodion, acetic acid, and can-
tharides — to the whole of the vaginal cervix, is a
simple method of accomplishing this object. It
is eftected by the aid of a Fergusson's speculum,
sufficient time being allowed for it to dry, when
another coating is applied, any excess running
down on to the vagina being carefully avoided. _
"Within the course of eight to twelve hours the Tampon or plug of
epithelial covering of the cervix is entirely re- cotton-wooi.
moved, a fine secretion of serum taking place
from the surface as in case of an ordinary blister. The same result
may be obtained by rubbing the solid nitrate of silver freely over
186 CHRONIC METRITIS.
the cervix; the epithelial covering soon sloughs oiF, leaving a granu-
lated surface beneath. Gljcerin-plugs should be inserted morning
and evening, so as to encourage the flow of serum, and prevent
the discharge becoming acrid or ofi:ensive.
As soon as the surface heals another application may be made,
or the iodine may be painted over the cervix.
Where the cervix is mainly affected, the introduction of lamina-
ria or sponge-tents at successive intervals of a few days will soften
the tissue and produce a copious, watery discharge, thereby alter-
ing the nutrition of the cervix. The application of strong caustics,
such as carbolic or nitric acid, or the linimentum iodi, to the cer-
vical canal has often a similar eftect in inducing a process analogous
to that of involution.
Amputation of one or other lip of the cervix by the galvanic
ecraseur, and the employment of glycerin-plugs until the surface
has healed, will reduce materially the bulk of the cervix and alter
its nutrition.
Where the methods indicated have been tried and failed there
are other means at our disposal, but these should always be re-
served for severe and very persistent cases, as their employment is
not unattended by risk. The three methods usually resorted to
are the application of potassa fusa, the actual cautery, and amputa-
tion of the cervix. Previously to the employment of either the
potassa fusa or the cautery, it is well to lessen the congestion as far
as possible by puncturing the cervix and using hot-water vaginal
injections.
The time chosen for commencing treatment should be shortly
after a menstrual period. The patient, being in bed, is placed
either in the dorsal or left lateral position, the latter being gen-
erally the more convenient. As large a size Fergusson's speculum
as the vagina will tolerate is then passed, and the cervix brought
well into the end of the speculum and wiped dry. Cotton-wool
steeped in \dnegar is then packed carefully under the cervix, so as
to neutralize at once any excess of the caustic potash that may run
down; a little \dnegar, injected so as to make a small pond under
the cervix, answers the same purpose. A portion of the fused stick
of caustic potash being held firmly in a porte-caustique is then
rubbed slowly and firmly over a surface not larger than a sixpence,
on one or both lips of the cervix, avoiding carefully the os uteri on
account of subsequent contraction. The mucous membrane is
thus completely destroyed. A stream of vinegar and water is then
injected, to wash away and neutralize any excess of the potash, any
cotton packing removed, and a tampon saturated with glycerin
passed up to the cervix. The patient must remain quiet until the
slough has separated, this usually occurring in about a week, some
antiseptic injection being used morning and evening. The potassa
is again freely applied to the raw, cuplike depression, the same pre-
cautions being observed as before. If the induration be localized,
the contractions of the uterine tissue, aided it may be by the ex-
hibition of ergot internally, may serve to extrude the indurated
CAUTERIES. 187
nodule, the potassa being reapplied until the whole of it is de-
stroyed. The more sensitive the tissues become to the action of
the potassa the more clear is the indication that the healthy struct-
ures have been reached. The excavation produced heals by granu-
lation, and may take many weeks to fill in, the cervix then present-
â– ing a normal appearance, with no cicatrix or evidence of the tissues
having been destroyed. The patient should be carefully w^atched
during the healing process, to see that no contraction of the cer-
5" vical canal or obliteration of the os uteri ensues.
The potassa fusa causes a deeper destruction of tissue than the
, potassa cum calce, and being more deliquescent is more apt to run
: down into the vagina, but still it is far more effective, and accom-
plishes the object in much less time.
p Chloride of zinc is also a powerful form of caustic, but produces
' more pain than the potassa, and is less generally useful.
There is always a certain amount of risk of setting up pelvic
- cellulitis ; strict care should be taken therefore to preclude any risk
of catching cold, or of the patient exerting herself imprudently.
The actual cautery is another method of producing an eschar
|i upon the cervix. Paquelin's benzoline cautery is probably the
most convenient form we can employ. A platinum button, heated
1 to a dull red or nearly white heat, is pressed momentarily upon one
• or both lips of the cervix, so as to produce a superficial or deep
.^ slough, as may be desired. A wooden, ivory, or horn speculum
- should be emplo^^ed, though a large cylindrical metal one may be
1 used if care be taken not to allow it to become overheated. The
> surface of the cautery being polished, there is less radiation of heat
I than with the ordinary cautery, and it does not adhere to the tis-
sues. A stream of cold water should then be injected, and a glyc-
!* erin tampon applied as before directed.
The galvanic cautery may be employed where we wish to produce
|!more extensive sloughing.
Amputation of a portion of the cervix, when the length as well
{ as the breadth is increased, by means of the galvanic ecraseur, has
ibeen recommended with a view to inducing involution. If a small
I portion of the hypertrophied organ be removed, a marked tendency
'to diminution in the bulk of the remaining tissues shows itself.
i One or other lip of the cervix may thus be removed, either by ex-
f cision with curved scissors and the subsequent application of the
i actual cautery, or by the galvanic ecraseur, thus saving much time
i in treatment. It is generally advisable to administer an anaesthetic,
; and every precaution should be taken to prevent any exposure to
• cold or retention of discharges in the vagina.
Thomas considers this method possesses none of the advantages
â– of trachelorrhaphy (the operation for repair of the lacerated cer-
vix), to which it is inferior in every respect.
188 DEGENERATION OF THE CERVIX UTERI.
CHAPTER XIII.
GRANULAR AND CYSTIC DEGENERATION OF THE CERVIX UTERI.
Granular Degeneration of the Cervix Uteri. — This condition almo>i
invariably complicates affections of the uterus where leucorrhoea
a prominent symptom. It may exist independently of other well-
marked disease of the uterus and give rise to little or no incon-i
venience beyond the leucorrhoea. In other cases it induces such a
condition of hypersemia in the uterus, and reflex irritation, as to in- â–
terfere materially with the patient's comfort and well-being.
It has been described as epithelial abrasion,, granular ulcer, or
erosion of the cervix, but the term granular degeneration best
describes the actual character of the affection.
Pathology. — The smooth mucous membrane covering the cervix,
which is continuous with that of the vagina, passes up the cervical
canal as far as the internal os uteri. I^umerous papillae may be
detected on the surface of this membrane, formed by vascular loops
covered with squamous epithelium. Either from the extension of .
catarrhal endometritis, or from the effect of other sources of irrita-
tion, the squamous epithelium proliferates, becomes softened by
maceration in the ichorous cervical discharge, and finally desqua-
mates, either gradually or en masse, only one layer of cells remain-
ing, giving the surface the appearance of being congested and
slightly granular. From this epithelial layer prolongations project
inwards so as to form glandular crypts, villous prominences arising
by the growth of the vascular connective tissue, these projections
being new formations and not hypertrophied papillae. They are
covered with epithelium and richly supplied with superficial blood-
vessels. This condition has been termed villous or papillary ero-
sion, varicose and bleeding ulcer, and cockscomb granulation.
The term "ulceration" is still frequently employed to describe
this granular degeneration, but although at first we have loss of
tissue, there is no progressive ulceration or gradual destruction of
tissue such as is met with in true ulceration, and therefore the term
is not appropriate,
Causation. — Anything that impairs the general health, more
especially if there be a strumous diathesis, predisposes to this affec-
tion. The actual exciting causes are anything tending to produce
or keep up congestion of the uterus, such as immoderate coitus, dis-
placements, habitual constipation, etc. The extension of gonor-
rhoea from the vagina, or the mere fact of the cervix being con-
stantly bathed in an ichorous secretion, or the chafing of a vaginal
or intra-uterine stem pessary against the cervix, will often be found
to set up granular degeneration. It may occur in virgins, giving
GRANULAR DEGENERATION. 189
mse to so much discharge as in some cases to raise suspicion of dis-
' ease having been communicated. It is, however, a condition more
:: frequently met with in married women and those who have borne
i children. In these latter cases there is often some laceration of the
« cervix complicating the granular degeneration, and we must be
[ careful to distinguish the two conditions, as in extensive laceration
of the cervix there is often such an amount of eversion of the mu-
cous membrane as well as destruction of the epithelial covering of
the cervix from injury during labor as to lead to error unless care
rbe taken.
'i Symptoms. — In simple uncomplicated cases there may be no evi-
Mence of the presence of the disorder beyond leucorrhoea. In cases,
L however, associated with cervical endometritis and other inflam-
matory conditions of the uterus, where the bulk of the organ is
increased and displacement results, a new train of symptoms en-
sues, such as dragging sensations in the pelvis, pain in the back
and loins (worse on standing or walking, as also after intercourse),
imenorrhagia, haemorrhage on coitus or exertion, profuse sanguineo-
purulent leucorrhoea, together with nervous symptoms such as pre-
viously mentioned as complicating endometritis.
Granular degeneration is frequently met with coincidently with
utero-gestation, and gives rise to many distressing symptoms, such
:ias burning pain in the pelvis, profuse leucorrhoea, intense nausea,
haemorrhage upon any slight exciting cause, and not infrequently
^abortion results from the excessive irritation.
Diagnosis. — On digital examination the cer^dx feels soft and vel-
> vety or granular, not smooth as in a normal condition. However
granular the surface, no haemorrhage is produced by an ordinary
careful examination, whereas in epithelioma uteri in the early
>tage the least touch is often suflftcient to produce considerable
haemorrhage.
On getting the cervix w^ell into view by means of a Fergusson's
speculum, the surface is found to be bathed with a thick creamy
pus. On mopping this away, the cervix will be seen to be intensely
red, florid, granular, the surface being somewhat elevated above
the normal level of the surrounding mucous membrane, having a
villous appearance.
In severe cases following parturition there is generally some
hyperplasia of the cervix together with a more or less nodular or
irregular condition due to slight lacerations. Where bilateral
laceration of the cervix occurs and ectropion of the cervical mucous
membrane is produced, this will be more evident to the touch than
to the sight.
In epithelioma of the cer\ix it feels more indurated, the os is
more clearly defined, often hard and irregular, haemorrhage is very
readily induced, and on looking at it through the speculum it ap-
pears less angry, more ulcerated than in cases of granular degen-
eration.
Prognosis. — The disease may go on for an unlimited time if not
properly treated, becoming worse as the congestion and reflex irrita-
190 DEGENERATION OF THE CERVIX UTERI.
tion increases. Where, however, appropriate measures are adopted
to improve the general health, alter the character of the surface
affected, and remove any existing complications, a cure may safely
be predicted. In long-standing cases treatment will need to be
persevered with steadily for some time.
Treatment. — This will differ materially, depending upon the se-
verity, duration, complications, and state of health. In simple
cases the mere employment of the syringe, with suitable injections
of borax, alum, zinc, chloral, acetate of lead, etc., will often prove
sufficient to relieve the condition, provided the general health be
also attended to and all obvious causes conducing to keep up the
irritation be removed.
Where the disease is of long standing it will generally be found
to be secondary to some other antecedent condition, such as va-
ginitis, endometritis, displacement, etc. It is essential for success
that any primary disease should be discovered and dealt with
simultaneously. If vaginitis be present this must be properly
treated, otherwise we shall in vain attempt to cure the granular
degeneration so long as the exciting cause of its production re-
mains. If endometritis exist, suitable means must be adopted to
remove it, as described when speaking of this condition.
If the cervix be lacerated to any extent, it will be necessary to
repair this by an operation. The eversion of the mucous membrane
consequent upon laceration is often mistaken for granular degen-
eration. Unless this be detected and repaired, all our applications
will be of no avail.
If any displacement, such as retroversion, retroflexion, or pro-
lapse be detected, a Hodge or other vaginal pessary should be fitted
so as to relieve the tendency to congestion and remove the cer^dx
from all influence of friction.
The action of the pessary may be still further assisted by mean*
of abdominal and skirt supporters, which take off the pressure
upon the lower abdomen of tightly fitting or heavy clothing.
Rest in the horizontal position during menstruation, regulation
of the bowels, avoidance of prolonged or undue exertion, or of too
frequent intercourse if the patient be married, should all be in-
sisted upon.
The general health must also be attended to, suitable tonics being
prescribed and the diet properly regulated. This is fully discussed
in speaking of endometritis.
Having attended to these preliminary points, we have now to
consider the various methods of influencing the local condition of
the cer\ix by means of vaginal injections, tampons, pessaries, ap-
plications of caustics, etc.
The employment of water, at a suitable temperature, to remove
all secretions from the vagina, and thus favor a more healthy con-
dition of the cervix, is absolutely essential for successful treatment.
This may be effected by means of an irrigator, siphon douche,
syringe, or bath.
The irrigator consists of a suitable vessel, near the bottom of
SIPHON UTERINE DOUCHE.
191
Fig. 103.
^- which is inserted a flexible tube, provided with a stopcock, so as to
' control the delivery of the fluid. To the end of the tube a vaginal
nozzle is attached.
The vessel having been filled with water is placed at a con-
venient height above the patient, either suspended from a nail or
â– standing on the top of a chest of draw-
ers. The stopcock being turned, the
fluid is allowed to flow into the vagina
k in a continuous stream.
The siphon douche is arranged by
filling a jug or can with water at the
desired temperature. A long india-rub-
ber tube, stiffened by means of guttii-
^percha at the bend, so as to prevent
it collapsing, provided with a hollow
leaden ball at one end and a vaginal
-delivery-tube at the other, is then im-
! mersed in the fluid, the stopcock being
i turned so as to allow the fluid to enter.
Before removing the vaginal end of the
' tube from the jug, the stopcock is again
! turned so as to prevent the water run-
I ning out. On now opening the stopcock
:a continuous stream of water can be
imade to flow into the vagina until the
i vessel be emptied, or the leaded end of
1 the. tube being placed in the vessel and
lithe stopcock opened, the fluid may be
I made to enter by simply drawling the
,t thumb and forefinger along the tubing
(from the rim of the vessel downwards.
The great advantage of employing
Uhe irrigator or siphon douche is that
the patient can administer it herself
whilst lying in the dorsal position. The
}hips being placed over a bed-bath, or
i bed-pan, to which a flexible tube is
attached to carry the fluid away into a
i foot-pan or other vessel on the floor, the vaginal tube is inserted a
short distance into the passage, the stopcock turned and the water
allowed to flow.
Another method is to lie with the buttocks projecting over the
edge of a low bed or couch, the feet resting on two chairs, and a
' mackintosh arranged so as to conduct the water into a vessel below.
Syringes of various kinds are employed. Those made of india-
rubber are the most suitable; pewter or glass should never be
used, the latter being very liable to break and so cause accidents.
Higginson's syringe is one of the most convenient forms. Ken-
nedy's is also a very useful one.
The vaginal tube should be adjusted so as to lessen the force
Siphon Uterine Douche.
192 DEGENERATION OF THE CERVIX UTERI.
with which the fluid is injected, and prevent the possibility of the
bone nozzle being inserted into the cervix.
Instances of severe uterine colic, intense agony, peritonitis, and
even death from the employment of vaginal injections have been
recorded. In some cases this may possibly be explained by the
tube being inserted into the patulous cervix of a retroverted uterus.
We cannot therefore be too careful in explaining to the patient
how to use the syringe properly.
In employing the syringe the patient may sit over a bidet, or
ordinary chamber-utensil, the water being placed in a basin stand-
ing on a chair or on the floor by her side, as most convenient to her.
Fig. 104.
Higginson's Syringe.
In some instances the syringe may be used whilst the patient is
sitting in her hip-bath, or the bath-speculum may be inserted in
the vagina so as to allow the water to gain ready access to the cer\TX.
For ordinary purposes of ablution the syringe answers perfectly
well, but where we need the stimulating, sedative, or alterative
effect of long-continued applications of cold or hot water, the irri-
gator, siphon douche, or employment of the syringe by a nurse,
becomes requisite.
After the employment of cold, tepid, or hot water to remove,
any secretions from the vagina and promote a healthier action oi
Fig. 105.
Syringe for Injecting Lotion.
the mucous membrane, the best way of applying any medicated
sokition is for the patient to recline on her back, with the hips
slightly elevated, so as to allow the retention of the fluid in the
vaginal cul-de-sac. A small syringe holding two to four ounces
having pre\dously been filled with the lotion is then used to inject
it into the vagina, the patient retaining it for some five or ten
minutes, when, on sitting up, the fluid runs out into any suitable
receptacle. This is a far more efiicacious method of applying in-
jections than using them very dilute merely to wash the surface
momentarily.
As emollient injections the following will be found very useful.
INJECTIONS. 193
especially if the vaginal secretion be much increased, and by its
acridity tends to keep up the granular erosion of the cervix:
Either sod^e biboratis 5j-ij ; glycer. boracis 5ss-j ; sodae bicarbon-
atis 5ij-iv; potassse bicarbonat. 5ij-iv; potassse chloratis 5ij-iv; or
u liquor, plumbi subacet. 5ij-iv; dissolved in Sviij of water.
Equal parts of the lotion and hot water may be used, the strength
being modified at discretion by the addition of more or less water.
The best sedative injections are — hot water, temperature 85-
100° F., continuously applied; tinct. opii 5j-iv; tinct. hyoscyami
5ij-iv; tinct. belladonn&e 5j-ij; tinct. iodi 5j-ij; chloral, hydrat.
3^-ij ; glycer. purific. 5j-ij ; added to Sviij of water.
The lotion being warmed, or diluted with an equal quantity of
4 hot water, increases the soothing eifect.
The most useful astringent injections are — either alum 5j-iv;
sulphate of zinc 5ss-ij ; tannin 5ss-ij ; plumbi acetatis 5j-ij ; liq.
plumbi subacet. 5ij-iv ; iron alum 5j-ij ; sulphate of copper 5j-ij ;
or tinct. ferri perchlor. 5ij-iv; dissolved in Sviij of water.
The addition of an ounce or two of glycerin to the mixture,
land aqua ros^e in place of plain water, makes a more soothing and
sat the same time a more elegant lotion. The alum and zinc lotions
are the most generally useful ; if the others be employed care must
be taken to prevent the linen being soiled, as otherwise a stain will
be produced. The old form of lotio quercus has this objection,
the tannin answers equally well. They should be employed cold,
unless otherwise desired. Ice-cold water may be useful in some
cases.
The principal disinfectant injections are — either acid, carbolic.
>5i8S-5iij ; liquor, chlori 5ij-3iv ; potass^e permanganat. gr. xx-xxx ;
sodae biborat. 5ij-5iij ; liq- sodse chloratae 5ij-5iv; or liq. carbonis
jdetergens 5iv-5j ; dissolved in 5viij of water.
The addition of glycerin and rose-water in place of plain water
;.adds materially to the efficacy of the lotion as a disinfectant.
Astringents may also be applied to the cervix by means of tam-
pons soaked in glycerin, in which borax, tannin, acetate of lead,
carbolic acid, etc., are dissolved. It is well to first saturate the
plug with pure glycerin, squeezing it slightly, so as to get rid of
any excess, then dip the face of it in the medicated glycerin, and
insert it in the vagina, close up to the cer\dx uteri. This may be
done by the aid of a speculum, or by the patient herself, either
through Barnes's tampon introducer, employed for this purpose, or
by merely passing the plug up the vagina as far as the finger will
reach. Glycerin is an excellent solvent for the drugs mentioned,
thirty to sixty grains to the ounce, one-half the strength of the
pharmacopoeial preparations, being sufficient. The glycerin itself
xcts most beneficially in depleting the cervix by producing a copious
vatery discharge.
Another method of applying agents to the cervix is by means of
suppositories or pessaries. These may be made either with cocoa
)utter; one part of powdered gelatin moistened with three parts
; )f glycerin gently heated and poured into moulds ; or one part of
13
194 DEGENERATION OF THE CERVIX UTERI.
pure paraffin to four of vaseline. As astringents, alum gr. x-xv ;
iron alum gr. x-xv ; alum and catechu gr. x-xv of each ; tannin
gr. iij-v ; acetate of lead gr. iv-vj ; matico gr. x ; persulphate of
iron gr. iv-vj, incorporated in a small conical pessary, may be em-
ployed.
As sedatives, morphia gr. ss, with atropine gr. -j^; chloral, hydrat.
gr. v-x ; extract, opii gr. j-ij ; morphia gr. J ; extract, belladonnte
gr. j ; extract, conii gr. v-x; may be employed either alone
iG. 106. ^j. -^ conjunction with an astringent.
Zinci oxidi gr. x-x^^; bismuthi oxidi gr. x-xv; borax
x-xv ; unguent, hydrarg. gr. x-xx ; plumbi acetat. gr. v-vj ;
iodoform gr. ss-ij, also form useful applications in cases of
granular erosion.
A single pessary is inserted into the vagina by the patient
herself on retiring to rest, and allowed to dissolve in situ,
the syringe being employed on rising in the morning to
wash away the debris. It is essential that the patient remain
Mng down during their employment.
Local applications to the cervix will generally need to be
employed about once a week by the physician himself.
In virgins the use of vaginal injections may first be tried,
a suppository being also passed at bedtime if requisite ; but
where after a fair trial relief does not ensue, it will be
necessary to pass the speculum and apply more powerful
agents. Any secretion should first be carefully wiped away
by means of a little cotton-wool inserted in an appropriate
holder, as in Fig. 106. A Playfair's probe, with cotton-
wool wound thickly round the extremity, answers every
I purpose when using liquid applications. A custom still
prevalent on the Continent is to pass a Fergusson's specu-
lum, get the cervix well in view, and then pour into the
speculum half an ounce or more of a strong solution of
nitrate of silver, etc., allowing this to bathe the cervix for
a minute or so, and then, by tilting the speculum, allow
the fluid to flow out again. In cases of vaginitis this
method has its advantages, but where the os uteri is merely
involved, it is rather a wasteful and unnecessary method.
The ordinary probe, Fig. 95, answers every purpose, and
h^idfr G^a^l^s us to limit the application to the surface desired.
The agents generally employed are :
Solid nitrate of silver.
Solution of nitrate of silver 5ij-iv ad 5j aquam.
Carbolic acid, saturated solution.
Carbolic acid and linimentum iodi, equal parts.
Chromic acid 5ij-iv ad .5j aquam.
Mtric acid.
Liquor ferri perchlorid. fortr.
Potassa fusa, or potassa fusa c. calce.
Richardson's styptic colloid.
In severe and protracted cases the application of the actual,
AGENTS. 195
Fuhermo-, gas, or galvano-cautery may become necessary, or we may
\ have to resort to scarification or snipping off the exuberant granu-
lations. If laceration of the cervix exist, an operation for the re-
moval of this may be requisite.
The solid stick of nitrate of silver is still largely employed, and
iin some cases proves very serviceable. It is rather apt to cause
ihsemorrhage.
The solution of nitrate of silver may be used where a liquid ap-
plication is preferred.
Carbolic acid is an extremely useful agent, and suits most cases.
It produces a somewhat anaesthetic influence, and so does not prove
â– as painful as some of the other applications.
This acid, combined with the linimentum iodi, exerts a more
alterative effect upon the cervix, and is useful in chronic cases
where hyperplasia exists.
If chromic acid be employed, great care is necessary to prevent
.any excess running down on to the vagina. In some cases it is
. apt to be followed by vomiting and diarrhoea. A saturated solu-
!tion of carbonate of soda should be used to neutralize any excess.
jS'itric acid should be reserved for severe cases, where other
remedies have been tried and failed. A single application to the
OS, and as far up the cer\dcal canal as the granular disease extends,
will often prove more serviceable than several applications of less
j powerful agents. Carbonate of soda will neutralize any excess,
'but great care should be taken to press out any excess of the acid
against the neck of the bottle before employing it.
The first application should be made shortly after a period, and
then not again for a month, except in severe cases, when a second
may be resorted to within a week or ten days of the first. Carbolic
acid or iodine may be applied once a week during the interval.
Liquor ferri perchlor. fort, is very usefal where the granulations
lare very vascular and bleed readily.
Potassa fusa and potassa cum calce are seldom called for in mere
granular erosion of the cervix. Where hyperplasia complicates
this latter condition, it may be necessary to resort to such power-
ful agents. The precautions requisite are fully given elsewhere.
Richardson's styptic colloid, which consists of a strong solution
of tannin in gun-cotton collodion, answers admirably in some cases.
IThoraas speaks very highly of it, and says he knows of no means
better calculated than this to accomplish the four indications, of
first putting the granular surface beyond the influence of friction ;
-aecond, protecting the surface from contact with ichorous dis-
charges; third, exerting a steady alterative influence upon the dis-
eased surface; and fourth, preventing congestion of the cervix.
?It appears to act not only as a direct alterative, but by forming a
protective crust over the surface, constitutes for it a shield against
friction and uterine discharges, while at the same time by its com-
pression of the excoriated villi, permeated by their loops of vessels,
and of the submucous tissue, with its increased vascular supply, it
diminishes local congestion.
196 DEGENERATION OF THE CERVIX UTERI.
In cases where the cervix is enlarged, infiltrated, and either soft-
ened or indurated, and where ordinary applications fail to relieve
the granular erosion, the cautery in one or other of the forms
enumerated will often furnish good results. A wooden or ivory
speculum should be employed to prevent the vagina being injured,
and a stream of cold water should be injected the moment tibe ap-
plication is completed.
It is not a painful operation in most cases, though naturally
somewhat dreaded by the patient. It may be prudent, therefore,
to give a few whiifs of chloroform preparatory to operating. If
the actual cautery be used, the iron should be nearly at a white
heat, in order to prevent the adherence of the tissues which takes
place when it is at a dull red. The eschar produced is detached
after eight or ten days, leaving a healthy granulating surface, and
is not followed by a contracting cicatrix.
Where the uterus is very congested and the granular erosion
very persistent, scarification of the surface by means of linear in-
cision is often very beneficial. A sharp-pointed, curved bistoury
is passed within the cervical canal as high up as deemed necessary,
and as it is withdrawn the mucous membrane is cut through, ex-
tending the incision towards the outer margin of the vaginal por-
tion of the cer\'ix as far as requisite. This process is then repeated
until five or six similar incisions have been made and the network
of vessels thus severed.
Puncturing the cervix with a lancet-shaped scarifier in several
places has often a similar beneficial influence, and in intractable
cases should always be tried.
Where the granulations on the cervix are very exuberant, so-
called cock's-comb granulations, they may be removed by long-
handled, curved scissors, or even by the curette, as close as possible
to the mucous membrane, and then either the thermo- or other
cautery or nitric acid applied to restrain haemorrhage and check
further gro\^i:h.
Cystic or Follicular Degeneration of the Cervix. — This is a less com-
mon affection than granular degeneration of the cervix, but is not
an infrequent complication of chronic endometritis. It has been^
described by some authors as acne, herpes, and aphthae of the cer-i
vix. Any inflammatory condition of the cervix may give rise to
these glandular enlargements.
Pathology. — The small mucous glands studding the vaginal face
of the cervix as well as the cervical canal not infrequently become
closed from the margins of the orifices becoming adherent. The
glands then dilate, owing to the retention of the secretion becom-
ing distended into small sacs or cysts, termed ovula ^N'abothi. On
the denser vaginal portion of the mucous membrane of the cervix
they merely form small protuberances or eminences, readily felt
by the examining finger. Just within the cervical canal, however,
they push up the mucous membrane and appear as small cystic
polypi.
It is probable that in some cases these small cysts are due to
FOLLICULAR DEGENERATION. 197
^ irritation of the rete Malpighii, and not to closure of pre-existing
glands, appearing as small collections of nuclei, which, becoming
transformed into cells, project upon the surface, when they are
. either thrown off or form small cystic polypi containing a gelatin-
ous mucus, mixed with cells and nuclei, fat-globules, spindle-
shaped and many-branched cells, and colloid granules. In some
cases the distended follicle bursts, discharging its con-
tents, a slight depression remaining constituting the con- 'Pio.ior.
dition known as follicular erosion. In other instances
the papillae become hypertrophied and project beyond the
surface as small, reddish, haemorrhagic-looking tubercles.
In patients who have passed the climacteric age these
distended follicles may give rise to occlusion of the os
uteri, and so prevent the exit of any secretions from the
interior of the uterus. The retained mucus gradually
distends the organ, especially if there be any chronic
catarrhal condition of the mucous membrane of the body
of the uterus, producing the condition known as hy-
drometra. '
The accumulation may go on indefinitely until even
retrograde dilatation of the Fallopian tubes takes place or
some ulcerative process produces perforation and peri-
ttonitis. Where the os internum remains narrow we
imay have the hour-glass form of uterus produced — the
i uterus bicameratus.
The fluid collection may vary in consistence and char-
.acter, from a thin, muco-purulent secretion of a yellowish
»or reddish-brown color to that of a chocolate-colored
iglutinous fatty fluid containing cholesterin or pus.
Diagnosis. — The sense of touch is generally sufl&cient
tto detect the existence of follicular degeneration. This
may be confirmed by examination with the speculum.
Iln elderly patients their presence may lead to the sus-
picion of malignant disease; the small protuberances
give to the cervix an irregular, nodular appearance, and
where the mucous membrane is much congested the pos- Sims's
flsibility of cancer may readily occur. The cervix, how-
ever, is seldom so hard or enlarged as in this latter condition, and
rthe mucous membrane is not fixed to the subjacent surface, nor
does bleeding easily occur on examination.
Treatment. — ^We may first attempt to obliterate the small cysts
hj puncturing them with a scarifier or bistoury and applying
mtric or chromic acid to the interior. K this fail, the potassa fusa
or potassa cum calce may be tried, or the actual cautery employed.
IThe diseased glands may be scraped away by the aid of the sharp
steel curette, and should the case still prove intractable, our only
remaining resort will be to remove the vaginal portion of the cer-
vix by the galvano-cautery wire, the bistoury or scissors.
Where follicular erosion exists, the application of strong carbolic
or nitric acid, or the nitrate of silver, may be tried. Care must be
198 DEGENERATION OF THE CERVIX UTERI.
taken not to produce occlusion of the os uteri by contraction from
employing too strong caustics just within the os uteri.
Si/jMitic Ulceration of the Cervix. — This is exceedingly rare. When
a true chancre does occur in the cervix it presents the usual char-
acteristic appearances of a well-defined, indurated margin, de-
pressed surface, and a marked tendency to become covered l)y
false membrane. The constitutional symptoms become rapidly
developed. If any doubt as to the character of the sore exist?^,
inoculation may be practised. In cases of soft sores on the cervix,
the diagnosis is simplified by the occurrence of other sores simul-
taneously on the external organs of generation. Mucous tubercles
and other secondary affections are also rarely met with in the cer-
vix uteri.
Tertiary syphilitic ulceration occasionally manifests itself. It is
excavated and bleeds readily on touch, not infrequently being mis-
taken for cancer. There is, however, generally less pain and less
foetor of the discharge than met with in cancer, and the other con-
stitutional symptoms will assist in the diagnosis. Syphilitic ulcera-
tion has been known to extend rapidly, penetrating into the
rectum and bladder.
Treatment. — In case of chancre it is well to destroy the surface
with the strong nitric acid or acid nitrate of mercury, and to resort
to the usual constitutional remedies. Black wash may be kept
applied by means of a tampon, which will also prevent the vagina
coming in contact ^^th the sore.
In case of secondary affections, the biniodide of mercury with
the local application of black or yellow wash will be indicated.
Tertiary ulceration must be treated on general principles.
A very guarded opinion should be given as to the nature of the
affection unless the evidence of constitutional infection is marked.
HYPERTROPHIC ELONGATION OF CERVIX UTERI. 199
CHAPTEK XIY.
HYPERTROPHIC ELONGATION AND LACERATION OF THE CERVIX UTERI.
Hypertrophic Elongation of the Cervix Uteri is intimately related
to and frequently associated with prolapsus uteri, although the
former may occur as a distinct affection. It may be found in nul-
liparae, though it is frequently not until marriage that inconven-
ience is experienced and relief sought.
The body of the uterus occupies its normal position, but the
elongated cervix projects into, and occasionally fills to a great ex-
tent, the whole length of the vagina, the os externum projecting
at the vaginal outlet, or even beyond. The cervix is usually conical
in shape, the base being uppermost; the vagina is often shorter
than normal, and the os uteri very small. The uterine sound
shows the cervix to be elongated, often to as much as two inches
or more.
The chief symptoms are such as would be experienced by the
presence of a foreign body — such as a polypus — in the vagina.
Vaginal irritation with leucorrhcea and occasionally erosion of the
mucous membrane of the vagina occurs. Dysmenorrhcea and
menorrhagia are not infrequent. In some cases the hypertrophied
cervix induces expulsive efforts, which tend to increase the condi-
tion. In married patients dyspareunia is almost invariably present;
the impact of the male organ increases the tendency to congestion
of the cervix, and often sets up inflammation, or even aJbrasion
and ulceration.
In these cases removal of the hypertrophied cervix is the only
plan of treatment. This will shortly be described.
After childbirth hypertrophic elongation of the cervix may
arise in consequence of the process of involution not taking place
properly. Hypersemia or even subacute inflammation occurs, with
serous exudation. Hyperplasia, or proliferation of connective tissue,
slowly ensues. The glands of the cervix become hypertrophied,
their secretion increased, giving rise to muco-purulent leucorrhcea;
eversion of the mucous membrane of the cervical canal, with en-
dometritis and metrorrhagia as a consequence, often results. Dys-
menorrhcea and dyspareunia are often complained of.
^ The gradual increasing hypertrophy of the uterus, the relaxa-
tion of the vagina and uterine ligaments, in time cause prolapsus
or retroversion.
The cervical mucous membrane, being extremely vascular, is
the primary seat of injury during labor, and of congestion and
inflammation; it becomes swollen, with gorged vessels, and serum
and fibrin poured out into its submucous layers; hence there is
200 HYPERTROPHIC ELONGATION OF CERVIX UTERI.
increased villous growth, which can only find room by bulgin
out through the os tincse (Barnes). Thus a process of gradua
continuous eversion and growth of the cervix takes place, hyper
plasia being most active at the inner and lower part of the cer\dx,
which becomes elongated.
As this latter descends to the vulva it excites reflex action, the
straining increasing the congestion and protrusion. Dr. Barnes
calls attention to the fact that when the condition has reached its
extreme limit, the cervix and uterus most frequently measure ex-
actly ^ve inches; that is, just double the normal length.
Other causes of hypertrophic elongation of the cervix are stretch-
ing of the uterus when adherent to an extra-uterine cyst; in-
volution of the uterus when fixed by adhesions due to perime-
tritis; the presence of fibroid tumors dragging up the uterus as
they grow above the pelvic brim ; prolapse of the anterior wall of
the vagina, with the base of the bladder producing tension upon
the uterus below the insertion of the ligaments which ordinarily
keep the organ in its place.
Treatment. — Emmet denies that under any circumstances ampu-
tation would be justifiable, or ought evef to be employed for the
relief of this condition.
Still, as elongation of the vaginal portion of the cervix unques-
tionably exists in many cases as a primary affection, and may give
rise to prolapse of the uterus, removal of a portion, if not the
whole, of the cervix is recommended by most authors. It is, how-
ever, an operation not to be lightly undertaken, as serious risks
and dangers are liable to be incurred. Primary haemorrhage is
often severe and difficult to check: secondary haemorrhage may
occur. There is great risk of opening the peritoneal cavity be-
hind from Douglas's pouch being carried downwards to a lower
level than normal; peritonitis may thus be set up and prove fatal,
though it is not invariably so, as cases have been reported where
the accident occurred without any well-marked symptoms being
developed. The bladder may also be injured anteriorly, and cel-
lulitis be set up in consequence.
Tetanus has been known to occur.
The risks from the operation are materially lessened by the em-
ployment of the galvano-cautery, very little constitutional disturb-
ance resulting if due precautions be observed.
There are various modes of performing amputation of the cer-
vix. That by means of the bistoury, or scissors, is the one most
frequently resorted to by the majority of modern operators.
The patient being anaesthetized and placed in the lithotomy, or
semi-prone position, on the left side, a Sims's speculum is intro-
duced, or the cervix pulled down as far as is prudent, outside the
vulva if possible, by means of vulsellum forceps. A sound well
curved is passed into the bladder to determine the point to Avhich
the bladder descends, a hare-lip pin is then passed right through
the cervix about a quarter of an inch below this j)oint, and another
at right angles to this. An elastic band tied tightly above this
AMPUTATION OF THE CERVIX. 201
will serve to restrain hseniorrhage. The cervix may be slit bilat-
erally, and the two halves severed transversely, by means of scis-
sors, just below the level of the pins, or the whole thickness may
be cut through at once with the scissors. In place of leaving this
surface to granulate and cicatrize over as formerly advocated, the
better plan is to pass silver sutures, as in Fig. 108, so as to draw the
mucous membrane over the face of the
stump. Before tightening the sutures ^^^- '^^^^
the elastic band must be removed and
the hare-lip pins withdrawn. By this
method it will be seen the mucous
membrane of the cervical canal is
united to that covering the outer cir-
cumference of the cervix, and thus oc-
clusion of the OS uteri by subsequent
cicatrization prevented.
The sutures passing through the tis-
sue of the cervix, there is less likely to
be secondary haemorrhage than where
the mucous membrane is merely drawn , Mode of Placing Sutures after
,, ^ ^ ,, , «^ . . Amputation of the Vaginal Cervix.
over the face of the stump, as origin- (After Schroeder.)
ally suggested by Marion Sims.
Primary union results as a rule, and the cervix remaining more
closely resembles the normal character.
Amputation by means of the chain or wire-ecraseur, although
apparently very simple, is attended by considerable risk of injury
to. the peritoneum or bladder, owing to the traction produced dur-
ing the tightening of the chain or wire dragging in the tissues
above the level of its application.
To ob\date this, the cervix having being pulled down and the
sound passed into the bladder as pre\^ously indicated, a hare-lip
pin may be passed through the cervix just below the point where
the sound reaches.
This will effectually prevent the in-dragging of any tissue not
intended to be involved.
Another plan is to sweep a bistoury round the cer^dx, di\iding
the mucous membrane at the level where the wire is intended
to be applied, so as to isolate completely the cervix from the
vagina.
It is not necessary to remove the whole of the vaginal portion ;
a certain amount of retraction ahvays occurs during the process of
cicatrization.
Chassaignac's or Braxton Hicks's wire-rope ecraseur is to be
preferred. Several strands of fine steel wire twisted in the form
of a rope should be employed. One end of this is attached to the
crossbar, so as to produce a saw-like action when tightened.
The galvanic ecraseur or cautery wire is by far the most expedi-
tious and easy method of amputating the cervix, when the instru-
ment is at hand.
Care must be taken, as in the other modes of operating, to as-
202 HYPERTROPHIC ELONGATION OF CERVIX UTERI.
Frr:.
certain exactly the point where the bladder extends to, so that it \
may not^be included.
The operation may be performed with the uterus in situ, or the
cervix may be drawn down by means of vulsellum forceps. The
battery being ready, the wire loop is carefully
adjusted around the cer\ix and tightened suf-
ficiently to become slightly indented in the
tissues.
The galvanic current being completed, the
wire is gradually screwed up, being tightened
slowly to avoid subsequent haemorrhage, until
the cervix is removed. Haemorrhage seldom
! occurs if the removal be not eifected too rapid-
ly ; should any small artery be found jetting,
the bleeding may at once be arrested "by touch-
ing the open mouth of the vessel with the por-
celain cone, brought to a dull-red heat by the
galvanic current.
A sound may be passed j ust within the canal
after the operation to see that the orifice is not
occluded, and a pledget or plug of carbolized
oil applied to the stump. To prevent contrac-
tion of the cervical canal it will be necessary
to pass a bougie or large sound at frequent in-
tervals for several weeks following the opera-
tion, or an intra-uterine stem may be worn for
a month or two.
The operation is not a very painful one, but
it is advisable as a rule to produce anaesthesia
so as to secure perfect quiet. It may be per-
formed in the lithotomy or semi-prone position,
a Sims's speculum being employed or not, as
deemed advisable. The patient will need to
remain in bed for a week or two following the
operation until the processes of granulation
and cicatrization have taken place. Some car-
bolized vaginal injection may be used t^vice
daily, or oftener if requisite.
Attention must be given to the case for many
weeks subsequently, to see that no undue con-
traction of the cer\dcal canal ensues.
The advantages of operating by this method
are the simplicity of its performance, the im-
munity from haemorrhage, and the absence of
risk of septic absorption.
Laceration of the Cervix Uteri. — This condition is a not infre-
quent result of parturition, the cervix being torn through, either
partially or entirely, on one or other side, or. bilaterally, or in a
stellate form. Although Simpson called attention to the occur-
rence of laceration of the cervix some thirty years ago, it is only
Chassaignac's Wire-rope
Ecraseur.
LACERATION OF THE CERVIX. 203
within the last few years that prominent attention has been di-
rected to the importance of laceration as a cause of uterine dis-
order, Emmet going so far as to say that, " at least one-half of the
ailments among those who have borne children are to be attributed
to lacerations of the cervix." It has not hitherto received the at-
tention in this country that its importance demands, the subject
being scarcely mentioned in the leading works on gynecology.
When the laceration is very slight it is often spoken of as a fissure,
but when severe, and the cervical mucous membrane becomes
everted, we have the condition termed ectropion.
Pathology. — The mucous membrane lining the cervix being retic-
ulated, and containing an immense number of ISTabothian glands,
when laceration of the cervix occurs, and eversion of this mem-
brane results, owing to the exposure and irritation from friction,
cystic hyperplasia ensues, with marked leucorrhoea, granular de-
generation, and the process of involution is materially interfered
with, so that subinvolution of the cervix or the whole uterus re-
mains. Should the tear extend to the vaginal junction, or beyond,
the tendency for the^ tissue to roll out from within the cervical
canal is marked as soon as the patient begins to get about, more
especially if the laceration be bilateral, dividing the cervix into an
anterior and a posterior lip. The angle of laceration soon becomes
the seat or starting-point of an erosion which gradually extends
over the everted surfaces. A source of irritation is thus established
which arrests the involution of the organ. With the increased size
and additional weight of the uterus induced by congestion, the tis-
sues gradually roll out as far as the neighborhood of the internal
OS (Emmet). As rupture of the perineum frequently co-exists,
prolapse of the uterus, with retroversion and subinvolution of the
vagina, are very apt to take place.
The everted mucous follicles gradually undergo cystic degenera-
tion; they become distended, rupture, and gradually empty them-
selves, by which the follicles are destroyed, and their cavities dis-
appear by contraction. Epithelioma may spring into existence from
the seat of the old injury, as a prodvict of perverted nutrition.
Cellulitis being a common result of this accident, and generally
situated between the folds of the broad ligament on the side of the
laceration, the effect of this is to shorten the ligament, tilting the
uterus somewhat, and fixing it towards the injured side.
Causation. — Simpson regarded laceration of the cervix uteri, not
as only of frequent occurrence, but so common after first labors as
to be regarded as a reliable sign of labor having occurred, and not
the result of mismanagement. The most frequent causes of lacera-
tion are precipitate labors, where the membranes have been either
spontaneously or artificially ruptured, where ergot has been given
early in labor, or where the use of forceps has been resorted to be-
fore the cervix Avas dilated. In breech cases, where it is often
necessary to expedite the passage of the after-coming head through
an imperfectly dilated cervix, laceration is very frequent. Rigidity
of the cervix, whether as a result of previous inflammatory mis-
204 HYPERTROPHIC ELONGATION OF CERVIX UTERI.
chief, or from cicatricial tissue, or from malignant degeneration,
would naturally predispose to laceration of the cervix.
Abortion has been mentioned as a cause, especially where crimi-
nally induced; but of this there is little evidence. Instrumental
delivery is credited with producing laceration.
Symptoms. — The only indication of laceration of the cervix during
labor may be haemorrhage persisting when the uterus has contracted ; .
this may vary from moderate oozing to a profuse discharge of bright
blood. It is, however, comparatively rarely that the utero-cervical
artery, or circumflex branch of the uterine artery, is torn through,
its own elasticity and its loose connections with the surrounding
tissues enabling it to stretch and to escape injury.
If immediate union takes place, which is more likely to occur if
the rent be in the antero-posterior or conjugate diameter, no other
symptoms beyond the primary haemorrhage may occur. But, as
Groodell points out, if the wound be a deep one, and slow to heal
up, or it gapes open and fails to close, symptoms of peri-uterine
inflammation are pretty sure to show themselves, such as a rigor,
pain in one or other or both iliac regions, accelerated pulse, elevated
temperature, etc. Involution is thus retarded, the lochia are pro-
fuse, and convalescence is delayed.
If the rent heals up, the patient's health will in time become re-
established; but should no union take place, she will never be the
same woman that she was before her labor. On getting about again
she experiences a sense of bearing-down, weight in the pelvis, con-
stant tired feeling, pain in the back and loins, leucorrhcea, pain and
haemorrhage on coitus with the loss of sexual desire, menorrhagia,
and other symptoms.
The nervous system in course of time becomes affected ; the pa-
tient cannot sleep, she becomes hysterical, low-spirited, and often
degenerates into a confirmed invalid. Sterility is a very frequent,
but not invariable result, depending a great deal upon the direction
and extent of the laceration. Should impregnation take place,
abortion is very liable to occur. Neuralgia of the cervix is not
infrequent from the constant fretting of the unprotected nerve-
filaments, or from imprisonment of a nerve in a dense mass of
cicatricial tissue where nature has attempted to establish a cure.
Profuse menorrhagia and leucorrhcea, hyperplasia of the cer^dx,
prolapse, retroversion, chronic ovaritis, and other analogous condi-
tions generally ensue. Epithelioma not infrequently results from
irritation and perverted nutrition.
Physical Signs. — These are by no means so well marked as might
be imagined. Emmet himself says, " After the parts have been
torn, and while they are soft enough to be flattened out by pressure
on the floor of the pelvis, there remains no evidence of the lacera-
tion, and the true condition frequently cannot be detected by either
the sight or by sense of touch."
Thomas also remarks: "It is an entirely fallacious position to
assume that an examination just after labor reveals the real state
of these parts. Examination later on, towards the end of the period
USE OF SPECULUM. 205
of involution, about the sixth or eighth week, would reveal the
true condition of things, and in a great many cases avoid for women
li\'e3 of suffering and invalidism. It is at this period that every
parturient woman should be examined as to the condition of the
perineum and cervix uteri."
An ordinary cylindrical speculum is not well adapted for diagnos-
ing these cases, as it tends to close the torn lips and to conceal both
the fissure and patch of erosion, or to flatten out still more the con-
vex surface of the cervix, and so obliterate all traces of the fissure
that the red, raw, and angry-looking papillae of the everted mucous
lining of the cervical canal will be inevitably mistaken for an
erosion — the so-called ulceration of the womb.
The bivalve speculum, which distends the vagina slightly, is also
not the form to employ, as the laceration is often not recognizable
and always imperfectly appreciated.
Sims's speculum, or some modification of it, should always be
employed, the patient being placed in the semi-prone position.
Where the laceration extends bilaterally and the tissues are rolled
out, it will be necessary to seize the anterior and posterior lips of
the cervix with a tenaculum in each hand, and bring them into
apposition, when the normal contour of the cervix will be restored.
In any doubtful case it will be well to place the patient in the genu-
pectoral position.
Emmet points out that laceration on the left side is the most
common, due, as is supposed, to the greater frequency of the first
cranial position, the left occipito-cotyloid. Double laceration — the
bilateral form — is the next most frequent. It is very rare for bad
effects to remain after laceration either backward or forward. In
practice we have to deal chiefly with the consequences of lateral
lacerations, and the effects are more marked when the lesion is
double than when confined to either side.
Differentiation. — The condition most liable to be confounded with
laceration of the cervix is granular erosion, the so-called ulceration
of the cervix. The only certain method of distinguishing the one
from the other is to examine the patient in the semi-prone position
with a duckbill speculum and a tenaculum, when in the case of
laceration the two lips of the cervix can be made to approximate,
: and all trace of erosion disappears.
Cystic degeneration of the cervix occurs independently of lacera-
tion, although in this latter the mucous follicles studding the cer-
vical canal undergo cystic degeneration, and from the amount of
inflammatory mischief present, the mucous membrane becomes
considerably everted. The same caution will have to be observed
in conducting the examination before we shall be able to decide
the question.
Simple hyperplasia or hypertrophy of the cervix may simulate
an analogous condition complicated by laceration, and it is very
important not to overlook this latter, as an operation for the restora-
tion of the normal condition of the cervix will cure not only the
laceration, but tend to remove the hyperplasia as well.
206 HYPERTROPHIC ELONGATION OF CERVIX UTERI.
Epithelioma of the cervix has often been diagnosed when no such
condition existed, the appearance being due to extensive laceration,
with eversion of the mucous membrane and extensive erosion, bleed-
ing on the slightest touch. Any one who has witnessed a case
where the cervix is bulky from the hyperplasia induced by the
constant irritation, where eversion with erosion exists, where the
surface is studded with enlarged follicles which feel like shot, or is
roughened by red and angry-looking papillae, perhaps fringed with
cock's-comb granulations, where a profuse leucorrhoeal discharge
and constant sense of discomfort impair the patient's health and
exhaust her powers, can readily understand how difficult it must
be to discriminate between the two conditions. In fact there is
little doubt that the perpetuation of these symptoms under such
circumstances is exceedingly prone to pass on almost imperceptibly
into the more serious affection. Thomas, Emmet, Breiskey, Veit,
and others record their opinion that neglected laceration of the cer-
vix is a fruitful, exciting cause of malignant degeneration of the
cervix. For this reason alone, operative interference should always
be resorted to for the closure of lacerations attended by local en-
gorgements and irritation.
Prognosis. — Where the laceration takes place through the an-
terior or posterior lips of the cer\dx, it generally heals rapidly,
leaving scarcely a cicatricial line to mark its course, unless the rent
passes beyond the cervix through the septum into the bladder an-
teriorly, or extends sufficiently into the posterior cul-de-sac to set
up an attack of inflammation. When cellulitis occurs at this point,
and from this cause, it always induces a most intractable form of
retroversion. When, however, the laceration is in a lateral direc-
tion, and extends beyond the crown of the cervix, a condition at.
once arises which will defeat all the reparative efforts of nature.
Sterility is a usual, though, as we have seen, by no means a uni-
versal result. Some patients seem to be almost unconscious of any
laceration having occurred, a process of cicatrization takes place,
the granular erosion disappears, the hyperplasia diminishes, and
the general health recovers itself to a wonderful extent, the patient
continuing to bear children without unusual risk or discomfort.
More generally, if the laceration be extensive the patient remains
to a certain extent an invalid for many years, until the menopause
in fact, when functional activity ceasing, there are no longer any
urgent symptoms. Epithelioma unquestionably arises in conse-
quence of laceration in some cases.
Treatment. — K laceration of the cervix be suspected or detected
at the time of parturition, and hemorrhage be a prominent symp-
tom, a lump of ice may be passed up to the cervix, a copious stream
of hot water allowed to flow into the vagina, or a tampon soaked
in a saturated solution of alum or tannin applied to the bleeding
surface. If the hemorrhage still persists, it may be necessary to
approximate the edges by means of silver sutures. Strict cleanli-
ness must be enjoined, the vagina being washed out twice daily
with some antiseptic lotion, such as carbolic acid (1 in 40), or Con-
PREPARATORY TREATMENT. 207
dy's fluid, so long as the lochia persist. Involution of the uterus
should he favored by the administration of ergot or appropriate
tonics, not chalyheates ; hy the adjustment of a Hodge's pessary to
prevent the organ becoming prolapsed when the patient begins to
get about again ; by the employment of the hot vaginal douche
twice daily, and by attention to the condition of the general health.
Locally, the application of styptics, such as alum, tannin, sul-
phate of zinc, or of iodine, powdered persulphate of iron, and other
similar remedies must be resorted to. Tampons saturated with
glycerin, pure or medicated, may be inserted in the vagina, close
up to the cervix, every night. Goodell speaks of tannin 5j, iodine
5ss, or iodoform 5ij, dissolved in an ounce of flexible collodion, as
forming an excellent application ; also painting the cervix every
five days with a saturated tincture of iodine, followed occasionally,
before it dries, by a weak solution of the nitrate of silver. This
forms a protective and an alterative crust of the" silver iodide. The
common practice of treating these erosions with the solid stick of
lunar caustic is a bad one, on account of the cicatricial tissue which
it leaves behind. Such a dense and gristly tissue often pinches
peripheral nerve-filaments so severely as to produce ovarian or
uterine neuralgia, wholly or partly quenching sexual desire, and
causing other psychological disturbances.
AVliere palliative treatment fails in afifording relief, operative
measures must be employed if the uterus remains large, becomes
displaced, congested, or hypertrophied, the lips everted, and the
surface secretes a viscid muco-purulent secretion, the patient mean-
while suffering from neuralgia and reflex irritation.
The operation of trachelorrhaphy (Tpri^^iXoc:, neck; pct{p»), a seam)
; should never be undertaken until palliative treatment has first been
tried and the general health attended to. If any symptoms of pel-
vic cellulitis, such as fixidity of the uterus or presence of deposit be
detected, all operative procedures should be postponed until this
has disappeared.
Preparatory treatment must not be neglected. K the uterus be
very congested, the cervix gorged with blood, or studded and stifl:-
ened with enlarged IS'abothian glands, the denuded surface will
probably not unite. Blood must be taken from the cervix by
-^ scarification, the congested condition being relieved by puncturing
! the cysts, the whole lacerated surface being gone over by little
stabs in every direction, so as to empty the cysts and reduce the
size of the flaps. Churchill's iodine is then to be applied freely
over the surface in which the cysts have been punctured. This
process must be repeated* again and again if deemed requisite. If
! the patient can rest up, Emmet frequently resorts to the use of a
silver wire, passed through each flap at about half an inch from
the edge ; by twisting the two ends until the lacerated surfaces are
brought just into contact, much will be gained by thus temporarily
preventing the parts from rolling out.
When an operation is decided upon, the week following the
menstrual period should be chosen. The patient, being aneesthe-
208 HYPERTROPHIC ELONGATION OF CERVIX UTERI.
tized and placed upon the operating-table either in Sims's or the
lithotomy position, a duckbill speculum is introduced, a tenaculura
fixed in each flap of the laceration, supposing the case to be one ol
bilateral laceration, and the two flaps approximated. Emmet a1
this stage used to apply the uterine tourniquet, a species of ecraseui
with watch-spring in place of a chain or wire, slipping it over the
cervix below the point of vaginal junction, and then tightening it
so as to control haemorrhage during the operation, which is some-
times excessive when the tissues of the cervix are usually soft.
Under ordinary circumstance he finds that the administration of a
large hot-water vaginal injection, just before the operation, will sc
far lessen the bleeding that the tourniquet can be dispensed with.
After separating the flaps fully, the surfaces which have beer
torn in a double laceration are to be freely denuded from one lip
to the other, leaving a broad undenuded tract in the centre from
before backward, which is to form the continuation of the uterine
canal from the os. Scissors are most convenient to employ, the
mucous membrane and a small portion of the parenchyma bein^
removed (Fig. 110). When the two flaps are brought together, a
to B, the new canal through the cervix will be trumpet-shaped.
This is necessary, since the hypertrophy increases in degree from
the bottom of the laceration towards the outer edges of the flaps
and as the uterus gradually returns to its normal size, this ne^
canal will become of a natural and uniform diameter throughout,
When it is safe to do so, the process of freshening the surfaces ie
very much facilitated by drawing the uterus gently down towards
the vaginal outlet, and then having the organ steadied by a strong
tenaculum in the hands of an assistant,
Having ascertained, by approximating the
flaps, that the denuded surfaces will lie ir
contact with each other when the sutures
are passed, these latter are then inserted.
Sharp-pointed short needles, held in g
needle-holder, are best when the tissues
are soft, as there is less risk of haemorrhage
in the track of the needles, but when the
tissues are dense and indurated, and there
fore less vascular, the lance-pointed needle
being easier of introduction, answers besi
for the purpose.
Three or four sutures are required foi
each side if the laceration be extensive oi
double. The needle is introduced about 2
quarter of an inch from the edge of the
denudation, passed through, and in the same
way carried through the opposite lip. One
after the other wire sutures are passed from
above downwards, about a third of an inch
apart, until the lower extremity of the laceration is reached. Ther
the other side is treated in the same manner, the sutures on botl:
Fig. no.
Lacerated Cervix, after
denudation on both sides,
and application of sutures
on one side. (After Gala-
bin.)
AFTER-TREATMENT. 209
sides being introduced before any are secured, otherwise great diffi-
culty will be experienced. When the bleeding has been trouble-
some, it is advisable to pass the first suture through the vaginal
tissue a short distance below the angle of laceration. The circular
artery, or its branch, from which the oozing generally comes, will
be secured by this plan. The sutures are now twisted one by one,
the upper ones being first dealt with, until all are twisted, when
each one is bent downwards so as to lie flat against the wall of the
cervix. The wound is first syringed with carbolized water, to
remove all clots before tightening the sutures. If any secondary
haemorrhage from a suture track, in which a vessel has been
wounded by the needle, occur, it may be arrested by injections of
hot water into the vagina, or by a saturated solution of alum, which
is a safe haemostatic and does not interfere with union by the first
intention.
Some operators recommend the absence of etherization, and the
use of silk instead of \^dre, as materially simplifying and shorten-
ing the operation, which they assert is comparatively painless, the
introduction of the sutures being the onlj really painful part, and
preferable to the nausea following etherization.
The after-treatment is much the same as for any other operation.
The patient must remain in bed for ten days or a fortnight, and
' be kept upon low diet. The bowels should be relieved regularly
! every, or every other day, the patient being allowed to pass water
on the bed-pan for the first day or two. A little warm water should
always be injected into the vagina immediately afterwards, to pre-
^vent any urine which may have entered the canal from remaining
: in contact with the uniting surfaces. After the first few days the
i patient may be allowed to pass water whilst turning over on her
i' hands and knees. A warm carbolic acid lotion should be injected
1 into the vagina night and morning.
The sutures may be removed about the seventh or eighth day,
[ beginning with those above, nearest to the vaginal junction. If
i there be any tendency to gape, or union has not occurred, or seem
' very weak, the lower sutures may be left for several days longer,
so that the ununited portion may heal by granulation.
An attack of cellulitis or peritonitis may follow the operation ;
t^buf, considering the good which it accomplishes, it is remarkably
^free from risk, and when performed with care is perhaps the most
-successful one in uterine surgery.
14
210 NEW GROWTHS OF THE UTERUS.
CHAPTER XV.
NEW GROWTHS OF THE UTERUS — UTERINE POLYPI.
Uterine Polypi. — These consist of tumors, varying in size, situa-
tion, and structure, attached to some portion of the uterus by a
pedicle or stem. They are formed by hypertrophy of some of the
normal tissues of the organ, and are covered by mucous membrane.
[N^umerous classifications of the various kinds of polypi have
from time to time been suggested, but for all practical purposes
an elaborate classification is an unnecessary refinement. We shall
therefore describe only the mucous, glandular, cellular, and fibroid
varieties.
Mucous and Glandular Polypi of the Uterus. — Mucous Polypi con-
sist of hypertrophied mucous follicles enclosed in a stroma of
nucleated cellular tissue, covered by a thin vascular mucous mem-
brane, of a bright or deep red color.
They generally originate in the cervical canal, seldom occurring
higher up. They vary in size from that of a small pea to that of
a cherry, seldom attaining a larger size than this. At first they
are sessile, but generally become pedunculated, the polypus de-
scending below the os uteri. They are usually multiple, and others
are apt to recur after removal.
Glandular Polypi are those in which the proliferation of the gland
follicles predominates over that of the cellular tissue.
Where a single follicle becomes distended with mucoid fluid, it
is spoken of as a cystic polypus.
Where several large, irregular cavities, communicating with
each other, and opening on the surface, lined by cylindrical epi-
thelium, and containing a thick viscid mucoid fluid, occur, they
constitute the channelled polypus of Oldham.
Where the cavities are relatively small, the cellular tissue pre-
dominates, and there is an absence of great vascularity, they have
been described as the jibro-cellular polypus.
These two latter forms generally grow^ to a larger size than the
former, sometimes as large as a pigeon's or even a bantam's ^gg.
Barnes describes a hypertrophic polypus of the cervix uteri occur-
ring in cases of prolapsus uteri. They are generally small, varying
in size from that of a pea to that of a cherry. They are commonly
single, but it is not infrequent to find two or three. They gener-
ally begin to form just within the ring of the os uteri, w^hich con-
ceals them and protects them from the touch. In structure they
are identical with that of the hypertrophied cervix from which the
polypi spring, being composed of bands of smooth fibres like those
of the un impregnated uterus.
THE CELLULAR POLYPUS. 211
The Cellular Polypus is generally of a pyriform shape, and at-
tached to one wall of the cervix, often having a long and slender
pedicle, so that in some cases the growth protrudes even beyond
the vulva.
It consists of hypertrophied cellular tissue, covered by mucous
membrane, and may attain the size of a hen's egg. They some-
times contain a certain amount of cervical fibrous tissue, and are,
therefore, really identical with the fibro-cellular variety.
Symptoms. — There is generally a certain amount of leucorrhoea,
with menorrhagia, but not invariably. Several small polypi may
exist without giving rise to any urgent symptoms. Where the
polypi are situated in the cervical canal, and have not become ex-
truded beyond the external os, dysmenorrhoea from obstruction is
mot infrequent.
The haemorrhage is often altogether disproportionate to the size
of the polypus. This is explained by the constant hyperemia kept
iup by the irritation produced by the presence of the polypus.
Diagnosis. — When concealed within the cervical canal, it may be
I necessary to dilate the cervix before we are in a position to detect
I their presence. Even when they have projected beyond the ex-
tternal os it is often difficult to detect them by the sense of touch
; alone, owing to their being so small and soft, as well as to their re-
t treating easily within the os uteri. On passing the speculum their
jpresence is at once recognized. Where they are within the cervix,
;a bivalve speculum, by distending the vaginal cul-de-sac, and so
(dragging open the lips of the os, will often expose the polypi to
'view when otherwise they would he overlooked.
Treatment. — Where the polypi are small, soft, and pedunculated,
tthey may be safely removed by twisting them off with a pair of
ovum or pile forceps, having a catch at the handles, and, if nec-
essary, touching the base with nitric acid, liq. ferri perchl. fort., or
nitrate of silver. They should not, as a rule, be cut off with scis-
sors, as troublesome haemorrhage may occur, though this is rare.
Fibro-cellular polypi, springing from one or other lip of the cer-
\T.x, occasionally attain the size of a hen's egg. In these cases it
is better to employ the single wire, or w^ire-rope ecraseur. It is
unnecessary to produce anaesthesia, as the growth is not sensitive
and the operation almost painless. The wire can generally be ad-
justed without the aid of a speculum, but this may be employed if
t requisite.
Small intra-uterine mucous polypi often give rise to prolonged
ihsemorrhage. The cervix having been dilated, if necessary, the
growth may be seized by the ovum forceps and twisted oiF, or it
may be scraped oiF with the curette, or destroyed by the applica-
tion of nitric acid.
Where several small mucous polypi are situated just within the
cervical canal, the pressure of a sponge-tent is often sufficient to
effect a cure, carbolic acid or iodine liniment being subsequently
applied to promote a healthier action of the mucous membrane,
and prevent a recurrence of the growths.
212 NEW GROWTHS OF THE UTERUS.
Placental Polypi may result from the remains of the placenta,
consisting of hypertrophied decidua, projecting into the uterine
cavity. Severe haemorrhage not infrequently breaks out some time
after delivery, often very suddenly, in consequence.
Removal by means of the finger, Sims's curette, or mre ecraseur
should be effected. Some styptic, such as the liq. ferri perchl. fort.,
may subsequently be applied if requisite.
Fibrinous Polypi result from partial abortion. The ovum being
driven down by uterine contractions into the cervical canal, its
attachments lengthen into a stalk by the stretching and growth of
their tissues. The embryo escapes, whilst a portion of the mem-
branes or stalk remains, and by accretions of fibrin-coagula forms
the basis of fibrinous polypus (Barnes). Removal by means of the
ecraseur forms the best method of dealing with these.
Fibroid Polypi, or Fibro-myomata, consist of submucous fibroids
projecting into the cavity of the uterus, springing from some por-
tion of the wall of the body of the uterus, or more rarely from the
cervix. Originally contained in the wall of the uterus, they be-
came extruded in consequence of the contractions that ensue, and
gradually acquire a pedicle.
They may remain within the uterine cavity, or ultimately become
expelled, the pedicle being drawn out, so tJtiat the tumor hangs in
the vagina, in some cases even descending so low as to be protruded
beyond the vaginal outlet.
In other instances, in place of a pedicle being formed, the tumor
is expelled entire. Where uterine action is strong, and the tumor
does not separate nor the pedicle lengthen, partial inversion of the
uterus may occur, or prolapsus.
Symptoms. — The presence of an intra-uterine polypus stimulates
the development of the uterus and produces increased vascularity,
thus giving rise to haemorrhages and leucorrhoeal discharge. Act-
ing as a foreign body, it excites uterine contractions, e\ddenced by
spasmodic pains, and pains in the back and loins. Where the
tumor occupies the cervical canal, and so impedes the exit of the
menstrual fluid, dysmenorrhoea may be a prominent symptom.
Excessive menstruation, or menorrhagia, is generally one of the
earliest symptoms. As the tumor enlarges and sets up increased
irritation, the haemorrhage becomes more constant or more fre-
quent, constituting metrorrhagia. This is especially the case where
the tumor is still retained in the cavity of the uterus. Haemorrhage
may occur not only from the surface of the tumor, w^hich is gen-
erally very vascular, but also from abrasion or ulceration of the
cervix, the result of friction.
The leucorrhoea may be merely of a watery, or of a mucous,
purulent, or sanguineous character. Where any impediment to
the free exit of the discharge occurs, it is often very offensive,
giving rise to the supposition of malignant disease. The body of
the uterus will be found to be enlarged where the polypus is of
any size. Spasmodic expulsive pains occur from time to time,
described as uterine colic or bearing-down pains. In some in-
FIBROID POLYPI. 213
stances nausea and vomiting are present. Irritability of the blad-
der, and even retention of urine, may be produced if the tumor be
large.
Results. — If hsemorrhage be allowed to go on unchecked, con-
stitutional symptoms, such as anaemia, impairment of digestion,
and disordered nutrition, ensue. The patient becomes emaciated,
exhausted on the least exertion, suffers from palpitation, is nervous
and irritable, and ultimately succumbs if relief be not afforded.
In married patients sterility usually occurs, but should impreg-
nation take place, abortion is pretty sure to follow. Metritis,
peritonitis, septicaemia, and even gangrene and sloughing of the
vagina, occasionally ensue.
In some instances the polypus is expelled, becoming detached
from the uterus. In others it may undergo a process of calcifica-
tion, fatty degeneration, ulceration, or sloughing. Prolapse or
partial inversion, and even spontaneous rupture of the uterus,
may ensue.
Diagnosis. — Prolapsus uteri and inversion are the conditions
•most liable to be confounded with a polypus that has been ex-
truded from the uterus.
In prolapsus the os uteri is detected at the most dependent por-
tion of the tumor, the uterine sound can be made to pass within
the OS, the structure is sensitive to pressure, the inverted vagina
can be felt moving over the surface of the tumor, the fundus
uteri is absent from its normal position behind the pubes, and the
upper portion or neck of the organ, really the body of the uterus,
' does not at all resemble the narrow pedicle of a polypus.
In partial inversion we detect a rounded tumor encircled by a
ring, but the sound will not pass up more than an inch beyond
this margin. If the abdominal walls be lax, the cup-shaped de-
pression of the fundus uteri may be felt on deep pressure behind
the pubes.
In complete inversion there is no os uteri to be detected. The
neck of the tumor is continuous with the roof of the vagina, and
the fundus uteri cannot be felt in its normal position behind the
pubes by combined rectal and abdominal touch.
For further details see diagnosis of " Inversion."
A fibroid polypus, hanging from the cervix into the vagina, may
be recognized by the following characteristics :
The tumor is generally more or less pyriform in shape, mostly
solid, smooth or lobulated on the surface. Its neck is usually
smaller than the lower portion ; the pedicle can be traced into the
OS uteri, which surrounds it like a ring, or can be felt springing
from one or other lip of the cervix, partially surrounded by the
ring of the os. The structure is not sensitive to pressure. There
is no orifice corresponding to the os uteri.
The fundus uteri can be felt either in its normal position or in
some other portion of the pelvis. The sound can be passed up
within the os uteri the normal distance, and can often be made to
sweep round the pedicle of the polypus.
214 NEW GROWTHS OF THE UTERUS.
When the polypus is retained within the uterus it is often more
sessile than pedunculated. If small, the sense of touch may not
he able to distinguish it, nor is it visible to sight on passing the
speculum. It may, however, project through the os uteri, when
the cervix is relaxed from menstruation or excessive hsemorrhage,
if uterine contractions are present, and again disappear w^ithin the
uterns when the contractions cease and the cervix closes.
Where the symptoms point to intra-uterine polypus, the cervix
should be dilated by means of tents, and the cavity of the uterus
carefully explored.
Cases have been recorded in which a submucous jSbroid, having
been expelled from the uterus, remaining pedunculated in the
vagina, has formed attachments to the surface of this canal, so
that, on passing the finger within the passage, the impression was
conveyed that malignant degeneration of the cervix, extending to
the vaginal walls, existed. The history of repeated haemorrhage,
profuse leucorrho^a, often foetid in character, emaciation, and other
constitutional symptoms, all seemed to point to the same conclusion.
In these cases it may be extremely difficult to arrive at a conclu-
sive diagnosis. The points most likely to assist us in recognizing
the nature of the case will be the length of time the symptoms have
continued, the inability to detect any central orifice corresponding
to. the OS uteri, or to pass the sound within the mass, as can gen-
erally be done in cases of cancer, and that on careful exploration
we shall find that the polypus is not uniformly adherent to its
entire circumference, but either the sound or finger can be made
to pass between the surface of the tumor and the vaginal wall.
Treatment — In cases where the patient has been subject to pro-
fuse menorrhagia for many consecutive months, and her general
health much deteriorated in consequence, before the presence of an
intra-uterine polypus has been detected, we must be careful not to
resort too hurriedly to intemperate efforts at removal.
It may be necessary to adopt palliative measures for a short
time, in order to repair the damage done to the system before at-
tempting any operative procedures, so as to lessen the risk of sep-
ticaemia, shock, or haemorrhage.
Rest in bed during the menstrual period ; ergot, cinchona, and
acid given internally ; swabbing the bleeding surface over with a
strong solution of alum (1 in 12), or the perchloride of iron, Avill
tend to check the excessive haemorrhage.
Dilating the cervix w^ith laminaria tents, or Barnes's bags, will
not only facilitate diagnosis as to the exact situation of the growth,
but also enable us to operate with greater freedom, and allow the
ready passage of the tumor when separated from its attachment.
If the cervix have been already dilated by the expulsive eftbrts
of the uterus forcing the polypus against the cervix, but still the
opening is not sufficiently large to admit of the removal of the
tumor, the walls of the cervix may be divided on either side,
nearly as far as the vaginal junction.
Where the polypus protrudes from the cervix into the vagina,
TORSION, LIGATURE, ETC. 215
^ even though the symptoms may not be very urgent, the wiser plan
us to remove it, as sooner or later mischief is likely to occur.
The various methods at our disposal are torsion, ligature, removal
by means of the ecraseur, or by some process of excision, or by
the galvano-caustic wire.
Torsion is only applicable to polypi with slender pedicles, and
should never be employed if the stalk be thick or firm. The
operation is painless; anaesthesia therefore is not requisite. In
case of small polypi the pedicle may be seized with ovum or pile
forceps, having a catch at the handles (Fig. Ill), and the growth
gradually twisted off. There is seldom any haemorrhage resulting,
but should this occur the base may be touched with the actual
cautery, strong liq. fer. perchl., nitric acid, or other agent. The
operation may be performed with the patient lying in the semi-
prone position, without the aid of a speculum if the pedicle be
slight, but if haemorrhage be at all likely to occur, or the operator
prefer it, a Cusco's bivalve or a Sims's speculum may be passed, so
as to expose the pedicle before applying the forceps, and also allow
of any application being made to the base to restrain haemorrhage.
The ligature was formerly employed with great frequency to
: produce strangulation of the pedicle, the tumor being allowed to
1 separate by sloughing or mortification.
As this process generally occupied two to ten days, according to
the size of the pedicle, and during this time a continuous offensive
discharge was produced, inflammation not infrequently extended
from the pedicle to the substance of the uterus. Metritis, peri-
tonitis, pyaemia, septicaemia, phlegmasia dolens, often resulted, in
many cases terminating fatally, so that this method of treatment
is now, very properly, seldom resorted to. Even removal of the
tumor below the seat of strangulation, although it diminishes the
source of decomposition, does not lessen the danger of absorption.
Ecrasement, by means of the wire-rope ecraseur (Fig. 112), con-
stitutes the simplest, safest, and most expeditious method of re-
moving polypi, combining the advantages of excision with those
of the ligature, without incurring the dangers incidental to the
latter. The pedicle is cut through within a few minutes, without
risk of subsequent haemorrhage, or of any of the evils men-
tioned as likely to occur from the employment of the ligature. If
the polypus occupies the vagina, or be easily accessible within the
uterus, the tumor not being unusually large, nor the pedicle very
difiicult to reach, it is seldom necessary to produce anaesthesia,
as the tumor is insensitive, and the operation itself therefore pain-
less. But if the patient be very nervous or sensitive, and the
growth difiicult to deal with, it may be well to give an anaesthetic
to keep the patient from moving, and to enable us to pass the hand
within the pelvis, so as to explore thoroughly the size and relations of
the tumor before proceeding to remove it by means of the ecraseur.
K the tumor be first seized by a vulsellum and drawn down low
in the pelvis, adjustment of the wire of the ecraseur is thereby
often greatly facilitated.
216
NEW GROWTHS OF THE UTERUS.
The patient lying in the semi-prone, left lateral, or lithotomy
position, as the operator may deem expedient, the wire loop of the
ecraseur is passed over the base of the tumor by the help of the
fingei*s, or a director notched at its extremity, until the loop is
Fig. 112.
Fig. 111.
Fig. 113.
Ovum Forceps, with
Rack.
Vulsellum Forceps,
Curved.
Wire-rope Ecraseur, with Heywood Smith's Adjustment to allow of the wire
being fixed after being passed round the base of a tumor.
beyond the equator of the polypus. The end of the ecraseur is
then pressed up and the wire tightened somew^hat, so that it adjusts
itself to the pedicle near its attachment to the uterine wall. It is
not absolutely necessary to include the w^hole length of the pedicle
aveling's polyptome. 217
up to its insertion, as the portion remaining ultimately becomes
absorbed or atrophied. Where the tumor is sessile on the fundus
uteri, there is often a tendency for this latter to become partially
inverted, more especially if traction be exerted on the tumor by
means of vulsella. Care will be needed therefore not to include
any portion of the uterine wall. If this should occur pain will be
produced, and thus give us timely warning that we are not dealing
with the polypus simply. Should no such inconvenience arise, the
loop having been properly adjusted, the screw of the ecraseur is grad-
ually tightened until the pedicle of the tumor is cut through and
the polypus is left lying loose in the vagina, when it may
be seized and drawn out by means of a vulsellum (Fig. Fig. 114.
113), or large ovum forceps. Excision by means of scis-
sors is not unattended by risk of haemorrhage, although
the operation was formerly extensively practised.
The Polyptome (Fig. 114) was also devised with a
similar object, when the pedicle was higher up in the
uterus, and could not readity be reached by means of
scissors or knife. The employment of the ecraseur has
almost entirely superseded this method of removal. It
is not a plan that can be recommended, and therefore
should not be resorted to unless in exceptional cases.
The use of the actual cautery to arrest the haemorrhage
will often be requisite.
The galvano-cautery wire should be employed when-
ever practicable in those cases where the tumor is im-
planted in the uterine wall or sessile, the base of the
polypus being very thick, especially if we have reason to
suspect that it is unusually vascular. " It not only cuts
without the application of force through the hardest tis-
sue, but being brought to a white heat by the electric
current which passes through it, it sears the open vessels,
. checks hsemorrhage, and prevents septicaemia" (Thomas).
It occasionally happens in cases of large intra-uterine
i polypi, that even when the pedicle is divided great diffi-
culty is experienced in removing the growth. If this '
cannot be accomplished by a reasonable amount of trac- Aveiing's
1 tion, it will be better to cut it up and remove it piece- Polyptome.
meal, either by dividing it in half with the wire of the
» ecraseur again applied, or by cutting through with strong scissors,
or by dilating still more the cervix by means of Barnes's bags, or
by incising the cervix. An unusually large fibroid polypus lying
! loose in the vagina, after division of the pedicle, may also ofter
considerable difficulty in extraction. It may be necessary to apply
a pair of obstetric forceps, and exert traction as in the delivery of
the fcetal head. If the vaginal outlet be too small to admit of the
escape of the tumor, or the perineum be so rigid as to preclude the
delivery of the tumor, bilateral incision of the perineum, or break-
ing up of the tumor itself, as before indicated, must be resorted to.
Nelaton's forceps were constructed for this purpose.
218 NEW GROWTHS OF THE UTERUS.
As a rule, it is inexpedient to perform any operation for the re-
moval of fibroid polypi in the consulting or out-patient room. It
is better to have the patient undressed in bed at the time, so that
she may remain absolutely quiet for some few days afterwards.
The risk of haemorrhage or other accidents is thereby lessened.
Ergot should be given to promote the contraction of the uterus.
Some disinfectant vaginal injection may be employed morning and
evening for the first week or two following the operation. If any
ulceration of the cer\'ix or vagina existed previous to the removal
of the tumor, and this does not heal readily, it may be well to
touch the surface with carbolic acid, nitrate of silver, or other
similar agent.
The stump usually becomes atrophied and in time disappears.
If much discharge from the surface occurs, this may be swabbed
over with the tincture of iodine, or an injection of iodine and Avater
employed.
Some preparation of quinine and iron, with strychnia, is gen-
erally indicated to recruit the health after the removal of the
polypus, but such preparations should be avoided before this has
been efl:ected, as otherwise they tend to increase the haemorrhage.
FIBROID TUMORS OF THE UTERUS. 219
CHAPTER XYI.
NEW GROWTHS OF THE UTERUS — Continued.
Fibroid and Fibro-cysUc Tumors of the Uterus,
Fibroid Tumors of the Uterus, or Fibro-myomata.
Definition. — The tissue of the uterus is very apt to undergo local-
ized hypertrophy, perfectly innocent in character, forming more
or less circumscribed nodules, which have been termed fibroid
tumors. Other terms, such as myoma, fibroma, hysteroma, fibro-
myoma, fibrous tumor, and numerous others have been given to
these growths. The term myo-fibroma or fibro-myoma best ex-
presses the exact nature of the growi;h, which from its resemblance
(sf^oj) to fibrous tissue is generally spoken of as fibroid.
Pathological Anatomy. — A fibroid tumor is simply a localized
hypertrophy of the uterine tissue from increased nutritive activity
at some point in the muscular layer, growing by an independent
proliferation of its own cells ; a fibroid neither infiltrates adjacent
tissues nor becomes intimately incorporated with them, simply dis-
places them as it increases in bulk. In its early stage the tumor
consists almost entirely of true muscular tissue, hence the term
myoma, the tissue of the tumor being continuous with that of the
uterus. This is especially the case in the softer and more rapidly
; growing varieties, found in younger women, than the harder varie-
1 ties. In older tumors the connective tissue is often exceedingly
i abundant, hence the term fibroid. They are encapsuled, hard, and
I resisting to the knife, the section being white and glistening, creak-
i ing when cut, but slightly vascular and of low \itality.
Causation. — ^N'othing certain is known as regards this. Celibacy
1 and sterility are both supposed to exercise some influence in their
j production, owing to the constantly recurring congestion due to
I uninterrupted catamenia, and in addition the unfruitiiil sexual ex-
K citement in cases of the latter. The congestions and extravasations
i of dysmenorrhoea, the localized inflammations, the result of abor-
Jtions or of parturition, are all supposed to favor the growth of
i fibroids. Hereditary predisposition seems to exercise some influ-
i ence, the African race being particularly liable to them, as also to
: a very early development of them. Inasmuch as fibroid tumors
occur only during the child-bearing period, this is spoken of as a
f predisposing cause.
Sexual intercourse always aggravates their symptoms, and mar-
riage is pretty sure to start the gro^^i;h of one hitherto dormant.
The periodical stimulus of menstruation encourages their growth,
and the enlargement of the uterus during pregnancy often stimu-
lates the growth of these tumors.
220
NEW GROAVTHS OF THE UTERUS.
Frequency. — Fibroid tumors are exceedingly common in the
uterus. There is perhaps no organic change in the uterus more
common than the development of tumors of this character (Barnes).
As in a large proportion of cases they occasion no marked distress
and entail little danger to health or life, their presence is often not
even suspected.
Varieties. — Fibroid tumors almost invariably commence in some
portion of the wall of the body or fundus of the uterus, very rarely
indeed below the level of the os internum. Owing to the muscular
contractions induced by the presence of the tumor in the substance
of the uterine w^all, it generally becomes compressed towards or
grows in the direction of least resistance, bulging either on the
outer or inner surface of the uterus, although sometimes it remains
imbedded in the uterine wall and continues growing there. Since
this accident of position determines to a great extent the symptoms
Fig. 115.
Fig. 116.
Diagram illustrating the varieties of Fi-
broids (modified from Emmet). 1. Sub-
peritoneal or sub-serous. 2. Interstitial or
intra-mural. 3. Sub-mucous.
A Sub-mucous Fibroid being gradually
transformed into a Fibroid Polypus.
(After Thomas.)
produced as regards especially pain and haemorrhage, and also in-
fluences the prognosis and treatment, it has very appropriately
been chosen as the basis of their classification, thus :
Sub-perito7ieal, or sub-serous when they project from the exterioi
of the uterus.
Interstitial, intra-parietal, or intra-mural, w^hen they remaim im-
bedded in the substance of the uterine wall.
Sub-mucous or Intra-uterine when they project into the interior o1
the uterus.
In the two latter varieties the uterus itself is generally increased
in bulk, and its cavity enlarged. In the sub-peritoneal, the uterut
is more often normal in size or even atrophied,
The sub-mucous fibroid not infrequently gives rise to so much
uterine contraction that the attachment in time becomes so slendei
and pedunculated as to constitute the growth a fibroid polypus.
Fibroid tumors vary in size from that of a pea to that of ar
adult head, or even larger, and in weight from a drachm to a^
much as fifty pounds or more. They may be single or multiple
the former consisting of one bundle or mass, or compound, con
MULTIPLE TUMORS. 221
sisting of several masses packed together in close approximation,
when they are termed conglomerate, each constituent mass appear-
ing surrounded in a separate matrix, whilst all are encapsuled in
uterine tissue.
Multiple tumors- are those in which separate masses occur in
different parts of the uterus. There is no limit to their number;
as many as thirty-five tumors, varying in size from that of a marble
to that of a foetal head, have been found attached to one uterus.
"Wlien numerous, they are generally of the sub-peritoneal variety.
They are generally more or less globular in form at first, but
when multiple often become irregular and undulated from com-
pression.
They vary in density, according to the stage of development,
from soft elastic to nearly cartilaginous.
In color they vary from red to nearly pearly white. They occur
more frequently in the posterior than the anterior wall of the uterus,
often producing flexion of the organ, one in the posterior wall pro-
ducing retroflexion, and vice versa. They are enveloped by a con-
siderable vascular network, more especially when submucous, but
there is a comparative absence of vessels in the interior, and con-
sequently they possess only a low vitality.
Their rate of growth is not uniform, but is influenced by the
ovarian stimulus. They are rarely found before puberty, their
gro^^i^h being most active during the period of sexual activity, and
as a rule cease to grow after the climacteric, in many cases dimin-
ishing even in bulk.
Symptoms. — These vary, depending upon the site of the tumor.
The sub-peritoneal tumors, unless very large, often cause but slight
manifestations of their presence. The intra-mural or interstitial
generally produce haemorrhage as well as pain, whereas the sub-
mucous more often give rise to haemorrhage only as a prominent
symptom.
The hcemorrhage generally assumes the form of menorrhagia, the
period being profuse and prolonged. This is due not so much to
the increased surface as to the active hyperaemia of the mucous
membrane produced by the presence of the tumor, and possibly
also to the passive hypersemia, the result of pressure.
In other instances the haemorrhage is more or less continuous —
metrorrhagia — there being no well-marked intervals between the
recurrence of the flow.
Profuse leucorrhoea commonly alternates with the haemorrhage,
at times being of a serous character and somewhat foetid, giving
rise to the suspicion of cancer.
Pain is generally most severe in the case of intra-mural fibroids.
It is more or less of a spasmodic intermitting character, a uterine
tenesmus, due to the muscular contractions endeavoring to force or
expel the tumor out of the wall of the uterus. Where the position
of the tumor interferes with the patency of the cervical canal or
tends to produce ante- or retro-flexion, the exit of the fluid from
the body of the uterus may be so impeded as to cause most dis-
222 NEW GROWTHS OF THE UTERUS.
tressing pain, the so-called obstructive dysmenorrhoea. Even
where the canal is patulous the increased hypersemia may give rise
to symptoms of congestive dysmenorrhoea. Where the tumor is
sufhciently large to become impacted in the pehds, the pain is due
to pressure upon the surrounding organs and structures. Pressure
upon the sacral plexus may cause excruciating pain in the form of
sciatica ; this may only be present at the menstrual epochs when
the uterus is increased in bulk from the congestion present at those
times.
Dragging pain is often complained of when the bulk of the uterus
is much increased.
When the tumor has attained the size of the gravid uterus at
the fourth month, like this latter organ it not infrequently rises
above the pelvic brim, dragging the uterus with it ; but this is by
no means uniformly so. In many instances, more especially when
the fibroid is sub-peritoneal and attached to the posterior wall of
the uterus, it becomes caught under the sacral promontory, and
thus impacted in the pelvis, when a fresh set of symptoms, from
pressure, become developed.
The neck of the bladder being compressed, frequent micturition,
vesical tenesmus, or retention of urine result, more especially at
the menstrual periods when the uterus is more congested and
swollen. If this condition be unrelieved, the ureters in time
become distended, and then the pelvis of the kidney, constituting
hydronephrosis. The rectum ultimately becomes compressed, the
faeces being passed in a ribbon-like form; constipation is very
troublesome ; and at length complete obstruction may occur, the
symptoms closely simulating those of strangulated hernia.
Sciatica from pressure on the sacral plexus; oedema of the legs
from pressure on the iliac veins ; and even gangrene of the vagina
from obstruction to the local circulation, may result.
Dysmenorrhoea, dyspareunia, and sterility are commonly found
in cases of fibroid of the uterus ; should impregnation, however,
take place, a marked tendency to miscarriage and very troublesome
haemorrhage are noticed; or if pregnancy advance to full term
serious difficulty may be experienced at the time of parturition.
Provided the tumor be sub-peritoneal and not impacted in the
pelvis, pregnancy may advance to full term, and delivery be effected
naturally.
Physical Signs. — These will xarj considerably, depending upon
the size and situation of the fibroid. If this be of any size, the
uterus will be found on vaginal examination to be enlarged, heavier
than normal when poised on the finger, less mobile, the surface
irregular or nodulated, and harder than natural.
On conjoined manipulation these several points will be still more
plainly made out, the mass being recognized as forming an integral
part of the womb.
Differentiation. — The conditions most liable to be confounded
with fibroid tumors are partial or incomplete inversion, pregnancy,
ante- or retro-fiexion, retro-uterine haematocele, peri-uterine cellu-
ANTEFLEXION AND RETROFLEXION. 223
litis or abscess, ovarian tumors, faecal accumulation in the rectum,
and cancer of the body of the uterus.
Partial or incomplete inversion may generally be recognized by
the history of its sudden production following parturition, the sen-
sitive condition of the tumor, the recognition of the depression of
the fundus uteri, and the shortening rather than increase in the
length of the uterine cavity. The converse of this generally holds
good in cases of fibroid tumor.
In pregnancy there is usually cessation of the catamenia wdth
other minor symptoms to guide us. The uterus is enlarged in a
uniform, symmetrical manner, more or less 'central in position,
soft in consistence, giving a feeling of tenseness when grasped ex-
ternally, alternately hardening and becoming soft under the hand.
The womb grows rapidly. Pregnancy may co-exist with a fibroid.
The cervix is bulky and soft, the os somewhat patulous, of a violet
hue when seen through the speculum.
. In fibroid, menorrhagia is usually a prominent symptom. The
uterus is irregularly enlarged, often bulging to one or other side,
harder than normal, giving a feeling of solidity when grasped by
the hand. The grow^th is slow. The cervix is often lost in the
tumor, or if not is fairly normal in size and consistence, but is not
so continuous in outline with the lower segment of the womb.
Anteflexion can only be difterentiated from a fibroid of the
anterior wall by the employment of the uterine sound. The symp-
toms will often point to one or other condition. Amenorrhoea more
often is associated with anteflexion and menorrhagia with fibroid.
Retroflexion may generally be distinguished from fibroid in the
posterior wall of the uterus, by the direction in which the sound
passes and the disappearance of the tumor when the displacement
is corrected. The fundus uteri is more sensitive and less dense
than a fibroid. On conjoined manipulation the fundus uteri is ab-
sent from its normal position behind the pubes in the case of retro-
flexion, not so with fibroid.
In some cases it is extremely difiicult to diflferentiate between a
retroflexed fundus, a fibroid tumor, a prolapsed and enlarged ovary,
and an extra-uterine gestation. The ovary is generally more sensi-
tive and less firm than a fibroid, and can be moved independently of
the uterus, except in cases where adhesions have taken place.
The diagnosis of extra-uterine gestation cysts is fully discussed
under this heading.
Retro-uterine hsematocele comes on suddenly with well-marked
symptoms of faintness, shock, and pelvic discomfort. The swelling
is less defined, merging more into the surrounding parts, and is
softer than in the case of a fibroid.
Peri-uterine cellulitis or abcess may also generally be distin-
g^uished by the history of the attack, following abortion or partu-
rition, the constitutional symptoms, the fixidity of the uterus, more
difiused swelling, less defined outline, and tenderness to touch.
In fibroid the symptoms have been of longer standing, menor-
rhagia being a prominent one, and the history is less defined.
224 NEW GROWTHS OF THE UTERUS.
*
Ovarian tumors of moderate size when prolapsed or impacted in
the pelvis may cause difficulty in diagnosis. The uterus can often
be made to move independently of the tumor, which is seldom so
dense as a fibroid. The history of menorrhagia is less marked, and
more distress is caused by pressure than in the case of fibroid. The
cervix uteri is more distinct, not merging in the mass as in fibroid.
The sound seldom enters beyond the normal distance in ovarian
cases, whereas the uterine cavity is often considerably elongated in
cases of fibroid.
Fluctuation can generally be detected in ovarian cysts. The
ulnar edge of the hand can be passed down deeply between the
tumor and pubes when it is ovarian, but not so when uterine.
Fsecal accumulation may generally be distinguished by indenting
the mass by firm pressure with the finger, by discovering the nature
of the enlargement on passing the finger per rectum, by being able
to move the uterus independently of the mass, by the absence of
any marked uterine symptoms, and by the history of constipation.
Cancer of the body of the uterus is comparatively rare. There
is generally more pain than in cases of fibroid, hsemorrhage is more
irregular, and the discharge is generally ofifensive. The diagnosis
is more fully discussed when speaking of cancer.
To determine the diagnosis between intra-mural and submucous
fibroids it may be necessary to explore the cavity of the uterus with
the finger. This may sometimes be possible at the time of the
menstrual period, without having to resort to artificial dilatation of
the cervix, inasmuch as the uterine contractions serve to open the
OS uteri; but should this not be practicable the cervix may be
dilated in the usual way by means of sea-tangle or sponge tents.
Sub-peritoneal fibroids may often be distinguished by their hard,
irregular, nodular outline, and by the fact of their being multiple.
It should always be remembered that, unless there be any well-
marked contra-indication, exploration by means of the hand in the
rectum may enable us to clear up a doubtful diagnosis when all
other means have failed. It should, however, never be resorted to
unless there is a clear indication for its necessity.
Progress and Termination. — The rate of growth is not uniform.
A fibroid may remain comparatively small and inert for many
years, growing very slowly until the menopause, when further
growth is usually arrested, the tumor remaining stationary or un-
dergoing a certain amount of atrophy.
In other instances a fibroid that has increased very gradually in
size may, without any assignable cause, suddenly commence grow-
ing rapidly until it attains an enormous size, as much as fifty
pounds' weight; this, however, is rare.
Menstruation, utero-gestation, and the menopause exercise a
distinct influence over the growth of fibroids. During menstruation
they become congested, enlarged, and sensitive, haemorrhage, pain,
and symptoms of pressure being more evident at these times.
During pregnancy their growth is often commensurate with the
development of that of the uterus, and following delivery a marked
FIBROID TUMORS. 225
retrograde metamorphosis or even a spontaneous absorption of the
tumor occurs pari pasm with the process of involution, probably by
a similar process of fatty degeneration.
After the menopause, when the uterus itself undergoes senile
atrophy, the nutrition of the fibroid becomes correspondingly im-
paired. The presence, ho'^ver, of these tumors generally post-
pones the menopause for some few years, so that even at the age of
fifty a patient may have periodically recurring haemorrhages.
Cretification, or, more properly speaking, calcification of fibroids,
lis not infrequent after the menopause, a species of peripheral in-
icrustation or of calcareous infiltration taking place, the tumor
^ being permeated with the phosphate and carbonate of lime. . The
-t vascular attachment of the tumor being thus impaired, its nutrition
is materially interfered with, and a uterine calculus is formed
which may either remain inert or be expelled per vaginam. The
process is analogous to the cretaceous transformation of pulmonary
tubercle.
Spontaneous disappearance of the tumor has been recorded in
some instances. This may be due to the process of involution fol-
lowing delivery, or to sloughing of the uterine wall covering the
tumor, when the latter becomes expelled by uterine contractions,
or breaks down and comes away in the form of debris, not infre-
quently proving fatal by the production of septicaemia.
It is doubtful whether fibroid tumors ever undergo malignant
degeneration. A fibroid may co-exist with a cancer in the same
womb. The putrid sloughs of a disintegrating tumor may be
readily mistaken for cancer, or the normal structure of the uterus
or vagina being first the seat of cancer, the disease may spread and
invade the fibrous tumor (Barnes). It is, however, comparatively
very rare for the two conditions to be associated.
Fibroid tumors are occasionally the subject of oedema, inflam-
mation, gangrene, apoplexy, and cystic degeneration. This latter
condition will be considered separately.
Speaking generally, fibroid tumors do not prove fatal. Death
may result from haemorrhage and exhaustion, from sloughing and
-septicaemia, from peritonitis, from pressure interfering mth the
ftinctions of the bladder and kidneys, or of the bowels, or from
fsome intercurrent secondary disease induced by the degraded state
of the system generally.
Should pregnancy complicate the question, the risk to life is
^greatly enhanced. Parturition may be difi&cult, dangerous, or im-
possible. By hindering firm uterine contraction, labor may be
retarded, or uncontrollable post-partum haemorrhage induced. The
tumor itself may be so bruised by the pressure as to kindle up a
iFatal peritonitis, or may break down and give rise to septicaemia.
Treatment — This may be either palliative or curative. As a
general rule we are only called upon to palliate symptoms and
3arry our patient on safely until the menopause, which in cases of
nterstitial and submucous fibroid is generally postponed for many
y'ears beyond the normal period. Ilcemorrhage being usually the
15
226 NEW GROWTHS OF THE UTERUS.
most prominent symptom, is what most frequently calls for atten-
tion. Much may be done in the way of prevention to check im-
moderate losses. If single, the patient should on no account even
contemplate marriage, for this condition invariably aggravates the
symptoms, and if pregnancy should happen to occur, the dangers
are greatly increased. Married patients should be advised to ab-
stain as far as possible from sexual intercourse. Just previous to
the menstrual period, a saline aperient may prove of service in re-
lieving the precursory engorgement of the pelvic \dscera. The pa-
tient should, if the case be severe, remain quiet in bed. The diet
should be limited, and stimulants avoided unless absolutely requisite.
During the period, if the loss be profuse, ergot is most likely to
exercise a beneficial influence in restraining it. Thirty minims to
a drachm of the liquid extract may be given every four or six
hours. In the interstitial variety this seldom fails to do good,
though it may increase the hsemorrhage in the submucous variety.
Gallic acid is probably the next most valuable haemostatic, and
may be given in scruple doses, alone, or combined with the ergot.
The glyc. acid, gallici in 5j (gr. xv) to 5iss doses forms a convenient
method of administration.
Cinchona, tt\^xx to "ixxx of the tincture, or even more, is a use-
ful addition to the two former.
The following mixture may be prescribed :
I^. Ext. ergotfe liq. 5vj-5iss, glyc. acid, gallici Siss-Sij, tinct. cin-
chonae, 5ss-5j, tinct. chlorof co. 5J-oSS, syr. aurantii Siss, inf rosae
acid, ad .5yj-Sviii. — M. One tablespoonful in a wineglassful of water
every three, four, or six hours.
If much pain be present as w^ell, it may be necessary to add liq.
opii sed. 5iij-5iv to the mixture.
Quinine gr. ij-iv, with acid, sulph. arom. n^xx-xxx, every three
or four hours, is sometimes of much service.
The tincture of cannabis indica in n\^xv-xx doses given in mucil-
age is highly spoken of by some authors.
Bromide of potassium in gr. xx to xxx doses in some instances
acts even better than styptics.
Digitalis, tt\,x to in^xv of the tincture, or 5j of the fresh infusion,
more especially if there be any cardiac complication, often acts
very beneficially.
Strychnine, alum, turpentine, hamamelys, vinca major, acetate
of lead and opium, have also their advocates.
In the interval between the menstrual periods every effort should
be made to improve the tone of the general health.
Iron in the form of the tinct. ferri perchlor. tt^x-xx, tinct. ferri
pernit. ni^x-xx, combined with strj^chnia, ergot, cannabis indica,
digitalis, or arsenic will usually be indicated.
The liq. hydrarg. perchlor. in 5j doses, combined with potassii
bromid. gr. x-xx, or potassii iodidi gr. iij-v, or with arsenic and
iron, occasionally proves of service.
Ergot in the form of subcutaneous injection will often succeed
when its internal administration fails.
HAEMORRHAGE. 227
The essential principle of ergot, sclerotic acid, in half-grain doses;
extractum ergotse liquidum in ttj^x-xxx doses, diluted with an equal
amount of water ; ergotin in gr. ij-iv doses ; or Bonjean's ergotin
in Riij-v doses, dissolved in the same amount of water, are the
most usual forms.
Whatever preparation be employed should be freshly prepared.
The best situation is to inject deeply into the substance of the
gluteus muscle, as there is less likelihood of its setting up inflam-
mation or causing abscess, though some local induration and red-
ness is generally produced. To be of any service, it will mostly be
necessary to repeat the injection on alternate days for some tw^o or
three months. The pain resulting from uterine tenesmus is gener-
ally much increased. This method is useless in the case of sub-
peritoneal fibroids.
Should medicines fail in checking or arresting haemorrhage, we
must then have recourse to other measures. The application of a
hot-water bag to the lumbar region, the injection of hot water 2?^
vaginam, or of cold water, or even iced water thrown up the rectum,
may all be tried. Where the haemorrhage is very persistent or very
profuse, we can at once check it by the insertion of a sponge-tent
into the cervix — a far more scientific plan than inserting vaginal
tampons. By this plan we not only check the haemorrhage at once,
but also facilitate further exploration of the interior of the uterus
by dilating the cervix, thus allowing the application of any styptics
if necessary. But in addition to this, it is a curious and unex-
plained fact that mere dilatation of the cervix is often sufficient of
itself to lessen the frequency and the duration of the haemorrhagic
attacks for some time to come. Whether it is by relieving tension,
preventing the retention of blood or clots, allowing more room for
the tumor (thus relieving the veins from the engorgement due to
pressure), or by exciting uterine action and so causing contraction,
is not known. The fact remains that the haemorrhage is checked.
Any theoretical objections as to the risk of blood being forced
Iback along the Fallopian tubes, causing haematocele or setting up
{peritonitis, are outweighed by the practical result that such a "con-
dition has not been recorded. This may be explained by the blood
rapidly coagulating, and not remaining in a tarry uncoagulable
condition, as noticed* in cases of haematometra from imperforate
hymen.
Haemorrhage having thus been arrested, the patient's powers
may be rallied by appropriate nourishment or stimulants.
Dilatation may be accomplished either by means of as large a
carbolized sponge -tent as the cervix will accommodate, by the
insertion of several small laminaria tents, packing the cervix as
tightly with them as prudent, or by incision of the" cervix. If on
removal of the tents at the end of twenty-four hours haemorrhage
still recurs to any extent, we must then swab out the interior of the
uterus with the strong liq. ferri perchlor., ferri persulph., chromic
acid, nitric acid, or some equally powerful styptic.
Where the uterine cavity is so tortuous as to preclude the appli-
228 NEW GROWTHS OF THE UTERUS.
cation of the styptic to the whole of the surface hy means of the
swab, it may be necessary to inject the ca\dty with tincture of
iodine, tinct. ferri perchlor., or other appropriate st}^tic sohition.
The precautions elsewhere mentioned must be strictly observed.
Injection should never be employed unless the canal be fully
dilated.
In order to swab out the interior, place the patient in the left
lateral or semi-prone position, pass either a Sims's, bivalve, or Fer-
gusson's speculum up to the cer^dx. This latter should then be
seized with a tenaculum or Sims's hook, so as to keep it steady
and prevent it receding from view. Having coated several Play-
fair's probes with cotton-wool, the interior is first mopped out as
clean as possible from clots and blood ; the styptic is then passed
in and the lining membrane thoroughly swabbed over, a second
application being used if necessary. Any excess is carefully neu-
tralized with carbonate of soda, a plug soaked in a saturated solu-
tion of this being left in the vaginal cul-de-sac as the speculum is
mthdrawn, so as to prevent the possibility of any of the styptic
running down into the vagina.
K after resorting to dilatation of the cervix by means of tents
and swabbing the cavity with strong stj^ptics the haemorrhage still
persists, incision of the cervix, either unilaterally or bilaterally,
should be proceeded with.
It is not necessary to incise very deeply the os internum, but the
lower portion of the cer\ix should be freely divided. This may be
effected by means of the metrotome in the usual manner; by a
curved bistoury, the speculum being emj^loyed to enable the oper-
ator to see exactly what he is doing; or by the long-handled,
curved scissors, the cervix being steadied with a tenaculum or
hook.
Incision of the cervix not only tends to arrest haemorrhage, but
also exercises a beneficial effect in modifying the nutrition of fibroid
tumors.
If this method be not sufficient to arrest haemorrhage, the tumor
being interstitial or a sessile submucous one, a longitudinal incision
may be made through the capsule investing the tumor, so as to
allow the mucous membrane to retract, and thus diminish the
haemorrhage. The vascular supply being 'interfered with, the
growth of the tumor may be arrested, or its expulsion ultimately
accomplished by the persistent administration of ergot. The cer-
vix ha\dng been previously fully dilated or incised, a long-handled,
curved, probe-pointed bistoury is passed up into the uterus as far
as the finger will reach, and is then drawn down over the surface
of the tumor, freely dividing its capsule, and cutting into its sub-
stance to the depth of about half an inch.
In addition to our efforts to restrain haemorrhage, another im-
portant indication is to obviate any displacement of the uterus by
a properly adjusted pessary, and to avert any symptoms of pressure
b}^ preventing the tumor becoming impacted in the pelvis.
If attention has not been called to the case until this latter con-
ABDOMINAL TUMOR. 229
dition has occurred, our object must be to press the tumor com-
pletely out of the pelvis, above the brim, making it an abdominal
in place of a pelvic tumor.
If any difficulty be experienced in accomplishing this, it will be
better to wait until shortly after the next menstrual period, in the
meantime making the patient rest up in the recumbent position,
lying in the semi-prone or even in the genu-pectoral position from
time to time. Ergot should be administered, and if necessary the
congestion still further lessened by the application of a few leeches
to the cervix, or by scarification. A few^ days after the menstrual
period, the patient being placed either in the genu-pectoral or the
semi-prone position (the bowels having been well relieved and the
bladder emptied), one or two fingers of the left hand are inserted
jper vaginam^ and steady but gentle pressure made upon the tumor.
The direction of the pressure should be somewhat lateral, so that
the tumor may partly rotate on its axis, and thus elude the sacral
promontory. The force employed must be gently graduated to the
resistance encountered. Unless the patient be extremely nervous
or the tumor very sensitive, it will not be necessary to produce
anaesthesia. It is an advantage having the patient conscious, as
she will be able to guide us as to the amount of force that it may
be prudent to adopt. Steady, firm, continuous pressure is more
likely to accomplish the object in view than any sudden or severe
force. If the resistance be very great, the uterine repositor may be
employed, the spiral wire-spring being placed on the chest of the oper-
ator, who can thus keep up a continuous pressure without fatigue.
The patient should be kept quiet in bed for some few days after-
wards, an opiate given if much pain or inconvenience has been
caused, and the diet limited. The bowels must be carefully regu-
lated for some time afterwards, so that no prolonged constipation
or violent expulsive efforts risk the return of the^ tumor into the
pehds again. An elastic abdominal belt may be worn wdth ad-
vantage subsequently to relieve the pelvic viscera from pressure.
To promote absorption and to restrain the growth of fibroid
tumors, in addition to what has already been advised, certain
drugs have from time to time been recommended. Bromine and
iodine waters, administered internally and employed as baths, are
•supposed to have been efficacious in this respect. Kreuznach and
Woodhall spa waters are held in repute for this reason.
Bromide and iodide of potassium are also useful. Chloride of
ammonium in combination with ergot has been highly spoken of.
Borax, cannabis indica, digitalis, and other drugs have also been
employed with the object of lessening the flux of blood to the re-
productive organs. Chloride of calcium was formerly much relied
upon as bringing about calcareous degeneration of the arteries,
and so interfering with the nutrition of the tumors, but its action
cannot be limited to the uterine arteries, and hence the danger of
producing an atheromatous condition of the arteries generallV.
Acupuncture and electricity have been suggested as likely to in-
• fluence the growth of fibroids.
230 NEW GROWTHS OF THE UTERUS.
The subcutaneous injection of ergot or sclerotic acid is probably
the most reliable method of restraining the growth of fibroids.
The fallacies which weaken any conclusion as to the influence
of remedies in arresting the growth of fibroid tumors have^^been
thus summarized by Dr. Barnes :
1. These tumors are often of extremely slow growth, so that any
change in size, within even a considerable time, would be diflicult
to appreciate, and still more to prove.
2. Many of these tumors, when they have reached a certain
size, exhibit no tendency to increase, but remain stationary, al-
though no treatment is employed.
3. In a large number of instances there is a natural tendency
towards inertness, or even retrogression, after the climacteric ; and
since these tumors frequently do not come under . treatment until
this period is approaching, such treatment may be merely coinci-
dent with the natural process of cure, not conducive to it.
4. The diminution in size may be apparent rather than real,
being simply due to the absorption of serous infiltration.
And lastly, the most persistent use of remedies in many cases
has not been followed by any sensible alteration in the hands of
many competent observers.
Surgical Treatment of Fibroids. — Medicine having failed to check
haemorrhage, arrest growth, or induce absorption, and the other
measures already described having failed to relieve the patient, we
have next to consider the various methods suggested for the entire
removal of the tumor, the so-called radical or curative treatment.
The mode of procedure w^ill vary, depending upon the situation
and size of the tumor.
The time selected for operation should never be immediately
after a profuse haemorrhage, but when the patient has had time to
rally from its eftects.
Whatever method be adopted it will be necessary to procure a>
free dilatation of the cervix as possible. This may be accom-
plished either by dilatation wath sponge or laminaria tents gradu-
ally, or by preparatory dilatation with tents and incision at the
time of operation. In some instances it may be found expedient
to increase the amount of dilatation by means of Moleswortli
dilator or Barnes's bags.
Various methods have been suggested and practised.
Ecrasement, either with the chain or wire ecraseur, or with the
galvano-cautery.
Avulsion, by traction and rotation.
Excision, by the knife, scissors, or other cutting instruments.
Enucleation, either immediate or gradual, by incision of the cap-
sule and manipulation.
Igneous Hysterotomy, perforating the growth with the actual cau-
tery so as to produce necrosis and expulsion.
Hysterectomy, Hysterotomy, or Gastrotomy, removing the uterus
and tumors together by abdominal incision.
Ecrasement. — Should the tumor project sufficiently from the
THE ECRASEUR. 231
uterine wall, or be pedunculated, assuming a polypoid form, so
that a loop of wire can be made to rest beyond the equator, or
greatest diameter of the tumor, an attempt may be made to re-
move it by means of the galvanic ecraseur.
The ordinary single wire ecraseur is not sufficiently strong to
cut through the base of attachment, if this be large and dense, as
often happens, and should not therefore be relied upon.
If the case be not an urgent one, it may be well to induce the
uterus to contract and still further expel the tumor from its bed
by means of ergot, quinine, strychnia, or galvanism, before pro-
ceeding to attempt its removal, taking care that the cervix is first
divided so as to facilitate expulsion.
It is not absolutely necessary to remove the whole of the tumor ;
if this be pedunculated, the portion left will soon shrink and dis-
appear, or if more extensive, the wire, as it becomes tightened, may
slip over the convexity of the tumor and thus cause its complete
enucleation. K this cannot be effected we must remove as much
as possible with the ecraseur, and deal with the remaining portion
as may subsequently be determined. When the tumor is firmly
and extensively attached to the uterus, we must be careful not to
exert too great traction upon the tumor in applying the ecraseur,
as partial or complete inversion may occur, and a portion of the
uterus be thus included as the wire is gradually tightened. Cases
of this nature have been recorded where the result proved fatal.
To apply the ecraseur, the patient lying in the lithotomy, left
lateral, or semi-prone position, the cervix having been previously
well dilated, the wire loop is compressed in an elongated form and
passed into the uterine cavity. When released from pressure the
loop expands again into an oval or circular shape, and is then
passed up over the tumor, the stem of the instrument being pressed
upwards towards the base, the loop being guided by the finger or
by means of a long crutch-shaped wire. The loop is now grad-
ually tightened and the base cut through. The tumor is then
removed by the finger, ovum forceps, or vulsellura. There is sel-
dom any haemorrhage, but if necessary the actual cautery, per-
chloride of iron, or other styptic may be employed, or the uterus
be packed with strips of lint soaked in a saturated solution of alum.
If the galvanic ecraseur be employed, care must be taken to
ensure sufficient battery power to heat a loop of sufficient size
while passing through moist tissues.
In some cases we may be called upon to operate when the tumor
has already been partially extruded into the vagina, interfering
with the functions of the bladder and rectum, and even producing
symptoms analogous to those observed during parturition when
the foetal head becomes impacted in the pelvis.
It may be impossible to pass the finger sufficiently far up to
ascertain the dimensions of the base, or to feel the os uteri. We
must be careful, therefore, not to mistake the tumor for an inverted
uterus by detecting the fundus behind the pelvis, by the relatively
greater size, and by the less sensitive condition of the surface.
232
NEW GROWTHS OF THE UTERUS.
In such a case we must pass the loop of the galvanic ecraseur up
as far as possible to the base of the tumor, either by using the
separable tubes of the galvanic ecraseur like Gooch's canula?, or
by carrying the wire up by the aid of two gum-elastic catheters
suitably curved. These being passed up posteriorly, one is passed
round on either side to the front, and the stem of the ecraseur
passed over them. The ends of the w^re being then fastened, the
stylets of the catheters are withdrawn and the battery set in action.
The wire when heated thus cuts through the catheters and tumor
together, this latter being then removed by aid of forceps or other
appropriate means.
Where this plan fails, the tumor may either be
• Fig. 117. removed in successive portions by means of the
ecraseur or by scissors.
Avulsion succeeds in some cases where the tumor
projects sufficiently from the uterine wall. Seizing
the tumor with a pair of vulsellum forceps traction
is exerted, and a slight rotatory movement given to
the instrument. If the attachments be not too firm
the tumor may thus be brought away. In some
cases it may be w^ell to combine the use of the ecra-
seur, the wire loop being slipped up over the vulsel-
lum, and tightened so as to cut through the capsule
as near the w^all of the uterus as possible. By
alternate twisting and traction the fibroid is thus
wrenched from its bed and at length removed. This
method is only applicable to submucous fibroids.
Sims^s Guarded Tumor Hook {Â¥ig. 117) is sometimes
of service in these cases. The vulcanite guard can
be slipped forward when the instrument is to be
introduced, and withdrawn when the hooks are on
the surface of the tumor.
Excision by the aid of knife or scissors is not
often practised, owing to the risk of hsemorrhage.
It may, however, be resorted to in cases of small
submucous fibroids projecting into the uterine cav-
ity, more especially w^hen they are situated low
dowm in the cervix, a thing of rare occurrence.
Aveling's polyptome (Fig. 114) answers well
when the growth is attached high up.
Enucleation is an operation that should never be
rashly undertaken. The risks to life are very great.
Haemorrhage, exhaustion, perforation of the uterus,
peritonitis, pyaemia, and pelvic cellulitis are the con-
sequences most to be dreaded. Unfortunately, the
operation being regarded as not only a difficult but
also a dangerous one, it is not resorted to until the
patient is often exhausted by profuse and protracted haemorrhages
and worn out w^ith prolonged suftering. A\Tiere ordinary palliative
measures have been tried and failed, and the situation of the tumor
Sims's Guarded
Tumor Hook.
ENUCLEATION. 233
1 is such that its removal is possible, the practitioner should not be
deterred from resorting to this operation until the vital powers
have become so enfeebled as to preclude all hope of recovery, but
should give the patient the option of having it performed while
there is still hope of rallying. Under no circumstances should the
operation be attempted unless it is pretty certain that there is a
sufficient thickness of uterine tissue covering the tumor to preclude
all risk of opening into the peritoneal cavity; neither should it be
T resorted to in the case of large tumors whose texture is continuous
with the uterine wall. It is for the encapsuled hard fibroids, that
show a tendency to become extruded from the muscular w^all, or
' even from the cavity of the uterus, that the operation of enuclea-
tion is specially applicable. Whenever practicable, the immediate
method, by w^hich the tumor is enucleated at one sitting, should
always be employed, as it is attended by far less risk of evil conse-
quences in the way of septicaemia, etc., than if the more gradual
-method be adopted, in which the fingers of the operator merely in-
augurate the process, the uterus being excited to contract and expel
i! the tumor subsequently.
' To perform immediate enucleation it is necessary to have the
vagina previously well dilated by means of Barnes's bags, as also
the cer^dx. The patient being then placed in the lithotomy posi-
I tion, and anaesthesia produced, an assistant steadies the uterus by
pressure over the abdomen. The operator then incises the cap-
sule of the tumor, either by means of a probe-pointed bistoury
with a long handle, or by long-handled scissors, a crucial incision
being made to facilitate expulsion. The fingers are then inserted,
liiand the tumor separated from its capsule. Strong vulsellum for-
ceps should then be applied, and a firm hold secured, so as to drag
I the tumor well forward. Its base of attachment is then separated
by the aid of the fingers, or of an instrument specially constructed
, for this purpose, in the form of a curved, blunt spatula with rough-
ened edges, and the tumor thus enucleated or shelled out. The
f haemorrhage induced is seldom urgent, but, if thought requisite,
the surface may be sw^abbed over with the liquor ferri perchlor. or
i 'Other powerful styptic.
If for any reason it be deemed prudent not to persevere with
the operation, having made a crucial incision in the capsule and
separated this as far as practicable, the patient is then put to bed,
-and the steady, systematic employment of ergot persisted in, so as
i to promote the gradual or spontaneous enucleation of the tumor,
f 'When this has advanced to a certain stage, or the vitality of the
I tumor is impaired, it may be well to expedite matters by the process
j of avulsion, the tumor being seized by the vulsellum, and traction
': with rotation made upon it, so as to drag it away from its bed.
: Should the tumor be so large as to be incapable of being extracted
entire through the pelvis, we may still succeed in removing it by
making a series of spiral or oblique incisions into its substance.
Firm pressure being made above the pubes, and traction exerted
by means of a strong vulsellum, the tumor elongates. Fresh in-
234 NEW GROWTHS OF THE UTERUS.
cisions are then made higher up, until the whole mass is extracted.
The same result may he secured hy removing wedge-shaped pieces,
and so extracting the tumor piecemeal, either by tearing or cut-
ting it away, or by the aid of the ecraseur.
Having removed the tumor, the cavity should be washed out
with hot water injected into it, this being a prompt exciter of
uterine action. Contraction may be increased or maintained, and
all risk of further haemorrhage obviated by the application of the
strong tincture of iodine, which is also a most valuable antiseptic.
The cavity may then be stuffed ^vith cotton saturated with glycerin,
or with a strong solution of alum, which is allowed to remain in
for the first day or two, depending upon circumstances, when all
further dressing may be dispensed with, some disinfectant solution,
such as iodine, carbolic acid (1 in 40), or permanganate of potash
being employed as long as any discharge continues, or until the
cavity has become filled.
Igneous Hysterotomy is the term suggested by Dr. Barnes for the
operation of boring a hole in the tumor by means of the actual,
benzoline, or galvano-cautery, so as to induce a process of slough-
ing or necrosis, followed by a spontaneous enucleation of the tumoi
through the artificial aperture. The risk of septicaemia occurring
is supposed to be less than in the case of cutting or tearing. This
method is proposed for cases where the tumor is low down in the
cervix, or where the growth develops in the posterior wall of tin
uterus, the cervix being carried high up behind the pubes, so thai
it is found impossible to get at this for the purpose of dilatation,
In this latter case the cautery is thrust through the posterior va
ginal wall into the fibroid tumor itself.
Spaying^ or Normal Ovariotomy, has of late been frequently re
sorted to in cases where the haemorrhage is so severe as to threater
life, and the time of the menopause is yet far distant. Extirpatior
of the ovaries by removing the ovarian stimulus lessens the peri
odical congestions of the uterus and induces artificially the meno
pause, thus abating haemorrhage, arresting growth of the tumor
and tending to promote the retrogression of it as well.
Goodell considers that when vaginal enucleation is impossible
and the question is reduced to one of three, viz., spaying, enuclea
tion by gastrotomy, or the extirpation of the invaded womb, ther(
is but one answer, and that one in favor of spaying, the operatioi
being a less serious one than either successful or unsuccessful at
tempts at enucleation.
Spaying is more especially indicated when, the tumor being in
terstitial, removal through the vagina cannot be efifected withou
incurring too great risk, and the haemorrhage is so severe as t(
seriously endanger life. Even when periodical haemorrhages fi'on
the uterus occur after removal of the ovaries, it is far more amen
able to the influence of cold, styptics, and other remedies than be
fore, and there is less risk of any evil effects ensuing in consequence
of arresting menstruation.
The operation may be performed either through the vagina oi
SPAYING, OR NORMAL OVARIOTOMY. 235
by means of an abdominal incision. The vaginal method has the
advantage of exposing the peritoneum less, but is not always ap-
plicable, as in cases where the ovaries are carried up by a large
tumor and lie beyond the reach of the jB.nger, or where strong pel-
vic adhesions exist.
If this method be adopted the patient should be placed in the
lithotomy position, the vagina cleansed with carbolized water, a
duckbill speculum introduced, and the perineum pulled down-
wards. A tenaculum is then inserted in the posterior cul-de-sac
of the vagina and an opening an inch long made into the peri-
^toneal cavity by snipping through with a pair of scissors. The
index-finger of the left hand is then introduced, the womb pressed
down by the right hand externally, and the ovary hooked down.
It is then seized by a fenestrated forceps and brought into the
vagina. A needle armed with a double thread is now passed
through the pedicle and each half securely tied. The ovary is
ithen removed, the ligatures cut short, and the stump returned
: into the pelvic cavity. The other ovary is then dealt with in like
I manner.
If the abdominal operation be performed, antiseptic precautions
must be adopted. An incision extending from the umbilicus to-
wards the pubes is made in the mesian line, and one ovary drawn
'. up into the opening by two fingers. The mesovarium is transfixed
iby a needle carrying a double carbolized silk ligature, the two
f halves are securely tied, the ovary removed, the ligatures cut short,
i and the pedicle returned into the abdomen. The same steps are
pursued with the other ovary, and the wound is then closed. The
risks appear to be less than in case of spaying, where the ovaries
'.are adherent and degenerated.
I Where doubt as to the exact nature of the case exists, or what
t'i kind of operation will be most advisable, an exploratory incision
t should be made and the question decided according to circum-
j stances, whether the ovaries alone, the tumor with a portion of the
' uterus, or the entire uterus and ovaries as well, should be removed.
: Subperitoneal fibroids are not amenable to surgical treatment, as
^ with the interstitial and submucous varieties. Removal by gastrot-
: omy is the only method at our disposal. Fortunately, they com-
paratively seldom give rise to so much inconvenience as to necessi-
( tate operative interference. But where their presence so interferes
'with the patient's comfort, whether by pressure upon the pelvic or
'abdominal organs, as to incapacitate her from performing the
'duties of her station, or the symptoms are such as to threaten life,
we are then perfectly justified in resorting to any operation that
! offers a reasonable prospect of success.
The great difficulty, as a rule, is in estimating beforehand the
extent of attachment to the uterus. If the pedicle be small and
^lie amount of adhesions to neighboring structures be slight, the
removal of a subperitoneal fibroid is not attended by greater risk
than that incurred in an ordinary case of ovariotomy.
The operation is performed in a similar manner and with like
236 NEW GROWTHS OF THE UTERUS.
precautions. The pedicles are transfixed and tied firmly with car-
bolized silk.
Hysterectomy, or Hysterotomy, are the terms employed to designate
the far more formidable operation of ablation or extirpation of the
uterus, w^hen enlarged by fibroid or fibro-cystic disease, by abdom-
inal incision.
It should never be resorted to until other less dangerous methods
have been fairly tried and failed. It is more especially adapted to
the fleshy and fibro-cystic kinds of tumors that are too large to
admit of removal by the vagina, and yet are endangering life by
uncontrollable hBemorrhage, (when the patient is yet many years
from the climacteric,) by very rapid increase in size, or by pressure
upon abdominal or pelvic organs, of such a kind, as to render life
no longer endurable.
Since the adoption of antiseptic precautions, and possibly also
owing to the increased experience recently gained in abdominal
surgery, the operation bids fair to become in time a recognized,
practicable, and expedient procedure.
M. Pean, who strongly advocates this operation, regards it as
not of much graver character than extirpation of ovarian cysts
complicated by adhesions.
The increased risk is mainly due to the bulk and vascularity of
the pedicle, which is formed by the cervix and broad ligaments.
The accidents w^hich have thus far contributed most to a fatal ter-
mination have been the shock or collapse, owing to the lengthened
period often occupied in performing the operation, primary or sec-
ondary haemorrhage, peritonitis, and septicaemia.
It is essential that the lower portion of the cer\dx should be free
and not involved in the tumor, as this constitutes the stump. The
danger of the operation would be increased if the cervix had to be
removed, owing to its relations with the bladder.
The operation should be conducted with the same precautions
both as to preliminary preparation and minor details as in the case
of ovariotomy.
The week following the menstrual period, unless this has been
very profuse, should be chosen. As it is impossible ahvays to pre-
dict the exact nature of the operation we may be called upon to
perform, it will be well to have suflacient skilled assistance at hand,
the same instruments as used in ovariotomy, and in addition sev-
eral powerful serre-noeuds.
The abdominal incision w^ill generally need to be somewhat
longer than for ovariotomy, taking care to avoid wounding the
bladder. Having exposed the tumor, the hand should be passed
low do\^Ti into the pelvis so as to explore the attachments and as-
certain the presence or absence of adhesions. If possible the tumor
should then be pulled well forwards and upwards, the broad liga-
ments on either side being transfixed and tied in two or more sec-
tions, below^ the ovaries, mth carbolized silk. A strong curved
needle is then passed through the cervix uteri, and a double strong
ware drawn back through the opening. Each half is tightened and
FIBRO-CYSTIC TUMORS OF THE UTERUS. 237
r held fast by Cintrat's serre-nceud, an instrument like a short ecras-
eur, taking care that the loops of the wire interlace. Or, what is
\ possibly better, in place of wire, whipcord or stout carbolized silk
I may be used to ligature the cervix, the ends being cut short, and
the stump returned into the abdomen, the wound being then closed.
Should the tumor at first be too large to permit of its being
withdrawn from the abdomen, it may be necessary to perforate the
tumor by several metallic wires, and tighten separate sections by
means of the serre-noeud, the part above the wire being then cut
away; "morcellement" as it has been termed.
If it be found impossible to secure a healthy portion of cervix
to form a stump, it may be necessary to extirpate the uterus entire
by Freund's operation, as described when speaking of cancer.
The success of the operation hitherto has not been such as to
justify a resort to it unless the life of the patient is unmistakably
threatened. Dr. Barnes considers that the justification for attempt-
ing enucleation, avulsion, or other mode of removing large fibroid
tumors, will rest upon : 1. Uncontrollable haemorrhages endanger-
ing life; 2. Signs of sloughing or decomposition of the tumor,
with present or threatening peritonitis or pyaemia ; 3. Dangerous
pressure upon the bladder and rectum ; 4. Such great size as to
cause dangerous pressure upon the abdominal and thoracic viscera.
Fibro-cystic Tumors of the Uterus ; Cysto-fibromata. — These are of
comparatively rare occurrence, and are chiefly of interest in relation
to the diagnosis of ovarian tumors. In place of the ordinary dense
fibroid tumors of the uterus we occasionally notice tumors of a
more or less soft, loose, fleshy character, clinically distinct from
the former, afl'ecting the body of the uterus chiefly, rarely multiple,
not often encapsuled, attaining a large size, very vascular, the
tissue becoming cedematous by infiltration with serum, giving the
impression to the touch of being fluctuating or semi-solid. In the
substance of these tumors cysts sometimes are formed, or rather
Uarge collections of fluid occur between the fibres, there being no
i cyst wall. In some cases no true fibroid element is met with in
the tumor, there being merely a cyst in continuity with the uterus,
whose thick vascular wall is formed of non-striated muscular fibres
and connective tissue. Paget considers that the cyst formation
ma^^ be due to a local softening and liquefaction of part of the
(tumor, with eflusion of fluid in the aflected part, or to an accumu-
llation of fluid in the interspaces of the intersecting bands.
Haemorrhages into the substance of the tumor may lead to the
t formation of cavities similar to the so-called apoplectic cysts. A
! localized inflammatory process giving rise to the production of
serum or pus may produce a cavity. Progressive dilatation of
i lymphatic vessels may give rise to cavities, which contain a limpid,
yellow, fibrinous-like lymph, spontaneously coagulable.
Symptoms. — These are similar to those we should expect to find
dn the case of a subperitoneal fibroid about the same size : more or
: less displacement of the uterus, pressure upon the pelvic and ab-
dominal organs, and in some cases menorrhagia.
238 NEW GROWTHS OF THE UTERUS.
Physical Signs. — On palpation an obscurely fluctuating sensa-
tion is discovered, different from the hard, solid, resisting feel
of a fibroid, or the more uniformly soft fluctuating character of
an ovarian cyst.
Differentiation. — This in many cases is extremely difl[icult. The
three conditions most likely to be confounded with fibro-cystic
disease of the uterus are pregnancy, fibroid tumors of the uterus,
and ovarian cyst.
In cases of pregnancy, the mammary signs, minor symptoms,
cessation of the catamenia, detection of the foetal movements and
heart-sounds, and the duration of the growth, will generally guard
us from error ; the former being absent in fibro-cystic disease, and
the duration of the tumor being more than nine months.
From fibroid tumor it may be recognized by not being so dense,
yielding evidence of obscure fluctuation, its larger size, more rapid
growth, and by its yielding fluid when tapped.
From ovarian cyst it is often impossible to decide. The history
of menorrhagia, the development of the tumor in the centre of the
lower part of the abdomen, the slow but steady growth of the
tumor, extending it may be over four or five years without impair-
ing materially the general health, the fact that the uterine sound
enters beyond the normal distance, and that the uterus moves with
the tumor and seems to be a part of it, will suggest the probability
of the tumor being fibro-cystic and not ovarian. If no^v the aspi-
rator or fine trocar be employed and the fluid examined, we shall
notice that in case of fibro-cystic disease the fluid is generally clear,
limpid, yellowish, coagulating spontaneously and also with heat;
the coagulum shrinking and separating into a clot and thin watery
serum on standing. The fluid contains albumen but not paral-
.bumen, and ^vhen examined under the microscope leucocytes or
spindle-cells are seen, but not the granular cells of ovarian fluid.
After withdrawal of the fluid it wdll be found that the sac has
only partly collapsed, some solid matter remaining. Should any
doubt still exist, and the symptoms be sufficiently urgent to justify
interference, an exploratory incision may be made. Nothing i&
more characteristic than the dark and congested appearance of a
fibro-cystic tumor of the uterus, so strongly in contrast with the
light, clear, pearl-like hue of most ovarian cysts.
Progress. — Fibro-cystic disease of the uterus, as a rule, grows
more rapidly than a simple fibroid, but develops more slowly than
an ovarian cyst. It may exist for a number of years without caus-
ing any serious impairment of health, unless it exercises pressure
upon important organs, or by its excessive bulk prevents the patient
taking out-door exercise.
Treatment. — The remarks made in reference to the treatment ol
large fibroids apply here. It will be needless to repeat them.
CANCER OF THE UTERUS. 239
CHAPTER XYII.
CANCER OF THE UTERUS.
Cancer of the Cervix Uteri. — Definition. — The term cancer is ap-
plied to ''new formations consisting of cells of an epithelial type,
without any intercellular substance, grouped together irregularly
within the alveoli of a more or less dense fibroid stroma " (Green).
' Clinically they are spoken of as malignant, in that they tend to
destroy the organ primarily attacked, to spread by contiguity into
the surrounding tissues, to infect the glands and other organs, t6
.return after removal, and by infecting the system to cause death.
Frequency. — Cancer of the uterus is of frequent occurrence. In
1 England alone the annual mortality from cancer exceeds 10,000,
â– of whom over two-thirds are females. As the uterus is more com-
monly affected than any other organ in the female, it will be thus
seen that the number of cases succumbing to this terrible malady
lis considerable.
The majority of the cases occur betw^een the ages of forty and
1 fifty, although instances have been reported of mere infants being
aftected wdth rapidly developing carcinoma, proving fatal, and
young girls of all ages have succumbed to it.
Rokitansky thus states the preference of cancer for various or-
.gans. First the uterus, the female breast, the stomach, the large in-
ttestines, and especially the rectum, then the lymphatic glands, etc.
Causation. — Cancer of the uterus, although met with in single
and sterile women, is far more frequent in those who have borne
' many children. Functional activity of the organ may thus be re-
garded as an important element in the production of cancer. Injuries
inflicted on the cervix during parturition, inflammatory conditions
resulting from these, granular degeneration of the cervical mucous
membrane, and irritation from mechanical causes, will also explain
(the tendency to malignant degeneration, more especially if there
I be any hereditary predisposition to the malady in multiparae.
Opinion is pretty equally divided between those w^ho regard the
' malady as a local manifestation of constitutional origin, and those
who regard it as a disease originally of local origin, rapidly infect-
ing the system. Against the theory of local origin, hereditary
tendency, although it may be dilficult to establish this evfen in a
' majority of cases, must be cited. Another fact strongly insisted
upon l)y Dr. Barnes is " the almost constant tendency to a fatal ter-
mination from the moment w^hen w^e have an undoubted diagnosis.
This means that it is rarely indeed possible to find the disease in
its presumed strictly local initiative condition. From its earliest
discovery it has already effected a stronghold upon the constitution."
240 CANCER OF THE UTERUS.
4
Emmet regards epithelial cancer as frequently arising from per-
verted nutrition in the attempt to repair injury. He has never
known a woman to have any form of epithelial cancer of the
uterus unless she had at some time been impregnated, and believes
that nearly all, if not all, cases of epithelioma, or cauliflower
growth, have their exciting cause or origin in a laceration of the
cervix.
Varieties. — The encepkaloid, medullar}/, or acute cancer is by far the
most frequent form met with in the uterus, ^ext in order comes
epithelioma, or epithelial cancer; and last and lea-st frequently, indeed
very rarely, scirrhous, fibrous, or chronic cancer.
In thus speaking of different varieties, it must not be imagined
that they are at all times separate and distinct. The encephaloid
carcinoma differs merely from the scirrhous form in the greater
rapidity of its growth, and the consequent small amount of its stroma,
and the softness of its consistence. They cannot be regarded as in
any way constituting distinct varieties of cancer. These are all
intermediate stages between them. The physical aspects of the
varieties of cancer depend merely upon varying proportions and
anatomical arrangement of their component parts.
Pathological Anatomy. — Encephaloid, or Medullary Carcinoma, is
characterized by the very small proportion of stroma and the
abundant growth of epithelial cells. It is more or less of a soft,
brain-like consistence, and lobulated. The central portions often
being completely diffluent, owing to fatty degeneration, and the
blood-vessels being very numerous, haemorrhage readily occurs.
The cells are for the most part larger than in scirrhus, and
quickly undergo fatty degeneration, so that often more free nuclei
than cells are visible.
The dissemination of encephaloid takes place much more rapidly
than that of scirrhus, owing to the greater rapidity of its growth,
its greater vascularity, and the greater activity of its epithelial
elements.
One form of this variety is sometimes spoken of as cauliflower
excrescence, though this latter term is generally applied to epithe-
lioma.
Epithelioma, or Epithelial Cancer, is distinguished by excessive
proliferation of the squamous epithelium. As this increases it be-
comes heterologous, extending beyond the normal limits into the sub-
jacent connective tissue.
As the cells increase in number they tend to become arranged
concentrically in groups so as to form globular masses, the concen-
tric globules, or epithelial nests, which, although not distinctive, are
exceedingly characteristic of epithelioma.
The stroma may be tolerably abundant, or almost entirely want-
ing, presenting every variation between rapidly growing embryonic
and an incompletely fibrillated tissue.
Epithelioma is much the least malignant of all the cancers. It
extends locally, and may infect the neighboring lymphatics, but
it comparatively rarely reproduces itself in internal organs.
EPITHELIOMA, OR EPITHELIAL CANCER. 241
Epithelioma of the cervix, contrary to what usually occurs when
the skin itself is affected, often merges into carcinoma as it ad-
vances, and does not remain true to its original character.
Galahin has recently shown that the histological characters of
those growths, which are generally clinically regarded as epithe-
lioma, are very variable. Epithelioma is apt to merge into carci-
noma, as soon as either the epithelial masses no longer simply
increase by their own growth, but begin, by a kind of spermatic
iiitiuence, to stimulate the nuclei of the adjacent stroma to grow
also into epithelioid cells, or else the epithelial cells or their nuclei
migrate along the lymphatic tracts into the cellular tissue. Hence
there are many cases which it is not easy positively to classify either
a> epithelioma or carcinoma.
It is only exceptionally that the bird's-nest bodies, or epithelial
ulobes, whose presence proves the growth to have originated from
s([uamous epithelium, are seen. Even when they are present it
is only just at the edge of the ulcerated surface that it is possible
to trace any ingrowth of processes from the surface epithelium,
and the cancer generally spreads for some distance beneath normal
or merely thickened epithelium.
The epithelial masses nearest the healthy surface generally con-
sist of cells resembing those of the squamous epithelium, bounded
by a regular margin of columnar-like cells, sharply demarcated
from the surrounding stroma. The cells are also cemented together
like those of the squamous epithelium, either by the delicate
processes uniting cell to cell, and constituting the so-called " cog-
wheel" cells, or apparently by adhesion of the whole cell-walls.
In older portions or deeper parts of the same growth the cell-
masses may be seen without any border of regular cells, and no
longer demarcated clearly from the stroma.
In more numerous cases no epithelial globes are seen, but the
large masses of cemented cells, often mth regular borders, render
it probable that these also commenced from squamous epithelium,
and sometimes their continuity with it can be traced. It is not un-
common to see the cell-masses elongated into the form of more or
less parallel columns, having borders of regular cells, and separated
by narrow bands of stroma.
In other parts of the growth may be seen an approximation
towards the characters of carcinoma. Sometimes the cells become
elono^ated into a long spindle-shape either at right angles to, or
parallel with, the axis of the cell-columns. In the more rapidly
growing forms of tumor the cells deviate in another manner from
the characters of squamous epithelium, and not only cease to be
cemented, but show proliferating nuclei and become very various
in shape and size.
In a small number of cases he has found evidence of the com-
mencement of the gro\Al:h by the degeneration of mucous glands.
The epithelium of the glands proliferates, so as more or less com-
pletely to fill up the acini. In this way the alveolar arrangement
of true carcinoma is at once reached. Eventually the cellular tis-
16
242 CANCER OF THE UTERUS.
sue is infected by the growth in it of similar cells, or migration of
cells from the primary alveoli.
In a small number of cases the structure is that of sarcoma, or
lympho-sarcoma, originating in the cellular tissue.
Epithelioma of the cervix in some rare instances shows a strong
tendency to ulceration, and has been described under the terms
rodent, or corroding ulcer, or cancroid of the uterus. Rapid destruc-
tion of tissue takes place. There is a complete absence of any in-
duration or infiltration, and although profuse haemorrhages may re-
sult as the ulcerative process extends, and death from exhaustion
or from peritonitis occur, still the progress of the disease is often
very 'slow, and may extend over many years before a fatal termina-
tion ensues.
But few well-authenticated cases have been observed of late, and
it is a question whether this variety merits a separate pathological
nomenclature.
Vegetating Epithelioma, or Cauliflower Excrescence, are the terms
employed to designate a sprouting form of papillary growth from
the cervix, characterized by an extraordinary development of cervi-
cal villi and proliferation of the cells which cover them. Eokitan-
sky speaks of it as villous cancer, and describes it as a conferva-
like growth developed out of an encephaloid. Yirchow regards
the excrescence as at first a simple papillary tumor, which subse-
quently passes into a cancroid state, but not into cancerous papil-
lary tumor. Thomas says, " these tumors, commencing as papillary
hypertrophies on the cervix or os, are at first local, but in time
affect the constitution. They are sometimes engrafted upon true
cancerous deposit in the cervical parenchyma." The tendency to
involve the adjacent tissues is far less than in ordinary cancer, the
morbid action is at first limited entirely to the cervix, and it is at
this stage that amputation of the vaginal portion is often successful
in removing the disease. On examination the growth is found to
consist of lobules, each separate papilla containing a central loop
of blood-vessels supported by delicate areolar tissue, their substance
consisting mainly of round cells, those on the surface being flattened.
Scirrhus, fibrous or chronic cancer, is characterized by the large
amount of its stroma and the small amount of its cells, which are
most abundant in the external portions of the tumor where growth
is taking place.
Owing to the excessive growth of the stroma and its subsequent
induration and contraction, obstruction and obliteration of the blood-
vessels result, thus limiting the vascular supply and checking the
epithelial generation, so that growth of the tumor is often very slow.
Symptoms. — Haemorrhage, especially on sexual intercourse, is often
the first symptom directing the patient's attention to the fact that
anything is amiss, and even then it may be found that the disease
has made considerable progress.
In cases where the menopause has not yet arrived, the catamenial
periods are often profuse, or the haemorrhage may recur at irregular
intervals without any apparent cause, or upon any extra exertion or
THE CANCEROUS CACHEXIA. 243
fatigue. Where the climacteric age has been reached, and uterine
haemorrhage recurs after a long interval, the possibility of cancer
being present should always be suspected, and a local investigation
made.
Hemorrhage, as a rule, occurs earlier in those cases where the
disease assumes the vegetating form.
Pain, so long as the disease is limited to the cervix, is seldom
complained of, and is by no means so frequent or severe as gen-
erally supposed until the disease has advanced to the latter stage
and the adjacent tissues have become infiltrated.
The pain is usually spoken of as shooting, stabbing, or lanci-
nating in character, radiating from the centre of the pelvis to the
lower portion of the back and groins, extending down the inner
sides of the thighs and not infrequently to the loins.
It is generally worse at night, preventing sleep, thus dififering
materially from the pain attending chronic inflammation, etc., of
the uterus, which is usually aggravated by standing or walking,
and is relieved when the patient assumes the recumbent position.
In the latter stages of the disease the pain is often agonizing and
persistent, effectually precluding sleep and rendering the patient's
existence most deplorable. The pain is often aggravated on loco-
motion or on sitting down.
Vaginal discharge^ at first of a watery character and free from any
well-marked ofiensive odor, generally alternates with menorrhagia.
As the disease progresses and the ulcerative stage is reached, this
watery discharge is often tinged with blood, and acquires a most
i penetrating and offensive odor which clings persistently to the
patient's linen, rendering her an object of disgust both to herself
as well as to those who are brought into contact with her. It soon
assumes an ichorous character, excoriating the vulva and surround-
ing parts, producing most troublesome erythema and irritation..
Later on, when disintegration of the cancerous mass commences,
ithe discharge becomes grumous, mixed with blood and putrilage,
i and not infrequently with urine from extension of the ulceration to
t the bladder. Shreds of gangrenous tissue, decomposing bl ood-clots,
and occasionally portions of the diseased mass, are not infrequently
< expelled.
The Cancerous cachexia is generally well-marked in the latter
? stages of the disease, and is due to the repeated or constant hsemor-
irhages as well as to the exhausting serous discharge, and probably
also to some septic absorption. The blood-globules rapidly dimin-
ish in number with the continuance of the haemorrhage, and also
become destroyed under the infiuence of the malignant toxaemia ;
the watery constituents of the blood are thus proportionately in-
creased while the albumen is diminished.
The cachexia is evidenced by a peculiar sallow, yellowish, or
dirty straw-colored tint of skin, which is difiSlcult to describe, but
is very characteristic in advanced cases.
The nutrition of the body becomes seriously impaired, emacia-
tion ensuing; the digestive functions are deranged, nausea and
244 CANCER OF THE UTERUS.
vomiting often resulting from the disgusting fcetor of the dis-
charges ; the howels become obstinately confined, often doubtless
owing to the influence of the opium taken to allay the pain, or
occasional attacks of diarrhoea, from reflex irritation, occur. In
some instances the diseased process extends to the walls of the
rectum, a fistulous opening resulting, with incontinence of faeces, p
Bladder symptoms are often present, and in many instances con'
stitute the earliest manifestation of the disease. Dysuria and reflex
tenesmus are generally first noticed, with subsequent incontinence
of urine from extension of the ulcerative process to the base or neck
of the bladder, and the formation of a fistulous opening.
Physical Signs. — Owing to the insidious manner in which cancer
of the cervix usually commences, attention is not often directed
to the uterus until the disease has made considerable progress,
ulceration having commenced, with the characteristic symptoms of
menorrhagia, and offensive watery or ichorous discharge.
The diseased process almost invariably begins at the external os,
spreading gradually to the deeper tissues of the cervix and upwards
in the course of the cervical canal.
If for any reason an examination be made at this stage, the cer-
vix is generally found to be increased in bulk, indurated, its surface
irregular or nodulated, the os puckered. The uterus itself is still
mobile, unless fixed by previous inflammatory mischief. There is
little or no tenderness on manipulation, though haemorrhage is
readily excited. The cervix feels hard like wet india-rubber, the
mucous membrane covering it gi^'ing the sensation as if it were
fixed to the subjacent tissues, not gliding over them as in a state of
health. The margin of the os uteri is more sharply defined than
normal, giving the impression to the finger that the cervix is more
friable than in health. In some instances the cervix becomes hy-
pertrophied, and assumes the form of a mushroom, the lower portion
spreading out whilst the cervix above retains its normal size.
When the ulcerative stage has set in, the diagnosis is compara-
tively easy. In place of the smooth, healthy cer\nx, the finger de-
tects a deep and ragged ulcer, with hard, unyielding edges, bleeding
readily on touch; the surface is rough and friable, crumbling away
if scraped w\\h the finger-nail, and gi^^ng rise to profuse haemor-
rhage. In the more advanced stages this condition has been de-
scribed as cancer crater.
The morbid process has by this time extended up the cervical
canal as well as to the vagina and surrounding tissues, which be-
come infiltrated with the malignant deposit, thus fixing the uterus
in the pelvis.
If a small portion of this friable mass be examined microscop-
ically, we shall find it to consist of cells closely resembling epithe-
lium, but varying considerably in outline, round, oval, fusiform,
caudate, or polygonal. These cells are grouped together irregu-
larly within the alveoli of a fibrous stroma, without any intercel-
lular substance, and are characterized by their large sige and by
the magnitude and prominence of their nuclei, which are round
SYPHILITIC ULCERATION. 245
or oval in shape, and contain one or more bright nucleoli. There
is no specific cancer-cell. It is the general character of the cells,
together with their mode of distribution in the meshes of a fibroid
stroma, that determines the nature of the growth to which they
belong. (Green.)
Differentiation. — In the very early stage, the diagnosis of cancer
of the cervix is extremely difficult. The main points to be relied
upon are the readiness with which hsemorrhage occurs on the
slightest touch; the induration, hypertrophy, irregular or nodu-
lat^ surface of the cervix; the fixidity or immobility of the mucous
membrane, and the unyielding nature of the cervix under the in-
fluence of sponge tents.
The induration due to areolar Hyperplasia has more feeling of
elasticity than is found in cancer, and under the influence of a
sponge tent the cervix becomes dilated and softened. There is
usualh^ a history of long-standing uterine disorder, menstruation
being more scant}^ than profuse, the pain being increased during
the menstrual flow in place of being relieved by haemorrhage as
in cancer.
Wliere hyperplastic induration of the cervix is combined with
fibroid of the uterus, and the organ is impacted in the pelvis, it
may be very difficult to differentiate this condition from cancerous
infiltration, inasmuch as menorrhagia, immobility of the uterus
and enlargement of the cervix are alike common to both condi-
tions. The history of the case, duration of the symptoms, and
progress of the growth, will generally enable us to decide the
question.
Hypertrophy of the follicles of the os uteri from occlusion, when
small nodular projections with a whitish translucent centre are
found on the lower portion of the cervix, which is very congested,
may give rise to a supposition of cancer. Puncture of the follicles,
thereby allowing the mucous secretion to escape, the softness of
the cer\dx, and absence of any constitutional symptoms, will gen-
erally prevent our mistaking the two conditions.
Syphilitic growths or ulcers are comparatively rare productions
on the cervix uteri; still, the possibility of their occurrence should
make us careful. The history of syphilis will generally be distinct.
On examination the surface does not present the soft friable char-
acter usually met with in cancer, it does not bleed so readily on
touch, and the discharge has not the penetrating odor so charac-
teristic of cancer. The application of nitric acid, and the influence
of constitutional treatment, if the case be syphilitic, will also tend
)to clear up the diagnosis. Examination of a small portion of the
growth microscopically should never be neglected.
Syphilitic ulceration has been known to extend to the bladder
: and rectum, laying open these cavities, and producing a condition
similar to that occurring in the latter stages of cancer.
When cancer of the cervix has progressed to the ulcerative stage,
it is sometimes confounded with laceration of the cervix from par-
turition, eversion of the lips, and intense granular degeneration of
246 CANCER OF THE UTERUS.
the exposed surface. In these latter cases, however, the cervix is
generally softer even than normal, and haemorrhage is far less
likely to occur from digital exploration than it would he in cancer.
The discharge met with in laceration of the cervix is usually more
of a viscid muco-purulent character, free from any oiFensive odor,
as would in all prohability he the case in cancer at such a stage.
The duration of the symptoms, progress of the case, results of
appropriate treatment and of microscopical examination, will also
assist materially in clearing up the diagnosis. In cases of cancer,
if the speculum he resorted to it must be passed with the greatest
care, as otherwise profuse haemorrhage may be induced. The nor-
mal contour of the cervix will be seen to be altered materially. It
is enlarged, irregular in outline, the central portion eaten away,
the surface being ulcerated and bleeding readily upon the least
touch, whereas in cases of laceration of the cer^dx, although the
cer\dx presents an intensely injected florid appearance, there is no
ulceration or loss of tissue, but merely a granular degeneration ol
the mucous surface. This does not bleed anything like as readily
as would be the case in cancer.
Fibrous polypus of the uterus that has been extruded from the
cervix and grown after its descent into the vagina may simulate
closely the appearance of cancer in the ulcerative stage. Instances
have been recorded where adhesions between the pol}^us and con-
tiguous portions of the vagina have taken place, preventing the
passage of the examining finger, which encounters only a soft
sloughing or ulcerated mass, bleeding readily on touch and giving
rise to a more or less constant watery or sero-sanguineous discharge.
Under these circumstances the case may easily be mistaken for
one of cancer. The duration of the disease, extending over a
longer period than would probably have been possible with can-
cer, the comparatively slight amount of pain, the absence of well-
marked foetor of the discharge, and the softer, less friable condition
of the surface, should put us on our guard.
If, then, on careful examination, we can succeed in passing the
sound or the end of the finger between the growth and the vaginal
wall, tearing through any adhesions if necessary, so as to distin-
guish the cervix uteri beyond encircling the pedicle of the poh^^us.
the diagnosis will be determined.
When a large fibrous polypus has descended into the vagina,
and its lower surface become irregular and sloughy, it may readil}
be mistaken for cancer. The absence of any depression in the
centre corresponding to the os uteri, the fact of the finger being
able to be passed between the growth and the vagina, so as to de-
tect the cervix uteri beyond with its smooth rim, and the pedicle
of the polypus emerging from it, will enable us to recognize the
nature of the case.
When the disease has extended to the surrounding tissues, in-
filtrating them and fixing the uterus, cancer has been mistaken
for pelvic cellulitis, but in this latter condition the history of the
onset, generally following parturition, the detection of the deposil
MEDULLARY CARCINOMA. 247
around the uterus, and the absence of any ulceration of the cervix
or foetid discharge, should prevent our making any mistake in the
diagnosis.
Prognosis — Where the diagnosis of the disease has not been
made sufficiently early for operative interference to be of any last-
ing benefit, the prognosis is generally most unfavorable.
It is true that instances of spontaneous recovery from uterine
ciincer have been recorded upon unquestioned authority, the mass
sloughing away, the surface healing over, and the patient recover-
ing; but these cases are extremely rare, and such a contingency
can scarcely be regarded as more than a bare possibility. The
more general result is for the disease to terminate fatally within
eighteen months to two years after recognition of its character.
In some cases profuse haemorrhage may cut short life within a few
months; in other instances life may be prolonged for many years,
the disease progressing very slowly.
The form of cancer will influence the prognosis as to the prob-
able duration of the disease. Medullary carcinoma is the most
acute of all cancers, and generally runs a very rapid course, whereas
epithelioma progresses far more slowly, and is also not uniformly
progressive, its course being apparently arrested for a time, leading
the patient to infer that a cure has been effected.
The prognosis is also influenced by treatment. If the diseased
mass can be removed, or the condition of the surface altered by
means of various applications, so as to restrain haemorrhage and
check septic absorption, life may be materially prolonged.
Under any circumstances it is not advisable to tell a patient, per-
fectly unprepared it may be to receive so severe a sentence, that
she is suffering from a hopelessly incurable form of cancer. There
is always the possibility of an error in diagnosis and of relief by
treatment, and we should hesitate to condemn a patient, already
the subject of much physical suffering as well as mental anguish,
to unmitigated despair. It is quite sufficient to guard oneself by
pronouncing the case to be one of a serious nature and not readily
amenable to treatment, or only susceptible of temporary benefit, at
the same time holding out hopes of improvement, and promising
that everything possible shall be done with a view to arrest the
progress of the disease and allay suffering.
Terminations. — Spontaneous cure, by sloughing of the diseased
mass, although extremely rare, is not impossible. It has been
known to follow parturition. The usual mode of termination is
by exhaustion from heemorrhage associated with septicaemia from
absorption of putrid fluid. The nutrition becomes seriously im-
paired, owing to the inability to take food, and in some cases actual
starvation occurs. Ursemic convulsions from suppression of urine,
in consequence of the retrograde impairment of the urinary ap-
paratus leading to hydronephrosis, or from occlusion of the ureters,
not infrequently produces a fatal termination.
Amyloid degeneration of the kidneys and liver is not uncommon.
Venous thrombosis may give rise to phlegmasia dolens or to em-
248 CANCER OF THE UTERUS.
holism which terminates fatally. Extension of the disease to the
peritoneum may set up peritonitis which proves fatal, or death may
result more or less suddenly from shock due to perforation into
the peritoneal cavity.
Contagiousness of Cancer. — The fact that husbands live with their
wives long after the disease has been recognized, and that no au-
thentic instance of the disease being propagated from one to the
other has been recorded, goes far to disprove the theory of its
being contagious. As Dr. Barnes suggests, possibly grafting on a
raw surface is necessary, and probably the malignant cells will
only retain their natality in tissues of congenial morbidity.
Complication with pregnancy is by no means uncommon, and
always increases the danger to life, inasmuch as the growth pro-
gresses more rapidly and haemorrhage is often severe. If prema-
ture labor be induced artificially, there is great difficulty in getting
the cervix dilated sufficiently to allow the foetus to pass, and even
if this be accomplished there is great risk of dangerous or even
fatal violence being produced. The cervix has before now been
amputated at the mid-period of pregnancy without interfering with
the progress of this latter, which went on to full term.
Treatment. — If detected sufficiently early, before infiltration has
taken place into the surrounding tissues, when the morbid process
is wholly confined to the cervix, the expediency of operative inter-
ference should at once be considered. If the physical signs be
sufficient to warrant the supposition of cancer, in place of waiting
to see whether the disease progresses, a second opinion should at
once be suggested, so that no delay whatever may oocur, for it is
only in the very early stage, when the uterus is still mobile, that
operative measures are at all likely to be of service. Even though
recurrence of the malady should take place after operation, the
course of the disease will be protracted, the patient's life pro-
longed, and much suflTering averted, if only proper care be taken
in eft'ecting as complete a removal as possible of all diseased tissue.
If the case be one of epithelioma or cauliflower excrescence of the
cervix, or medullary cancer assuming the mushroom form, where
the mass is circumscribed, where a distinct neck of normal tissue
can be felt above the diseased mass, w^here the uterus is mobile
and there is no evidence of glandular or constitutional infection,
removal by means of amputation of the cervix should certainly be
performed.
Amputation of the cervix may most readily and with the greatest
amount of safety be performed by means of the galvano-cautery.
The danger of drawing in a portion of the vaginal cul-de-sac, the
risk of haemorrhage, and the fear of septic absorption are thus ma-
terially lessened.
In order to allay nervousness and prevent the patient moving
whilst adjusting the wire, it is generally better to give the patient
an anaesthetic. Placing her then either in the left lateral, semi-
prone, or in the lithotomy position, the diseased mass is seized with
a vulsellum and the cervix thus held firm, little or no traction being
AMPUTATION OF THE CERVIX. 249
emplojecl. The cold wire loop is then passed over the handle of
the vulsellum and adjusted, by aid of the finger, round the cervix,
the loop being gradually tightened until it becomes somewhat im-
bedded in the tissue of the cervix. The current of electricity is
then passed through the w^ire, which is thus brought to a white heat
or made red-hot, as desired. The loop is meanwhile slowly tight-
ened until the w^hole thickness of the cervix is cut through, It is
well to proceed very gradually and not to induce too white a heat,
or otherwise the tissues are divided so rapidly that haemorrhage
may occur. The diseased mass being removed, the stump should
now be examined carefully. A duckbill speculum being intro-
duced, the surface of the stump should be explored wdth the finger,
when, if any induration be detected, the tissues may still farther
be destroyed by means of the galvanic porcelain button, which may
also be employed to arrest haemorrhage.
If the operator prefer seeing what he is doing, a Sims's speculum
may be employed and the sides of the vagina held apart by retrac-
tors, before adjusting the galvanic wire.
After removal, care must be taken not to exert too great pressure
on the stump, if it be found requisite to plug the vagina on account
of haemorrhage. A stream of iced w^ater will generally be found
to be suflicient to stop any bleeding, the porcelain button being
used if any small spouting arteries be detected. A few plugs of
cotton-wool or strips of lint soaked in carbolized oil should then
be packed in the vagina, a T-bandage applied, and the patient
kept quiet in bed. Should any oozing continue, it may be neces-
sary to remove the packing and apply the liq. ferri perchlor. to the
stump, or this may be done before the packing is resorted to. The
dressing should be removed the following day, the vagina syringed
out with a little w^arm carbolic acid lotion, and then a strip of oiled
lint again inserted ; this being repeated for the first w^eek or so.
It will be necessary to watch the case and adopt means to prevent
the OS uteri closing during the process of cicatrization, which gen-
erally occupies two or three weeks at least. All risk of impreg-
I nation should be avoided. Tf any recurrence of the disease show
itself, the application of nitric acid, bromine, or other similar agent
should be resorted to from time to time.
Removal of the vaginal portion of the cervix may be accom-
i plished by means of curved scissors, but should never be done if
* the galvano-cautery can possibly be obtained, as the risk of haemor-
rhage which may prove uncontrollable is very great. The fact of
having to drag on the cervix so as to bring it as near the vulva as
possible to enable the scissors to be used efifectually, constitutes a
' serious danger, in that in our effort to remove the whole of the
diseased tissue we may readily cut into the retro-uterine peritoneal
pouch.
The ordinary single wire or chain ecraseur has also a similar ob-
jection, and the risks of septic absorption are much increased. If
either of these methods be adopted it is well to apply the actual
or benzoline cautery after removal of the cervix, so as to destroy
250 CANCER OF THE UTERUS.
effectually all traces of the diseased tissue, as well as to prevent or j
check hgemorrhage and lessen the risk of septicsemia.
Whatever method he employed, some little inflammatory mis- ,
chief with subsequent infiltration around the uterus generally i
occurs. ^
In those cases where the disease seems to be limited more to the
cervical canal, extending up beyond the level of the vaginal por-:^
tion of the cervix. Dr. Marion Sims's operation may be advisable, i
The patient being placed in the semi-prone position, a Sims's spec- J
ulum is introduced into the vagina, the cervix held firmly by a 1
tenaculum, and then a wedge-shaped portion excised by means of â–
his own uterine knife, so as to form a cone-shaped cavity, the apex
being at the internal os. A cautery is generally requisite to check
haemorrhage, it is also of service in enabling the operator to de-
stroy the tissues more deeply than might be deemed prudent with
the knife, and the risk of septic absorption is also lessened.
Emmet advises making a clean amputation of the cervix when
we can do so, and to cover the stump by sliding the vaginal tissue
over it, and securing the edges of the flaps with sutures.
Extirpation of the Uterus, by gastrotomy, has recently been advo-
cated by Freund and others, when the disease has been discovered
early, the uterus being still mobile and the vagina unafiected, as
offering a better prospect of effecting a radical cure than by any
other means. The steps of the operation are similar to those pur-
sued in cases of ovariotomy up to a certain stage. Anaesthesia
having been produced and the carbolic spray employed, the vagina
is syringed out with a sohition of carbolic acid, 1 in 10. An inci-
sion along the linea alba is then made, the intestines are drawn up
out of the pelvis and held there in a soft linen cloth or by means
of a large flat sponge wrung out of a 5 per cent, solution of car-
bolic acid. The fundus uteri is then seized by means of fenestrated
forceps, or by means of a stout ligature passed through the tissue
of the uterus, if this be healthy, and the organ drawn upwards by
an assistant. The broad ligaments are then secured by three liga-
tures on either side, the upper loop being passed through the Fal-
lopian tube above and the ovarian ligament below, the middle one
transfixing the ovarian ligament above and the round ligament be-
low, so as to avoid wounding any of the vessels contained in the
broad ligaments.
The lowermost loop requires a special manoeuvre ; an unarmed
perineal needle is pushed up from the vagina into the peritoneal
cavit}^ in fi^ont of the broad ligament, and anterior to the uterine
artery, the site of which has previously been determined by bi-
manual examination. The needle is then threaded and drawn
back into the vagina, returned through the same vaginal puncture
into Douglas's pouch behind the broad ligament, unthreaded, and
the ligature draAvn upwards into the abdomen. The loop is now
completed by transfixing the substance of the round ligament.
The six ligatures are now tied, and the free ends of each one fast-
ened together by a knot, the uppermost ligature on each side
CANCEROUS ULCERATION. 251
having two knots made in it in order to distinguish it from the
others. The broad ligament should next be severed on each
side as far down as the round ligament, and all bleeding vessels
secured.
The upper and posterior limits of the bladder having been de-
fined by the catheter, the peritoneum uniting the bladder to the
womb is divided by the knife. The front surface of the womb is
then separated from the bladder by the fingers or the handle of a
knife, the fundus uteri being meanwhile drawn upwards and back-
wards by an assistant out of the pelvis, by means of the transfixing
ligature or forceps.
As soon as the anterior vaginal vault appears as a reddish fold
at the bottom of the wound, it is punctured from the vaginal side
by a guarded knife and the opening enlarged on both sides. One
or two fingers are then passed from above through the wound into
the OS uteri, and the cervix is gradually draw^n upward by their
means until the posterior vaginal cul-de-sac is fully exposed, and
the position of the two lowermost ligatures is seen. The incision
can then be carried round the cervix so as to sever the uterus com-
pletely from its remaining attachments, without risk of dividing
the lowest loop of ligatures, and with the least risk of injury to
the ureters.
The uterus is then removed through the abdominal wound, and
the parts thoroughly cleansed with a 5 per cent, solution of car-
bolic acid. If the woman has not yet reached the menopause, the
ovaries should be also removed.
This may be done either by placing the uppermost loop of the
three ligatures outside of the ovary, or by transfij^ing and tying
the pedicle of each, ovary independently of this loop. After the
uterus is detached, the knotted ends of the six ligatures are pushed
down through the hole in the vaginal vault and drawn tense.
" Strong traction is made upon the uppermost ligatures on either
side, distinguished by the double knots, so as to bring the
1 ligatured stumps of broad ligament down into the vagina. The
uninjured portions of the anterior and posterior layers of pelvic
; peritoneum fall together in a transverse fold and obliterate the
opening. The transverse slit thus formed is sewn up by gut
sutures so as to shut ofiT completely the peritoneal cavity from the
^vagina.
A tampon of cotton, secured by a colored string to distinguish it
rfrom the ligatures, soaked in (10 per cent.) carbolized oil, is then
I pushed up into the vagina, by which canal the ligatures also are
brought out, and the operation is finally completed by closing up
the abdominal wound.
"Where the cervix is in a state of cancerous ulceration, or its con-
dition is such as to cause a risk of contaminating the peritoneum,
amputation may be performed previously, or the diseased mass
scraped away and the surface touched with the actual cautery or
strong carbolic acid.
As the operation is of necessity a prolonged one, the carbolic
252
CANCER OF THE UTERUS.
spray should not be allowed to play directly into the abdominal
cavity. The surface of the body should be protected as far as
possible from exposure, so as to avoid the depressing
Fig. 118. influence of cold. The bladder must be emptied just
previous to the operation, and great care ex-
ercised not to injure the ureters during the ^^g. 119.
removal of the uterus.
Of twenty-eight recorded cases, onl}^ nine
recoveries occurred, so that the operation
must still be regarded as one requiring fur-
ther experience to determine its merits.
Even when the disease has not been de-
tected sufiiciently early to allow of its com-
plete eradication, it may still not only be
justifiable but advisable to remove as much
of the diseased mass as possible, in order to
diminish haemorrhage and foetid discharge
and lessen the risk of septic absorption. If
any large vegetating surface exist, the gal-
vano-cautery may first be used to remove
this, and then as much more diseased tissue
as deemed prudent removed, by scraping the
exposed surface, either with Eecamier's or
Sims's curette, or by means of Simon's scoop
(Fig. 118), or one bent at right angles as in
Fig 119.
The selection of a sharp scoop or blunt
curette wdll depend upon the nature of the
mass to be removed, whether it be deeply
imbedded in the uterine tissue or is more
superficial.
The deeper we get the greater the caution
that must be employed not to tear through
the peritoneal border of the uterus. The
normal tissue being more resistant than the ^ ^^ ^^
diseased, and the latter more friable, this right* angles.
Simon's Scoop, danger may be avoided if the examining fin-
ger explore fi'om time to time the condition of the sur-
face and care be taken to employ a blunt curette.
Unless the patient be very nervous, it is not necessary to give
an anaesthetic, as the operation is comparatively painless, nor is it
requisite to use a speculum, the operator having to depend upon
the sense of touch.
Haemorrhage is often very free, and the operation should never be
undertaken unless either the actual, benzoline, or galvanic cautery
are at hand to sear the surface so as to check bleeding. In many
cases it is prudent, having removed the superficial portions of the
diseased mass, to employ the cautery only for the deeper structures.
Either Sims's speculum or a cylinder made of boxwood or ivory,
from one to two inches or more in diameter, and varying in length
APPLICATION OF ACIDS. 253
from four to six inches, depending upon the capacity of the vagina,
should then be inserted, so as to expose the surface to view and
enable the cautery to be employed without injury to the vulva.
Where the disease has advanced to the ulcerative stage, the
vagina is implicated, the rectum or bladder involved, and i'nfiltra-
tion into the deep pelvic tissues has taken place, the cancerous
cachexia being well pronounced, it is seldom expedient to attempt
any operative interference with a view to removal of diseased
tissue. Still, where the haemorrhage and discharge are very pro-
fuse and the patient's powers are not utterly prostrated, the appli-
cation of one or other form of cautery to the surface, or of the
strong perchloride of iron or other similar agent may be ad-
missible.
Certain chemical agents have from time to time been recom-
mended as local applications for the destruction of the diseased
mass. Of these the strong nitric acid, bromine, potassa fusa, po-
tassa cum calce, chloride of zinc, strong acetic acid, chromic acid,
sulphuric acid, sodium ethylate, are the chief.
A\niere the practitioner cannot command either of the forms of
cautery previously alluded to, the application of the strong nitric
acid offers certain advantages. If efficiently applied it relieves
pain, arrests haemorrhage, and lessens the amount of discharge.
To apply it, a Fergusson's glass speculum, as large as the vagina
will admit, must first be passed up to the cervix, against which the
end is firmly pressed. The surface having been mopped as dry
as possible by means of cotton-wool, a Playfair's probe, coated
with the same material tightly wound around it, is saturated with
"the acid, any superfluity being carefully pressed out against the
iiieck of the bottle. The acid is then applied thoroughly to the
whole of the diseased surface, the point of the probe being also
;)ressed into any irregularities so as to destroy more effisctually the
nass. It is well to have several probes ready, so that fresh relays
of acid may be employed. A mop soaked in a saturated solution
of carbonate of soda should then be used to neutralize any excess
)f acid and prevent it injuring the vagina. A plug of cotton-wool
^oaked in glycerin is then passed up to the cervix uteri and left
here for the next twelve hours or so.
The same precautions will need to be taken if either of the other
;trong acids be selected. If chromic acid be employed, the crys-
als are moistened with water, so as to make a fresh saturated
solution. Acetic acid, added to a section of cancer on the micro-
scopic slide, dissolves the cell-walls and also affects the nuclei. ITot
'oagulating albumen, the acid may diffuse itself through a tumor,
eaching every part equally, and may probably produce similar
esults when the cells are in situ. For this reason Dr. Broadbent
uggests injecting equal parts of acetic acid and water into the
issue of the cervix, thereby hoping to put an end to the dividing
nd multiplying of the cells, and consequently to arrest the growth
'f the tumor.
Sidphurk acid may be employed in a similar manner to the
254 CANCER OF THE UTERUS.
metliod described for nitric acid, asbestos being employed in place
of cotton, or the acid may be made into a kind of paste with
asbestos and thus applied to the cervix, whilst the speculum is
retained in the vagina. A solution of carbonate of soda should
then be injected so as to wash away and neutralize every trace of
acid. A plug of cotton-wool soaked in oil or glycerin should then
be inserted and left in situ for the next twelve hours or so.
Bromine is regarded as exercising a special influence in destroy-
ing cancer-cells, and has been tried with marked benefit in many
cases. Care must be taken in preparing the solution not to inhale
the fumes, which are very irritating. One part of bromide is dis-
solved in five parts of rectified spirit.
A small pledget of cotton-w^ool the size of a nut is saturated
with the solution and passed up through the speculum to the cer-
vix uteri. This is covered over with a piece of gutta-percha tissue,
and a large plug of cotton-wool soaked in carbonate of soda then
passed into the vagina to neutralize any excess of bromine that
may escape. The whole is left in situ for from six to twelve hours,
when it should be removed, and warm water injected into the
vagina to remove all traces of the bromine. Where any distinct
nodules of diseased tissue are detected, it is advisable to inject
some of the bromine solution into them by means of an elongated
hypodermic syringe, the canula of which is made of platinum.
Potassa fusa, or what is better still, as being more manageable,
potassa cum calce, in the proportion of two of quicklime to one of
caustic potash, fused into sticks, is sometimes applied. It should
never be done unless the patient be in bed and remain quietly for
some few days or more, until all irritation from its application has
subsided.
As large a Fergusson's speculum as the vagina will tolerate
having been passed up to the cervix — this latter must be carefully
cleansed and dried — a dossil of cotton-wool saturated wath vinegar
or acetic acid is then passed gently just within the os, and more of
the same material similarly prepared shauld be packed round the
cervix, so as to neutralize any excess of the alkali and prevent the
vagina being injured. The stick of potassa cum calce, secured in
a caustic-holder, is then pressed firmly against the cervix, changing
the point of application every few seconds, until the w^hole surface
has been cauterized.
A solution of equal parts of vinegar and w^ater should then be
injected into the speculum, withdrawing this latter a little, so as to
allow the fluid to circulate freely all round the cul-de-sac of the
vagina. The pledget of cotton-wool from the os uteri should then
be removed, and the vagina w^ashed out thoroughly. A tampon
of cotton-wool saturated with glycerin is then passed up to the
cervix and the speculum withdrawn. A morphia suppository ma}
be passed per anum, or a full dose of opium given to allay pain
and procure rest.
Whenever caustics are employed they should be applied as thor-
oughly as the circumstances of the case will permit, otherwise
PALLIATIVE TREATMENT. 255
whilst the superficial portions are being destroyed increased ac-
tion is set up in the deeper portions where the caustic has not yet
reached, and thus the growth of the cancer is in reality augmented
instead of being retarded.
If caustics are employed with a curative intention, they must be
used early, fully, and decisively (De Morgan).
The caustic treatment is especially useful in cases where the pa-
tients have an invincible horror of the knife. It is more applicable
to the disease when it occurs in the mammse or other superficial
structures than it is to the uterine manifestation of the disease.
It is well to bear in mind that peritonitis, pelvic cellulitis, phleg-
masia dolens, thrombosis in the pelvic veins, and even tetanus have
followed as a result of the operation of applying caustics, and
therefore every precaution should be taken both in forewarning
the patient of the possibility of such a sequence, in keeping her
strictly quiet for several days following the application, and in
promptly allaying any irritation that may be set up by means of
opium and other appropriate remedies.
Agents such as chloral hydrate, chlorate of potash, and pepsin,
applied in form of powder to the cervix, and kept there by means
of a tampon moistened with glycerin or water, have been recom-
mended strongly and deserve a trial.
To be of service they must be applied once or twice daily, and
their employment persevered in for a lengthened peried. A sat-
urated solution of the salt does equally well. Chloral acts as a
local sedative as well as a disinfectant. A solution of ten to thirty
grains to the ounce answers best. A plug of cotton-wool is sat-
urated with this and applied to the diseased surface.
Palliative Treatment — Unfortunately, it too often happens that
:he disease has already made such progress before the patient ap-
plies for relief that all hope of a radical cure being effected is
utile. We can but treat symptoms. Pain, haemorrhage, and
offensive discharge being the three most prominent symptoms,
our attention is commonly directed to relieving these.
Pain can be best allayed by means of opium in some form. It
-s always desirable to attempt this at first by the employment of
Ir-uppositories, so as to leave the stomach free for the assimilation of
lourishment. Five grains of pil. saponis co., one grain of the ex-
tract of opium, morphia in half to one grain doses, combined or
lot with the twentieth of a grain of atropin, either made up with
•ocoa-butter or the isinglass and glycerin mass, may be inserted in
Ihe rectum, or a starch and opium injection, containing n^^xx-lx of
incture of opium, may be employed.
The hypodermic injection of morphia, or of morphia and atro-
)in, answ^ers well in many cases, but unless the patient or some
\urse or friend be instructed how to inject it, the duty of attending
punctually at stated hours daily for many consecutive months is
^pt to become very irksome to the practitioner. It is well to begin
dth about a third of a grain of morphia and gradually increase
he dose as necessity requires, or lessen the intervals, or both.
256 CANCER OF THE UTERUS.
As the pain increases in severity, opium in some form, by the
mouth, generally becomes necessary ; in fact, the patient should be
encouraged to become an opium-eater. Solid Turkey opium, in
doses sufficiently large to etfectually assuage pain, commencing
with half a grain, and increasing this up to one, two, or three
grains, every four, three, or two hours should be given. Some
patients prefer Battley's liquor opii sedativus, chlorodyn, nepen-
the, or the alkaloid morphia itself.
Instances are recorded where patients have taken as much as 120
grains of solid opium, three pints of laudanum, or three drachms
of morphia in the twenty-four hours, and kept up its administra-
tion for many consecutive months.
Other sedatives, such as camphor and hyoscyamus, cannabis in-
dica, belladonna, conium, chloral, etc., may be tried, iDut sooner or
later opium, in some form, is instinctively selected as the drug that
aftbrds most relief
Various local applications have been tried from time to time to
allay pain, such as cold by means of ice, iced water injections, and
ether spray, but their influence is but temporary. Chloroform
vapor and carbonic acid have also been tried, but with only slight
results. Iodoform and tannin in equal proportions may be dusted
over the surface ; the odor of the former is thus to a great extent
destroyed, and the mixture serves to relieve pain as well as correct
fcetor.
Hemorrhage when profuse will need to be restrained, though it
has often been noticed that pain and haemorrhage occur in an in-
verse ratio to each other, the pain being most severe when haemor-
rhage is slight, and disappearing to a great extent when this latter
is profuse. Still there are limits beyond which it is not prudent to
allow the haemorrhage to go, as the patient's powers become ex-
hausted. The first indication is to modify the condition of the
diseased surface by one or other of the methods already suggested,
removal of as much of the disease as practicable by cautery or
scraping, so as to lessen the morbid acti\dty and the determination
of blood to it.
The next is to apply such caustics or styptics as will exert a
direct influence in preventing haemorrhage. Chromic, nitric, or
carbolic acid, perchloride or persulphate of iron, powdered sulphate
of zinc, etc., may be applied as previously ad\dsed. Astringent
lotions, such as a saturated solution of alum, iron alum, acetate of
lead, persulphate of iron, etc., may be employed by the patients
herself or by a nurse.
Lastly, we must endeavor to regulate and moderate vascular ex-
citement by means of salines, digitalis, bromides, aperients, ergot,
rest at the menstrual periods, and other similar measures.
Should a severe burst of haemorrhage occur when skilled assist-
ance is not available, the vagina may be syringed out with ice-cold
water, or water as hot as the patient can well bear it, and then a
plug of cotton-wool in which powdered persulphate of iron has
been incorporated, with a string attached, introduced into the
CONSTITUTIONAL TREATMENT. 257
vagina, pressed firmly up against the bleeding surface and retained
there for an hour or two, when it should be carefully withdrawn ;
or a good-sized plug of cotton-wool soaked in a saturated solution
of alum may be similarly employed, the patient meanwhile reclin-
ing on the couch or in bed, or even lying with the hips somewhat
elevated.
To correct the foetor of the discharge, cleanliness is the first req-
uisite. Injections of acetate of lead (5.j ad Oj aquam), alum (,^j
ad Oj), glycerin of carbolic acid (Sij ad Oj), chlorate of potash (.5J
ad Oj), chloral hydrate (oss-j ad Oj), tincture of iodine (5j-ij ad
Oj), sol. bromine. B.P. (5v ad Oj), liquor sodse chlor. (5ij ad Oj),
chloride of zinc (5ss-5ij ad Oj), or creasote (tt\,xx ad Oj), are among
the most useful. The acetate of lead is not only a haemostatic,
but also deodorant and sedative. Alum is one of the best deodor-
ants. Carbolic acid is, however, one of the most certain and
effectual.
Small pillows filled with charcoal roughly powdered, if changed
sufficiently often, say once a week, are of service in these cases.
A double case of ticking and linen is necessary to prevent the
charcoal soiling the sheets. Small wooden boxes, about six to
eight inches long and four inches wide, with a perforated zinc top
filled with small lumps of chalk saturated with carbolic acid, also
prove very useful.
A saucer filled with a mixture of common salt and bin oxide of
manganese, in the proportion of seven and a half of the former to
six of the latter, may be allowed to stand under the bed or in the
room. When a little strong sulphuric acid is added to this, chlorine
is 'generated and forms a valuable disinfectant.
Constitutional Treatment. — It will frequently be noticed that pa-
tients afflicted with cancer are in good general health at the com-
mencement, well-nourished, and even robust, showing that the
disease does not arise from want of tone or defect of nutrition.
Under these circumstances it is seldom advisable to suggest the
patient's taking plenty of nourishment and stimulants to " keep
her up," as the disease is probably thereby increased and its growth
accelerated. The better plan is to take a light, unstimulating diet,
such as milk and farinaceous food, and to avoid alcohol, unless for
special reasons.
Physiological rest is absolutely essential ; fatal attacks of haemor-
rhage have before now resulted from a neglect of this precaution ;
in any case the disease would be rendered more active, and if preg-
nancy should happen to occur, the risk would be very great at the
time of parturition.
It is by no means requisite to enjoin complete rest, provided the
pain and haemorrhage are not increased by moderate exercise,
whether walking or driving. The mere fact of keeping the patient
constantly indoors has a prejudicial effect on the general health,
and is apt to depress the mind very greatly. As to the effect of
drugs, no remedy has yet been found that has borne the test of
prolonged experience as exercising any specific influence on the
17
258 CANCER OF THE UTERUS.
progress or cure of cancer. Dr. Clay has recently recommended
strongly Chian turpentine. He asserts that " it appears to act upon
the periphery of the growth with great vigor, causing the speedy
disappearance of the cancerous intiltration, and thereby arresting
the further development of the tumor. It produces equally effi-
cient results on the whole mass, seemingly destroying its ^sdtality,
but more slowly. It appears to dissolve all the cancer-cells, leav-
ing the vessels to become subsequently atrophied, and the former
structures to gradually gain a comparatively normal condition.
It is a most efficient anodyne, causing an entire cessation of pain
in a few days, and far more effectually than any sedative."
He prescribes six grains of Chian turpentine; flowers of sul-
phur, four grains ; to be made into two pills, to be taken every
four hours. Twenty-five grains daily is the maximum dose which
can be safely and continuously given.
Another mode of prescribing it is by dissolving the drug in
double the quantity of ether, and then giving a mixture composed
of tinct. terebinth. Chia ether. ,5ss ; sulphur, subl. gr. xl ; mucilag.
tragacanth. Siv; syrup. ^ ; aquam Sxvj. An ounce thrice daily or
oftener.
The marvellous results recorded by Dr. Clay have not been
attained by other observers ; in fact, in other hands, the drug has
been absolutely inert, failing both to relieve pain or in any way
arrest the progress of the disease. Even making every allowance
for the possibility of impure specimens being used, there is a sin-
gular unanimity of opinion as to the utter uselessness of the drug,
and if subsequent experience should confirm this, the sooner the
drug is erased from the list of vaunted specifics the better for suf-
fering humanity.
It would serve no wise purpose to mention the innumerable list
of drugs reputed from time to time to exercise a curative influence
on cancer. Mercury, iodine,- arsenic, bromine, conium, have all
been tried without standing the test of time.
Iron in combination with salines often proves of service in im-
proving materially the general health, but has little or no influence
in arresting the progress of the disease. Quinine in some casee
does good. Ergot and gallic acid have been prescribed with a
vicAV to control haemorrhage. Cod-liver oil is useful in improving
the nutrition of the body. Some form of aperient is generally
requisite, the simpler the better. Pills containing aloes and bella-
donna, confection of senna, or an enema may be employed.
Cancer of the Body of the TTtems. — This affection is by no means
so rare as generally supposed. It is more common in nulliparae,
and, as a rule, occurs later in life than carcinoma of the cervix. It
commences in the body of the uterus, but may extend to the cervix
later on, the uterus remaining mobile for a considerable period
after the disease has been recognized.
Pathological Anatomy. — When the body of the uterus is primarily
affected with cancer, it is generally in one of two forms, true car-
cinoma, or more frequently still, sarcoma, either round-celled oi
CANCER OF BODY OF UTERUS. 259
spindle-celled. True carcinoma commences generally in the uter-
ine glands; it is doubtful whether it originates in the parenchyma
of the uterus. It may occur as isolated nodules, or may infiltrate
the whole organ diffusely.
The cells of carcinoma generally resemble those of the epithelium
from which it grows ; there is little intercellular tissue ; the vessels
run in the fibrous tissue, not among the cells, and multiplication
of cells is by endogenous formation (Butlin).
Symptoms. — Haemorrhage is generally the most prominent symp-
tom, associated usually with foetid discharge. Pain, severe and
lancinating in character, may be present almost from the com-
mencement, or may not occur until the disease has made marked
progress, and the neighboring organs are becoming infiltrated. At
this stage the cancerous cachexia is manifested, and the vital forces
rapidly deteriorate.
Physical Signs. — On examination the uterus will be found to be
enlarged and indurated, often tender on pressure. Profuse hsemor-
rhage generally occurs on passing the uterine sound, which seldom
enters the normal distance. The cervix, unless the disease has ex-
tended to this portion, is normal in consistence, the os often patu-
lous.
Differentiation. — The conditions most liable to be confounded with
cancer of the uterus are fibroid tumors, or large fibrous polypi,
more especially if sloughing has occurred.
Retained portions of placenta, and cystic degeneration of the
chorion, have before now led to the supposition that cancer of the
body of the uterus existed. Intra-uterine vegetations have also
been mistaken for cancer. In these three latter conditions, how-
ever, pain is seldom severe, and the discharge is not often offensive
in the two last-named.
In case of fibroid tumors there is generally a history of menor-
rhagia extending over several years, the uterine cavity is usually
longer, and profuse haemorrhage on passing the uterine sound sel-
dom occurs as in cases of cancer. Dilatation of the cervix will
enable us to explore the cavity of the uterus with the finger, and
ascertain the condition of its surface, whether vegetations or a soft
^fiingoid mass exists, or whether an intra-uterine polypus be pres-
ent. Care must be taken, if the uterine sound be employed, not
tto use any violence, as otherwise the end may perforate the soft-
ened diseased fundus and set up peritonitis which may prove fatal.
The only sure method of settling the question of malignancy is
by removing a small portion of the mass and examining it under
the microscope. To accomplish this, the blunt wire curette may
be passed in, or the end of a silver catheter turned round in utero,
•and a small fragment thus scraped off or brought away.
Should these means fail, the cervix may be dilated by means of
a sponge tent, and the interior explored with the finger, a small
piece being detached with the finger-nail or a curette. This should
be placed in a solution of equal parts of glycerin and water, and
submitted to some competent microscopist for examination.
260 CANCER OF THE UTERUS.
Progress. — The disease, commencing at the fundus, may extend
to the cendx and neighboring organs, or may involve distant organs
by metastasis. Cavities are not infrequently formed in the uterine
wall with gangrenous or semi-purulent contents; these may ex-
tend outwards, perforating the peritoneum, find causing fatal peri-
tonitis.
Death usually results, as in cancer of the cervix, from prolonged,
haemorrhage and exhaustion.
Treatment. — If the nature of the affection can he determined in
the early stage, whilst the uterus is still mobile, and the surround-
ing organs are not implicated, extirpation of the entire uterus by
Freund's method may be practised with a fair prospect of success.
As a rule the treatment can only be palliative. Pain must be
relieved by opiates.
If the haemorrhage be very severe, the cervix may be dilated, the
interior of the uterus scraped out with the blunt or sharp curette.
Simon's scoop, or the strong nitric acid applied. If any mass suf-
ficiently large be detected, it may be removed with the ecraseui"
or galvano-cautery.
Sarcoma of the Uterus.
Definition. — The sarcomata are tumors consisting of embryonic^
connective tissue. They include what have generally been known?
in this country as fibro-plastic, fibro-nucleated, recurrent fibroid 3
and myeloid tumors.
The sarcomata occur most frequently in early and middle life
and, next to the cancers, are the most malignant of the new forma »
tions. They are especially characterized by their great tendency^
to extend locally and to infiltrate the surrounding structures, 8( *
that they are exceedingly prone to recur in loco after removal-
They comparatively rarely infect the lymphatic glands, and in thin-
respect present a marked contrast to the cancers. They are alsc
very liable to become generally disseminated, although this is no
usual in the earlier stages of the disease (Green).
Pathological Anatomy. — Two principal varieties occur in the uterus
The round, and the fusiform or spindle-shaped. The cells, whicl
constitute nearly the whole of the growth, consist for the mos
part of masses of nucleated protoplasm, and rarely possess a lim
iting membrane.
The spindle-celled variety arises in the muscular tissue, oftei
from degeneration of a fibroid, in fact it is often difiicult to dis
tinguish it from a fibroid, except by the microscope, and by th
fact of its recurrence. It is generally of slower growth than th
round-celled variety, and when it contains muscular tissue, is spokei
of as myo-, or fibromyo-sarcoma. The round-celled variety, mor
distinctly malignant than the former, is of softer consistence, aii"
from its frequent resemblance in physical characters to encephs
loid, it is sometimes known as medullary, encephaloid, or soft sai.
coma. It is distinguished from encephaloid cancer by the absenc
SARCOMA OF THE UTERUS. 261
of an alveolar stroma, and by the uniformity in the character of
the cells. It is exceedingly vascular, rapidly assuming a fungating
character, and breaking down readily, thus leading to haemorrhage
and fa3tid discharge. It extends rapidly by peripheral growth, in-
filtrating the surrounding structures, reproducing itself in internal
organs, and often involving the lymphatic glands.
Symptoms. — These are similar to those occurring in cases of
cancer; pain, haemorrhage, offensive discharge, cachexia, etc.
The pain is generally a more prominent symptom than is the
case in cancer of the cervix, though it is not uniformly present.
In some instances it comes on early in the disease, and is both con-
stant and severe, lancinating or stabbing, in others it does not ap-
pear until later.
The pain is due partly to the stretching of the muscular fibre,
^ partly to the contractile efforts aroused by the parasitic growth,
partly by the pressure of the enlarged uterus upon surrounding
structures, partly to the invasion of surrounding structures by the
disease, and partly to the nerves themselves being affected by it
(Barnes).
The haemorrhage is often very troublesome, and alternates with
a pinkish w^atery or offensive mucous discharge, shreds or small
portions of the tumor being occasionally passed. These symptoms
occur earlier in the round-celled variety, being seldom present
until quite late in the spindle-celled variety.
Physical Signs. — The tumor generally springs from the interior
of the fundus, being more or less sessile, and projects into the
J cavity, in some cases assuming a polypoid form.
. The uterine contractions excited by its presence ultimately serve
%to dilate the cervix, and thus allow the growth to be partially
! forced into the vagina. The surface is felt to be soft, spongy, and
'friable in the round-celled variety, but denser and firmer in the
spindle-celled form. On conjoined manipulation the uterus may
be felt to be enlarged, irregular in shape, and tender on pressure.
Differentiation. — The only way of determining the nature of the
tumor is by examining a small portion of it under the microscope,
I when if it be sarcoma the characteristic appearances mentioned
will be detected. The conditions most likely to be confounded
with sarcoma are fibroid tumor, and cancer of the body of the
uterus. The history will often assist us in forming an opinion, but
tthe microscope alone can be relied on in determining the diagnosis.
Sarcoma occurs more frequently than carcinoma during the
^period of sexual activity.
Termination. — As a rule sarcoma runs a much slower course
than carcinoma, not infrequently extending over a period of sev-
eral years.
The soft, round-celled, and large spindle-celled varieties are
usually much more malignant than the firmer, small spindle-celled
growths. Their infiltrating powers are much greater. They some-
times infect the lymphatic glands, and they tend to reproduce
themselves very rapidly in internal organs.
262 CANCER OF THE UTERUS.
Deatli ultimately results from haemorrhage, infiltration of the
neighboring organs, interference with nutrition, or acute peritonitis.
Prognosis. — The ultimate issue is certain; the disease invariably
proving fatal sooner or later, depending upon the variety, whether
round- or spindle-celled, the former being more rapid in its de-
velopment. As a rule, the softer and more vascular the tumor,
and the less its tendency to form a fully developed tissue, the
greater is its malignancy.
Treatment — Extirpation of the uterus before the process of in-
filtration has taken place in the neighboring organs offers the only
hope of removing the disease. Where the disease has progressed
beyond this, the growth presenting through the dilated cervix, re-
moval of as much of the mass as practicable by the galvano-cauter}^,
ecraseur, or other means, and the application of nitric acid to the
base, may serve to arrest the progress of the disease for a time. If
not already dilated, the cervix may be opened up by sponge tents.
DISEASES OF THE OVARIES. 263
CHAPTER XVIII.
DISEASES OF THE OVARIES.
Diseases of the Ovaries. — Absence. — ^Except in cases where the
entire sexual apparatus is deficient, it very rarely happens that
both ovaries are congenitally absent. Even when the uterus is
.absent, the ovaries are oliten found well developed.
When the ovaries are congenitally absent, in place of the usual
sexual development at puberty, the period of childhood is indef-
initely prolonged, the stature remaining small, the figure unde-
weloped, the mind often childish or deficient, even approaching to
idiocy. In some instances the girl lacks vigor both of mind and
body, sufiers from depression of spirits, remaining a child without
retaining the vivacity and cheerfulness of childhood. In other
cases there is more or less approximation to the male type.
Manual exploration by the rectum may be justifiable in certain
f cases, and saves us from inflicting unnecessary interference in
> other ways.
There is a complete absence of any sexual feeling.
A peculiar condition, excessive obesity with idiocy, occasionally
(is witnessed in cases where the ovaries are presumed to be absent.
Imjyerfect Development. — The ovaries retaining their foetal condi-
ftion, in place of becoming rapidly developed at puberty, is one of
Ifar more frequent occurrence than entire absence.
It is often associated with a rudimentary condition of the rest of
^the sexual apparatus; puberty is indefinitely postponed, menstrua-
tion, if it occur at all, commences very late, is generally very
>3canty, and is absent for long periods at a time, the menopause
occurring very early.
Not infrequently we find a marked tendency to masculinity, the
woice being harsh, the mammse undeveloped, the chin and legs
covered with hair, and occasionally a well-marked moustache, the
>3tature small but muscular.
The pelvis is either uniibrmly small, undeveloped, or of mascu-
line type. The sexual feeling is either absent, causing complete
frigidity, or so slight as to prove a source of much unhappiness
3hould the patient marry.
Even by rectal exploration it may be impossible to diagnose be-
tween complete absence and imperfect development of the ovaries.
If, with arrested puberty, there is complete absence of any sexual
feelings, and menstruation cannot be induced by the means to be
mentioned directly, it will be well to abandon any further attempts
at treatment.
264 DISEASES OF THE OVARIES.
Atrophy of the Ovaries may occur independently of the normal
involution which takes place at the menopause from some pelvic
inflammatory mischief, such as cellulitis, or still more frequently
in consequence of pelvic peritonitis, or even acute ovaritis. The
dense surrounding deposit and adhesions prevent the natural lib-
eration of the ovules, the existing follicles shrink, and the stroma
retracts.
Any severe constitutional depression, such as results from a
serious or prolonged exhaustive illness, or even some sudden shock
or deep sorrow, may result in atrophy, more especially if there has
been feeble development of the ovaries from the first.
Treatment. — Where complete absence is presumed or proved,
nothing can be done. If imperfect development be suspected,
something may be attained by stimulating the sexual organs by
means of a general tonic course of treatment, in which iron plays
an important part ; nutritious diet, and regular exercise in the fresh
air, being also resorted to.
Uterine irritation by means of laminaria tents, occasionally in-
serted, the employment of the hot-water douche, the wearing of an
intra-uterine galvanic stem, may also be tried with a \dew to irri-
tating the ovaries.
Direct local stimulation to the ovaries by means of Faradization
may also be tried, one pole of the battery being applied to each
ovary successively, the other being placed over the sacrum, or ap-
plied to the cervix uteri, or even to the interior of the uterus by a
rheophore shaped like a sound, protected by some non-conducting
material excepting the terminal 2J inches.
The influence of marriage has occasionally a beneficial result,
especially if pregnancy ensue.
Where atrophy has occurred from pelvic peritoriitis, we must be
extremely careful in attempting to irritate the ovary. Intra-uterine
stems are distinctly contra-indicated.
Apoplexy of the Ovaries occurs as a physiological act at each men-
strual period ; where it is excessive, the haemorrhage continuing
longer than natural, or returning after cessation, it constitutes a
pathological process. The collection of blood may be as large as
an orange, or the tunica albuginea of the ovary may rupture and
the blood be eflTused into the peritoneal cavity, constituting pelvic
hsematocele.
Symptoms. — Sudden and violent pain in one ovarian region, with
nausea, vomiting, and occasionally extreme exhaustion or collapse,
occurring at the time of a menstrual period.
On examination by conjoined manipulation the ovary may be
detected, enlarged and tender. Great care should be taken lest by
pressure w^e rupture the cortical portion of the ovary, and so cause
a hsematocele.
Treatment. — Perfect rest and quiet; avoidance of all emotional
disturbance. Poultices or fomentations with sedatives if the pain
be urgent; a blister to the seat of pain later on.
Displacements of the Ovaries may arise from their increased weight
PROLAPSE OF THE OVARY. 265
>r bulk, due to hypereemia or commencing cystic degeneration;
from the pressure of neighboring organs or tumors ; from relaxa-
tion of the supports which usually hold them in position ; from
displacements of the uterus as in retro-version and -flexion, or pro-
lapse dragging the ovaries with it; or from inflammatory^ adhesions
" binding them down.
Prolapse of the ovary dowm wards and inwards towards the mesial
:line is the most usual displacement, the ovary descending into
Douglas's pouch. Here it often becomes fixed from inflammation,
the result of pressure or other injury.
- SymiJtoms. — A peculiar sickening pain is generally complained
iof, often coming on in severe paroxysms, increased on def^ecation
a and coitus, generally worse on standing or on walking. The pain
zis referred to the sacral and inguinal region, as of a throbbing,
4 aching character, a sense of bursting being often spoken of at the
menstrual period, when the pain is greatly intensified. This con-
stitutes ovarian dysmenorrhoea.
On vaginal examination the prolapsed ovary, more often the left,
is felt low down, slightly to one side of the uterus, as an oval or
, almond-shaped body, slightly irregular or nodular on its surface,
extremely sensitive to the touch, a sickening pain being produced
i on pressure, analogous to that of the testicle, and often giving rise
ito hysterical manifestations.
Examination fer rectum enables us to pass the end of the finger
1 abov^e the ovary, and thus to ascertain more definitely the exact
♦ size and condition of the organ.
Diagnosis. — A retrofiexed fundus uteri is not infrequently mis-
' taken for a prolapsed ovary. This is, as a rule, denser, less mobile,
†¢ and less sensitive than an inflamed prolapsed ovary.
The uterine sound will soon clear up any difficulty. If this
I passes in the normal direction, upwards and forwards, the fundus
I uteri being felt behind the pubes, the tumor posteriorly remaining
unafiected, we may conclude that this latter is the prolapsed ovary.
But if the sound passes backwards and downwards, and the fundus
uteri can be lifted out of its abnormal position, no tumor being
then detected posteriorly, it is a case of retroflexion of the uterus.
Treatment. — The genu-pectoral position, frequently and persever-
â– ingly resorted to, often proves of much service. The introduction
' of a Hodge's pessary, either with an elastic or broad posterior end,
carefully adjusted so as to put the posterior cul-de-sac on the
stretch, will also prove useful.
The bowels must be carefully regulated by means of alteratives,
salines, enemata, etc.
If much pain be present, a few leeches may be applied to the
: posterior cul-de-sac, of the vagina ; suppositories or pessaries of
morphia, conium, or belladonna may be employed at bedtime.
All unnecessary fatigue in the way of prolonged standing, walk-
ing, etc., especially at the monthly periods, must be avoided. Hot-
water vaginal or rectal injections may be tried.
The bromide of potassium is often of service.
266 DISEASES OF THE OVARIES.
Hernia of the Ovary. — This may be congenital or acquired. In
very rare instances the ovary descends into the labium majus, or
into a pouch of peritoneum, which remains patent in the inguinal
canal as a congenital error of development, giving rise to the sup-
position of hermaphroditism. In these latter cases, however, it is
more likely to be a testicle than an ovary.
Acquired hernia of the ovary may occur shortl}^ after delivery,
when the attachments are often very loose. It is generally asso-
ciated with hernia of intestine or omentum, and is more commonly
inguinal, though it may also occur in cases of vaginal, crural, ab-
dominal, or even ischiatic hernia.
Periodical swelling and tenderness at the times when the cata-
menia are present, with a dragging pain when the patient lies on
the opposite side, and tenderness on pressure, should suggest the
nature of the case.
Treatnient. — In congenital or irreducible hernia the ovary may
be protected from pressure by a concave shield. If the hernia be
reducible, the taxis and a truss should be applied. If the ovary
becomes inflamed and fixed by adhesions, and produces consider-
able discomfort, it may be removed by operation. This has fre-
quently been done successfully.
Inflammation of the Ovary. — Oophoritis; Ovaritis. — This condition
probably occurs more frequently than we are apt to imagine, but
inasmuch as it is seldom fatal, we have not frequent opportunities
of verifying the diagnosis. On making post-mortem examina-
tions of patients who have died from other causes, it is not at
all infrequent to find fibrous bands or adhesions surrounding
the ovary, induration of the stroma, and thickening and opacity
of the peritoneum covering the ovary, where no history of pre-
vious oophoritis existed, or had been suspected or inquired into.
It is usually associated with other forms of pelvic inflammation,
and occurs more frequently in puerperal than in non-puerperal
patients.
It is in the latter class only that we shall here consider it. It is
usually spoken of as acute and chronic.
Acute Oophoritis, uncomplicated by inflammation of the adjoin-
ing peritoneum or cellular tissue, is rarely met with, and the post-
mortem records of cases are so few, that to divide the aftection into
parenchymatous, follicular, and peritoneal seems an unnecessary
refinement, and will serve no useful purpose.
Pathology. — At first the ovary is extremely congested, enlarged,
and hea^^^ It then becomes softer in consistency and friable, much
increased in size and weight, infiltrated with serum, with hsemor-
rhagic points which become purulent later on ; suppuration takes
place, the organ becomes soft and diflluent, disorganized, or con-
verted into an abscess.
Causes. — Imprudences during menstruation, from exposure to
cold or fatigue, immoderate sexual indulgence, secondary extension
of inflammation from the neighboring organs (the uterus. Fallo-
pian tubes, and broad ligaments) ; operations upon the uterus, in-
ACUTE OOPHORITIS. 267
sertion of laminaria, sponge tents, or stem pessaries into the uterus,
intra-uterine injections.
In the majority of cases the exciting cause will be found to be
pelvic cellulitis or peritonitis, often due to gonorrhoea. Oophoritis
may also occur in the course of acute fevers, as small-pox, etc.
Symptoms. — These are similar to those of pelvic cellulitis and
peritonitis, elsewhere described, and it is often impossible to dis-
tinguish them. There is generally severe pain in the region of the
aifected ovary, wdth great tenderness on pressure. On conjoined
manipulation the ovary will be found to be exquisitely sensitive to
the touch, somewhat lower in position than normal, and also en-
larged; but frequently the accompanying inflammation of the
otlier tissues and the extreme sensitiveness of the parts effectually
preclude our detecting the ovary. Examination per rectum will
often enable us to ascertain more clearly and with far less discom-
ifort, especially in virgins, the exact condition of the ovary.
Menstruation may be either suppressed or the flow may be in-
i creased in quantity.
In severe cases, especially where the peritoneum becomes in-
volved, or is already inflamed, oophoritis may continue for many
weeks or months, with more or less marked remissions or distinct
intermissions, the paroxysms being synchronous with the catame-
mial epochs.
Results. — Resolution and recovery may ensue, or the inflarama-
ttion ma}' become chronic.
The exudation may ultimately disappear, becoming absorbed, or
imay remain as firm fibrous bands or adhesions, binding down the
( ovary to the neighboring organs, interfering with its functions and
â– so causing sterility.
The adhesions may be so dense, or the exudation so firm, as to
i encapsule the ovary and lead to atrophy of its tissue.
The ovar}^ may undergo suppuration, an abscess forming wdiich
may burst into the peritoneal cavity and produce general perito-
nitis, which ends fatally, or cause death at once by shock or collapse.
Small perforations may take place, setting up more circumscribed
[peritonitis. Adhesions may form between the bladder or intes-
tine, the pus becoming discharged by fistulous communications,
or may even gain exit by the vagina or through the abdominal
\wall.
Where large quantities of pus escape, suppuration taking place
in the cavity of some ovarian cyst is generally the explanation.
Diagnosis. — This is often impossible. Intense pain in either
ovarian region is not sufficient to constitute oophoritis ; still, the
localization of the pain and tenderness, with the detection of an
enlarged, exquisitely sensitive swelling in the position of the ovary,
will assist materially in forming an opinion. The association of
oophoritis with peri-metric inflammation, either as cause or con-
sequence, is generally so intimate as to preclude our coming to any
certain conclusion.
Prognosis. — As a rule this is favorable, though the affection may
268 DISEASES OF THE OVARIES.
prove fatal in a very short time, may remain active for many
months, give rise to frequent relapses, or cause death by perfora-
tion of an abscess.
Treatment — Perfect rest, leeches to the groin or perineum, hot
fomentations or poultices, opium suppositories. Where suppura-
tion occurs, and fluctuation can be detected per vaginam, the aspira-
tor trocar may be employed to evacuate the pus. Especial care
must be taken to avoid anything likely to cause rupture of the
abscess into the peritoneal cavity.
Chronic Oophoritis is an aftection apparently of far more common
occurrence than the acute. It may be preceded by the acute form,
or commence in a subacute manner as frequently witnessed in con-
nection with parturition, or may arise independently in connection
wdth dysmenorrhoea. As a primar}^ affection which creates sec-
ondary uterine disorder and results in dysmenorrhoea, sterility, and
hysteria, it is by no means rare.
Congestion of the ovaries beyond the physiological limit, with
severe pain, may occur. But intensity of pain is not necessarily
evidence of inflammation. As Dr. Barnes suggests : It may be
true that the ovary proper may be inflamed alone, but it is hardly
conceivable that repeated attacks of oophoritis should fail to in-
volve the peritoneal investment. It is moreover scarcely in accord-
ance with the history of inflammation to return in an organ every
month, to run its course in a few days, and to leave the organ
essentially sound, that is, in a condition ultimately to perform its
functions.
Causes. — Any influences calculated to keep up a state of hyper-
semia of the ovary, such as is not infrequently met with in the
unmated or the ill-mated, long engagements, disappointments in
love, immoderate sexual excitement, masturbation, imperfect coitus,
the strong emotional susceptibility of hysterical subjects, and other
similar conditions, will be very liable to produce such a constant
state of congestion as readily to pass the limits of health and be-
come one of inflammation.
The ovary, increased in weight, becomes partially prolapsed, its
venous circulation being thereby still further interfered with, hyper-
plasia with thickening of the capsule results, and the extrusion of
the ovule by rupture of the follicle being thus rendered more dif-
ficult, inflammatory changes are apt to ensue, or cystic degenera-
tion to take place.
In single women chronic oophoritis will be found to be fre-
quently associated with some form of dysmenorrhoea often de-
pendent on some misplacement of the uterus. The affection is
often relieved by marriage, even if pregnancy does not occur;
menorrhagia, dysmenorrhoea, and other e\idences of ovarian irri-
tation becoming less marked.
The left ovary is more frequenth' affected than the right, due,
doubtless, to the left ovarian vein opening into the renal in place
of into the vena cava, as happens on the right side, but also to the
pressure produced by the ever-recurring distention of the rectum
\
CHRONIC OOPHORITIS. 269
and sigmoid flexure on the venous circulation, especially in cases
where constipation occurs. Latent gonorrhoea, or syphilis, may
prove in some instances the exciting cause.
Pathologij. — In acute cases we have seen that the ovary at first is
enlarged, and subsequently becomes softened. In chronic cases
hypertrophy of the parenchyma similar to the interstitial hyper-
plasia of other glands, as in cirrhosis of the liver, produces indura-
tion, the surface of the ovary becomes roughened or corrugated,
the capsule thickened, so much so as to interfere with the rupture
of the follicles at the menstrual periods, sanguineous effusion often
takes place not only in the interior of the vesicles, but also in their
immediate neighborhood, producing the so-called apoplexy of the
ovary.
Cystic degeneration or atrophy may ensue, or the structure of
the ovary be broken up by the formation of abscess. It is needless
to enter upon the refinements of follicular and interstitial ovaritis.
Symptoms. — There is generally more or less fixed pain of a dull,
heavy character over one or both ovaries, increased towards the
menstrual period, aggravated by much standing, constipation, etc.
If the ovary be prolapsed the pain is often severe on defaecation
or coitus, described as of a sickening character.
The pain radiates from the ovary to the back and hips, often
extending down the inner side of the thighs. It may be periodical
at first, but ultimately becomes continuous. It is often worse the
week before the period, and abates somewhat on the appearance
of the flow if no cause of obstruction exist, though in some cases
tl^e pain is worse after the period, as if the ovarian congestion had
aggravated the already existing mischief. In other cases the pain
occurs midway between the periods, the so-called inter-menstrual
dysmenorrhoea.
Menstruation is usually profuse in the early stages, being either
increased in quantity, prolonged in duration, or too frequent.
Amenorrhcea is a more frequent accompaniment of the later stages.
There is, however, no invariable rule. Menstruation may be fairly
normal, scanty, irregular, or profuse. This may be partially ex-
plained by the fact of one ovary only being involved, when accord-
ing to ^N'egrier's theory of the alternate action of the ovaries, ovu-
lation may be normal when the healthy ovary is at work, there
being no dysmenorrhoea or profuse menstruation, whereas these
latter symptoms may be marked when the inflamed ovary is acting.
Some amount of uterine catarrh is often present, but whether
this be the cause of the ovarian mischief or the consequence it is
often difficult to say. The fact that when the disease of the cer-
vical canal is cured by the application of caustics or other appro-
priate treatment the ovarian pain ceases, may prove that the latter
was dependent upon the former, but the treatment applied to the
uterus may have acted on the principle of derivation or counter-
irritation, and so have cured the ovarian disease.
Physical Signs. — On conjoined manipulation we shall generally
be able to detect on one or other, or both sides of the uterus, not
270 DISEASES OF THE OVARIES.
infrequently more towards Douglas's pouch, an oval, enlarged, ex-
tremely sensitive body, about the size of a Spanish olive, or even
larger. Pressure upon this causes a feeling of nausea and often
provokes hysteria.
The ovary is usually prolapsed, but in cases where the ovarian
disorder is secondary to or symptomatic of preceding pelvic peri-
tonitis, the organ is often bound down by adhesions which prevent
its descent, and it may then be beyond the reach of the examining
finger internally.
It will often be noticed that the abdominal muscles on the
affected side are held tense and rigid so as to prevent any pressure
externally. There is also a certain amount of fulness, due to flat-
ulent distention of the intestine, often described by the patient as
a tumor in the side. Rectal exploration will frequently enable us
to detect the inflamed ovary more thoroughly than is practicable
by the vagina.
The uterus is more often misplaced than not, retroflexion being
the most usual. The cervix is often in an unhealthy condition.
Other signs of pelvic mischief may also be present.
Diagnosis. — Attention to the symptoms and physical signs al-
ready enumerated, the exclusion of other forms of pelvic diseases,
the detection of the inflamed ovary by conjoined manipulation,
vaginal and rectal touch, will generally enable us to distinguishi^
the nature of the affection.
If the fundus uteri be retroflexed, the introduction of the uterine '
sound will serve to discriminate the fundus from a prolapsed ovary,
although the two are often bound together by adhesions and in
some cases the diagnosis is very diflicult.
Results. — In long-standing cases, the patients often develop?^
marked symptoms of hysteria, anomalous sensations are com-
plained of, the patients become extremely nervous and irritable, ;
and often confirmed invalids. The general health is much im-
paired and ansemia results.
Professor Charcot has recently called attention to hystero-epi~
lepsy with hallucinations bearing a constant relation to disorders
of the ovary, mere pressure upon this organ being sufl^icient to
produce the most marked manifestations.
Sterility is the rule, impregnation the exception, though it is .
possible that this latter may occur in those cases where only one
ovary is involved, or where some follicles remain in a condition to ;
bring forth healthy ova even when both ovaries are more or less I
affected. j
Resolution may occur, but the affection is generally very intract- j
able. The healthy structure of the ovary often becomes destroyed, j
the vesicles compressed and atrophied, amenorrhoea and sterility
being the natural result. In septic cases suppuration and the
formation of abscess generally ensues, peritonitis or even death
from rupture of the abscess into the peritoneal cavity occurring in
consequence.
Prognosis. — Although chronic oophoritis does not often prove
TREATMENT OF CHRONIC OOHORITIS. 271
fatal except when suppuration occurs and the abscess bursts into
the peritoneal cavity, it is yet a very intractable disease, little
amenable to treatment, often causing life-long suffering and expos-
ing the patient to constant danger from the liability to peritonitis.
Many cases are rendered incurable in consequence of the profound
annemia induced by the habit of resorting to opium to allay pain.
Epilepsy and insanity are not infrequently the result of the long-
continued ovarian irritation.
Treatmetit. — Chronic oophoritis being on all hands admitted to be
a very intractable malady, we must be extremely careftil to avoid all
influences calculated to depress the vital forces, or to encourage
any habits detrimental to the general well-being of the individual
who is the subject of this affection.
Prolonged rest, either in bed or on the couch, should not as a
rule be suggested, the impairment of the general health from the
loss of appetite, constipation, sleeplessness, want of exercise, and
concentration of the patient's thoughts upon herself wall probably
do far more harm than good. At the same time it will be w^ell to
avoid any prolonged or undue exertion. The patient should not
be allowed either to stand or sit, to walk or ride, too long at a
time. The employment of the treadle sewing-machine, practising
the piano or harmonium, standing in the laundry, at the ironing-
board, or in the school-room teaching, or behind the counter, and
other similar fatiguing occupations, should as far as possible be
avoided.
A certain amount of rest at the menstrual period is not only
advisable, but often absolutely necessary.
Physiological rest is indicated. All influences calculated to ex-
cite the emotions or the sexual passions in the unmarried should
be carefully avoided. In married patients it is not absolutely req-
uisite to abstain entirely from indulgence in sexual relations, but
strict moderation must be enjoined ; provided of course the act is
not attended by any severe exacerbation of pain.
Should impregnation fortunately occur, and the ovaries thus ob-
tain immunity from the periodical monthly congestions for the
ensuing nine months, it will probably have a very beneficial in-
fluence upon the course of the disease.
As to local treatment, if the ovary be prolapsed, the insertion
of a carefully adjusted light elastic ring or Hodge's pessary, so as
to sustain the ovary at its proper level, thus ensuring rest and
favoring the normal circulation in the organ, will probably afford
marked relief. If any misplacement of the uterus exist, the pes-
sary will also prove of service in reinstating it in its proper posi-
tion, and so relieving any undue congestion. If menstruation be
scanty or the local pain and tenderness very severe, the application
of a few leeches to the cervix uteri, just before or immediately
after the menstrual period, may be advisable. They should not,
however, be repeated too frequently, for patients seldom bear de-
pletion well in these cases.
The application of potassa c. calce to produce a small issue or
272 DISEASES OF THE OVARIES.
eschar on the cervix uteri, and so act as a derivative, has been
recommended by Dr. Barnes. The complication of uterine dis-
orders in many of these cases is sufficient to justify the treatment
suggested.
Hot-water vaginal injections should he employed night and
morning. Painting the cervix uteri and the upper portion of the
vagina over once or twice a week with tincture of iodine has also
been recommended. Fomentations or poultices to the lower ab-
domen should be used when requisite. Counter-irritation over the
seat of pain in the inguinal or iliac region by means of blistering
fluid, iodine liniment, or other similar application, should be kept
up for months at a time.
As regards medicinal treatment, the iodide and bromide of potas-
sium, as being calculated to promote absorption, relieve hyperse-
mia, and produce a sedative influence upon the sexual organs, have
been strongly recommended. They will need to be persevered
with for many months at a time, but their action should be care-
fully watched lest they tend to upset the digestion, cause marked
mental depression, or in any way impair the general health.
Vfhere any syphilitic history exists, or there seems to be any
constitutional taint of this disorder, the iodide and bromide may
be combined with small doses of liq. hydr. perchl. and persevered
with steadily for many months. It is often advisable to combine
these with some preparation of quinine or bark — the tinct. cinch.
CO. for instance, or calumba or cascarilla.
Iron, as a rule, is not indicated in these cases, especially if men-
orrhagia or any active congestion be present, but where amenor-
rhoea exists, or marked nervous symptoms are develoved, iron often
proves of much value.
There are two agents not infrequently resorted to in these cases
that the practitioner will need to be on his guard against. These
are opium in its various forms, and alcohol. It is to be feared that
the frequent resort to the use of morphia, hypodermically, as sup-
pository, or by the mouth, tends to produce anorexia and in tinu
anaemia, with neuralgia as a frequent accompaniment. A morbid
craving for the drug is frequently engendered which at length be
comes more detrimental to the general health than the origina
disease for which it w^as employed. Opium should be reserved a.'
much as possible for acute paroxysms. Alcohol also has its evils
The glass of port wine taken in place of food to avert some threat
ened neuralgic attack, the tumbler of hot toddy at bedtime tha
steeps the senses in a happy oblivion for some hours to come, ma^ \
ultimately grow into such a pernicious habit that it is impossible j
to break the patient of it.
"Where much pain occurs at the menstrual period and there i;
other evidence of congestive dysmenorrhoea, warm hip-baths, o
better still a full warm bath, will generally afford marked relief
At other times, where the case is of long standing, the nervoui
symptoms marked or the general health much deteriorated, cole-
sponge or shower baths may be prescribed w^ith beneflt. Sea-bath'
battey's operation. 273
ing in summer, or a resort to some hydropathic establishment in
Avinter, may also prove of service. ^_^
Battey^s Operation. — Should all ordinary measures fail in procur-
ing relief, and the continued pain and discomfort be so great as
not only to embitter the patient's existence but also to render her
a helpless and confirmed invalid, threatening her reason, or in-
ducing recurring attacks of epileptiform mania or hystero-epilepsy,
it will then become an anxious question whether removal of the
ovaries by spaying should not be resorted to. ;
The operation has been done repeatedly both by vaginal as well^
as by abdominal section. The latter seems the preferable mode of
proceeding in all cases w^here adhesions of the ovary are suspected
or known to exist. If attempts be made through a vaginal in-
cision to gouge out the adherent ovary piecemeal with the finger-
nail, we incur the risk of leaving some of the organ behind, and
also of producing so much haemorrhage that it is almost impossible
to restrain it.
The operation has thus far been performed about thirty times,
with a result of three deaths — rather a large proportion— the ab-
dominal having proved more dangerous than the vaginal section.
Dr. Sims sums up his opinion upon the operation as follows :
1. Remove both ovaries in every case.
2. As a rule, operate by abdominal section, because if the ovaries
are bound down by adhesions, it is possible to remove them entire,
whereas by the vaginal incision it is impossible.
3. If we are sure that there has been no pelvic inflammation,
no cellulitis, no hsematocele, no adhesions of the ovaries to the
neighboring parts, then the operation may be made by the vagina,
but not otherwise.
The vaginal operation is performed wdth the patient lying on
the left side. A Sims's speculum is introduced, the cervix drawn
down by a strong tenaculum, and Douglas's cul-de-sac opened by
knife or scissors. The finger is then passed into the aperture to
feel for the ovary, which is then seized by forceps or tenaculum,
and drawn out into the vagina. It may be removed by means of
the ecraseur, or the application of a silk ligature, and then cut oft",
the stump being returned into the cavity, the opening being left to
close gradually so as to admit of drainage. The presence of the
stump, and rapid adhesions, prevent any prolapse of the intestines
into the vagina.
The abdominal operation is performed in a similar manner to
ordinary cases of ovariotomy, only on a smaller scale.
Dr. Battey himself, in a recent paper, thus points out the field
for the application of the operation. The operation should never
be one of election; it is applicable only to a certain class of cases
— cases in the first place incurable by any other means; in the
second place, cases menacing life; and in the third place cases
from which w^e may reasonably expect to relieve the patients of
the direful consequences of their disease by a change of life.
Three questions must be properly answered before deciding to
18
274 DISEASES OF THE OVARIES.
perform the operation. Is it a mortal case? Is it incurable by
other known resources of the art? Is it curable by a change of life ?
The first class of cases in which the operation is advised is where
there is an absence of the uterus, with more or less irregular ovu-
lation, and a violent nervousness of the system.
The second class of cases is where there is a complete occlusion
of the whole utero-vaginal canal, attended with \dolent nervous or
vascular perturbations.
A third class consists of cases of menstrual mania, or ovarian
mania, where reason becomes dethroned in consequence of violent
perturbations attendant upon the stoppage of the menstruation.
A fourth class of cases is where ovarian epilepsy is found.
In another class, there is a pernicious amenorrhoea that is utterly
destroying the life of the patient.
Interstitial fibroid tumors, not amenable to any of the ordinary
resources of art, afford another justification for operating in cer-
tain cases.
In cases of contracted pelvis, where abdominal section is re-
quired, he thinks it natural and proper to ligate and remove the
ovaries. The operation offers great hope to a large number of
women who suffer from ovarian disorders, attended with nervous
manifestations of the most distressing character.
OVARIAN TUMORS. 275
CHAPTER XIX.
OVARIAN TUMORS.
1. Adenoid
id: <
Ovarian Tumors. — These may be divided into the Solid and the
Cystic.
The Solid are mainly represented by Fibroma and Carcinoma.
Tid)ercle and Enchondroma are exceedingly rare.
Spencer Wells reduces tumors of the ovary to three classes :
1. The adenoid tumors, comyposed of gland-structure in variously
altered conditions.
2. Tumors of a fibrous character, the result of growth from the
connective tissue of the organ.
3. Those tumors which assume a malignant form, and are essen-
tially degenerations or new formations.
f a. Simple cysts — enlarged Graafian follicles.
h. Multiple cysts — cysts in apposition becoming
multilocular.
e. Proliferous cysts — parent cysts with secondary
cysts growing from the interior of cyst wall.
2. Fibrous — growth of stroma of ovary.
3, Malignant — cancer; tubercle.
Cystomata, or Cystic Tumors of the Ovary. — These may be divided
into the Simple Unilocular, or barren cyst, containing fluid or un-
'organized matter; the Multiple or Multilocular, a variety of the
â– ^i former; the Compound, or Proliferous; and Dermoid Cysts. Peas-
lee adopts the term Oligo- Cystic (oX/yo^:, few, and xuavig, a cyst)
Cystoma, as more distinctive than monocystic, and considers the
latter as an accidental modification of the former ; the occurrence
of a tumor originally monocystic being extremely rare, and inca-
pable of demonstration. Paucilocular has also been employed to
liesignate the same condition.
Cystomata constitute by far the most frequent and important
t^ariety of ovarian tumor, and hence cannot but prove of much
nterest to the practitioner, since the advances of modern antiseptic
>urgery have enabled us to deal with them in a more satisfactory
nanner than was formerly the case.
Simple Ovarian Tumors. — The simple or unilocular ovarian cysts
ire organized sacs, containing fluid, which grow from some part
)f the ovary itself. They commence their growth as small vesi-
cles, but no limit can be mentioned as to their ultimate size, except
hat of the containing power of the abdomen, and the extent to
vhich the abdominal walls may be distended. The walls of even
hese enormous sacs are, after all, in their simple forms, only the
continued growths of some of the original ovarian tissues, ^o
276 OVARIAN TUMORS.
new elements are superadded. There is only a surplus of ma-
terial, malarranged and out of place. At first, the cysts are seen
projecting from the surface of the ovary, the remainder being im-
bedded in its stroma or enveloped by its fibrous tunic. The coats
are then thin, membranous, and translucent, and not in any way
to be distinguished from the natural structure of a Graafian folli-
cle. With growth comes greater thickness, opacity, and firmness.
There is no uniformity of thickness, which in different cases, or
even in the same tumor, may vary from an inch to the extreme
bursting point of tenuity. The histological elements of this coat
are identical with those of ordinary fibrous tissue, consisting of
fibres very difiicult to disentangle, nucleated fibre-cells, and
granules.
The vessels supplying the tumor enter at its base, enlarge with
its growth, and ramify very freely on its inner surface. They form
a complete network in and under the peritoneum ; and the capil-
laries passing into the fibrous layer traverse it, and have a peculiar
arrangement on the inside, where they form knots of anastamosis,
with bulbous dilatations and terminal pouches, like, but less regu-
lar than, those found in the chorion. Outside, under the peritoneal
covering, numerous large and tortuous veins may be traced plainly.
Kerves pass with the vessels into the substance of the coats, and
lymphatics, often of large size.
The simple ovarian cysts generally originate in a Graafian folli-
cle, either before or after its rupture. When small they have a
similar structure — a fibrous coat derived from the stroma of the
ovary ; an inner coat, lined by epithelium, corresponding to the
tunica propria of the follicle. They contain a clear fluid, and the
ovum has in some instances been found in such cysts ; the conditior
is evidently due to hypersecretion of the fluid of the follicle. Ir |
many cases the follicles are so deeply seated in the structure of the \
ovary, that though the ovum is fully formed and ready for impreg
nation, there is no possibility of its escape by rupture ; and its un
wonted presence in such a position may give rise to morbid action
or there may be thickening and induration of the coats of the folli
cle in consequence of inflammation preventing the escape of th(
ovule. The fact that dysmenorrhoea is a frequent antecedent o
ovarian dropsy tends to corroborate the opinion that some obstruc
tion to the due maturation and escape of ova is one cause of th(
production of ovarian tumors.
The comparatively great frequency of these follicular dropsies ii
women who have long suffered from chlorosis or other disease:
combined with amenorrhoea may be explained by the fact that th»
menstrual congestions in the ovaries not attaining sufficient inten
sity to effect the bursting of the follicular wall, the result is an in
crease of secretion and its accumulation in the cavity.
Multiple cysts are formed by two or more Graafian follicles ii
the same ovary undergoing cystic transformation simultaneously
Failing in the evolution of an ovum they abort, grow side by side
fill with fluid, become an enormous assemblage of similar unite
PROLIFEROUS CYSTS. 277
disfiguring and stimulating each other by pressure and reflex
action, forming preternatural adhesions within and without, and at
length, by their very excess of development, inducing in their com-
ponent tissues the inevitable process of involution, and in the
organized being to which they belong, a lingering decay and death.
In this is recognizable an adenoid tumor of the true type and ten-
dency, aggressive and destructive, though not essentially malignant.
Gaining a certain size, however, it generally happens that one out
of the many dropsical follicles takes the lead of the rest. Annihi-
lating some of its neighbors, it dwarfs others, lessens their vitality,
vitiates their contents, and fills more rapidly thali they. And this
struggle for existence seldom goes on long without destroying their
integrity. Pressure and expansion cause obstruction to the circu-
lation in the cell walls ; atrophy and absorption are the natural
consequences, and the boundaries being wholly or partially gone,
or represented only by bands or bridges of membrane, the adjacent
cells communicate, and the tumor assumes what is called the nmlti-
(locular form.
This process of excavation may even go further, until all the
)f cavities become continuous, or, with a total clearance of every par-
rtition, the cyst remains only one-chambered. It is but rarely, how-
' ever, that we find a true ovarian cyst to be unilocular; more usually
nit is, what has been termed, paucilocular, if it be not multilocular.
These transformations are found taking place in some instances
i^at an early period in some small tumors, while others of larger size
i preserve their multiple vesicular character intact. The nature of
•the, contents of the several loculi varies almost indefinitely. Liquid-
ity, consistence, color, and chemical composition may be different
throughout. One cell may contain nearly solid matter, the next a
limpid fluid ; in one may be pus, in another serum, without any
trace of cell formation. There is union in the mass, but no uni-
J formity of action in the parts ; and the growth having overstepped
the bounds of healthy influences, comes to ultimate destruction by
the irregular play of a series of morbid changes.
Although multiple in number they are nothing but agglomera-
|itions of simple cysts, and do not, collectively any more than singly,
I possess the distinctive property of the compound or proliferous
fcyst — that of self-multiplication by endogenous gemmation.
There are often discovered, in examinations of the ovary, cysts
which bear no relation to Graafian follicles or corpora lutea, but
which seem to have originated in the deep areolar tissue, or among
the vessels of the gland. They may have commenced as tiny
deposits of fluid in some one of the areolar spaces, about which
condensation of the surrounding tissue would soon take place, with
the speedy production of a limiting capsular membrane, channelled
out with capillary vessels ; or it is allowable to retreat a step fur-
ther for explanation, and fall back upon the easily roused innate
power of evolution of the plastic nuclei and cells of the tissue.
Proliferous Cysts. — Compound, composite, complex cysts, cystoma,
cystoid or adenoid tumors, have a very different structure.
278 OVARIAN TUMORS.
An ovarian adenoid proliferous tumor is a parent cyst filled with
its progeny of endogenous cysts, or surrounded by others of exog-
enous growth. It may have the same origin as other cysts, and
its early condition w^ould be that of a common unilocular cyst. In
fact, any epithelial cysts may become proliferous, and they are
found in all parts of the body. But wherever they are they have,
when filled up, the same complex appearance to a casual observer,
and seem equally to defy description or comprehension.
When cut open, the interior is seen to be choked up with other
cysts, growing from all sides, crowding and pressing each other out
of shape. From the outside of these secondary cysts others grow,
and the same outgrowth may be again repeated upon them. So,
too, if these inner cysts are opened, another endogenous series may
be disclosed within, and the budding does not necessarily stop
there. Want of space and failing vitality only, either in the patient
or the part, put an end to the process.
But proliferous cysts have degrees of fertility. Some breed to
suicidal repletion ; others fill with fluid and nourish a few clusters,
or only a single symmetrical cluster, of secondary cells, Avhich have
room enough and to spare, and hang pendant in the cavity. Xow
and then only one solitary bud indicates the self-multiplying ten-
dency of the parent cyst.
Their mode of development varies. The Graafian follicle is a
proliferous cell, lined mth epithelium. If injured or tainted by
some morbific influence, the ovum is blasted ; the vesicle then takes
on a cystic form and enlarges.
Dr. Fox has shown that the first and most frequent manner in
which secondary cysts are formed is the result of the production of
a series of glandular structures, presenting a tubular type, on the
inner wall of the parent cyst. Masses of glands thus imbedded
are dilated into cysts by their own secretion, and form the small
semi-solid masses which project into the interior of the parent cysts,
and in them similar processes may be repeated indefinitely, An-
other process of secondary cyst formation is of a somewhat diff*erent
character. The cysts in these cases give off diverticula, which ex-
pand at once into cysts which project into the interior of similar
adjacent formations ; or long tubular follicles are given oflT from the
diverticula, portions of w^hich become, by a series of successive con-
strictions, converted into cysts. The third class of cases are those
where cysts are found associated with cauliflower grow^ths, spring-
ing from the interior of the parent cysts.
Ovarian cysts are attached to the uterus by a pedicle formed oi
the broad ligament, Fallopian tube, ovarian ligament and vessels,
w^hich latter are sometimes very large. There are also lymphatics
running into the cysts, as well as nerves. The pedicle varies in
length and consistence, being sometimes long and slender, at others
short and broad; sometimes it is tough and dense, in other in-
stances being so fragile as hardly to admit of being secured by a
ligature.
The Fallopian tube is often much elongated, the broad ligamenii
CONTENTS OF CYSTS. 279
often cohsiderably thickened, the utero-ovarian ligament occasion-
ally hypertrophied into a large fibroid stem. The utero-ovarian
ligament and the Fallopian tube are not invariably connected by
the broad ligament ; a considerable space may intervene between
them, so that they appear as two pedicles to one tumor.
Ovarian cysts are covered by peritoneum. In the larger cysts the
walls can be separated into two layers : the external consisting of
tough fibrous tissue, with very few cells ; the internal layer is softer,
more fleshy-looking, and vascular, is composed of fine fibres, with
an abundance of cells. The walls are highly vascular ; the epithe-
lial lining varies in character, from flattened polygonal cells to
cylindrical cells.
When the fibrous inter-cystic structure grows rapidly, the thick-
ness of the cyst wall being disproportionate to the contained fluid,
the tumor is spoken of as being a cysto-sarcoma of the ovary. The
more active the tendency to proliferation, especially if it present
the character of round-cell sarcoma, and the further the departure
from simplicity of organization, the greater the tendency towards
malignancy.
When this form occurs it frequently affects both ovaries at the
same time ; and when adhesions take place with neighboring vis-
cera, these tissues are apt to become involved. There is also a
tendency for this form of gro\\i;h to recur in the pedicle, or by me-
tastatic deposits, when the tumor has been removed by operation.
From the isolated position of these tumors they can be removed
without fear of recurrence if the operation be performed early
enough, before adhesions have taken place.
The Contents. — In the simple unilocular cysts the fluid is gen-
erally perfectly clear, hyaline, colorless, pale yellow or straw-col-
ored, thin and limpid, varying in specific gravity from 1007 to 1015,
and in quantity from a few ounces to several pounds ; as much as
160 lbs. having been drawn off from one cyst.
In the multilocular, and especiall}^ in the proliferous cysts, the
contents are more viscid and gelatinous, often resembling a firm
jelly or colloid material, which will not flow through even a large
canula, or may even be semi-solid, almost friable and crumbling
colloid.
The contents of the different cysts forming the same tumor may
vary immensely in character.
Even in the perfectly clear fluid of simple cysts there may be
considerable quantities of cholesterin crystals, which, after stand-
ing, form a glittering pellicle on the surface. Scales of epithelium
are almost always found floating in these fluids. The color of the
fluid varies from that of clear water to a turbid yellow-green,
brown-red, or chocolate color, depending upon the admixture of
blood or pus, which may be recent and pure, or old and under-
going changes.
As a rule, after tapping the fresh accumulation of fluid is thicker,
more viscid, and of a darker color.
Chemically the contents have been divided into two classes — the
280 OVARIAN TUMORS.
mucous and the albuminous (Eichwald). The mucous series con-
sists of the material of colloid globules, mucin, colloid material,
and mucous peptone. The albumen series consists of albumen
(and fibrin), paralbumen, metalbumen, albumen peptone (fibrin
peptone). The mucous series are soluble in mineral acids, never
precipitated from their acid solutions by ferrocyande of potassium,
not usually precipitated by tannin, or by neutral metal salts, but
are completely thrown down by basic lead salts. The albumen
series are distinguished from the mucin series generally by their
being precipitated from their solutions by tannin and neutral metal
salts. The first three contain sulphur.
The solids usually found on microscopic examination are gran-
ules, globules of fat, granular cells, epithelial cells, crystals of cho-
lesterin, blood corpuscles, and disintegrated blood, pus cells and
compound granular cells, or inflammatory globules of Gluge.
Some of these are present in the contents of every ovarian cyst,
but it is rarely that all are found together in one specimen. Of
these bodies the most important is the granular cell, and it is
almost invariably present.
Cutaneous Piliferous, or Dermoid Cysts of the Ovary constitute a
distinct class, though they may be found in combination with serous
or colloid cysts, these latter being dependent upon the irritation
produced by the former. They are frequently developed before
puberty, and by many regarded as always congenital.
Pathology. — The cyst wall consists of two distinct layers, the inner
one resembling skin in structure, being either smooth or uneven
from circular elevations. The lining membrane is composed of
thick layers of pavement-epithelium, the innermost of which are
flattened and non-nucleated, while the deeper are round or polyg-
onal in shape. Under this is a layer corresponding to the cutis,
frequently having papillae, though not arranged in parallel rows or
regular groups. IN'ext to this is a mass of looser areolar and adi-
pose tissue, containing the usual tegumentary appendages, seba-
ceous and often sweat-glands, and hair follicles. In the areolar
tissue beneath the skin formation, laminae or spiculae of bone are
found, assuming when larger the most extraordinary irregular
shapes, often occurring as lumps of dense compact substance hav-
ing the true structure of bone, the Haversian canals and bone cells
being arranged in lamellae, though the canaliculi are less numerous.
Occasionally these bony masses resemble distinct foetal bones.
Teeth, in some instances perfectly formed, but more generally
rudimentary, are generally present. They arise either from bone,
which in some instances resembles perfectly-formed alveoli, or from
the stroma of the cyst wall.
The contents of dermoid cysts are generally of a greasy, pulta-
ceous nature, consisting of free fat, cast-oft' epithelial cells, and
cholesterin crystals, which often give it a glistening appearance.
Mixed with this we have tufts of hair, often collected in balls, and
teeth, varying in number from a few to as many as three hundred.
Brain substance, nerves, muscular fibres, and bone have also been
ORIGIN OF CYSTS. 281
found. The cyst is usually single, at other times it seems to be
divided into compartments by the growth of septa from its walls.
The external covering is fibrous in structure.
Causation. — Various hypotheses have from time to time been
started to explain the origin of these cysts. It was thought they
might be the result of the imperfect development of an ovum, tak-
ing place either spontaneously or in consequence of impregnation,
but they have a character quite distinct from that of extra-uterine
foetations, and form independently of spermatic influence, being
found in young children, and even before birth, so that anatomists
now generally agree that they are quite independent of conception.
Another explanation suggested was that they arose from the early
inclusion of an ovum which is imperfectly developed within an-
other ovum which attains perfection. But the constant situation
of these cysts in the ovary goes far to disprove this theory ; such
an ovum would be attached to some more external part.
The evidence against all theories which refer the origin to the
development of an ovum under any circumstances is overwhelming.
They have been found in other organs than those of generation, as
the lungs, thyroid glands, kidneys, etc., and also occur in the pro-
portion of about two-fifths in the male, the majority of these being
in the testicle.
The view of the origin of these cysts now generally received is,
that they are congenital, and due to a displacement of the external
layer of the blastoderm. From this layer the epidermis and other
structures are developed, and it is supposed that a portion of it be-
comes included in the part of the middle layer from which the
ovary is formed, and forms the rudiments of cysts of a dermoid
character (Williams).
Symptoms. — These differ in several respects from those met with
in the case of ovarian cystomata. In the majority of cases probably
the tumor commences in very early life, while formative energy is
specially active, taking on a more active growth when the ovary
becomes developed about puberty, their presence being then de-
clared. Their rate of growth is slow, and they seldom attain a
larger size than that of the adult head. They are hard and gener-
ally globular. There is generally only one tumor of one ovary.
Fluctuation is generally indistinct, unless suppuration occur, or the
accumulation of fat becomes excessive. They are very liable to
undergo inflammation and suppuration from the pressure of the
gravid uterus during pregnancy and parturition. They are apt to
contract adhesions with the viscera among which they are imbedded,
with the bladder or intestine, or even with the abdominal wall.
Fistulous communications then occur, and the contents of the cyst
become discharged, but seldom so perfectly as to ensure a cure.
The tumor does not appreciably diminish in size, suppuration goes
on, the signs of hectic or irritative fever set in, emaciation with
exhaustion, and death ensuing, if means be not taken to obviate
this termination. The cyst rarely ruptures into the peritoneal
ca\'itv.
282 OVARIAN TUMORS.
Diagnosis. — Where a moderate-sized, slow-growing, semi-solid
tumor is discovered about the age of puberty, that presents no evi-
dence of fluctuation, but often of hard bony plates on the cyst wall,
our suspicions as to the character of the tumor may well be excited.
Care will, however, be requisite not to mistake an extra-uterine ges-
tation cyst for a dermoid cyst. The frequency with which adhe-
sions occur to surrounding organs in these latter, and the presence
of bony plates, may mislead even the most wary. The history of
possible pregnancy, and a careful consideration of all the sj-mptoms,
will alone enable us to distinguish them. Even when rupture of
the cyst externally into the bladder or rectum has taken place, we
may still be lead into error in imagining that we have an extra-
uterine gestation to deal with. The escape of fatty matters, hair,
teeth, or portions of bone, should at once enable us to clear up the
diagnosis.
Treatment. — Should inflammation, or rapid enlargement of the
tumor ensue, removal by ovariotomy should be advised before sup-
puration has taken place, or the risk of rupture of the cyst has been
incurred.
If evident pointing of the tumor towards the surface be detected,
the skin becoming inflamed and tender, it will be well to make a
small incision by means of a bistoury, and then carefully explore
the cavity by the sound, finger, and hook, when if fat, hair, teeth,
or bone be detected, the opening may be enlarged by means of a
crucial incision, and the evacuation of the contents thus facilitated.
The cavity of the cyst may then be washed out with some antisep-
tic fluid, a solution of iodine, Condy, or carbolic acid. If thought
desirable, eflforts may be made with a view to obtaining contraction
of the c\'st by lightly cauterizing the interior with the galvanic cau-
tery, to modify its character, as suggested by Dr. Barnes.
Extirpation of the cyst may be attempted if the adhesions are not
too extensive, but should these preclude removal, a counter-opening
through the roof of the vagina may be made by the thermo-cautery,
the contents of the cyst as far as practicable removed, and a drain-
age tube inserted, the cavity being washed out regularly with some
antiseptic fluid.
Where the dermoid cyst is of moderate size, and wedged down
in the pehds by adhesions, an exploratory puncture with the aspira-
tor trocar may be made, and the opening subsequently enlarged.
Fibroid Tumor of the Ovary. Fibro-myoma ; Fibroma. — This is ex-
ceedingly rare. Tumors beginning in the uterus, overgrowing and
involving the ovary so as to disguise its natural appearance or con-
ceal it altogether, have not infrequently been mistaken, even after
removal, for tumors of the ovary. Fibroid tumors consist chiefly
of fibroid tissue, and appear to be due to hypertrophy of the stroma
of the ovary. Muscular fibre-cells have also been discovered in
them, but in small quantities only. Some of these growths, how-
ever, are not due to simple hypertrophy of the ovary, but are dis-
tinct nodules growing in the substance of the organ. Several such
nodules may be agglomerated together and form one tumor. They
FIBROID TUMOR OF THE OVARY. 283
vary in density, some having a hard, uniformly dense structure,
Others containing smaller or larger loculi or cysts, while a third
class possesses a loose vascular texture, and present a cancerous
appearance (Williams).
True fibroid tumors of the ovary seldom attain a large size,
rarely larger than a child's head. Although fibro-cystic ovarian
tumors may attain an immense size, and there seems little doubt
that much confusion has arisen between these separate forms, Dr.
Barnes observes that in most of the presumed fibrous tumors the
cystic cavities have been the most noticeable features. The cysts
may be more or less obliterated by the hyperplastic condition of
their walls.
These overgrown partitions are made up of a fibrous vascular
mass, not in any way distinguishable from that usually seen in cyst
walls. This kind of fibro-cystic tumor grows very rapidly, and
has a strong hsemorrhagic disposition, causing in some cases effusion
of blood into the cyst cavity. It appears then to be highly prob-
able that most of the apparent fibrous tumors of the ovary differ
from undoubted cystic tumors chiefly in the greater relative pro-
portion of the fibrous walls and the lesser development of the cysts.
Like fibroid tumors of the uterus they occasionally undergo a pro-
cess of calcification. Far more serious changes, however, occur,
for occasionally they become gangrenous, or break down and sup-
purate, forming fistulous communications w^ith the vagina or else-
where.
The pedicle may become twisted, thus producing congestion and
softening of the tumor, leading to gangrene, or it may be so bruised
and injured during parturition as to lead to suppuration or gangrene.
Diagnosis: — There is nothing very characteristic in the s^^mptoms
during the development of these growths. It is extremely difficult,
if not impossible, to distinguish them from pedunculated fibroid
tumor of the uterus. Their mobility or fixity may guide us slightly,
but where, as not infrequently happens, they are impacted in the
pelvis, even this fails us, and at best our diagnosis is purely con-
jectural. From cystic tumors they may be distinguished generally
by their hardness and absence of fluctuation ; from cancer by their
slow growth, and more or less smooth surface.
Prognosis. — As a rule, fibroid tumors of the ovary grow slowly,
and cause but little inconvenience, as they seldom attain to any
very large size. They may, however, become impacted in the
pelvis, thus obstructing the bladder and rectum, or interfere ma-
terially with parturition.
Treatment. — This will generally consist in relieving symptoms.
Should the tumor become impacted in the pelvis, and cause ob-
struction, our first eftbrts should be directed to dislodging the
tumor. The patient should be placed in the genu-pectoral posi-
tion, and digital pressure made either per rectum or jper vaginam, as
in cases of impaction of the retroflxed gravid uterus.
Should these means fail in relieving the obstruction, the question
of extirpation will present itself.
284 OVARIAN TUMORS.
The operation of gastrotomy will generally be preferable to any
attempts at removing the tumor by the vagina or rectum.
Where the tumor attains a considerable size, and interferes with
the comfort or health of the patient by producing much pain or
distress, its removal by gastrotomy will be advisable.
Cancer of the Ovary. — Carcinoma may occur, as in other organs
of the body, either as a primary or secondary affection. N'ext to
cystic disease, cancer is the most frequent disease of the ovary. It
is frequently consecutive upon disease of the uterus and the pel-
vic and abdominal glands. Every kind of cancer infesting other
organs is in turn reproduced in the ovary. The peculiarity of its
tissues, and the arrangement of its component parts, perhaps in
some respects facilitate the development of the disease. The fibrous
stroma, the dense investment, the abundant groups of innocent re-
productive vesicles, and the ever-growing intra-follicular epithe-
lium, seem respectively typically to prefigure the forms of scir-
rhous, colloid, papillary, and medullary cancer (Wells).
The encephaloid form is one of the most frequent varieties. It
may attain considerable size, forming a globular mass, w^ith sphe-
roidal knobby projections, difiiuent in parts. In some cases it ap-
pears to have sprung up on the internal membrance of the Graafian
vesicle, preserving an areolar or alveolar aspect, the centre being
filled with blood, the result of internal haemorrhage.
Scirrhom degeneration may be either primary or secondary. It
is less commonly met with than the other varieties, occurs usually
after middle life, and may create a tumor of large dimensions. It
develops slowly, and presents the same physical appearance as
noticed in other organs similarly affected. The ovary seems occu-
pied by a nodulated mass of uniformly hard, heavy, white, and
fibrous tissue; its toughness exceeds even that of the firmest
fibrous tumor.
Melanosis almost always attacks the ovary secondarily.
Medullary carcinoma occurs, especially in young persons, as a
primitive disease, and is also associated w^ith cancer of the other
organs as a part of a general w4de-spread cancer formation. It
may originate in the Graafian vesicles, in a corpus luteum, or in
the stroma of the organ.
It is often symmetrical in size, and forms a distinct mass as large
as a child's head. In some places it resembles in its firmness and
the preponderance of its framework, the fibrous cancer ; in others
it is soft, very juicy, fluctuating, encephaloid. The tumor is some-
times free, but mostly united to surrounding structures by adhesion.
Medullary cancer may affect the cyst w^alls in the form of villous
cancer, so completely invading the cyst w^alls in some cases as to
make it appear that cystic degeneration had occurred secondarily
to its deposit. The gelatinous cancer thus appears in the cystoid
growths. Flat, rounded medullary knots, or villous cauliflower-
like excrescences, appear on the inside of the cysts, growing until
they fill the cavity. Distention sometimes causes rupture of the
tunica albuginea of the ovary, and then exuberant medullary
COLLOID CANCER. 285
growth develops in contact with the peritoneum and abdominal
viscera, the whole cystoid formation becoming fixed in all direc-
tions, producing either a dangerous peritonitis or abundant ab-
dominal dropsy. This cysto-carcinoma also often occurs symmet-
rically in both ovaries, more commonly so in the more mature
periods of life. With this form of cancer colloid degeneration is
often associated, when it constitutes that variety called alveolar
cancer.
The frequent transition from the cystic tumor to colloid cancer
suggests the suspicion that some forms at least, especially the pro-
liferous, partake of the cancerous character. The history of patho-
logical processes does not lend much confirmation to the hypothe-
sis of the ready convertibility of one form of morbid product into
another. So far then as analogical reasoning may be trusted, that
which in its advanced stages is obviously cancer in the ovaries, is,
as elsewhere, cancer ab initio. The strong innate disposition of the
ovary to develop cystic formations may determine the frequent
assumption by the original cancerous element of the cystic or
alveolar form (Barnes).
Colloid cancer grows rapidly and to a large size, but does not
quickly tend to destroy life by contaminating the system. It is a
sort of intermediate form of disease, having intimate alliances and
resemblances on the one hand with the innocent single cysts, and
on the other often being intermingled and confused with the most
rapidly spreading and malignant cancer growths.
In structure they consist of countless alveoli, often involving the
whole ovarian structure, and acquiring a bulk equal to that of any
of the cystic tumors, and filling up the pelvis and abdomen.
The contents are a tenacious viscid matter, varying in consist-
ency from set-jelly solidity to a ropy, glairy stuff which may be
drawn out into strings. It is seldom clear, often brown or yellow-
ish, having mixed with it flocculent, whitish, creamy substance,
and many epithelial cells, oil drops, and granular matter.
Diagnosis. — The symptoms pointing to the malignant character
of an ovarian tumor have been summed up as follows by Thomas:
1. Rapid development of a solid tumor in an ovary.
2. Marked depreciation of the strength, vital forces, spirits, and
general condition of the patient.
3. The occurrence of cedema pedum and spansemia with a small
tumor, which are consequently dependent upon a general blood-
state, and not the results of pressure by the tumor.
4. Lancinating and burning pains through the tumor.
5. Cachectic appearance.
6. The occurrence of ascites without evidence of cirrhosis or
other hepatic disease, organic disease of the kidneys or heart, or
chronic peritonitis.
Treatment. — That cancer of the ovary preserves for a compara-
tively lengthened time its exclusive habitat in the ovary, before
spreading to other parts, may be explained by the comparatively
isolated terminal position of the ovary. As soon, therefore, as the
286 OVARIAN TUMORS.
least suspicion of the nature of the tumor occurs, before it has be-
come adherent, ovariotomy should be performed and the tumor
removed.
Where patients do not present themselves sufficiently early in
the progress of the case to allow of the removal of the tumor, ad-
hesions being e\ddently so extensive, or the constitutional cachexia
so marked, we can but treat symptoms, allaying pain by opium,
relieving the ascitic distention by tapping with a very fine trocar
and drawing off some of the fluid gradually, and promoting in
every way euthanasia.
Tubercle of the ovary is exceedingly rare, except in association
with tubercle elsewhere. Even when it occurs secondarily it is
not generally until the whole system has become so infected that
the idea of directing any special treatment to the ovary is out of
the question.
Enchondromatous tumors of the ovary have been observed by
Kiwisch in two cases, but are so extremely rare that it will be un-
necessary to more than mention the possibility of their existence.
Extra-Ovarian Tumors,
It will be well to mention these in conjunction with ovarian
cysts in order to facilitate diagnosis. They include :
Cysts of the Fallopian tube and terminal vesicle.
Cysts of the broad ligament, or vesicles of Wolffian body, and
those developed from tubules of the parovarium.
Cysts developed from aberrant ova attached to the peritoneal
surface.
Cysts of the Fallopian Tubes. Hydrosalpinx, or Fallopian Eroj^fsy.
— Distention of the tubes with fluid is occasionally met with in
old people, both tubes being generally symmetrically affected.
There is usually some preceding inflammation causing closure of
both extremities of the tube ; saccular dilatation then occurs from
accumulation of secretion, and the outlets being closed, sacs of
considerable size may form.
The cyst is not necessarily single, but may be subdivided by
tight fibrinous bands, the product of peritonitis, encircling and
constricting the tube at various points, throwing it into convolu-
tions more or less tortuous in character. They seldom attain a
size larger than the foetal head, though instances have been re-
corded of their growing to a much larger size, even having attained
a capacity of eighteen pounds. The mucous membrane is changed
in appearance, becoming smooth, or roughened by papillary vege-
tations from the submucous connective tissue.
The contents vary, being mucous, watery, purulent, or san-
guineous.
Tubo-Ovarian Cysts are those whose walls are formed jointly by
the tube and the ovarian stroma, the distended end of the Fallopian
tube connected with and opening into a cavity within the ovary.
The ovarian portion of the cyst walls possesses either reticulated
PAROVARIAN CYSTS. 287
or smooth, yellow, yellowish-red, or russet-colored lining-mem-
brane, which does not continue into the tubal part of the cyst. It
is seldom that the whole of the tube is involved, more generally
the distal third is dilated, the junction of the tubal end with the
rest of the cyst being marked by a slight constriction, or this may
even be indistinct. These cysts occasionally pour their contents
into the uterus along the Fallopian tubes, and then collapse. The
fluid draining off through the cervix uteri and vagina has not in-
frequently been mistaken for urine, the patient being supposed to
have had an ovarian tumor, which has either burst into the peri-
toneal cavity, the fluid being drained off by the kidneys, or has
established a communication directly with the bladder, allowing
the fluid from the cyst to pass off jper urethram. The formation of
these cysts is presumed to be as follows. The fimbriated extremity
of the Fallopian tube grasping the ovary at the time of rupture of
a Graafian follicle, in place of retracting, remains adherent to the
ovary. Excessive secretion of fluid follows, and a cyst is formed.
Cysts of the Broad Ligaments are commonly either cysts arising
from dilatation of the terminal bulb, or vesicles of the tube, or re-
mains of the Wolfiian body. They rarely exceed in size that of a
pea or nut, though occasionally they become as large as an Qgg.
They usually have very thin walls, are covered by peritoneum,
hang by a long slender pedicle, and contain clear watery fluid.
They often burst and the contents escape into the cavity of the
peritoneum, but the small quantity and innocent nature of the fluid
' causes little or no irritation, and seldom gives rise to any trouble.
They are more often discovered post-mortem, and of more interest
. pathologically than clinically.
Parovarian Cysts constitute a more important class of cysts of
; the broad ligament. They are formed by distention of one of the
tubules of the parovarium, or organ of fiosenmiiller, a small body
which is the relic of the ducts of the Wolfiian body, situated be-
' tween the folds of the broad ligament, between the outer extremity
of the ovary and the Fallopian tube.
They usually occur in young women, are of slow growth, seldom
f attain any considerable size, although cases have been met with
where the cyst was so large as to distend the abdomen. They
cause comparatively little constitutional disturbance.
The cyst is almost invariably unilocular, though occasionally
more than one tubule becomes dilated. The walls are usually
very thin, so that fluctuation is generally very distinct and equal
in all directions.
In some cases they are pedunculated, but are more likely to ex-
tend deeply between the layers of the broad ligament than in the
case of true ovarian tumors.
The ovary is generally found separate and distinct from the cyst,
the mes-ovarium being intact. The Fallopian tube is more likely to
be flattened out over the cyst than in the case of a true ovarian cyst,
and may even extend over the greater part of the circumference.
The cyst is lined internally by pale cylindrical nucleated epithe-
288 OVARIAN TUMORS.
Hum, corresponding with that found naturally in the tubules. The
fluid contained in the cyst is limpid like water, generally of very
low specific gravity, seldom above 1005, and contains only a trace
of albumen, which is not, as a rule, precipitable by heat alone, but
only by nitric acid.
These cysts are strictly simple and innocent in their nature, and
are not likely to refill, should they be tapped, or from any acci-
dental cause burst; hence a single tapping may be suflicient to
cure the patient without exposing her to the risks of an operation
for extirpation.
Where a cyst of small size, with apparently a very thin wall, oc-
cupies Douglas's pouch, puncture with the aspirator trocar through
the vaginal roof should be resorted to.
Cysts from Development of Wandering Ova. — Instances have been
recorded of simple cysts, perfectly unconnected with the ovary or
its appendages, being found attached to the peritoneum. The sup-
position is that they were originally unimpregnated ova, which, on
the bursting of the follicle, failed to reach the Fallopian tube, and
falling into the peritoneal cavity, attached themselves to the peri-
toneum in a similar manner to that of the impregnated ovum in
abdominal pregnancy. These aberrant ova undergo changes, ac-
quire vascularity, and the nutritive energy being concentrated on
the formation of tissue sufticient for cell walls and the exudation
of fluid, the cyst may go on developing even to a considerable size.
Another form of extra-ovarian simple cyst has been described
by Huguier under the title of " Serous Cysts on the Exterior of
the Uterus." The seat of their development appears to be the
tissue connecting the peritoneum to the uterus, and for the most
part they are found on the back of that organ. They sometimes
grow as large as an orange, but are commonly of insignificant size.ri
The attachment to the uterus is broad compared with the bulk,
but in some cases the cyst elongating acquires a distinct pedicle, ;
and being fi-eely mobile may easily be mistaken for a similar cyst
arising from the broad ligament or ovary.
OVARIAN TUMORS. 289
CHAPTEK XX.
OVARIAN TUMORS, Continued; including the diagnosis of.
ABDOMINAL TUMORS.
We may now consider the causation, symptoms, course, and
^termination, diagnosis and treatment, of cystomata or cystic tumors
of the ovary.
Causation. — As it is not until the tumor has attained some size
tthat we are conscious of its existence, and cannot then determine
â– how long it has been growing, it is almost impossible to say what
has been the exciting cause. Observation proves that small cysts
arising from the ovaries are by no means uncommon even in the
J foetal state, some authors asserting even that all cystomata have a
s congenital origin, and may remain in a more or less latent or pas-
sive condition until roused into active growth at puberty, or later,
when the natural functional activity of the ovary comes into play.
. Although the operation of ovariotomy for the removal of ovarian
j tumors has now been successfully performed in several thousands
i'of cases, nothing positively certain or definite has been made out
tas to the probable cause of their occurrence. It has been thought
• that an insufficient menstrual hypersemia of the ovary, as witnessed
iin cases of chlorosis and other forms of anaemia, may fail in pro-
'ducing rupture of the follicle : when in place of becoming atrophied,
tit undergoes cystic degeneration.
' Again, any influences which keep up and intensify ovarian con-
gestion, leading to fibrous h^q^erplasia of the ovary, or thickening
^^f the capsule from ovaritis or pelvic peritonitis, may prevent the
hie maturation or rupture of the Graafian follicles, which then
mdergo cystic degeneration.
In some instances it seems probable that the development of the
bllicles too far from the surface to allow of their reaching it, may
oe the exciting cause of subsequent morbid action. Equally the
premature death of the ovum may prevent maturation of the fol-
icle, which, however, undergoes other changes, and may ultimately
iventuate in some cyst-formation.
Inflammation affecting the wall of the vesicle may also exert an
nfluence on the production of the disease.
It is, as a rule, during the period of most vigorous ovarian ac-
ivity that the aftection shows itself, nearly half the cases occurring
>etween twenty and forty years of age. The exercise of the sexual
unctions does not predispose to ovarian cystic disease.
It has, however, been noticed that women who are the subject
)f ovarian cysts are less prolific than others, while many of them
ire absolutely sterile; this may be from the fact that in most cases
19
290 OVARIAN TUMORS.
of this disease there is from the first the abnormal condition of
the ovaries which accounts for the absokite or comparative steriUty
present, and which tends to develop cysts.
Symptoms. — These will vary, greatly depending upon the natural
disposition of the patient and the character of the tumor. During
the early period of development there may be little or no evidence
of anything abnormal taking place until the tumor is manifest by
its size. In other cases local discomfort is experienced from the
first, such as pain in the ovarian region, which may assume the
character of ovarian dysmenorrhoea. AVliilst the tumor is still
small and contained in the pelvis it may produce irritability of the
bladder, with frequent desire to micturate, or even retention of
urine from impaction of the tumor in the pelvis and pressure upon
the neck of the bladder.
Should the tumor occupy the retro-uterine pouch, as is not in-
frequently the case, there may be pain in the back with a sense ol
weight or bearing-down in the pelvis, and aching pain extending
down the thighs from pressure upon the nerves as they pass
through the pelvis. The function of the rectum is usually more
or less interfered with, there being irritation with a constant sense
of discomfort as if the bowels were about to act, or constipatior
with tendency to hsemorrhoids. Should the tumor contract ad
hesions in the pelvis at an early stage, and thus be preventec
rising into the abdomen as the growth enlarges, it may become
impacted, and thus cause complete obstruction to the passage o
faeces, necessitating operative interference.
The uterus is often displaced, thrust down, or to one or othe:
side, retroverted or anteverted. Later on it becomes dragged uj
by its attachments, so that it cannot be reached by the finger oi
vaginal examination.
Its form is distorted and its functions often rendered difficul
and painful, though not absolutely impossible, as pregnancy oc
casionally happens.
Menstruation may be regular and normal in character, thougl
it is usually affbcted, in one way or another, from the commence^
ment of the development of an ovarian tumor. j
At first there may be menorrhagia, but generally menstruatioi
becomes scanty and may ultimately cease entirely. Dysmenoi
rhoea is not infrequent. Even though both ovaries are invaded b
the morbid action, it is seldom that the proper structure of both i
entirely destroyed, and if only as much of one ovary as pertair
to one mature vesicle remains sound, conception may take plac<
Pregnancy ma}^ then advance to full term, and delivery be accon
plished without accident, or abortion or premature labor may I
induced by the pressure of the tumor. During pregnancy th
tumor may become twisted on its axis, inflammation of the cys
haemorrhage, or even gangrene resulting, or it may burst an
cause death by peritonitis.
During labor the tumor may impede delivery, causing eith(
rupture, of the uterus or of the ovarian cyst.
SYMPTOMS. 291
Symptoms of pregnancy occasionally arise when no such condi-
tion is present. There may be amenorrhoea, morning sickness,
swelling of the breasts with the characteristic symptoms of en-
largement and discoloration of the areolae and development of the
glandular follicles, gradually increasing size of the abdomen, and
other well-marked evidence of utero-gestation.
After the tumor has attained a large size, or has been of long
•standing, the breasts usually become flaccid and shrunken.
When the tumor first rises out of the pelvis into the abdomen,
â– it is generally more to one side than in the centre. The pelvic
symptoms are now relieved, unless adhesions had previously taken
rplace, when from the dragging and other discomfort the distress
is aggravated. In some instances a certain amount of peritonitis
is set up, often local in character and assuming a latent course,
but still producing some pain or tenderness. As the tumor in-
creases in size it generally becomes more central, gradually rising
:above the umbilicus until it occupies the whole of the abdominal
cavity.
The symptoms are now mainly those of pressure. There is a
f^sense of fulness or distention, dyspnoea on exertion, aching in the
loins, gradually increasing sense of feebleness, and emaciation
begins to show itself. Occasionally there is pain extending down
rone leg from pressure on the nerves, and oedema from the venous
* circulation being interfered with; later on both legs suffer.
:^ As the tumor goes on increasing in size, the abdomen becomes
"t^till larger, the superficial veins in the abdominal walls become
jnlajged owing to the obstruction to the return of blood by the
ommon iliac veins: linese albicantes appear from the stretching
)f the abdominal walls ; the stomach and intestines, crowded out
)f their natural position and subject to increasing pressure, have
heir functions seriously interfered w^ith ; digestive and intestinal
lisorders show themselves, vomiting, constipation or diarrhoea, an-
)rexia, and other similar symptoms being generally present.
Dr. Atlee regards pulsation of the abdominal aorta felt through
he mass as pathognomonic of ovarian tumor.
With increasing size the thorax at length becomes implicated.
Che diaphragm and heart are pushed up, the lower ribs spread
)ut and more or less fixed. The lungs being compressed and the
leart's action interfered with, palpitation, dyspnoea, and imperfect
eration of the blood result. Pressure upon the kidneys and the
enal vessels produces congestion of these organs ; scanty secretion
s the natural result, and albuminuria is not infrequent. Where
xtensive pelvic adhesions occur, there is often also pressure upon
he ureters with consequent damage to the kidneys ; oedema of the
bdominal walls and loins may be present : ascites from occasional
ttacks of peritonitis is also common. With the gradually aug-
tienting size of the tumor we have progressive emaciation of the
'ody occurring ; it is more noticeable generally in the face, neck,
best, and arms. The features are chiselled out into the peculiar
inched expression which has been described as the fades uterina,
292 OVARIAN TUMORS.
but which would probably be better n^Tned fades ovariana. It has
thus been described by Mr. Spencer Wells : The emaciation, the
prominent or almost uncovered muscles and bones, the expression
of anxiety and suffering, the furrowed forehead, the sunken eyes,
the open, sharply-defined nostrils, the long compressed lips, the
depressed angles of the mouth, and the deep wrinkles curving
round these angles form together a face which is strikingly char-
acteristic.
In the latter stage a low t}^e of gastritis, marked by intensely
red tongue, aphthous stomatitis, vomiting, and tenderness over the
epigastrium, is not infrequent.
Death at length supervenes, often being preceded by intense
distress.
The distress, however, occasioned by ovarian tumors is not
always determined by the size of the tumor; it appears earlier,
and is more decided in cases of compound than in those of simple
cysts, and is often dependent upon individual idiosyncrasy. Pain
in the back or iliac regions may occur from tension of the Fallo-
pian tubes and the broad ligaments.
Course and Terminations. — The natural course of ovarian cystic
tumors is to go on gradually, or in some cases rapidly, increasing
in size until they fill not only the abdominal cavity, the walls o1
which they greatly distend, but also encroach upon the thoracic
ca\dty, pressing up the abdominal viscera, interfering with the
action of the diaphragm, impeding respiration, and also the circu
lation by pressure upon the aorta and vena cava. The intestines
are generally driven backwards and upwards ; the capacity of th(
stomach is so interfered with and the pressure upon the abdomina
viscera so great as seriously to aftect the process of nutrition. Th<
patient thus becomes emaciated ; there is gradual failure, first o
one power then of another, until at length she dies from ex
haustion.
The rate of growth or natural duration of ovarian cysts depend
upon the age of the patient, nature of the tumor, and other circum
stances. The simple cysts may go on steadily increasing for som
two to three years without interfering with the three importan
functions of respiration, circulation, and nutrition sufiiciently t
produce a fatal result. But the early growth of an ovarian eye
may be very slow; it may remain quiescent for a time, or ma
cease suddenly and finally to grow. The partly solid non-mali^
nant tumors often grow very slowly, so slowly, indeed, that tb
system adapts itself to the gradual change, and a fatal result i
thus postponed, often for many years. Instances are on record c
ovarian tumors being present for twenty to thirty years.
The proliferous cysts and malignant tumors grow more rapidh
It is then often more a question of months than years.
There are, however, many contingencies that may happen in tl
course of an ovarian tumor, and these we will mention seriatim.
Small ovarian tumors becoming impacted in the pelvis may pus
the uterus forwards against the neck of the bladder, and so caw
SPONTANEOUS CURES. 293
retention of urine. They may also cause such an amount of press-
ure upon the rectum as to produce obstruction to the passage of
fteces which may even terminate fatally. Again, the cyst may,
from accident or injury, become the seat of inflammation, leading
to suppuration of the cyst, peritonitis resulting and death ensuing
: in consequence. Instances have been recorded of tumors coming
down before the head in labor, rupturing the vagina, and becoming
protruded externally. The tumor has been known to escap.e, by
bursting or perforation of Douglas's sac, through the rectum, the
tumor being removed and the patient recovering.
Whenever a small ovarian tumor complicates pregnancy, it is
Biable to interfere with delivery by occupying the pelvic cavity and
^preventing the descent of the head.
Spontaneous cures of ovarian cysts. Cases of supposed spontane-
^ous resorption of the fluid, with subsequent shrivelling of the cyst
and cure, have been recorded, but it is more than doubtful whether
they can be regarded as authentic. There has been some error in
diagnosis. Cases have unquestionably occurred in which consid-
erable accumulations, believed to be in ovarian cysts, have disap-
â– jpeared more or less completely, either spontaneously or under the
influence of diuretic and other medicines, but so long as the fluid
is confined in the ovarian cyst, it is beyond the influence of absorp-
• tion. Dr. Barnes suggests in explanation that the fluid escapes
f first into the peritoneal cavity by rupture or a small perforation,
4 and then becomes absorbed, or else by a fistulous channel directly
liinto the bowel, and so becomes discharged.
; It may have been a pseudo-cyst, or even ascitic fluid,
i Bursting of the tumor into the peritoneal cavity, with absorption
•of the fluid into the general circulation and its rapid discharge by
!:he excreting organs, may occur. I^umerous cases are on record
of the spontaneous or accidental bursting of ovarian cysts, followed
•}y cure in this way. Where the walls are thin and tense, the sim-
iltaneous growth of the pregnant uterus, with its consequent press-
ire, under sudden exertion, direct violence, or concussion from a
all, may cause rupture of the cyst.
Recovery is not always, however, complete. The tumor may
brm again,. the rent cicatrizing. More frequently the patient dies
•apidly from shock, or from subsequent peritonitis, if she rallies
rom the shock. This will depend upon the nature of the fluid,
-f clear and watery it may cause little irritation, but where it is
)uriform or gelatinous it possesses acrid and irritating properties,
;.nd sets up peritonitis which may prove fatal. Even should this
lot prove so, the ovarian disease will pursue its natural course
lotwithstanding.
When rupture occurs, vessels are often torn, and large quantities
>f blood may be eflused along with the ovarian fluid. This com-
>lication increases the danger of peritonitis, and adds that of
^neemia.
Twisting of the Pedicle from rotation of the cyst on its axis, in
ases where the cyst is free from adhesions, may occur from the
294 OVARIAN TUMORS.
gravid uterus tilting it over, or from any sudden exertion. The
pedicle thus becomes strangulated or partially so. Should the in-
terference with the circulation be only sufficient to produce gradual
atrophy, a cure may result. Evidence of this has been occasionally
found post-mortem. The tumor may either shrink without being
detached, or may be completely separated from its attachment and
be found lying loose in the abdomen. In other cases the blood-
vessels being unable to return the blood from the tumor, they
become congested and burst.
Haemorrhage into the cyst, causing sudden distention and pro-
ducing symptoms of shock and anaemia, may prove rapidly fatal
without rupture of the cyst or haemorrhage into the peritoneal
cavity, which, however, not infrequently occurs. If the patient
survive the more immediate danger from shock, haemorrhage, and
peritonitis, the strangulation of the tumor is almost certain to lead
to gangrene, and death from septicaemia if the tumor be not re-
moved by gastrotomy, but even then the chances of sa\^ng the
patient are slight.
The pedicle may give way spontaneously, and the tumor float in
the abdominal cavity, or become attached to some other part and
continue to grow, its vitality being maintained througb the medium
of vascular adhesions.
Bleeding from the surface of the cyst or into its interior may take
place spontaneously from papillary growths, without the occur-
rence of rupture, or twisting of the pedicle. The blood may es-
cape through the Fallopian tube and uterus; may collect in the
retro-uterine pouch, constituting a haematocele; or it may remain
diffused in the peritoneal cavity and cause fatal peritonitis. Death
may occur rapidly, as in cases of rupture of an extra-uterine ges-
tation cyst.
Inflammation in the interior of the cysts occasionally happens. It
may be in consequence of injury or from tapping, or apparently
without any assignable cause. Where the cyst is multilocular the
inflammation maybe limited to one or more of the cysts, the others \
remaining unaffected. Suppuration, and the formation of pus or j
of a foul and offensive fluid, generally ensues. This ma}^ become |
absorbed and give rise to pyaemia or septicaemia which proves fatal, i
Perforation of the cyst and discharge of the decomposing fluid intc
the peritoneal ca\dty may take place and cause death by shock oi
by intense general peritonitis.
Adhesions to the adjacent organs and tissues not infrequenth
occur during the progress of ovarian tumors, especially to th<
omentum and abdominal walls, but occasionally also to the intes
tines, bladder, pelvis, and even the liver and stomach. A coil o
intestine may be found running over the anterior surface of thi
tumor, to which it is firmly adherent. As the tumor enlarges, th(
intestine becomes pressed upon so much as to cause obstruction
stercoraceous vomiting sets in, and the patient succumbs.
The cyst may contract adhesions with the bladder, bowel, vagina
or Fallopian tubes, and by bursting or ulcerative perforation int(
ATROPHIC INVOLUTION. 295
one of these viscera, its contents may be discharged. When an
opening forms from the intestine into the cyst, the contents of the
bowel may enter its cavity and give rise to faecal abscess which
terminates fatally.
Perforation may occur from a wearing through of the cyst wall
by partial pressure of the growths from within a papillary cystoma,
or by suppuration. It is a gradual process, and more likely to
occur in the glandular cystomas than in the simple cysts. Minute
perforations between the cyst and the peritoneum not infrequently
occur ; the opening is at once glued up by plastic adhesion, thus
limiting effusion and causing merely local peritonitis.
Occasionally adhesions form to the diaphragm, and the ulcera-
tive process, continuing in an upward direction, the pleura and
lung may be attacked.
Intercurrent attacks of peritonitis are common in the progress
of ovarian tumors, apart from bursting or perforation. They may
prove fatal, but more usually recovery takes place, and the surface
of the tumor may then become completely adherent to all the sur-
rounding parts.
Atrophic involution seems in some cases to occur. The nutrition
and growth become impaired. The tumor may remain quiescent for
many years, or be found, post-mortem^ shrunken and degenerated.
The growth of an ovarian cyst is sometimes also, though very
rarely, arrested by a so-called ossification of its w^alls, or rather
calcification, no true bone being formed.
Methods hi ivhich death is produced. Terminations :
By exhaustion arising from inanition, due to pressure upon the
-ifomach and alimentary canal.
By asphyxia, from pressure on the diaphragm, fixity of the chest
and compression of the lungs ; respiration and aeration are inter-
fered with, pulmonary congestion supervenes, and bronchitis or
pneumonia prove rapidly fatal from any slight exposure to cold.
By collapse or shock, from the extreme distention interfering with
the heart's action, from sudden bursting of the cyst into the peri-
toneal cavity, or from haemorrhage.
By septiccemia or pyoemia, from twisting or rupture of the pedicle,
or from inflammation of the cyst and decomposition of its contents,
especially if pregnancy complicate the case.
By peritonitis, intercurrent, or in consequence of rupture of the
cyst, especially in cases of polycysts.
By intestinal obstruction from adhesions, or pressure.
Diagnosis. — If attention has been given to the foregoing symp-
toms there should be little difi&culty in arriving at a conclusion as
to the existence or otherwise of an ovarian tumor. The history of
gradual enlargement of the abdomen, commencing low down to
one or other side, the tumor not being tender on pressure, easily
displaced, causing little or no inconvenience until it became bulky,
extending above the umbilicus ; the general health, good at first,
gradually becoming impaired; the abdominal veins becoming en-
larged; the altered expression of the countenance; the gradual
296 OVARIAN TUMORS.
emaciation of the upper portion of the body ; the diminution of
the urine ; the oedema of the extremities and other symptoms of
deranged functions, form a characteristic group.
The local signs elicited by inspection, palpation, and percussion
show the existence of a tense, elastic tumor, dull on percussion,
fluctuating, separate from the uterus.
As these symptoms and signs will be more fully discussed in
considering the differential diagnosis; it will be needless to enter
more fully into them at present.
Differential Diagnosis. — When we state that the abdomen has
repeatedly been opened with a view to performing ovariotomy,
when not only no ovarian but no other tumor was present ; that
the pregnant uterus, nearly at full term, has been tapped with a
trocar with the intention of drawing off ovarian fluid, and even
been opened after abdominal incision before the mistake was dis-
covered; that the chastity of virgins has been impugned by the
assertion of their medical attendants that pregnancy existed; and
that immerous and frequent mistakes are made in attempting to
decide upon the character of abdominal tumors, we have said suf-
ficient to show that the question of diagnosis in these cases is often
one of serious difiiculty and anxiety to the practitioner.
Fortunately it is not always so ; some cases are so simple as to
be recognized almost instinctively, others cause much greater dif-
ficulty, and in some cases it is simply impossible to arrive at any
conclusion except on making an exploratory incision, and even
then it may be impossible to determine the nature of the growth.
The diagnosis not infrequently involves the decision between life
and death, for if we leave a patient to die unrelieved from not
being able to make out the character of the tumor, when it is
subsequently discovered that an operation might have been per-
formed with success, or if we attempt to operate upon a patient,
exposing her to all the risks of a formidable operation when no
tumor exists or even one unfitted for operative interference, in
either case we incur a grave responsibility.
It will be well then in every case, no matter how simple appar-
ently it may at first sight appear to be, to examine the patient
thoroughly and systematically. We must employ every faculty
available: sight, touch, hearing; aiming rather at making a thor-
oughly reliable and trustworthy, than a brilliant, showy diagnosis,
arrived at often too hastily, and regretted at leisure. The exami-
nation should be pursued systematically. Having made out the
history of the case so far as it is likely to throw light upon the
question at issue, and ascertained that some abdominal complica-
tion exists, the patient should be requested to loosen her dress —
unfastening everything that surrounds the waist, remove her stays,
and then lie on her back on the couch, her shoulders being slightly
elevated, the knees drawn up, and the abdomen uncovered.
Where possible, it should always be arranged that the bladder be
emptied and the rectum unloaded before the examination be made.
Should the patient, from nervousness or from any wish to de-
ERRORS IN DIAGNOSIS. 297
('oive and mislead us, or from tenderness preventing careful ex-
ploration, hold the abdominal muscles so tense as to preclude our
making a satisfactory examination, some aneesthetic must be given
and a full investigation carried out. This should never be done
hurriedly at the time by the practitioner alone; a second person
should always be present in the room, and, if possible, the anses-
thetic administered by another medical man, whose opinion also
might prove of value. It is comparatively seldom that it Avill be
found requisite to administer an ansesthetic, but in cases of phantom
tumor or spurious pregnancy, which are specially liable to mislead
the practitioner, a double advantage is gained, in that a thorough
examination is facilitated, and the tumor also dispersed.
More errors in diagnosis are made from too hasty conclusions
from imperfect data than would be believed. It is not sufficient to
see that the abdomen is enlarged to decide that a tumor is present,
nor to feel that the abdomen is distended. Unless percussion and
auscultation are systematically employed, we shall be continually
arriving at w^ong conclusions.
When it is remembered that the diagnosis of ovarian tumors
involves the analysis of every enlargement possible to occur in the
abdomen, the practitioner should not be in too great a hurry to
arrive at a decision as to the character of any individual tumor.
We shall on this account enter somewhat fully into the subject,
and endeavor to make it as clear as possible.
Our first object, then, will be to discover whether any abdominal
tumor exists, and if so, our next, what is the character of the
tujnor or swelling.
Having uncovered the abdomen sufficiently to command a fair
view, w^e then bring into play our faculty of sight by
1=1 Inspection. — IN^ote carefully the size, whether enlarged or fairly
1 normal; the shape, whether symmetrical or otherwise, arched and
prominent or flat and bulging in flanks, whether there is any
alteration of shape on sitting up, or any irregularities, as met with
from distended coils of intestines. I^sTote also the condition of the
skin, whether health}^ and normal in appearance, or (Edematous,
marked with linepe albicantes or discoloration.
Mensuration should always be employed to give more precision
to what may have been detected by the eye, and also as a record
of any alteration in size from time to time.
Having ascertained all that we can in this way, then proceed to
bring another sense to bear upon the question, that of touch by
Palpation, — W^ith the outspread hands applied to the abdomen,
note whether it be soft and resilient, hard and tense; whether the
hand .can be pressed down towards the spine or encounters resist-
ance from some cystic or solid tumor. If so, determine the size,
shape, evenness or inequality of surface, presence of fluctuation,
pain or tenderness on pressure, evidence of movement as in utero-
gestation.
Per vaginam ascertain if the uterus be normal in position, size,
consistence ; if the finger can detect any tense cyst wall at the roof
298 OVARIAN TUMORS.
of the vagina to which impulse is communicated from above by
conjoined manipulation.
Should the case seem to require it, examine per rectum as well.
Then bring the faculty of hearing into play by means of
Percussion. — ^ote whether the abdomen be resonant or dull, the
area of dulness in front or more laterally; whether, if dulness be
detected, the line of dulness alters on change of position.
The sense of hearing may still further be made use of by means of
Auscultation, either with the ear direct, a soft towel being placed
over the abdomen, or with the stethoscope.
Notice whether borborygmi, placental bruit, foetal heart-sounds,
etc., can be heard.
The examination thus far conducted should enable us to say
whether the abdomen is abnormally enlarged, and, if so, whether
from distention with air or fluid, or from the presence of a tumor,
fluid or solid, or from a combination of any of these conditions.
Where an accumulation of fluid is detected in the abdomen,
either free or encysted, other means at our disposal are : aspirating
a small quantity of fluid by the hypodermic syringe, or an ordinary
aspirator and trocar, or by paracentesis and examination of the
fluid under the microscope and by chemical tests. An exploratory
incision may also be rendered requisite to clear up a diagnosis.
The abdomen may be considerably enlarged from obesity with
tympanitic distention, hysterical tympanites, phantom tumors, spu-
rious pregnancy.
Obesity with Tympanitic Distention occurs not infrequently towards
the menopause, especially in sterile women. The obesity is rarely
limited to the abdomen and breasts, but occurs in the face and ex-
tremities as well.
Although large, the breasts are doughy, and have neither the
characteristic feel of physiologically active glands, nor is there any
increase in the area and darkening of the areolae as met w^ith in
utero-gestation. Pregnancy and obesity seldom concur, and speak-
ing generally, the subjects of ovarian tumor are mostly slim and
slightly built.
On inspection of the abdomen it is seen to be more or less sym-
metrically enlarged. On making the patient sit up the abdominal
walls are thrown into pendulous folds, the umbilicus is hollow and
depressed.
On palpation the abdominal enlargement is felt to be doughy,
yielding on Arm pressure. There is no sensation of a well-deflned
globular tumor with resisting outline, giving the peculiar feeling
of a wavy or living impulse under the hand as marks the peristaltic
movement of the uterine wall, or the movements of the foetus in
pregnancy. The abdominal walls may be pinched up between the
two hands, lifted as it were and made to roll over the muscular
floor beneath.
If ancesthesia be produced, the hand can be made to sink almost
to the spine, making due allowance for the thickness of the ab-
dominal walls.
HYSTERICAL TYMPANITES, ETC. 299
On vaginal examination the uterus is probably found normal in
size, central, mobile ; the cervix not softened, as in true pregnancy,
and directed backwards, but hard and central, often low down.
There is no displacement of the uterus, with tilting to one side
or dragging upwards, as met with in ovarian tumor.
On conjoined manipulation with firm pressure the uterus can
generally be felt of normal size, not enlarging out uniformly as in
pregnancy, nor is there any sensation of a cyst in front of the uterus
as met with in ovarian tumors.
On percussion obscure resonance over the whole abdomen is gen-
erally detected. If firm pressure be made over the lower portion
])etween the umbilicus and pubes, where the enlarged uterus would
be if pregnancy existed, or where an ovarian cyst would be most
likely to be found, and percussion so as to get out the deep note be re-
sorted to, the resonance is even more marked than it is superficially.
On auscultation the rolling and rumbling of confined air in the
intestines, so-called borborygmi, is essentially difierent from the
placental bruit and foetal heart-sounds of utero-gestation, or the
complete absence of any sound as noticed in ovarian tumors.
Hysterical Tympanites, Phantom Tumors, and Spurious Pregnancy
may practically be considered together to obviate confusion, since
the actual physical condition is almost identical in each. The same
systematic method of investigation must be followed as just indi-
cated. The abdomen is often uniformly distended to the size of
the pregnant uterus at full term. It is rounded, hard, and resistant.
The apparent enlargement is often increased by arching of the back,
either involuntarily or at will, the recti muscles being held tense,
so that no impression is made upon it by pressure of the hand.
Change of position causes no alteration in shape.
On'percussion the abdomen is uniformly resonant. If the pa-
tient's attention can be diverted by engaging her in conversation,
or if she be placed under the influence of anaesthesia, the swelling
entirely disappears, the hand can be pressed dow^n to the spine, the
abdomen becomes flaccid. There is no fluctuation or any solid
tumor present.
In these cases but little dependence can be placed on the subjec-
tive symptoms, the patient often being very hysterical, occasionally
the subject of delusion amounting almost to monomania, in other
cases merely of a natural mistake.
In cases of spurious pregnancy, in addition to the above physical
signs, the mammary signs of pregnancy are often entirely absent.
The catamenia in young women are often regular, though this fact
may be suppressed. At the time of the menopause the cessation
of the catamenia in due course may really prove to have been the
starting-point of the delusion as to the existence of pregnancy.
On vaginal examination the uterus, in place of being enlarged, is
found to be more or less normal in size, mobile ; the cervix of
natural density, not softened; the os uteri normal.
In place, however, of being resonant on percussion, we find the
abdomen is dull, and there is a more or less distinct sense of flue-
300
OVARIAN TUMORS.
tuation. The two conditions most likely to account for this are an
ovarian cyst and ascites, and as it is of great importance to distin-
guish these two, the leading points of difference are here tabulated
for comparison.
The mere fact that no fluctuation can be detected must not always
be accepted as proof of the non-existence of fluid, without further
investigation. Fluctuation may be rendered very indistinct, or may
be entirely prevented, though fluid be present, by the following
causes (Peaslee) :
1. Great thickness of the abdominal walls, from fat or oedema,
whether the fluid be in the peritoneal cavity or in a cyst.
2. Great thickness of the walls of a cyst, they being, in dermoid
tumors and polycysts, sometimes 1 to IJ inch thick.
3. Great tenseness of the cyst, even though it be a large one.
4. Great density of the fluid, as in colloid cysts.
5. Small amount of fluid in each cyst, as in many polycysts.
Ascites.
Health failing often before swelling
noticed, often rapidly.
Ovarian Cyst.
Histonj. — General health good at time
of discovery of enlargement in abdo-
men ; fails gradually and slowly.
Catamenia often regular, though
scanty.
Hydragogues and diuretics produce
no effect as a rule.
Fig. 120.
Often irregular, profuse, or scanty.
Hydragogues and diuretics produce
temporary relief
Fig. 121.
Ovarian Tumor. Dorsal Decubitus, (After
Barnes.) o. t. Dull area of Ovarian Tumor.
I. Intestinal resonance. L. Liver.
Ascites. Dorsal Decubitus. (After Barnes.)
A. Ascitic dulness. i. Intestinal resonance.
L. Liver.
No evidence of cardiac, renal, or he-
patic disease as a rule.
Tumor often first noticed to one side
of abdomen, becoming more central
further on.
Grenerally evidence of organic mis-
chief in one or other of these organs,
or of peritonitis.
Swelling first noticed as a fulness or
bulging in the lower abdomen on stand-
ing.
DIAGNOSIS.
301
Ovarian Cyst
(Edema of face, hands, feet, etc.,
seldom present until a late period.
On Inspection. — Abdomen enlarged,
bulging in front, arched, often more to
one side than another, changing but
little if at all in shape on change of
posture.
Umbilicus never prominent, or bulg-
ing, or thinned; on deep inspiration
upper part of cyst often seen to rise
and fall.
Greatest circular measurement often
some inches below level of umbilicus.
Abdominal integuments normal, or
merely thinned.
Chest conical from bulging of false
ribs.
In advanced cases the characteristic
fades ovariana is generally marked.
On Palpation. — Abdominal walls
tense, resisting pressure.
Ascites.
Generally present early in the case ;
oedema of extremities in all cases.
Uniformly enlarged, flattened in front,
bulging in the flanks. Shape of abdo-
men alters materially on change of post-
ure, the fluid bagging to the lower part
on sitting or standing.
Umbilicus often prominent or bulg-
ing, and thinned. Not so ; occasionally
simulated by distended coils of intes-
tine, but these are resonant on percus-
sion.
At level of umbilicus.
Skin of abdomen smooth, tense,
shining.
Floating ribs not bulging.
Cachectic appearance often marked
from the first.
Soft and resilient if amount of fluid
moderate, tense when excessive.
Fig. 122.
DiflFerential Characters of Ovarian and Ascitic Dropsies in upright posture. (After Barnes.
Fluctuation usually most distinct in
centre of abdomen, superficially ; does
not vary with position of patient ;
limited to line of dulness ; more dis-
tinct in recumbent position.
Aortic pulsations transmitted through
the cyst to the abdominal wall.
Per Vaginam. — Cyst often detected
at pelvic brim or vaginal roof in front
of uterus, impulse being communicated
from above. Fluctuation often indis-
tinct, or not felt in case of polycysts.
Most marked in most dependent parts,
in the flanks on lying down ; less marked
anteriorly ; varies with position of pa-
tient ; felt beyond line of dulness, dif-
fused through abdomen ; more distinct
in erect position.
Aortic pulsation not felt through ab-
dominal wall.
No cyst felt; no impulse communi-
cated; sense of bulging; fluctuation
often detected.
302
OVARIAN TUMORS.
Ovarian Cyst.
Uterus generally drawn upwards or
tilted to one side; mobility often im-
paired; cervix shortened ; uterus gener-
ally displaced behind the cyst.
On Percussion. — Dulness is most
marked over centre of abdomen ; line
of dulness in the erect posture is con-
vex ; one or both flanks resonant.
Areas of dulness and resonance re-
main the same on change of posture if
the cyst be of large size. A moderate-
sized cyst may move somewhat from
side to side when the patient turns over.
Ascites.
Uterus either low down and movable,
or normal in position; cervix of nor-
mal length.
Dulness in both flanks when lying on
the back ; resonant anteriorly in the
most elevated parts ; line of dulness
on sitting or standing concave.
^ Alter according to the position of pa-
tient; on side, upper flank resonant;
on sitting up, fluid gravitates to lower
part of abdomen, the dependent parts
being dull, the uppermost resonant.
Exceptions occur when intestines bound
down by adhesions, or when fluid exces-
sive in quantity.
Gurgling sounds of intestines over
centre of abdomen, movement of fluid
heard on succussion; no aortic pulsa-
tion transmitted.
Limpid, light straw color, highly al-
buminous; sp. gr. 1010-15; deposits
fibrin spontaneously as a delicate film,
but no sediment; does not contain par-
albumen, metalbumen, or cholesterin.
Coagulates spontaneously.
Squamous epithelium cells, leucocy-
tes, and fibrin, with occasionally pus
cells ; oil globules and amaeboid bodies
are found.
On Auscultation. — Nothing heard
over seat of tumor except, possibly, the
aortic pulsation is transmitted. The
fluctuation wave of fluid may be heard
on succussion.
Character of Fluid. — Fluid usually
amber-colored, somewhat viscid, sticky
to the feel, often like syrup; sp. gr.
1018-24; varies in color in different
cysts ; contains no fibrin, but albumen,
paralbumen, metalbumen, and peptone.
Never coagulates spontaneously.
Microscopically. — Cylindrical epi-
thelium, cholesterin, leucocytes, and
granular masses are found. The char-
acteristic granular ovarian cell contains
a number of fine granules, but no nu-
cleus, and is distinguished from other
cells by becoming more transparent and
its granules more distinct on the addi-
tion of acetic acid. It remains un-
altered on the addition of ether. No
amaeboid corpuscles present.
We have here for sake of clearness indicated the leading points of
distinction in the two conditions. It must be remembered, though,
that numerous complications may vitiate these conclusions and lead
to fallacies. Thus ovarian tumors, especially if malignant in char-
acter, may be associated with ascites, when the flanks will be dull,
and the areas of resonance and dulness change when the position be
altered. There may be gaseous distention of the large intestine in
cases of ascites, and thus resonance in either flank be present in
place of dulness, especially in the right, where the ascending colon
is more bound down by adhesions. Where the abdominal disten-
tion from ascites is very great, the mesentery may be too short to
allow the intestines to float to the surface, or they may be bound
down by adhesions, the result of peritonitis, and thus more or less
uniform dulness be the result. On careful auscultation, however,
in these cases the movement of flatus in the intestine may usually
be heard on deep pressure over the centre of the abdomen, this not
being the case in ovarian tumors of such a size. Again, the an-
PAROVARIAN CYSTS.
303
terior surface of the abdomen may be resonant in cases of ovarian
tumor where the cyst contains air as a result of tapping, or of a
communication with the intestine. We may have pregnancy or
other tumor associated with ascites, this latter condition being so
considerable that the presence of the tumor is masked or not dis-
coverable.
Differential Diagnosis of the Three Varieties of Ovarian Cyst (Peaslee).
Monocyst and Oligoeyst.
Slower growth ; not un-
common.
A peculiar expression
comes later.
General health fails
much later.
Abdomen symmetrical.
Enlargement from 35 to
45 inches.
Surface smooth if mono-
cyst.
Tumor disappears after
tapping.
(Edema of lower ex-
tremities very rare; ab-
dominal veins less en-
larged, and later.
Adhesions less common
and less firm.
Inflammation of cyst
wall not common.
Ulceration of cyst wall
not common.
Spontaneous rupture not
common.
Amenorrhoea comes la-
ter.
Fluctuation distinct and
throughout, if a monocyst,
and from any point to all
others.
Per Vaginam. — Uterus
is higher, and the fluctua-
tion also.
Pedicle longer as a rule.
Fluid limpid, amber,
bluish or greenish, viscid,
with much albumen.
Contains epithelial
scales, cholesterin, and
fatty granules, and the
ovarian glomeruli.
Poly cyst.
Rapid growth ; more
common.
Comes much earlier.
Fails early.
Not symmetrical.
Sometimes to 55 or even
78 inches.
Lobulated, irregular.
Does not disappear.
Very common ; veins
enlarged early.
Adhesions the rule, and
vascular.
Not so common.
More common.
Far more common.
Comes much earlier.
Less distinct and circum-
scribed.
Uterus is lower, and the
fluctuation also, or none at
all.
Shorter as a rule.
Not clear ; brownish,
dense, gelatinous, or albu-
minous.
Contains also blood pig-
ment and blood corpuscles.
Dermoid Cyst.
Congenital; very slow,
very rare.
Latest of all.
Very late.
Not symmetrical.
Smallest; generally 30
to 40 inches.
A monocyst as a rule.
Does not completely col-
lapse.
Very uncommon.
Adhesions not very rare.
Most uncommon, pro-
portionally.
Most common of all.
Very uncommon.
Very late.
Fluctuation more ob-
scure.
Uterus lower, fluctua-
tion dull.
No rule.
Light color, curdy, no
albumen ; partly soluble
in ether.
Contains epithelial
scales, sebaceous matter,
crystals of cholesterin,
hairs, teeth, bone, etc.
Parovarian Cysts. — Cysts of Broad Ligament. — These are rare
compared with ovarian cysts, occur more frequently in young per-
sons, are of very slow growth, often continue for a long time without
deranging the general health, and seldom prove fatal.
304 OVARIAN TUMORS.
As they are often cured by a single tapping, and so do not need
extirpation, it is important if possible to make out the diagnosis.
They may be thus contrasted with unilocular ovarian cysts.
Parovarian Cysts. Unilocular Ovarian Cysts.
Rare ; always monocystic. Common.
Mostly in youn^ persons. Occur at all ages.
Greneral health unimpaired for a long Gives way earlier,
time.
Seldom attain any considerable size. May attain any size.
Abdominal veins less prominent. Veins more marked.
Walls usually very thin. AValls often thicker.
Fluctuation very distinct and super- Less distinct,
ficial.
Fer Vaginam. — ^Fluctuation very dis- Fluctuation less evident; uterus gen-
tinct; uterus normal in size and position, erally behind tumor, often dragged up
or somewhat lower in pelvis. somewhat, or tilted to one side.
Scarcely ever refill after tapping. Refill often rapidly.
A^ery seldom fatal. Almost alwaj's fatal in time.
Fluid limpid like clear water, of low Fluid clear, viscid, highly albumin-
specific gravity, generally under 1005; ous; specific gravity 1007 to 1015, or
contains only a trace of albuuien, which more ; a glittering pellicle of cholesterin
is only precipitated by nitric acid, not often forms on the surface,
by heat alone.
Hydatids, growing from some part of the peritoneal surface or
from the liver, often acquire an enormous bulk, distending the abdo-
men proportionally, and simulating in many respects large ovarian
tumors.
The history usually shows that the enlargement commenced in
the upper part of the abdomen, and gradually extended downwards
towards the pelvis, and that the gro\\i:h has been very rapid.
Fluctuation is mostly obscure and circumscribed, but when the
hydatid fremitus can be felt it is decisive.
The surface of these tumors is often irregular, the interspaces or
depressions between the projecting masses very distinct. A vaginal
examination generally proves the pelvis and hypogastric region to
be free from the presence of a cyst.
Where the diagnosis is still doubtful, puncture of the cyst with
the aspirator and trocar, and examination of the fluid, will eitectually
clear up the question.
The fluid is perfectly colorless, transparent, and watery as a rule,
occasionally slightly opalescent, of low specific gravity — 1007 to
1009 — generally alkaline or neutral in reaction, but occasionally
acid, consisting mainly of a strong solution of chloride of sodium,
without any albumen or other organic substance, but said to con-
tain succinate of soda (Roberts), is'umerous booklets are often
detected under the microscope.
Renal Cysts. — Hydro- and pyro-nephrosis, and hydatid cysts, are
often mistaken for ovarian cysts. Solid renal tumors, whether
innocent or malignant, may simulate pseudo-colloid, cysto-sarco-
matous, or malignant tumors of the ovaries. Renal tumors may
generally be recognized by the following characteristics :
They push the intestines forward, ovarian backwards.
RENAL AND OVARIAN TUMORS. 305
Renal tumors begin in the lumbar region, and grow forwards
and downwards.
Ovarian tumors generally begin in one inguinal or iliac region,
and extend upwards and inwards.
Renal tumors lie behind the intestines, ovarian in front, except
ill those cases where the intestine has become adherent to the an-
terior surface of the ovarian cyst.
The descending colon usually crosses the left kidney obliquely
from above downwards, the ascending colon usually runs along the
inner border of the right kidney, when these organs are enlarged.
^ K any doubts exist whether it be intestine in front of the tumor,
'\ on rolling it under the fins^ers the intestine contracts into a firm,
J cord-like band; or insufflation per rectum may be eftected, when
the gurgling of flatus may be heard on auscultation, or the altered
resonance prove that it is really intestine.
An elastic tube might also be passed jper anum, with a view to
! clearing up the question when the left kidney is involved.
Although the urine may be perfectly normal, the healthy kidney
alone secreting urine, in many cases there will be found evidence
of pus, blood, albumen, or epithelium in the urine, and frequently
a history of urinary troubles, such as hsematuria, calculus, albu-
minuria, nephritic colic, or some notable change in the quantity or
state of the urine.
In ovarian tumors there is more likely to have been menstrual
derangements, and some alteration in the mobility or situation of
the uterus is generally detected.
.Renal tumors are comparatively rare, and grow slowly.
Should the nature of the case, after careful examination, be still
doubtful, it will be well to aspirate, and draw oiF a small quantity
of fluid for examination.
If renal, the fluid will often possess a faint urinous odor, urea,
urates, and chlorides in the normal proportion being detected.
Simon's method of exploration by the hand in the rectum is often
of great value in determining the pelvic origin or not of tumors.
A floating or movable kidney may become enlarged, and then be
mistaken for an ovarian tumor. The kidney usually preserves its
normal characteristic shape, though the hilus may be turned up-
wards. The kidney cannot be detected in the region it normally
occupies, but the tumor can be pushed back into this position, and
may also be moved about freel)' in the abdomen. It is rarely con-
nected in any way with the pelvis. An exploration of this cavity
will generally enable us to decide that the tumor is not ovarian.
Large Renal Cysts. Ovarian Cysts.
Very rare, and grow slowly. Common, and grow more rapidly.
History generally of urinarj^ troubles. None. May be history of dysmen-
} Evidence at some time of pus, blood, orrhoea, or other menstrual derange-
or albumen in urine ; of nephritic colic ment.
from an impacted calculus, etc.
No catamenial derangement. Catamenia often scanty.
No characteristic expression of fea- Facies ovariana.
tores.
20
306 OVARIAN TUMORS.
Large Renal Cysts. Ovarian Cysts.
Emaciation appears late. Early.
Early oedema of lower extremities. (Edema appears late, if at all.
Tumor commences in lumbar region, Commences below, and extends up-
and grows forwards and downwards. wards and towards mesial line.
Unilateral and fixed from first. Unilateral and movable at first.
Not quite symmetrical at any time. Symmetrical when cyst large.
Lies behind the intestines, which are Lies in front of intestines, which are
pushed towards mesial line. ^ pushed upwards and outwards.
Per Vaginam. — Tumor, even if it Tumor almost invariably detected,
extends to pelvic brim, perfectly inde- and felt to be connected with pelvic
pendent of pelvic organs ; often not de- organs,
tectable.
Rectal exploration confirms this. Rectal exploration shows tumor to
be attached to one or other side of the
uterus.
Fluid contains urea, urates, and chlo- Fluid highly albuminous ; no urea,
rides ; not necessarily albuminous. Often contains cylindrical epithelium,
cholesterin, leucocytes. Granular cell.
Urine usually contains pus, blood, or Urine normal, though diminished in
albumen. quantity.
Pregnancy is often mistaken for ovarian tumor.
Little reliance as a rule should be placed upon subjective state-
ments, for in cases where these are of most value they are often
least reliable. " Where pregnancy is real or suspected, the patient
may mislead the surgeon intentionally, or from her own hopes or
fears biassing her judgment. An unmarried girl, or a married
woman whose husband is absent, or a widow, may have very strong-
reasons for concealing pregnancy, and hoping or asserting that she
has an ovarian tumor. Or a sterile wife, or one advancing in age,
suffering from a tumor, may have grounds almost equally strong
for hoping that she may be pregnant" (Wells).
Objective signs then should mainly be trusted to.
In pregnancy the mammary signs are usually very characteristic
at the time when an ovarian tumor is at all likely to be confounded
with this condition, say from the fifth to the seventh month. The
breasts are full, the areolae darkened, the follicles enlarged, the
nipple prominent and exudes a milky fluid on pressure.
On Inspection of the abdomen, it is found to be enlarged symmet-
rically, prominent in front. In primiparae the umbilical areola is
often very distinct.
On palpation a central, firm resistant tumor, less dense than a
fibroid, more solid than a cyst, pyriform in shape, may usually be
detected. Rhythmical contractions may often be felt if the tumor
be gently grasped by the outspread hand ; the contour of the foetus
or distinct movements may often be perceived.
Per vaginam the abdominal tumor may be felt to be continuous
with the neck of the uterus, which latter is enlarged, softened, in-
ftindibular in shape, the os admitting the finger readily, and being
directed backwards. Ballottement detects the foetal head or breech,
which produces an impulse when pushed up and allowed to
descend.
On percussion the areas of resonance and dulness are similar to
MOLAR PREGNANCY. 307
those noticed in ovarian tumors : dull in front, resonant in the
Hanks, but little altered on change of position.
On miscultation foetal heart^sounds are distinctly audible towards
the end of the fifth month, averaging 140 in a minute. The pla-
cental bruit may also be heard, but is of less value diagnostically,
a sa similar bruit is occasionally produced in the case of uterine
fibroids.
Cases of pregnancy with hydrops amnii are very liable to be con-
founded with large ovarian cysts, especially as the size of the uterus
is out of all proportion to the stage of development, thus simula-
ting a rapidly growing ovarian cyst. The uterine walls are much
thinner than usual from the undue distention, so that fluctuation is
very superficial, and may readily simulate that detected in thin-
walled ovarian cysts.
The signs of pregnancy previously enumerated, especially ballotte-
ment, softening of the cervix — the tumor being continuous wnth
this — the cervix spreading out or enlarging gradually into the
tumor and moving simultaneously with this, should enable us to
form a correct diagnosis.
The sounds of tlie foetal heart are often obscure and distant, but
the foetal movements, if detected, or the head pressing down in the
cer\dx, can hardly be mistaken for anything else.
Should, however, the diagnosis be very difficult, and the question
of operation urgent, it will be better to pass the uterine sound,
which would at once clear up the diagnosis. Even if labor were
thereby induced, this would be better than puncturing the pregnant
uterus with a trocar, or exposing it by an exploratory incision.
Normal Pregnancy about Sixth Month. Ovarian Tumor up to Umbilicus.
Enlargement has developed within Has developed more slowly, as a rule,
six months at furthest ; only noticed a and been noticed for many months, if
few weeks at most. not a year, at least.
Symmetrical. More to one side.
Countenance natural, healthy. Anxious.
Catamenia absent for some months. Generally regular, though may be
scanty.
^ Mammae full, areolae darkened, fol- Mammae only exceptionally enlarged ;
licles enlarged, nipple prominent, exu- seldom other signs manifest,
ding a milky fluid on pressure.
Umbilical areola in primiparae. Not present.
Superficial abdominal veins not en- Veins often distinct,
larged.
Tumor pyriform-shaped, resisting, Tumor less uniform in shape, often
and dense. _ irregular.
Rhythmical contractions. None.
Fluctuation very indistinct. Fluctuation often distinct.
On vaginal examination uterus found Uterus normal in size, usually behind
to be enlarged, cervix softened, and ap- cyst, often displaced. Ballotfementj
parently shortened. Ballottement de- even if practicable, detects nothing,
t^cts body within uterus.
Foetal heart-sounds heard. Move- None,
ments felt when child living.
Molar Pregnancy. — Vesicular mole, or uterine hydatids, from
cystic, or so-called h^'datidiform, degeneration of the chorion, when
308 OVARIAN TUMORS.
prolonged, may give rise to some confusion. There is often rapid
increase of the uterine tumor, the size not corresponding with the
supposed period of pregnancy. Usually more or less profuse watery
and sanguineous discharges take place about the mid-period of
pregnancy, often even earlier, which will at once put us on our
guard as to the probable nature of the case.
There is more general disturbance of the health than is natural,
the vomiting is often excessive, and the discomfort from the rapid
and undue distention of the uterus often very distressing.
The discovery of portions of cysts with the discharge resembling
currant juice is a certain diagnostic sign of this condition.
Retained Encysted Foetus, in cases of extra-uterine gestation, may
usually be recognized by the history of supposed pregnancy which
never terminated in parturition. The outline of the foetus may be
detected possibly, or where a long interval has elapsed the tumor
may present a firm and irregular outline, situated low down in the
abdomen or even entering into the pelvis.
The condition of the tumor has been stationary for some time.
Ovarian Tumor complicating Pregnancy. — This condition not infre-
quently occurs, and may complicate the diagnosis considerably.
The abdomen is more widened out than in either of the single con-
ditions, and the limits of each tumor may generally be defined by
the ordinary methods. There is commonly a marked sulcus or de-
pression between the two tumors. There is often a history of the
presence of a comparatively slow-growing tumor — ovarian — rap-
idly becoming more prominent, or apparently enlarged, from the
complication of pregnancy supervening, the symptoms of this latter
condition being marked by the usual amenorrhoea, sickness, etc.
There are other enlargements of the uterus unconnected with
pregnancy which are often mistaken for ovarian tumors.
Of these Jibroki and fihro-cystic tumors probably offer the greatest
difliculty as regards diagnosis.
Fibroid Tumors of the uterus occasionally attain a very large size.
There is usually a history of menorrhagia. They are generally of
slow growth, confined to the lower part of the abdomen (unless
very large), apparently fixed there, cannot be raised at all, or only
with difficulty, by the hand pressed backwards between the tumor
and the pubes.
On vaginal examination the vagina may be found to be more or
less completely obliterated by a dense, solid mass, the cervix uteri
eftaced, the os uteri reached with difficulty, the cervical canal so
compressed or contorted that the uterine sound will not pass, or
where this is practicable the sound enters a tortuous canal many
inches beyond the normal length. Every movement of the ab-
dominal tumor is communicated immediately to the uterus, which
is felt to move in all directions with the pehdc portion of the tumor.
If, in addition to these signs, we detect small, marble-like tumors,
sessile or pedunculated on the main mass, we need have little doubt
that the case is one of fibroid tumor.
Large, uniformly solid ovarian tumors are exceedingly rare.
FIBRO-CYSTIC TUMORS OF THE UTERUS. 309
Utenne Fibroid. Ovarian Cyst
General health fair. No emaciation. Health impaired. Emaciation.
Countenance natural or anaemic. Anxious, pinched, seldom anaemic.
Not uncommon. Large solid tumors very rare.
History of monorrhagia. ^ Catamenia often scanty.
Slow growth, often extending over More rapid growth, seldom over one
years. year.
Surface lobulated and firm. Smooth and yielding generally.
Abdominal veins not enlarged. Enlarged.
Tender on pressure, more marked Not so.
during menstruation.
Sense of elasticity occasionally, but Fluctuation distinct,
no true fluctuation.
Tumor confined to lower abdomen, Not so. Can be raised fi'om pelvis,
apparently fixed there ; cannot be raised
from pelvis.
Per Vaginam. — Tumor inseparable Separable from uterus, not moving
from uterus, with which it moves; with it; tense, elastic, fluctuating,
dense and firm. Cervix often obliter- Uterus normal ; cervix natural length ;
ated. Uterine cavity elongated ; canal canal not tortuous,
often tortuous.
In cases of sub-peritoneal pediculated
fibroids, tumor more mobile indepen-
dently of uterus.
Fibro-cystic Tumors of the Uterus, when they have attained a con-
siderable size, are with great difficulty distinguished from multi-
locular or semi-solid ovarian tumors. Of nineteen cases collected
by Dr. C. C. Lee, eighteen were operated on under a mistaken
diagnosis of ovarian cyst.
Both uterine and ovarian tumors may lead to very great enlarge-
ment of the abdomen ; be central in position or incline to one or
other side ; be either round, ovoid, or irregular in form ; smooth
or lobulated on their surface ; either hard or elastic or fluctuating ;
either tender or insensible to pressure ; and either adhering to the
abdominal wall or moving beneath it with or without crepitation
(Wells).
Koeberle thinks the diagnosis of a fibro-cystic tumor may be
established by the following signs :
1. The discolored line and dejected expression of the face, the
so-called /aa65 uterina of the patient.
2. The variable consistency of the tumor as made out by ab-
dominal palpation.
3. The results of tapping. If the trocar touch a fibrous spot in
the tumor wall, blood will flow. Even when the cyst is reached,
the fluid never presents the clear viscid character of ovarian cystic
fluid, but is either yellowish, thin, serous, and rich in lymph or
cholesterin, or it is brown, muddy, sero-purulent, or bloody, and
the tapping leaves only partial collapse.
4. The indurated or nodular feel of the tumor after tapping.
5. The uterine connections of the growth, as made out by vagi-
nal, and uterine examination by aid of the sound. The uterus is
more displaced than in ovarian tumor.
The history may guide us somewhat. Fibro-cystic tumors rarely
occur before thirty; the rate of development is slow, often extend-
310
OVAKIAN TUMORS.
ing over several years. The solid portion of the tumor preponder-
ates over the cystic. The tumor involves the body and neck of the
uterus, cannot be raised from the pelvis ; the abdominal tumor
moves synchronously with the pelvic portion. On exploratory in-
cision the tumor is dark, vascular, thick, and frequently fascicu-
lated with fibrous bands, differing essentially from the pearly white
or blue and glistening surface of an ovarian tumor.
Fihro- Cystic Tumor of Uterus.
Seldom occurs before the age of thirty
years.
Comparatively rare.
Generally of slow growth at first.
General health not affected for a long
time.
No emaciation.
Complexion often florid, discolored.
Expression dejected. Fades uterina.
Abdominal veins not enlarged.
Umbilicus not prominent.
Menorrhagia more often than amen-
orrhoea.
Urine normal in quantity.
Tender on pressure.
Elasticity ; subsequently fluctuation.
Variable consistence; lobulated sur-
face.
Solid portion preponderates over
cystic.
Tumor dark, vascular, fasciculated,
with fibrous bands.
Per Vaginam. — Tumor firm at first,
continuous with uterus, involving the
body and neck of uterus, with which it
moves, if at all, but cannot be raised
from pelvis.
Uterine cavity elongated.
Fluid, on tapping, j^ellow, thin, se-
rous, not viscid ; little albumen ; rich
in lymph or cholesterin ; or brown,
muddy, sero-purnlent, or bloody ; spon-
taneously coagulable.
HaBmatometra, or distention of the uterus from retention of the
menstrual fluid, may in rare cases simulate ovarian tumor. The
history of amen orrhcea, severe pain at the menstrual epochs, and
the discovery of occlusion of the vagina or cervix uteri, should
serve to distinguish this condition. It may be congenital, the pa-
tient never having menstruated, or acquired from accidents during
labor.
The increase in size is very gradual. There is tenderness in the
tumor at the monthly periods.
Physo-haematometra occurs when the accumulated fluid undergoes
decomposition, and gas becomes mixed with blood.
Hydrometra, or distention of the uterus from the accumulation
of mucous or muco-purulent secretion, occurs in rare instances as a
Ovarian Tumor.
Often earlier as well as later.
More common.
Growth more rapid.
Often fails early in case of compound
cysts.
Emaciation.
More often pale.
Anxious, but more hopeful. Fades
ovariana.
Enlarged.
Prominent.
The reverse.
Often scanty secretion.
Not so.
Fluctuation from first.
More uniform in consistence and sur-
face.
Cystic portion predominates.
Pearly white, or blue and glistening
surface.
Cystic from first, not continuous with
uterus ; uterus normal in size ; tumor
can be raised from pelvis independently
of uterus.
Not so. ^ ^
Fluid clear, viscid, highly albuminous,
though it may be turbid, chocolate
color; not spontaneously coagulable;
sometimes colloid.
ENCYSTED DROPSY. 311
senile form of occlusion, but seldom attains any considerable size.
It often ends spontaneously by the discharge of a grayish and
sometimes very foetid fluid.
Physometra, or accumulation of air in the uterus, is a very rare
condition, occurring in hysterical women. There would be more
or less resonance on percussion. Air is not infrequently discharged
jper vaginam.
Distention of the Bladder from retention of urine has before now
led to the supposition of the presence of an ovarian tumor, and
has led to the viscus being tapped. The dribbling away of urine,
being simply the overflow from the paralyzed bladder, has been
regarded as due to incontinence of urine from pressure of the
imaginary cyst.
The central position in the lower abdomen, rapid formation, with
intense discomfort, should at once suggest the passage of the cath-
eter. A small elastic one should be employed. The rapid disap-
pearance of the tumor on the mthdrawal of the urine will at once
settle the question.
Encysted Dropsy of the peritoneum from the occurrence of peri-
tonitis may occasionally give rise to some difiiculty in diagnosis.
The intestines are bound down by adhesions, the fluid being con-
tained in front, often extending over the whole of the abdomen.
Separations may sometimes be felt in the form of depressions.
There is usually the history of acute inflammatory symptoms, and
more or less sudden appearance of the effusion. The abdomen is
flat, not prominent. Respiration is not impeded. Fluctuation is
feeble and limited, and does not alter in situation on changing the
position of the patient. If felt, it gradually diminishes and ulti-
mately disappears. No enlargement of the abdominal veins or
oedema of the legs ensues. If the fluid be aspirated flakes of
lymph will often be found, a coagulum of fibrin will spontane-
ously be deposited, and the fluid will coagulate on heating it.
Enqjsted Dropsy of Peritoneum. Ovarian Cyst.
Extremely rare ; preceded by attack Common ; preceded by good health ;
of peritonitis ; increases slowly. increases more rapidly.
Respiration not impeded. Dyspnoea as cyst attains large size.
Digestion unimpaired. Generally aiFected.
Abdomen not prominent; often de- Everywhere prominent,
pressed in places, or fat.
Abdominal veins not enlarged. Enlarged.
No oedema of legs as a rule. Often oedematous.
Fluctuation feeble and limited ; fluid Marked, extending over area of dul-
in front of intestine. ness ; intestines pushed to sides of ab-
domen.
Per Vaginam. — No tumor felt; sel- Tumor well defined; fluctuation oc-
dom fluctuation detected. casionally marked.
Uterus normal in position, occasionally Uterus generally posterior to tumor ;
fixed by adhesions. occasionally drawn up or tilted.
On tapping, amount of fluid small. Very large quantity often obtained.
Flakes of lymph often found. Co- No flakes of fibrin unless previous in-
agulum of fibrin spontaneously de- flammation of cyst,
posited.
Coagulates on heating. Also coagulates.
812 OVARIAN TUMORS.
Encysted Abscess of the peritoneum, from septic peritonitis, can-
cer, or tuberculosis, may simulate ovarian dropsy.
The rapidity of its formation and the history of previous in-
flammatory mischief may assist us in forming an opinion as to the
character of the accumulation.
The vaginal examination disclosing adhesions between the pel-
vic organs, or the presence of a dense deposit at the roof of the
vagina, may also help to clear up the diagnosis.
Fibro-fatty Tumors of the Abdomen may cause enormous disten-
tion, rendering the walls exceedingly tense, presenting a distinct
sense of fluctuation, the vibratile wave being most perfect, so that
it is impossible to distinguish them from ovarian tumors.
Cancerous Disease of the Omentum may form a tumor of consider-
able size, and where, as not infrequently happens, this is compli-
cated with ascites, the difficulty of determining the nature of the
growth is often extreme.
They are generally of irregular shape, often of rapid growth,
more or less painful. The general health is aflected, emaciation
sets in early, and the characteristic cachexia ensues.
FsBcal Tumors occasionally occur, but seldom sufficiently large
to be mistaken for ovarian tumors.
They possess a peculiar doughy feel on manipulation, and on
steady pressure a distinct indentation may be made in them, which
remains after the pressure is removed.
There is usually a history of constipation, alternating with colic
and attacks of diarrhoea.
They may occur in any part of the large intestine, not neces-
sarily only in the lower portion.
Enlargement of the Liver takes place from above downwards.
There is an area of resonance below the tumor, that is between
the lower margin and the pelvis ; the tumor is independent of the
pelvis. The sharp edge of the liver can often be plainly felt, and
the fingers can be inserted underneath.
The position on the right side is also typical.
The symptoms of hepatic disorder are often well-marked.
Enlargement of the Spleen from leukaemia may be suspected from
the appearance of the patient. The tumor is situated on the left
side, grows downwards and towards the middle line, is dense,
with a well-defined, sharp, hard border. The notch may often be
recognized.
The tumor is not connected with the pelvis.
Diagnosis in the early stage of an Ovarian Tumor.
Although practically it but seldom happens that we are called
upon to diagnose an ovarian tumor before it has become sufficiently
large to be felt in the abdomen, it will be well briefly to consider
how we can recognize a small intra-pelvic ovarian tumor, and with
what other conditions it is liable to be confounded.
An ovarian cyst, the size of a large orange or small cocoanut, may
PELVIC ABSCESS. 313
occupy the pelvis, pushing the uterus out of position, and causing
serious discomfort from pressure. It will usually be found lying
in the retro-uterine pouch, displacing the uterus forwards, or it may
be upwards and to one side.
The cyst is generally tense, smooth, rounded. On conjoined
manipulation, fluctuation may be distinct. On passing the uterine
sound, the uterus may be felt to move independently of the cystic
tumor.
The conditions most liable to simulate a small ovarian cyst are :
Hetro-version or -flexion of the gravid uterus from the third to the
fourth month.
Tubals or other form of Extra-uterine Gestation.
Pelvic Abscess. Dropsy of the Fallopian Tube.
"Where retro-version or -flexion of the gravid uterus about the third
or fourth month occurs, there is usually the history of pregnancy,
with possibly the occurrence of a fall, to account for the misplace-
ment.
The cervix uteri is generally high up behind the pubes, and
difiicult to reach with the examining finger ; it is enlarged and
soft. The fundus uteri presents the character of a softish solid
mass, not fluctuating, mere fleshy and resisting than in the case of
an ovarian cyst, enlarging uniformly to either side of the cervix.
The mammary signs of pregnancy, — fulness, increase of area
and darkening ^of areola, enlargement of follicles, etc. — are gen-
erally well marked.
In tubal or extra-uterine gestation, within the fourth month, the
patient generally believes she is pregnant. The uterus is enlarged,
the cervix softened. The uterus is pushed out of its normal posi-
tion by a tumor, generally behind or to one side of the uterus.
The tumor is elastic in character, often presenting an obscure sense
of fluctuation. Ballottement may often be detected. The history
of amenorrhcea for two or three months, with irregular crampy or
paroxysmal colicky pains, occasional attacks of menorrhagia, with
possibly the expulsion of the decidua in one mass, will also assist
us in forming an opinion.
The mammary signs of pregnancy are generally distinct, often
typically developed.
Pelvic Abscess. — The history here will be important. The fact
of a rigor followed by febrile symptoms and other local indications,
such as throbbing pain, irritability of bladder and rectum, with a
sense of pressure, and discomfort, will be sufficient to show that
pelvic cellulitis has taken place.
The detection, per vaginam, of a painful, tense, fluctuating
tumor, pushing the uterus out of position, and fixing it more or
less, will generally serve to distinguish the nature of the affection.
It must, however, be remembered that an ovarian cyst may set up
pelvic peritonitis, w^hich fixes the tumor in the pelvis, though this
is comparatively rare.
Puncture with the aspirator trocar, and examination of the fluid,
will settle all doubts.
314 OVARIAN TUMORS.
Dropsy of the Fallopian Tube. — This is usually of limited size.
The cyst, in place of being uniform or rounded, is often subdivided
by tight fibrinous bands encircling and constricting the tube at
various points, so that it presents the character more of a tortuous
convoluted saccular dilatation than that of a simple cyst. Other
conditions may cause some little difficulty to the inexperienced,
and may therefore be mentioned; but to class them with those
most likely to mislead the practitioner would create more con-
fusion than necessary. Such are :
Distention of the Itectwn by Faeces; Cancer of the Rectum; small
Fibroid Tumors of the Uterus ; Hcematocele ; Pelvic Cellulitis.
Accumulation of Foeces may be recognized by the peculiar doughy
feel of the mass — ^the finger when pressed upon it through the
vagina indenting it permanently.
Examination per rectum, at once detects the fsecal accumulation.
The effects of castor oil, and the administration of an enema, wdll
generally be sufficient to remove the mass.
Cancer of the Rectum. — The general symptoms of irritation of
the low^er bowel, diarrhoea, offensive slimy discharge, like coffee-
grounds mixed with pus, are usually present. When of an en-
cephaloid character, there is often a large softish tumor to be felt,
blocking up the rectum. There is frequently very little pain or
discomfort if the growth be not near the anus.
A small sub-peritoneal Fibroid of the uterus may be diagnosed
by its hardness and its connection with the uterus.
Retro-uterine Hcematocele. — The history of the sudden invasion of
symptoms in connection with some uterine disorder or menstrual
irregularity, the fixity of the uterus, and the character of the effu-
sion, will generally enable us to distinguish this affection.
Pelvic cellulitis rarely presents any serious difficulty. The history
of inflammatory mischief following parturition or operation on the
uterus, the absolute immobility of the swelling, and its more dif-
fused character than in the case of ovarian tumor, will be sufficient
to distinguish the two affections.
Diagnosis of Adhesions of Ovarian Cysts.
Although moderate adhesions offer no serious difficulty to the
removal of ovarian tumors, nor the fact of their presence dimin-
ishes the prospect of recovery, yet where extensive and intimate
adhesions to the pelvic cavity, or to the lower surface of the liver
or intestines, exist, ovariotomy may be altogether frustrated, or its
completion inflict so great an amount of injury as to produce a
fatal result.
The tumor may be presumed to be free fi^om adhesions if
1. There have been no attacks of peritonitis, as evidenced by
pain, etc.
2. If on grasping the tumor with both hands through the abdo-
minal Avail it can be moved from side to side, or the abdominal wall
can be freely moved over the tumor, or lifted up from its surface.
DIAGNOSIS OF MALIGNANCY. 316
3. If on inspiration the tumor can be seen to glide downwards,
and upwards again on expiration.
4. If the tumor can be seen to fall to the dependent side on
altering the position of the patient.
5. If a layer of ascitic fluid co-exists with the tumor.
6. If the abdominal walls be very thick.
7. If the uterus be normal as to position and mobility.
8. If the cyst collapses and falls towards the pelvis after tapping.
Adhesions may exist posteriorly although the tumor appears
mobile. It is more in respect to adhesions anteriorly and lat-
erally that the previous remarks apply. There may be extensive
adhesions, and yet these have become so drawn out that the tumor
may admit of free movement, although its removal may be attended
with difiiculty. Pelvic adhesions may be simulated by a portion
of the tumor being more or less impacted in the pelvis.
Where the uterus and tumor seem to be intimately associated
and the sound m utero fails to produce separate movement, or the
uterus is found to be fixed in the pelvis, adhesions are probably
present. Malignant forms of tumor are more commonly adherent
than benign. Where adhesions are recent, a fremitus or friction-
movement may often be felt by the hand as the tumor moves up
:and down on respiration, but this is also simulated by promi-
nent vessels or other inequalities on the surface of the tumor, and
' often shows that no adhesions exist. Wliere the tumor is low in
• the pelvis, and especially if the uterus be elevated or drawn out of
iits natural position, adhesions are likely to exist. Adhesions are
more likely to occur where pregnancy complicates the course of
•the' tumor.
The fact of previous tapping having been resorted to, unless the
cyst be already adherent at the seat of puncture, does not deter-
mine adhesions.
Diagnosis of 3Ialignancy. — This is often important, for if malig-
mant the case is not suitable for ovariotomy, whereas if a benign
I tumor be diagnosed as malignant, and an operation be refused, we
' deprive the patient of her only chance of recovery.
Carcinoma is the least common of all the diseases of the ovary.
'The general health fails early; emaciation is often out of all pro-
1 portion to the size and duration of the tumor; the w^ell-known
cachexia supervenes. Where a rapidly growing solid tumor, nodu-
Uar or irregular in. outline, accompanied by a rapid accumulation
of ascitic fluid, occurs in an elderly person, the presumption is
strongly in favor of malignancy. Evidence of cancer in other
organs would also guide us in our opinion. Lancinating pain,
especially at night, is alw^ays suspicious.
If the uterus be found adherent to the tumor, if nodular masses
exist posterior to or around the cervix, as detected by rectal ex-
ploration, together with the other symptoms just mentioned, the
e^ddence is very strong.
Malignant degeneration of the cyst wall, as a secondary deposit,
occasionally occurs, in the form of proliferating papilloma. K the
316 OVARIAN TUMORS.
fluid be examined, we shall detect grape-like clusters of cells, of
very varying shape, many of which have multiple nuclei. In this
case speedy removal of the tumor offers the only hope for the
patient. K, however, a similar condition of the ascitic fluid he
detected, it indicates that the peritoneum is involved, and that an
operation is too late.
Where the measures already described fail in enabling us to
establish a correct diagnosis, there are still others at our disposal.
These are aspiration^ tapping, and exploratory incision.
Aspiration of a small amount of fluid for chemical and micro-
scopical examination may be performed by means of an ordinary
hypodermic syringe. Two or more punctures may be made in
different situations, in order to determine whether the case is one
of polycystic tumor, though if this latter be suspected, it will be
better to employ a Dieulafoy's aspirator, as the fluid is often very
viscid, or may be colloid in character, and in that case the hypo-
dermic syringe would probably be inefficient.
Tapping, for diagnostic purposes only, should not be rashly un-
dertaken, as it is not free from danger. In simple ovarian cysts,
where the fluid is generally of a bland, unirritating nature, tapping
is not, as a rule, a dangerous operation. But in polycystic tumors
it is a very dangerous operation, for the cyst wall being very vascu-
lar, heemorrhage may ensue from wounding a vessel ; or inflamma-
tion of the cyst may supervene with consequent suppuration; or
peritonitis may result from the escape of irritating fluid from the
cyst into the peritoneal cavity.
In cases of ascites with suspected ovarian tumor, tapping may be
resorted to in order to determine the presence or otherwise of a
tumor, and if possible to settle the question of malignancy.
If a very thin- walled unilocular cyst be detected, tapping may
decide whether it be merely a cyst of the broad ligament, or a true
cystoma of the ovary. In the former case the cyst does not often
refill, and thus w^e have gained a double advantage, having made a
permanent cure. In the latter, tapping may determine the exist-
ence or non-existence of extensive adhesions.
Tapping may also be of great service in determining the differ-
ential diagnosis of ovarian cysts and flbro-cystic disease of the
uterus.
Where it is doubtful whether we have an ovarian polycyst, at!
renal, or an hepatic cyst, tapping may be justifiable, pro\dded that
if the character of the fluid shows the tumor to be ovarian, the
operation of ovariotomy shall forthwith be proceeded with.
Exploratory incision should not, as a rule, be resorted to for diag-
nostic purposes until surgical interference of some kind is de-
manded, and not then, unless ovariotomy be proceeded with, if
the case prove a favorable one for operation.
As it involves opening the peritoneal cavity as well as manipu-
lation of its contents, the operation is by no means free from danger,
many cases terminating fatally within a few hours or days.
Prognosis. — A consideration of the natural course and termina-
MEDICAL TREATMENT. 317
tion of ovarian cysts shows that in at least ninety per cent, patients
die within two years after first seeking medical aid, unless an oper-
ation be resorted to.
The methods in which death is produced have been alread}^ in-
dicated. Trivial intercurrent affections, of no importance to a
woman in health, may rapidly prove fatal to a patient whose every
flmction is deranged, and whose general standard of health is so
deteriorated.
Treatment [Medical). — As regards effecting a radical cure of an
f ovarian tumor by any knowm internal remedy or external appli-
cation, there is not trustworthy evidence that anything has the
slightest influence either in arresting the growth or producing ab-
sorption of the contents. Instances of supposed cure have more
tthan probably been cases of mistaken diagnosis.
Wells remarks : " It is better at once to put aside the old pre-
' sumptuous talk about deobstruents, discutients, evacuants, and such
like delusively promissory inanities."
Bromides, iodides, chlorates, mercurials, and pretty well every
' drug in the pharmacopoeia, have been tried in vain.
In fact, so utterly useless is medical treatment as a means of
cure, that any further consideration of the subject is unnecessary,
land would be eminently unprofitable.
Any measures calculated to improve or preserve the general
I health may prove of service in delaying a fatal termination. Seda-
tives or stimulants, tonics and aperients, attention to diet, exercise,
land other similar indications, maybe of service in palliating symp-
: toms, but beyond this the physician can accomplish nothing. The
^3urgeon, however, has rescued ovarian tumors from the domain of
hopeless incurability, and we shall now consider the various expe-
^Idients that have been adopted for the removal of these growths.
318
SURGICAL TREATMENT OF OVARIAN CYSTS.
CHAPTER XXL
SURGICAL TREATMENT OF OVARIAN CYSTS, INCLUDING OVARIOTOMY.
Surgical Treatment of Ovarian Cysts. — To prevent the repetition
of operations which experience has condemned as unsatisfactory
and unreliable, it may be well to mention the various proceedings
which have from time to time been tried for the relief or cure of
ovarian cystic tumors.
Tapping, as a preliminary or palliative measure, and ovariotomy
as a curative method, are, however, the only ones to be relied upon.
{1. Through the abdominal walls.
2. Through the vagina.
3. Through the rectum.
A. Tapping followed bj^ pressure.
B. Tapping followed by injection
of iodine.
II. Curative Treatment. -
C. Formation of permanent open-
ing in cyst.
D. Ovariotomy, or entire extirpa-
tion of the ovarian cyst.
Externally.
Per vagi nam.
Per rectum.
Internally, by
partial inci-
sion of sac.
I. Palliative Treatment. Simple Tapping ; Paracentesis. — "We
have already considered the advantages of tapping as an aid to
diagnosis. The operation may be expedient in certain slow-grow-
ing, unilocular, thin-walled cysts, occurring in young persons, on
the chance of their being parovarian, when as a rule they do not
refill, and thus a permanent cure is established.
In other cases, where the diagnosis is doubtful, or where ovari-
otomy has been decided to be impracticable, tapping may prove of
much value in facilitating diagnosis, or in prolonging life by ren-
dering the patient's condition more endurable.
Tapping is also of service, as a preliminary measure, in those
cases where from the enormous distention of the abdomen the
tumor has produced such an amount of pressure as to interfere
materially w^ith the functions of the kidneys, heart, and lungs.
Removal of this pressure will give the several organs time to re-
cover themselves, and thus not only diminish the shock of the
more important operation of ovariotomy, but also improve the
prospects of recovery.
As a rule, if the tumor has been diagnosed to be polycystic,
tapping should be avoided for the reasons previously indicated.
TAPPING THKOUGH THE ABDOMINAL WALLS. 319
Apart from the dangers attending the operation, the cyst rapidly
refills and the progress of tlie disease is often accelerated.
Where an ovarian cyst complicates pregnancy, or parturition,
tapping may be necessitated irrespective of the nature of the cyst.
Where the general health has become much enfeebled before
the case of a large ovarian cyst has been brought under observa-
tion, tapping may enable us to relieve the patient for the time
being, and thus postpone the operation of ovariotomy until a more
convenient time.
1. Paracmtesis abdominis; Tapping through the abdominal walls. —
Either instruct the patient to evacuate the contents of the bladder,
or pass a gum-elastic catheter immediately before the operation.
Ascertain whether pregnancy be suspected. Percuss the abdomen
carefully at the time, to detect any intestine in front of the tumor;
note also the presence of any enlarged superficial veins, and avoid
them. See that a hip-bath, foot-pan, pails, or other large vessels
are handy. Let the patient lie on her side, near the edge of the
bed, so that the abdomen projects over the edge. If she happen
«to be exceedingly nervous, a few whiffs of chloroform may be
given, or the seat of puncture may be frozen by ether spray. The
'linea alba is the preferable site for puncture, but if the tumor con-
tain solid matter, this must be avoided, and the most elastic or
• distinctly fluctuating part of the tumor selected.
A small incision with a scalpel or lancet is then made through
!the skin, abbut midway between the symphysis pubis and umbili-
â– â– cus, in the linea alba, unless otherwise contra-indicated ; the trocar
lis then plunged into the cyst. Thompson's trocar, with a yard of
"india-rubber tubing attached to the canula, answers the purpose
best, as there is less risk of air gaining access to the cyst, especially
df the end of the tubing be placed under water. The trocar is now
withdrawn from the canula, exercising a suction power which draws
; a little of the fluid into the canula, and so a siphon action is pro-
duced, the fluid continuing to run until the cyst be emptied. Care
must be taken to keep the end of the tube under the fluid when
the cyst is nearly empty, lest air be sucked into the cyst from the
movements of respiration.
Before incising, a long binder may be placed round the abdo-
men, a slit being made in it opposite the intended seat of puncture,
or an assistant may compress the abdomen with the extended hands
as the fluid is evacuated, so as to prevent the occurrence of faint-
ness from sudden withdrawal of the abdominal pressure, as also
the admission of air into the sac. The binder is gradually tight-
ened, or compression by the hands increased as the fluid flows.
Should the cyst only partially collapse, the trocar can be again
replaced in the canula to clear any obstruction, or another cyst be
punctured, without withdrawing the trocar from the original open-
ing. If solid matter be detected, it will be well to avoid interfering
with it, lest haemorrhage result. When the fluid has ceased run-
ning, press the abdominal walls well down upon the cyst, gradually
withdraw the canula, and with the finger and thumb compress the
320 SURGICAL TREATMENT OF OVARIAN CYSTS.
abdominal wall behind the escaping canula, so as to prevent the
entrance of air.
A small dossil of cotton-wool steeped in collodion, or a small
pad of lint and a few strips of adhesive plaster, should then be
placed over the opening. If any bleeding occur, and this cannot
be stopped by pressure, a hare-lip pin passed across the opening
under the bleeding vessel, and a few turns of silk twisted round
the pin, will generally suffice to arrest any further bleeding.
Where the amount of fluid withdrawn be great, it is better to
apply some pads of cotton-wool, or other material, to the sides of
the abdomen, and then a binder, so as to compress the abdomen
and afford support. The patient must be kept perfectly quiet in
bed for a few days, to avoid all risks of inflammation or other com-
plications. When the fluid withdrawn is viscid, many recommend
washing out the sac with warm carbolized water.
The dangers attending the operation of tapping by the abdomen
are the risk of haemorrhage from wounding a vessel either in the
abdominal wall or in that of the sac. The former may generally
be obviated by avoiding any superficial vessel, or even securing it
after incision before the cyst be punctured. The latter is scarcely
avoidable ; peritonitis may ensue as a consequence, or effusion of
blood into the C3'st take place to a serious amount. If there be
evidence of this, ovariotomy should at once be performed. Col-
lapse may follow the rapid emptying of the cyst. Peritonitis may
be set up by some of the fluid escaping into the peritoneal ca\dty,
and prove fatal. Air may be sucked into the sac. Exhaustion
may arise from repeated tapping. These dangers will be best
avoided by attention to details already mentioned, and by perform-
ing the operation antiseptically.
2. Tapjnng through the vagina is more difficult than by the abdo-
men, and is also more dangerous. It is only applicable in a limited
number of cases, as of a small cyst, which descends into the pelvis
and bulges the posterior vaginal cul-de-sac^ where fluctuation is well
marked, and there is no solid portion detectable. There is more
danger of injuring the vessels of the tumor, which are larger and
more numerous at its lower part, as well as of wounding other
organs. In polycystic tumors the larger cysts are generally upper-
most, and solid masses in the lower portion. As a rule air enters
the cyst, the opening fills up, and the fluid remaining in the cyst,
or that freshly secreted, putrefies. Suppurative inflammation of
the lining membrane of the cyst comes on, and is accompanied by
a low form of exhaustive fever or pyaemia, which can only be re-
lieved by making and maintaining a free outlet for the discharge.
Tapping through the vagina should therefore be practised only
exceptionally, where the cyst is bound down in the pelvis by adhe-
sions, and it is necessary to relieve the distress caused by pressure
on the bladder and rectum. The employment of the aspirator
trocar lessens the risks. Before operating, the bladder and rectum
should be emptied, and the exact position of the uterus ascertained
by touch and by the sound.
CURATIVE TREATMENT. 321
The patient may either be placed in the lithotomy position, or
in tlie usual obstetric position on the left side. A moderately tight
binder having been employed, or an assistant pressing the tumor
firmly down into the pelvis, the forefinger or the middle and index
fingers of the left hand are then passed per vaginam to the lowest
and most accessible part of the tumor, an inch or so behind the
cervix uteri. The point of the trocar having been withdrawn
within the canula, this is then glided along the fingers by the right
hand until the point is in contact with the intended site of punc-
ture ; the trocar is then projected and thrust in perpendicularly to
the surface, and carried in the direction of the axis of the pelvis
until the sense of resistance is suddenly lost. The trocar is then
withdrawn, the canula remaining in situ, and the fiuid allowed to
drain oif, or exhausted from time to time if the aspirator be
employed. The trocar and canula are then withdrawn, and the
patient kept perfectly quiet in bed. Nothing further should be
done at present, beyond, possibly, injecting the cyst with some dis-
infecting liquid if the fluid be very viscid. Firm pressure over the
abdomen must be employed for several days. Repeated tapping
may result in gradual shrivelling up and obliteration of the cyst.
This may often be attained with greater certainty by means of a
drainage-tube being inserted, incision of a small portion of the
cyst wall, or by injections of iodine. Severe reaction often follows
these expedients; a discharge of ichorous fiuid, gradually chang-
ing to purulent, takes place, which continues for several weeks,
becoming less and less as the cyst becomes obliterated.
3. Tapping through the rectum is not an operation to be encour-
igecl. Dysenteric tenesmus of a very distressing character not in-
iequently occurs, and fatal infiammation has followed the entrance
|)f fecal gases into the cyst. Except in cases of atresia vaginae, or
vhere the vagina is so small as to preclude the requisite manipula-
ion, puncture per rectum should not be resorted to.
K deemed expedient, the same precautions as those advised in
)uncture per vaginam should be attended to. A long curved trocar-
hould be employed.
II. Curative Treatment. — a. Tapping followed hy pressure has
>een tried, but without success. It is a somewhat painful and quite
iinreliable procedure. After tapping, thick pads are applied to the
bdomen, and pressure exerted by strips of plaster extending right
ound, so as to embrace the spine, meeting and crossing in front;
laced bandage being applied over these, prevented from slipping
I pward by a strap round each thigh. This method should never
e resorted to ; it is liable to produce adhesions, and has nothing
o recommend it.
B. Tapping, followed hy injection of iodine, may be tried in cases of
' mple, movable, uncomplicated, unilocular cysts, where from any
sason, such as the existence of phthisis, or where the patient will
ot submit to ovariotomy, no more reliable operation can be re-
jrted to. It is at best a doubtful proceeding, and though spoken
ivorably of by a few enthusiasts, has not received the approval of
21
322 SURGICAL TREATMENT OF OVARIAN CYSTS.
modern ovariotomists. Wells says the onh^ class of cases where
its employment should he recommended, is where inflammation of
the cyst has occurred subsequently to tapping, and the patient is
suffering from absorption of the decomposing contents of the cyst,
and then only conjoined with drainage.
Tincture of iodine, pure, about four ounces, may be injected and
allowed to remain in ten minutes, then withdraAvn ; or a solution
of tincture of iodine and water, equal parts, injected. As a disin-
fectant, one part of the tincture to twenty of water may be em-
ployed.
c. Formation of permanent opening in cyst. — Wells considers this
practice far more dangerous than ovariotomy, very much more
uncertain in its results, and very much less likely to be followed by
complete cure. It should therefore only be considered admissible
in cases where ovariotomy cannot be completed.
It will be unnecessary to describe the various modes of oper-
ating. The vaginal one has apparently been most successful of
any when undertaken as a primary operation. The cyst is punc-
tured and either the canula or drainage-tube left in, the cyst being
washed out repeatedly with disinfectant solutions. But Avhen we
consider that the treatment will need to be continued for months,
and sometimes for years, that the patient is subject to an exhaust-
ing and offensive discharge, that peritonitis may at any time super-
vene which may prove fatal, it is needless to say the operation is
not one that can be recommended.
Cases occasionally occur, where, on making an exploratory in-
cision with a vicAv to ovariotomy, the cyst is found to be so firmly
adherent everywhere that its removal is impossible. Instead of
closing up the wound completely, the tumor may be tapped, and
the edges of the opening in the cyst fixed to the abdominal wall
by suture, and the case treated as an abscess, by drainage, and the
injection of disinfectant or deodorizing agents.
Ovariotomy.
This term, now so familiar to surgeons that any suggestion ol
changing it seems hopeless, is a barbarous compound of Latin and
Greek which does not express the meaning intended. It implies
cutting an ovary, or ovario-section, while the more appropriate
and distinctive term, as suggested by Peaslee, to signify cutting out
an ovary, or ovario-exsection, should be Oophorectomy ('r!o(popov
and ixT£>v6j, to cut out the ovary).
Ovariotomy is the only reliable curative means at our disposa
for the relief of patients who are the subject of ovarian tumors.
Indications for Ovariotomy. — Wells sums up the important prac
tical conclusions that, so long as an ovarian tumor does not mate
rially interfere with the appearance, prospects, or comfort of tli<
patient; so long as no injurious pressure is exercised by it on th< '
organs of the pelvis, abdomen, and chest; so long as heart an*
lungs, digestive organs, kidneys, bladder, and rectum perform thei
CONTRA-INDICATIONS FOR OVARIOTOMY. 323
functions without much disturbance; so long as there is no great
emaciation, no very wearying pain, no distressing difficulty in lo-
comotion; or, so long as such injurious influence can be counter-
acted by ordinary medical care, the patient should be left to that
care, undisturbed by any surgical treatment.
Most modern operators agree in postponing ovariotomy until
the tumor has attained such a size as to interfere somewhat with
the general health, until the abdominal parietes have become at-
tenuated, the patient slightly ansemic, and accustomed to an in-
valid life. The reasons being that a person in robust health does
not bear a severe operation well ; she incurs a greater risk of
peritonitis, which destroys one-fourth of all who succumb to the
operation, the healthy peritoneum being more liable to become
inflamed than after protracted pressure, when it becomes less sus-
ceptible and more tolerant of interference. Anaemic patients are
also less liable to haemorrhage. If menstruation has been arrested
by the ovarian disease, the uterus and ovaries being inactive, there
is less danger of inflammation.
At the same time, the patient should not be allowed to go on so
long unrelieved that the pressure of the tumor causes interference
with the functions of circulation or respiration, or with the renal
secretion, or the digestive function.
In unmarried patients, whose enlarged abdomen subjects them
to nmch annoyance from uncharitable remarks, who regard their
honor even of more value than life itself, we may be justified in
performing ovariotomy sooner than we should otherwise do. It
is a question whether the method of operating antiseptically may
not shortly modify our views as to the time of operation. Com-
paratively small cysts are now frequently removed without any
apparent increase of risk.
Where evidence of inflammation of the cyst, haemorrhage into
the sac, or peritonitis exists, we may be called upon to operate
without delay. Cases have been reported of successful removal
even during an acute attack of peritonitis. Should it be deemed
advisable to wait until the acuteness of the attack has subsided,
the operation should not be delayed too long, lest the adhesions
become so firm as to interfere with the removal of the cyst.
If the tumor be suspected to be malignant, the sooner it is re-
moved the better the prospect for the patient.
If on tapping, to confirm diagnosis, the tumor be found to be
colloid in character, it should be removed without delay.
Contra-indicatioiis for ovariotomy. Extensive adhesions, especially
of the lower portion of the tumor to the pelvic organs, if clearly
diagnosed before the operation be attempted, may deter us from
operating.
Ascites does not contra-indicate ovariotomy, provided it is caused
by the ovarian tumor and is not due to any organic afiection of
some other organ. Extreme debility need not necessarily preclude
ovariotomy as a forlorn hope, if it be due to the ovarian disease
alone, and the patient desires the operation.
324 SURGICAL TREATMENT OF OVARIAN CYSTS.
Peritonitis, as we have stated, instead of being a contra-indica-
tion, should be regarded as a reason for the prompt performance
of ovariotomy.
Albuminuria, unless associated with other signs of Bright's dis-
ease, may be due to pressure on the kidneys, and need not prevent
our operating.
Suspicion of malignancy should not forbid the effort to save the
patient; if in doubt, operate.
Valvular disease of the heart is not necessarih^ a contra-indication.
A previous ovariotomy need not deter us from removing the
other ovary should it become the seat of cystic degeneration.
Ovariotomy is absolutely contra-indicated by actually recognized
cancer of the ovary, or of any other organ ; by rapidly advancing
tuberculosis, or scrofula; by all organic diseases of the brain,
heart, liver, or kidneys; by ascites, if produced by disease of
either of the three last-mentioned organs; by ulcers of the stomach
or diseases of the alimentary canal which permanently impair gen-
eral nutrition.
Scurvy, extreme anaemia or chlorosis, hectic fever, great weak-
ness, red tongue, with rapid and feeble pulse ; profuse diarrhoea,
extreme emaciation and exhaustion, decided unwillingness to sub-
mit to the operation, or mental despondency and despair of recov-
ery, would lead, if not to absolute prohibition, to a very unfavor-
able opinion as to the probable result.
Precautions before Operating. — ^Be extremely cautious in arriving
at a diagnosis. Examine carefully the condition of the chest, in
order not to overlook tuberculosis, heart-disease, pleuritic effusion,
or other condition which might seriously interfere with prolonged
anaesthesia. Test the urine for albumen, and examine it also under
the microscope for casts, lest advanced Bright's disease prove to
be the exciting cause of the ascites or oedema, and not merely
pressure on the kidneys from the tumor.
Ascertain when the menstrual period is due, and do not operate
for at least four days after, or ten days before, the expected period.
If much ascites, anasarca, or oedema of the legs complicate the
case, it may be well to tap the patient some few days before resort-
ing to the more serious operation, so as to remove pressure and
allow the several organs and functions to recover themselves a
little. Having decided when the operation shall take place, avoid
every possibilit}^ of the patient being exposed to any risk of infec-
tion from any of the exanthemata, and especially of erysipelas,
pyaemia, or septicaemia, whether from the nurse or from any case
of this description existing in the house where the proposed opera-
tion is to be performed.
Avoid all risk yourself of being inadvertently called to see any
patient who may be the subject of any infectious disorder. Allow
no friend to assist at the operation who has recently performed
any post-mortem examination or who has attended any infectious
disease.
Preparation of the Patient for Operation. — Before performing the
PREPARATORY ARRANGEMENTS. 325
most formidable operation the surgeon encounters, every possible
precaution should be taken to secure a favorable result. Should
the patient be in a very anaemic condition when first seen it may
be well, if the case be not urgent, to postpone the operation for a
short time, until the condition of the general health has been im-
proved by tonics, attention to diet, rest, etc. The skin should be
induced to act by means of warm baths, frictions, and warm cloth-
ing. The digestive function should be attended to, any inactivity
of the liver counteracted by a little blue pill, podophyllin, or other
suitable remedy. The bowels should be regulated by an occasional
dose of castor-oil, salines, or other aperients. Wells advises a
draught of five grains of tartrate of iron, five of carbonate of lithia,
and ten each of the bicarbonate of potash and soda, with a few
drops of chloric ether two or three times a day. If the urine be
scanty and high-colored, depositing lithates in abundance, nothing
tends so rapidly to clear it as lithia, which leads to a more abun-
dant secretion of urine, free from deposit. The bowels in any case
should be freely opened by castor-oil the day before the operation,
opium being given at bedtime to ensure sleep and allay any intes-
tinal irritation. Thomas recommends opium every six or eight
hours for a few days preceding the operation, to quiet the nervous
system, allay any fears as to the operation, and lessen the tendency
to peritonitis after the operation.
The diet for the last day or two should also be light and easily
digestible, the least bulky and the most nutritious.
' At the time of operation the patient should be clad in flannel
drawers, worsted stockings, a flannel jacket with long sleeves, the
night-dress being rolled well up round the waist, to prevent its
becoming soiled and to avoid the necessity of having to change
the linen after the operation. She should have no solid food within
an hour or two of the operation. An enema may be given early
in the morning, if deemed requisite, and the bladder be emptied
the last thing before anaesthesia be commenced.
Preparatory Arrangements. — A properly trained nurse, experi-
enced in these special cases, who can draw ofl' the urine, record
temperatures, administer enemas, attend to any dressings, etc., is
absokitely essential. She should take charge of the patient a few
days before the operation, so as to carry out any instructions as to
preliminary treatment, and also to have everything in readiness.
A large airy room, high up for choice, as quiet as possible, should
be selected. Thorough ventilation is of the utmost importance.
If possible, a bright clear day, when the wind is not in the east,
should be chosen. The time for operation varies with different
operators; either early in the morning, from nine to ten, or in the
afternoon at three, seems to be preferable.
A strong narrow table about four feet long (an ordinary dress-
ing-table answers the purpose well), another small one being placed
crosswise to support the head and shoulders, should be placed
somewhat obliquely opposite a window, not too near the wall ; a
folded counterpane or blanket is placed on this and covered with
326 SURGICAL TREATMENT OF OVARIAN CYSTS.
a mackintosh sheet, several pillows being handy to raise the head
and shoulders as may be deemed requisite. A small table should
be placed to the right of the operator to hold instruments, and
should be within easy access.
Another larger table, at some little distance, will be necessary
for basins and other appliances for cleansing sponges, etc.
All unnecessary furniture, especially curtains and carpets, should
be removed from the room. It is advisable to have two small iron
bedsteads, three feet six inches wide, with horsehair mattresses
upon them, away from the wall, so that the patient can be reached
equally well from either side. A plentiful supply of hot and cold
water should be in the room. The temperature must be regulated
by an open fire, which will also serve for heating any cautery-irons,
boiling water, etc. About 65° to 70° F. is a comfortable tempera-
ture for the room. A large bath, or several foot-pans or other suit-
able vessels, will be needed.
At least twenty small sponges, carefully washed and disinfected
by ammonia and sulphurous acid (1 in 8), and then in hot water,
should be provided ; they should be counted both before and after
the operation, to prevent the risk of one being left in the abdomen.
A plentiful supply of carbolic acid solution (1 in 40) is neces-
sary. Strips of stout adhesive plaster, two inches wide and about
eighteen inches long, should be hung over the back of a chair,
ready for use when wanted.
A supply of lint, cotton-wool, carbolized gauze, carbolized oil ; a
flannel belt, safety pins ; brandy, champagne, ice ; a small india-
rubber enema bottle, laudanaum, a catheter; a feeding-cup, and
anything else likely to be required, should be at hand.
Green blinds or some arrangement whereby the room can be
darkened after the operation, should not be forgotten.
Everything should be in such readiness, before the patient is
brought in, that it may not be necessary to send for anything or to
open the door.
A mackintosh apron, with an oval aperture about eight or ten
inches by six or seven inches, spread for about an inch round the
margins of the aperture with emplastrum plumbi, so as to enable
it to adhere to the skin all round, should be in readiness.
A long belt, similar to a horse-girth, will be required to strap
the patient's legs, just above the level of the knees, to the table, as
also wristbands and straps to secure the hands, or bandages, if this
be preferred.
Instruments. — Those required for a simple case are few, but as
w^e never know, until the abdomen be opened, what complications
may occur, or how formidable the operation may be, it is better to
have everything at all likely to be wanted in readiness, so as to be
prepared for every emergency.
In any case it will be necessary to have a steam spray-producer;
a scalpel to divide the abdominal wall ; a director to protect the
cyst as this division is completed ; a pair of scissors ; a trocar to
empty the cyst; torsion forceps and ligatures to secure any bleed-
ANTISEPTIC PRECAUTIONS. 327
ing vessels ; a clamp to secure, or stout silk cord to tie, the pedi-
cle ; a pair of stout dressing forceps ; needles and silk to close the
wound. Sponges, cotton-wool, carbolized gauze, carbolic solution
(1 in 20), and other similar requisites, have been already enumer-
ated. In addition to these, however, it wall be safer to have ready
on a reserve tray, separate from the instruments already mentioned,
needles of different shapes and sizes ; ligatures of varying thick-
ness; hare-lip pins or acupressure needles; artery, torsion, bull-
dog, and other forceps ; vulsella and clamp forceps to grasp the
cyst; galvanic or other cautery; straight and curved scissors; a
tenaculum ; w^ire retractors ; an ecraseur ; drainage-tubes ; some
styptic solution, as the perchloride of iron ; a sound to explore for
adhesions ; a syringe, and anything that the operator may be in
the habit of using in the course of the operation.
The operation should always be performed antiseptically, the
instruments being placed in metal or porcelain trays and covered
with a solution of carbolic acid (1 in 20). The sutures must also
be kept immersed in a similar solution, in a separate tray.
Assista7its. — One is requisite to administer the ansesthetic. This
should be his sole duty.
Another stands on the left-hand side of the table, opposite to
the operator, w^ho stands on the right side of the patient, with his
right hand towards the light, and if thought desirable, a third as-
sistant takes up his position on the left hand of the operator, and
may also attend to the steam-spray from time to time, the nurse,
with sponges and other necessary articles, being behind and to the
left of the patient. She should have basins with w^arm and cold
carbolized water (1 in 40), to wash the sponges in, ready.
The chief assistant, opposite the operator, with sponge in hand,
should be ready to dry the wound during the incision of the ab-
dominal walls, apply torsion forceps or ligatures to bleeding ves-
sels, secure the cyst with clamp forceps after it has been punctured
with the trocar, see that the end of the tube attached to the trocar
is properly directed into the receiver, support the cyst on its being
brought out, replace or prevent extrusion of intestines or omentum,
apply a large flat warm sponge to prevent their being unneces-
sarily exposed, assist in applying sutures to the wound, or any-
thing the operator may suggest. Absolute silence should be en-
joined, no officious suggestions or pathological questions being
mooted unless specially desired by the operator, whose every want
should be anticipated and judgment respected.
Antiseptic Precautions. — The follow^ers of Lister contend that these
should invariably be observed in performing an operation that in-
volves such a serious risk as ovariotomy. AVith the experience
recently gained by Thornton and others, of the application of
Lister's antiseptic method to the operation under consideration, it
would seem hardly justifiable to deprive the patient of the advan-
tages that have been proved to result from the carrying out of
this procedure, although recently the system itself has been called
in question. Li any case it will be well to describe the process.
328 SURGICAL TREATMENT OF OVARIAN CYSTS.
The steam-spray apparatus should be one capable of playing
continuously for at least two hours without the boiler becoming
exhausted. A solution of carbolic acid of the strength of 1 in 20
is placed in the jar, so that Avhen diluted Avith the steam-spray, it
will be about the strength of 1 in 40. It should be in perfect
w^orking order before anaesthesia is commenced. It is well to have
in reserve an extra supply of at least a Winchester quart bottleful
of 5 per cent, strength, which must be placed handy, so as to re-
plenish the jar as the solution becomes exhausted. The apparatus
should be placed at the foot of the table, and the spray directed on
to the abdomen of the patient, so as to envelop the surface in a
cloud of mist before the incision is made.
The operator and assistants should wash their hands in carbolic
solution (1 in 20), previous to the operation being commenced, and
even the abdomen of the patient should also be treated in a similar
manner.
Dr. Bantock, Mr. Lawson Tait, and others have recently ques-
tioned the advantages attributed to the Listerian precautions, and
endeavored to show^that pyrexia is more likely to follow antiseptic
operations from the absorption of carbolic acid, which is an irri-
tant poison, and prevents the wound healing by lirst intention.
They contend that the use of the spray is not only inefficient, but
positively injurious. The great point w^as strict attention to clean-
liness. Success depended more upon the man than the method ;
as experience increased the mortality diminished.
Bantock says that since he has departed from Listerism, merely
using warm water without any carbolic acid, both for the spray as
well as for the instruments, he has had better results both as to
mortality as well as pyrexia. He regards cleanliness as the most
potent factor, and the only true antiseptic system. On the other
hand, the evidence of Thornton is entirely in favor of Listerism.
He thus summarizes his experience in the following general con-
clusions : 1. Simple cases recover under Lister's method with a
certainty previously unknown. 2. There is less fever, and con-
valescence is more rapid than under the old method. 3. The suc-
cess obtained in the more complicated cases is in proportion to the
exactness with which the antiseptic method can be applied to the
individual cases. 4. The accidents and complications occasionally
following operation, such as haemorrhage for example, are more
easily overcome in aseptic cases. 5. There are difficulties and
some dangers in the application of the method, and the more ex-
perience the individual surgeon has in it, the more readily he fore-
sees and avoids these, and the more complete becomes his success
in applying it.
Anesthesia. — Chloroform almost invariably produces distressing
and persistent vomiting after the operation, and in long and diffi-
cult cases is apt to depress the pulse to a dangerous extent.
Ether often produces an irritating cough, the vapor becomes dif-
fused throughout the room, and it is difficult to induce complete
anaesthesia by it.
THE OPERATION OF OVARIOTOMY. 329
Chloromethyl, or bichloride of methylin, administered by Junker's
inhaler, is by far the safest ansesthetic. It does not produce bron-
chial irritation, is less depressing, even when administered through-
out a prolonged operation, and possesses more advantages and
fewer drawbacks than any other form of anaesthetic. It should
therefore be employed.
Everything being in readiness, the patient may either be anses-
thetized in an adjoining room, and then carried in to the operating-
table, or she may be placed in proper position on the table, the in-
struments being covered over with a towel, and the room tempo-
rarily darkened, and ansesthesia commenced. The catheter having
been passed, or the bladder previously emptied, the mackintosh
apron is applied to the abdomen, the belt is then placed round the
legs, the hands secured, the blinds drawn up, the assistants placed
in the position assigned to them, and the operation commenced.
The administrator of the ansesthetic stands at the head of the
operating-table, so as to be out of the way of the operator and his
assistants. It is not necessary to keep the patient continuously at
the point of narcosis, indicated by stertorous breathing, lividity of
lips and face, but merely to produce such an amount of anaesthesia
as will render her incapable of experiencing pain. If the opera-
tion be very prolonged, it may be prudent to allow the patient to
come to a little, and administer a little brandy and water by the
aid of a feeder.
The operation of ovariotomy includes the following procedures :
Incision through the abdominal walls ; exploration for adhesions ;
tapping the cyst; detachment of adhesions; drawing out of the
cyst ; constriction of the pedicle ; removal of the tumor ; examina-
tion of the other ovary ; cleansing the peritoneal cavity of blood,
or ascitic or cystic fluid; securing any bleeding vessels; closure of
the incision by sutures ; application of dressings.
The incision is made in the median line, three to four inches in
extent, from just below the umbilicus to within an inch and a half
or so of the pubes. All bleeding should be arrested before the
peritoneal cavity is opened, by torsion forceps, which are left hang-
ing outside the abdomen. If any ascitic fluid be present, the peri-
toneum may bulge through the opening and lead to the supposition
that it is a thin-walled cyst ; care must be taken to distinguish this,
lest the peritoneum be stripped from the abdominal wall on the sup-
position that extensive adhesions exist. The more solid cyst may
commonly be felt behind it. The peritoneum is then opened, and
a grooved director inserted in the aperture ; a blunt-pointed bistoury
being passed, the peritoneum is divided to the requisite extent. If
the cyst be adherent it may be well to extend the incision upwards
until some point is reached where the cyst is free, and from this
point separation of adhesions may be commenced, parietal adhe-
sions alone being dealt with at this stage, adhesions to omentum or
intestine, especially those at the posterior part of the cyst, being
left until the cyst be evacuated and the adherent viscera can be
seen. The hand is carefully inserted between the cyst and the
330
SURGICAL TREATMENT OF OVARIAN CYSTS.
Fig. 123.
abdominal wall, palm downwards, to search for adhesions, and if
not very tough, to separate or tear them. The cyst is now tapped
with Wells's Cyst Trocar (Fig. 123), having clamps attached to fix
the cyst wall to it. If a simple cyst, the
most prominent part is selected ; if mul-
tilocular, the largest cyst visible. The
fluid is conducted into a suitable recep-
tacle by a flexible tube attached to the
trocar. As the cyst becomes flaccid the
assistant presses the parietes of the ab-
domen in close approximation to the
cyst, so as to prevent an}^ fluid gaining
access to the peritoneal cavity, and also
to prevent the protrusion of intestines.
The cyst is gradually drawn out of the
abdomen, either by the hand or by
means oi Nelaton's Cyst Forcep (Fig. 124),
any adhesions not already separated
being broken dow^n or torn through.
Where several cysts are present in the
same tumor, they may be tapped suc-
cessively by pushing the trocar forwards
and thrusting it through the septa, or
by passing the hand into the cyst first
emptied, and so crushing them. Where
the tumor proves to be solid, or semi-
solid, and too large to pass through
the incision, this must be carefully ex-
tended.
The assistant at the operator's left
hand receives the C3'st in a towel or
basin, and supports it until it is com-
pletely separated, great care being taken
that no traction be exerted either on
the pedicle or on any undivided adhe-
sions, and that no fluid gravitates into
the abdominal cavity.
If, w^hile the tumor is being with-
drawn, the omentum, the mesentery, or
the intestines are seen to be adherent to it, the adhesions should
be cautiously detached by the fingers, or divided by the scalpel, or
b}^ scissors. Ligatures of carbolized gut or silk may be used to
secure any small bleeding vessels, cut short and left in situ. Every
portion of omentum where adherent to the cyst should be most
carefully examined, to see that no bleeding vessel be returned into
the peritoneal cavity. If the adherent surface be large, it may be
di^dded into sections, and each one tied separately before dividing
the adhesions, or compressed by the clamp forcep (Fig. 125), until
it is decided w^hat shall be done wdth it.
Adhesions to stomach, intestine, or liver need to be very cau-
SpencerWells's Ovariotomy Trocar.
THE PEDICLE.
331
Fig. 125.
tiously dealt with. If the cyst adheres so firmly that it cannot be
separated without danger, the adherent portion must he cut out
and left attached, the internal secreting mem-
FiG. 124. hrane being removed. The same method may
be adopted in regard to pelvic adhesions, the
cyst wall being split into two layers, the outer
being left attached and treated as a pedicle by
ligature or otherwise.
Should the intestine be in-
jured in any way by the knife,
scissors, fingers, or from de-
taching intimate adhesions,
the opening must be neatly
stitched up with a fine needle
and silk, and the ends cut
short.
The Pedicle. — Numerous
methods of securing this have
been adopted, but they may
all be classed under two heads,
the extra- and the mtra-perito-
neal method. In the extra-
peritoneal method the pedicle
is secured by a clamp (Fig.
126), of which endless varie-
ties have been invented, and
then secured in the lower an-
gle of the wound, the tumor
being cut away within an
inch or so of the clamp.
The method is not applica-
Nelaton'sCystForcep. ^^^ whcu the pcdiclc is VCry
short or very broad. It pos-
sesses the advantage that the surface, which may bleed or give rise
to discharge, is always kept in sight, and the discharges escape ex-
ternally.
The disadvantages are that the stump strangulated in the clamp
may slough and fall back into the abdomen; serious symptoms
may arise from traction ; the clamp may slip or be forced off by
violent retching or coughing ; it may fail to arrest haemorrhage ; it
prevents the entire closure of the incision, and thus subsequent
weakness of the abdominal wall, or even hernia, may result. The
clamp necessitates a permanent union of the pedicle with the ab-
dominal walls; this may predispose to internal strangulation of
a portion of intestine, and to a miscarriage if pregnancy should
occur.
The clamp is often a long time in separating, and not infrequently
produces ulceration of the abdominal wall from pressure, which
takes a long time to heal.
The intra-peritoneal method includes the ordinary plan of securing
1
Spencer Wells's Small
Clamp Forcep.
332
SURGICAL TREATMENT OF OVARIAN CYSTS.
Fig. 126.
the pedicle by ligatures and other less usual methods of torsion,
acupressure, the ecraseur, and cautery.
The essential objects in the management
of the pedicle are to prevent haemorrhage
from the di\dded vessels, and to avoid set-
ting up peritonitis or septicaemia by the
means employed.
The objections urged against the employ-
ment of the ligature are that a foreign body
is left in the peritoneal cavity, which is
liable to set up peritonitis. If silk or other
suitable material be employed, this objec-
tion has little or no value.
Again, the ligature is supposed to cause
sloughing of the stump of the pedicle, which
gives rise to putric matter and produces sep-
ticaemia. This, however, is mere theory;
practically, sufficient capillary circulation is
established to maintain the nutrition of the
stump beyond the seat of ligation, and so
prevent any sloughing.
There is certainly some risk that the
stump may become adherent to some por-
tion of the intestine, and so lead to intesti-
nal obstruction, but this accident has been
met with very seldom.
It was formerly supposed that as the tis-
sues in the pedicle became shrunken, the
ligatures would become loose, and either slip off or allow haemor-
rhage to take place, but practically, if proper precautions be taken
to the contrary, this very rarely occurs.
Carbolized silk or hemp, not too stout, but still sufficiently strong
to bear a good strain, forms the best material for ligature. The
pedicle is transfixed about the centre of its width, being careful to
avoid puncturing any vessel, by a needle armed with a double liga-
ture. This is cut into two equal portions ; by twisting the two
ends one turn the ligatures will be made to cross each other ; one
half of the pedicle is then firmly tied with each of these, the two
crossing like a figure of eight at the centre. If deemed requisite
the whole of the pedicle may then be encircled by one of the liga-
tures, firmly tied, and the ends either cut short or brought out at
the abdominal incision. In sluj case the ends may be left long and
held by an assistant as a guide to the stump, until the other ovary
has been carefully examined, the pelvic cavity cleaned out, and all
the steps of the operation completed, but great care must be taken
that no traction be employed.
The ligatures must be drawn very tightly in tying them, to avoid
their slipping. There need be no fear of strangulating the stump
so as to produce gangrene. Do not cut the pedicle too near the
ligature ; leave at least three-quarters to one inch.
Spencer Wells's Clamp.
CLEANSING OF THE PERITONEAL CAVITY. 333
If it be decided to leave the ends of the ligatures long, and
hanging out of the incision, so that they may be drawn out when
they become detached, let the ends be sufficiently long, six or eight
inches at least, to prevent their being drawn into the abdomen, if
t}^mpanites supervene or any dragging upon the pedicle occur if
the patient should happen to turn over.
The time required for ligatures to become detached varies from
three weeks to a month, but may exceed this greatly.
The method of cutting the ligatures short, close to the stump, is
the one usually adopted.
Where the pedicle is thick and fleshy, and too short even for the
ligature to give a secure hold, it may be grasped by the cautery-
clamp, and the tumor severed from it by the actual cautery, heated
to a dull heat, so as to char down very slowly.
Pocketing the pedicle consists in fastening the extremity of the
pedicle between the inner lips of the wound at its lower angle.
In very rare instances no pedicle at all is found, the tumor hav-
ing broken away from its original connections, and become attached
to some portion of the peritoneal surface.
Arrest of Hoemorrhage. — ^Any vessels that have not previously
been secured, when separating or tearing through the adhesions,
that are still bleeding, must be secured by carbolized silk ligatures
cut short and left in situ, by torsion, or by cautery, ligatures being
the preferable method. Where there is general oozing from an
inflamed or vascular surface, where the peritoneum itself has been
detached, and no special vessels can he distinguished, if pressure
and exposure to the air fail in arresting the haemorrhage, swabbing
the surface carefully with the perchloride of iron, lightly wiping
ofl" any superfluity, may safely be recommended as both efficient
and harmless.
If any vessel leading up to the seat of the oozing can be de-
tected, a small silk ligature may be passed underneath it, tied, and
the ends cut shoi:t.
Where adhesions of the omentum have been extensive, it is well
to spread out the omentum on a clean towel, and examine carefully
every inch of the torn surface to see that no vessels have been
-overlooked, and if necessary apply ligatures. All shreds and loose
portions of omentum should be trimmed oflT.
Examination of the other Ovary. — As soon as the pedicle has been
secured and the tumor removed, and any omental or other vessels
injured during the separation of adhesions (if bleeding) have been
tied, the other ovary should be examined.
If the ovary be hardened or so enlarged that disease appears
likely to go on, it should be removed, the pedicle being dealt with
according to circumstances. A second clamp may be applied, or
ligatures, as the case demands.
Cleansing of the Peritoneal Cavity. — The " toilette " of the perito-
neum is of the utmost importance. Any ascitic or cystic fluid or
blood must be carefully removed by small sponges on holders,
otherwise peritonitis or septicaemia may result, these being two of
334 SURGICAL TREATMENT OF OVARIAN CYSTS.
the most frequent causes of death in fatal cases. If any further
bleeding points be detected, or even general oozing, this must be
arrested before closing the abdominal wound. The sponges should
be passed deep down into the pelvic cavity, in the most dependent
parts, where any fluid would be likely to gravitate.
Drainage. — ^ow that the antiseptic method of operating is re-
sorted to, drainage through the abdominal wound, or through an
opening made expressly in the bottom of Douglas's pouch into the
vagina, is generally necessary. Still, cases occur in which, owing
to extensive adhesions having been present, much oozing of blood
or serous fluid may be expected, or w^here septic or colloid fluid has
escaped into the peritoneal cavity, drainage may be considered ad-
visable.
Keith's glass drainage-tube, open at both ends, about six or seven
inches long, so as to reach to the lower portion of Douglas's pouch,
the lower end being perforated with several holes, is placed tightly
between the two lower stitches. The top of the tube is covered
by a cup-shaped sponge wrung out of a solution of carbolic acid,
one in thirty, a piece of thin sheet india-rubber being wrapped
over this. Any fluid w^hich collects in the pouch may be drawn
oft' by a tine india-rubber tube attached to a syringe, night and
morning. Disinfectant injections may also be employed if thought
necessary. The dressings should be so arranged as to enable the
tube to be uncovered without interfering with them. The tube
may generally be removed within a few days.
It is especially in those cases where the fluid is of a sero-san-
guineous character that drainage is of most service. When blood
itself is effused into the peritoneal cavity, coagulation in due course
takes place, the serous portion becomes absorbed and the fibrinous
clot organized. Where, however, a mixture of blood and serum
occurs no such coagulation takes place, the blood-corpuscles un-
dergo a process of necrosis, and septicaemia too often results.
Where the effusion is not extensive, the inconvenience of soiling
the patient's linen, and consequent necessity for changing it, may
often be avoided by passing the outer end of the drainage-tube
through a small aperture in a piece of mackintosh sheeting, cover-
ing the end with a cup-shaped sponge, and then folding the mack-
intosh over the sponge, this latter being removed from time to
time and squeezed dry.
Experience has not confirmed the plan of drainage through
Douglas's pouch and the vagina, wdth the injection of antiseptic
solutions, as a judicious one, and it should therefore not be re-
sorted to.
Another method of bringing the end of the pedicle itself out
through an opening in the vaginal cul-de-sac has also been sug-
gested, but does not seem to have met wdth much consideration.
Closure of the Abdominal Wound. — After having carefully ex-
amined every source of haemorrhage, thoroughly cleaned the peri-
toneal cavity, and restored the intestines to as natural a position
as possible, so as to guard against all twisting of the convolutions
AFTER-TREATMENT. 835
one upon another, a large, broad, flat piece of thin sponge should
be inserted just within the wound, so as to cover the intestines
whilst the sutures are being passed, and protect the peritoneal
cavity from any further haemorrhage which may follow the pass-
age of the needles.
The sutures may be of wire, silkworm gut, or carbolized silk.
Portions of silk, about eighteen inches in length, are previously
threaded at each end with strong, straight or slightly curved
needles about two inches long.
Each needle is introduced from within outwards, by means of a
needle-holder, including about half an inch of the peritoneum,
and then brought out near the margin by perforating the whole
thickness of the abdominal walls. They should be placed about
an inch apart, and not secured until all have been introduced. An
assistant holds them as they are inserted, and draws up the mar-
gins of the wound. The abdominal cavity is again inspected to
determine if any further haemorrhage continues; a sponge on a
holder is passed deep down with a similar object. The protecting
sponge is then removed, the sponges counted, the sutures are tied,
and the ends cut off.
Where the clamp is employed, a suture should be passed close
to the latter, in order to bring the lips of the wound so accurately
around the pedicle that the peritoneal cavity is perfectly closed.
Should the abdominal walls be very fat, intermediate superficial
sutures may be needed.
'Before closing the wound, an}^ air in the peritoneal cavity should
be expressed as completely as possible.
Application of Dressiiigs. — The exposed surface of the abdomen
is first carefully sponged and dried, and the mackintosh apron re-
moved. If the clamp be used, pledgets of lint soaked in carbolized
oil are placed under the angles of the clamp, so as to protect the
skin from undue pressure. The surface of the stump is sprinkled
with dry perchloride of iron, tincture of iodine, or carbolic acid.
If ligatures have been applied to the pedicle, and the w^ound
closed perfectly, it is unnecessary to apply carbolized oil or oil-
silk. The better plan is to cover over the wound with several
layers of carbolized gauze. Pads of antiseptic cotton-wool are
placed on each side, broad strips of plaster are passed over all,
so as to give firm support, and lastly the flannel belt is adjusted,
the night-dress pulled down, and the patient lifted carefully on to
the bed.
She should be placed on her back, her knees supported by a
pillow, the body covered with light but warm blankets, and hot-
water bottles provided if she be at all chilly. The room should
then be darkened, and the patient left absolutely quiet, alone with
the nurse. All instruments should, when practicable, be removed
to another room and there washed and dried.
After-treatment. — Success depends upon attention to minute de-
tails. The patient is not cured when the tumor is removed; she
has yet many risks and dangers to encounter. JSTumerous precau-
336 SURGICAL TREATMENT OF OVARIAN CYSTS.
tions will have to be observed, complications and contingencies
dealt with and provided for, that will often tax the experience and
patience of the operator even more than the performance of the
operation itself. Our first care, especially if the operation have
been prolonged or the patient much exhausted, will be to establish
reaction.
Stimulants such as brandy and champagne should only be used
when called for by faintness or chilliness, or some sign of ex-
haustion, or where sickness is troublesome. A little of one or
other of these stimulants in iced soda water may be sipped from
time to time from a feeder; or an enema of beef-tea and brandy,
not more than tw^o ounces at a time, administered at short intervals.
Small pieces of ice to suck will also have a good effect.
A morphia suppository, a hypodermic injection, or a succession
of small opiate enemata, left to the discretion of an intelligent
nurse, with directions to give only enough to keep the patient free
from severe pain, answer better than large doses administered at
stated intervals under medical prescription.
Very little food is required during the first three days; milk
and soda water, barley water, thin gruel, water arrowroot, chicken
or veal broth or beef-tea, may be allowed in small quantities at a
time, if sickness be absent and the patient desires them.
The catheter should be passed every six or eight hours for the
first few days. If flatulent distention of the bowel prove trouble-
some, O'Byrne's tube may be passed a foot or more up the rectum,
or five grains of quinine in an ounce of water injected every four
hours.
If the urine be turbid or scanty, lithia water, or a mixture of
the citrates of potash and lithia, should be given at short intervals.
The bowels should not be encouraged to act, even if they do not
do so for the first week or ten days, provided no discomfort arise
in consequence. If deemed requisite, an enema of salad oil may
be administered, and the accumulated feecal mass broken up by
the finger or a spoon.
Ko one but the physician and necessary attendants should be
admitted to the apartment during the first three days, even in the
most favorable cases.
Surgical Treatment. — As a rule, the dressings need not be inter-
fered with for the first few days unless there happen to be much
discharge, when of course this must be attended to. Union gen-
erally takes place by first intention.
The sutures should not be removed until the fourth to the eighth
day, depending upon the amount of irritation they cause. If any
seem to be too tight, they may be divided. In very stout or feeble
patients union may be slower ; the stitches must then be left in
longer. It is well to remove only alternate ones at first, and be
guided as to the others by the amount of union that has taken
place. If much flatulence exist, or the patient be troubled with a
cough, care should be taken not to remove the sutures too early.
Where the clamp is employed, unless there be any soaking of
SURGICAL TREATMENT. 337
discharge, the dressings need not be disturbed for the first thirty-
six or forty-eight hours. The plaster near the clamp may then be
raised and divided, and the stump cleansed, any soiled dressings
being changed and replaced by dry lint, fresh plaster being then
applied. After this, daily dressing is generally necessary. The
abdomen must be supported by plaster for at least a fortnight
longer if thought necessary. The clamp and portion of pedicle
compressed by it usually fall ofi" from the seventh to the tenth day,
but may do so earlier or later.
The patient will need to wear an abdominal belt or binder for
twelve months after the operation, to prevent ventral hernia.
Should peritonitis ensue, it must be dealt with on general prin-
ciples, special care being taken not to allow any accumulation of
septic matter to remain deep down in the pelvis or dependent
parts.
22
338 DISEASES OF THE BROAD LIGAMENTS.
CHAPTER XXII.
DISEASES OF THE BROAD LIGAMENTS, INCLUDING PELVIC CELLULITIS
AND PELVIC PERITONITIS.
Diseases of the Broad Ligaments, including the cellular tissue and
investing peritoneum. — Many different names have been employed
from time to time to designate inflammatory conditions affecting
the tissues surrounding and covering the uterus and its appendages
as well as lining the pehns.
Of these the terms pelvic cellulitis and pelvic pyeritonitis are
probably best understood. Although we rarely meet with inflam-
mation of the one tissue without the other being to some extent
involved in the process, the two being almost invariably associated,
one by contiguity lighting up the other, yet the two affections are
entirely distinct from each other, and should not be confounded
simply because they complicate each other. As Thomas remarks,
they may be compared to serous and parenchymatous inflamma-
tion of the lungs — pleurisy and pneumonia. Like them they are
separate and distinct, like them affect different kinds of structure,
and like them generally complicate each other. The terms pelvic
celluHtis and ]3elvic peritonitis are adopted in the nomenclature of
diseases approved by the Registrar-General, and as there are cer-
tain advantages in describing them separately, we shall for sake
of clearness do so, although, after what has been said, the practi-
tioner will understand that the terms are not applied in an exclu-
sive sense, but according as the affection of one or other structure
is predominant.
Virchow proposed the term peri-metritis as the equivalent of
pelvic peritonitis, and para-metritis as that of pelvic cellulitis, but
these terms are open to many objections, which need not be insisted
on here, and seem more calculated to produce confusion than to
facilitate our understanding of the subject.
Other terms, such as peri-uterine cellulitis, peri-uterine phleg-
mon, metro-peritonitis, peri-metric inflammation, pelvic abscess,
etc., have also been employed to designate one or other of these
conditions, or the two conjointly. The term suggested by Dr.
Barnes — ^peri-metric inflammation — includes the two conditions,
and is certainly a very appropriate one. When patients speak of
inflammation of the bowels, it is generally some form of pelvic in-
flammation they refer to.
In attempting to estimate the frequency of the two affections, it
is difiicult to form a correct opinion. A large proportion of the
cases often regarded as instances of pelvic cellulitis, are really those
of peh^c peritonitis. This latter is more likely to prove fatal than
PELVIC CELLULITIS.
the former, and therefore the results of post-mortem investigations
cannot be trusted to as affording any direct evidence on the ques-
tion. Pelvic cellulitis is comparatively rare in the non-puerperal
patient, while pelvic peritonitis is exceedingly common, so that
excluding parturition or abortion, or operations upon the cervix
uteri, pelvic peritonitis seems to be the much more common affec-
tion.
Pelvic Cellulitis (Para-metritis). — Definition. — This consists in in-
flammation of the cellular tissue surrounding the uterus and other
pehdc organs, and extending up between the folds of the perito-
neum which form the broad ligaments of the uterus. This connec-
tive tissue exists in abundance between the vagina and rectum,
i between the uterus and bladder, passing by continuity upwards
into the iliac fossa and along the surface of the psoas muscles pos-
teriorly, and between the peritoneum and transversalis fascia an-
teriorly. Between the anterior and posterior surfaces of the
I uterus and the peritoneum, the amount of connective tissue is so
slight, that its presence even has been doubted, but at the sides
, and at the cer\dx distinct loose cellular tissue exists.
It is, however, between the folds of the peritoneum constituting
the broad ligaments that the cellular tissue is most abundant, and
'that inflammation is most frequently met with.
'i Pathology. — In an ordinary case of pelvic cellulitis we have flrst
% condition of congestion producing intumescence or swelling from
eftusion of serum or exudation of lymph into the areolar tissue.
iThis may terminate by resolution, or go on to suppuration and
the formation of an abscess. In some rare cases the tissue in-
v^olved becomes destroyed and sloughs, as seen in cases of anthrax
ind phlegmonous erysipelas. In the very early stage of the affec-
i'ln, the infiltration of serum produces a swelling somewhat elas-
tic to the touch.
Where the exudation of lymph occurs, the most notable char-
icters of the swelling are its hardness, irregularity, and immobil-
ty, as if plaster of Paris had been poured in and become consoli-
lated, fixing the uterus immovably.
When suppuration occurs, which does not usually take place
br at least ten or fourteen days after the onset of the attack, even
â– n acute cases, the presence of fluctuation may be so masked by
'he surrounding exudation, that it is almost impossible to deter-
nine whether pus be actually present, or the pus may escape per
ectum or vaginam before its presence has been detected.
Suppuration at first may be only circumscribed and not diffuse ;
)r there may be two or three centres of suppuration, pointing in
lifterent localities, each abscess having a separate opening, and
tursting at different times ; or suppuration may be more general,
esulting in the formation of a large pelvic abscess by the break-
ng down of the intervening barriers, which at first served to cir-
umscribe the several collections of pus. In some instances these
'elvic abscesses are of enormous size, filling up the pelvis and ex-
ending almost as high up as the umbilicus.
340 DISEASES OF THE BROAD LIGAMENTS.
Causation.— In by far the larger number of cases of pelvic cellu-
litis it follows as a consequence of parturition or abortion, more
especially where there has been any traumatic injury, as laceration
of the cervix uteri, as not infrequently happens in cases of instru-
mental delivery, or where turning has been resorted to, or the
perineum ruptured.
Primiparous patients are more liable to peMc cellulitis, prob-
ably from the greater protraction and difficulty of tirst labors.
The head being allowed to remain impacted in the pelvis for many
consecutive hours, producing such an amount of bruising and press-
ure upon the maternal soft parts, the cervix and cellular tissue ;
the increased risks of laceration of the cervix, and rupture of the
perineum, and the increased risk of septic absorption, are quite
sufficient to explain this.
The fact of the occiput being directed to the left side of the
pelvis, as happens in the first presentation, the left occipito-coty-
loid, may explain the occurrence of cellulitis being more common
on the left side. Patients who do not suckle are supposed to
be more prone to develop cellulitis than those who nurse their
offspring.
Lying too long in the soiled linen after parturition, before being
changed, getting up too soon after delivery, and resuming house-
hold cares, sitting on draughty water-closets, the injudicious use
of the vaginal douche, or exposure to cold, too early indulgence
in coitus after abortion or parturition, and other imprudent actions.
are often fertile sources of pelvic inflammation.
It is a question whether pelvic cellulitis in the non-puerperal
state can occur idiopathically or independently. The tendency oj
recent investigations is rather to show that it is secondary to ante-
cedent acute inflammation of the uterus or its appendages. Amon^
the more usual exciting causes may be mentioned the employ men"
of strong vaginal injections ; sudden suppression of menstruatioi
from cold or other causes ; the employment of the syringe witl
cold water immediately after coitus, mth a view to preventing
conception, more especially just before or after the menstrua
period ; immoderate coitus, particularly when there has been som*
pre-existing uterine disease ; mechanical injuries either from acciden
or surgicali interference ; the use of laminaria or sponge tents, o
intra-uterine pessaries, the application of caustics to the cervica
canal, injections of styptic or other irritating solutious into th'
uterine cavity, the injudicious or rough use of the uterine sound
division or amputation of the cervix uteri, attempts to enucleat-
uterine fibroids. Gonorrhoea, malignant disease of the uterus o
its appendages or of the rectum, or any operations, such as th.
ligature of haemorrhoids, etc., may also set up pelvic cellulitis.
Symptoms. — These will vary somcAvhat, depending upon whethe
the attack be acute or slow and insidious.
The acute form is generally ushered in by a distinct chill o
rigor, followed by fever, rapid pulse, 120 to 130, full and bounding
elevation of temperature, 103° or 104° F., hot skin, flushed cour
PELVIC CELLULITIS. 341
tenance, furred tongue, headache, vomitmg; pain and tenderness
in one or other iliac region or in the h^'pogastrium, increased on
movement, or on attempting to sit upright or walk ; a sensation of
fulness and pressure, often spoken of as bearing-down or dragging
pain ; dysuria, frequent desire to micturate, with tenesmus, or an
unsatisfied sense of the bladder not being emptied; urine scanty
. and loaded with lithates and mucus ; constipation or difficulty in
defalcation may alternate with a kind of dysenteric diarrhoea. The
secretion of milk is generally lessened or may be altogether ar-
rested, the lochia are usually suspended, though occasionally men-
orrhagia occurs. Excessive sweating on awakening from sleep is
a very characteristic symptom of cellulitis.
The chronic or subacute form commences so gradually and in-
sidiously as often to escape observation, until when the patient
^begins to get about it is suddenly kindled into activity. There
may be no distinct rigor or pyrexia to indicate when the mischief
began, the patient is somewhat feverish towards the evening, does
not recover her appetite or strength, feels nervous and depressed,
complains of deep-seated uneasiness in the pelvis, increased on
micturition, defsecation, or standing, when it becomes more acute,
and is described as shooting and lancinating, with a feeling of ten-
sion and weight in the perineum and lower extremities. At other
times it is described as pulsating and throbbing. The pain often
assumes a periodic character, returning in distressing paroxysms,
iand occasionally in severe nightly exacerbations.
Bhyskal Signs. — If a vaginal examination be made in the very
3arly stage, there will generally be found increased heat, puffiness,
Bxtreme sensitiveness, with possibly evidence of some localized
^welling or oedematous spot, which feels somewhat soft and elastic.
But this stage is of very short duration, and our first examination
nay reveal the presence of a hard, brawny infiltration, occupying
he roof of the vagina, fixing the uterus and obscuring the cer^dx
iteri, which is merged as it were in the surrounding induration.
The amount of inflammatory deposit varies considerably. In
some instances it is localized, being more or less limited to the
)osterior cul-de-sac, or to one or other side, pushing the uterus
)ver to the opposite direction, and interfering with its normal
nobility, although it may be possible to move the uterus together
vith the swelling : this, however, is rare.
A\niere the effusion is more general, the uterus will be found
ixed in the centre of the pelvis, on a lower level than natural, or
t may be pushed over to one or other side, pressed back into the
lollow of the sacrum, or carried upwards and forwards under the
rch of the pubes, compressing the neck of the bladder and caus-
iig retention of urine.
The displacement may be so great, and the amount of effusion
extensive, as to effectually preclude our detecting any portion
f the cervix, or even feeling the os uteri.
If possible, the conjoined manipulation should be resorted to, in
rder to determine the direction and amount of the effusion ; but
342 DISEASES OF THE BROAD LIGAMENTS.
this must be done with extreme care, for the parts are often so
tender and sensitive, the vagina so narrowed and distorted by the
surrounding deposit, that only the gentlest vaginal examination is
tolerated.
Rectal exploration here often proves of much service, enabling
us to extend our investigations considerably above the level of the
OS uteri and the lower margin of the inflammatory swelling, as
also in determining whether the tissue around the rectum is in-
volved, as not infrequently happens, the adhesive effusion forming
a collar through which the rectum passes. In other instances the
bulk of the effusion being limited to Douglas's pouch, the rectum
is compressed against the sacrum. In cases of post-partum pehdc
cellulitis, the swelling often extends upwards to one or other in-
guinal or iliac region, or across the hypogastrium above the brim
of the pelvis, as evidenced by the dulness on percussion, tender-
ness on pressure, sense of hardness and resistance on pressure over
the lower abdomen, and also by the communicated impulse on con-
joined manipulation.
Differmtiation. — The history of the onset of the attack following
parturition, abortion, or some operation will serve to put us on our
guard. From puerperal fever and general peritonitis following
labor, the fact of the constitutional disturbance being of a less se-
vere character, and the localization of the symptoms more marked
in cellulitis, together with the progressive development of the symp-
toms, will usually enable us to distinguish the different aff*ections.
From pelvic peritonitis it is often impossible to differentiate
cellulitis. The two forms of inflammation are so commonly asso-
ciated, the one rarely occurring without being complicated with
the other, and the treatment for both is so similar, that any repeated
or minute examination is more likely to prove detrimental to the
patient than is justified by any good we are likely to derive. Peri-
tonitis more fi-equently results from cold or exposure during men-
struation, from disease of the ovaries, escape of fluid into the peri-
toneum, or from extension of gonorrhoea. The tumor is generally
confined to the true pelvis ; there are more or less distinct hard
prominences to be felt ; suppuration is less frequent, and there is
seldom retraction of the thigh in the more chronic stage.
Malignant deposit around the uterus may be mistaken for cellu-
litis. In cases of cancer the cervix is generally involved, hard and
nodular or ulcerated, and bleeding readily on touch ; the history is
one of insidious disease not accompanied by febrile action ; the de-
posit is more uniform, surrounding the cervix entirely ; the can-
cerous cachexia, oflfensive discharge, and severe pain, especially at
night, will all assist us in forming an opinion.
Felvic liEematocele occurs suddenly, generally at or about a men-
strual period ; prostration, syncope, collapse, or other indications
of loss of blood occur ; the tumor is soft and fluctuating at first,
and hardens as time goes on. The febrile disturbance and signs
of local inflammation supervene upon, not precede, the effusion in
the pelvis.
PELVIC CELLULITIS. 343
In pelvic cellulitis there is generally the history of its following
parturition, abortion, or operation ; the swelling is hard at first,
and may soften later on ; febrile disturbance is present at the com-
mencement ; there is seldom evidence of shock or collapse, but the
attack commences gradually.
Extra-uterine gestation may be distinguished by the history of
amenorrhcea and other signs of pregnancy, the spasmodic pains,
absence of fever, gradual growth of the tumor, irregular haemor-
rhages, etc., as mentioned under this heading. Should rupture of
the foetal cyst occur, the symptoms are those of hsematocele, not of
cellulitis.
Later on the spontaneous discharge of an encysted foetus may
give rise to doubt, but the history will generally guard us from
error.
Fibroid tumors are attached to the uterus, generally movable
with this organ, of which they form a part. They are of slow
growth, painless, circumscribed. There is no history of febrile
disturbance, but generally of menorrhagia.
Retro-version or -flexion of the uterus may readily be determined
by the introduction of the sound ; but when a small ovarian, or a
fibroid tumor, or a retroflexed uterus is bound down by inflamma-
tory adhesions and deposit in the posterior cul-de-sac, especially
if any recent inflammation be present, the diagnosis is often very
difficult. The sound will at once distinguish the retroflexion, and
on careful conjoined manipulation the ovarian cyst may be detected
by its tenseness and elasticity.
Teecal accumulation or impaction may prove a source of error ;
examination per rectum will obviate this.
Abscess in the pelvis from caries of the vertebrse, or of the pelvic
bones, or in connection w^ith the caecum or rectum, perityphlitis,
etc., must be made out by the antecedent and general symptoms of
these conditions.
Progress. — Whether the attack be acute or chronic, as soon as
exudation of lymph has taken place into the cellular tissue we shall
find other symptoms superadded. Pains of an anomalous character
are often complained of, due to the pressure of the efiiised products
on the nerves passing through the pelvis, viz., the external cutane-
ous nerve, the crural nerve, or the great sciatic nerve. Depending
upon which of these is chiefly involved w^ill be the fact of the pain
being referred to the knee, dorsum of the foot, back of the thigh,
etc. Sciatica is not infrequent. Neuralgic pains or other evidence
of perverted nervous influence, such as a sensation of coldness or
increased warmth, or of hyper- or an-aesthesia may also be experi-
enced.
Flexion and adduction of the thigh are frequently noted, caus-
ing the patient to limp, or preventing her getting the heel to the
ground, and so causing lameness. (Edema of one or other leg,
simulating or even running into phlegmasia dolens, is not infre-
quent whenever the inflammatory action is extensive enough to
involve the trunks of the large blood-vessels w^hich proceed to the
344 DISEASES OF THE BROAD LIGAMENTS.
lower extremities, when thrombosis of the veins results. In these
cases it is important to insist upon prolonged rest to avoid all risk
of pulmonary embolism.
The rectum is variously affected by the exudation in the pelvis.
Bearing-down and pressure, with pain and difficulty in defjecation,
are not infrequent symptoms. There may be incessant desire to
go to stool ; the fgeces may be flattened into thin bands like rib-
bon ; the irritated intestinal mucous membrane may exude so much
half-purulent mucus, occasionally tinged with blood, that it may
erroneously be taken for a discharging abscess ; or obstinate consti-
pation may alternate with dysenteric diarrhoea, which often proves
severe and exhausting when an abscess opens into the bowel.
In many cases the bladder is seriously implicated, producing fre-
quent and painful micturition, and as the urine frequently contains
pus, the symptoms are liable to be attributed to chronic inflamma-
tion of the bladder. A careful consideration of the symptoms,
together with a local examination, will generally enable us to
differentiate the two and to determine that the bladder-aftection is
only a secondary complication of a more general pelvic inflamma-
tion. Incontinence of urine may occur in some cases from the
bladder being bound down by adhesions. Retention may also pre-
cede the bursting of an abscess into the rectum or vagina, or into
the bladder itself.
There is generally more or less muco-purulent discharge due to
congestion of the cervix uteri and vagina. Menorrhagia or metror-
rhagia are less frequent.
Terminations. — Where suppuration occurs the pus may find exit
through one of the channels shortly to be indicated, the sac of the
abscess gradually contracting and ultimately healing ; or it may go
on discharging for an almost unlimited time ; or several small ab-
scesses may burst at various places, leaving fistulous tracts that are
extremely difficult to heal.
It should not be forgotten, however, that suppuration is only one
of the results of cellulitis, pelvic abscess may result the same as
empyema in cases of pleurisy, but every case of this does not end
in empyema, nor does every case of pelvic cellulitis end in the for-
mation of pelvic abscess.
It may be stated generally that in the non-puerperal state ter-
mination by resolution is the rule, although the induration may
remain for some considerable time, and the adhesions contracted
among the various pelvic organs may be detected months after the
patient is to all appearance perfectly well ; whereas, in cases follow-
ing delivery and abortion, suppuration occurs in at least half of
them, if not in a still greater proportion. The termination in sup-
puration is liable to be overlooked, for the pus escajDing per rectum
or per vaginam may not be noticed, and the case be regarded as one
ending in resolution.
In puerperal cases the most frequent seat of evacuation is through
the abdominal wall, generally above Poupart's ligament, in one or
other groin or iliac region. l!^ext in order of frequency comes that
SEPTICEMIA. 345
through the rectum or vagina, more rarely into the bladder, beside
the anus, through the obturator or sacro-ischiatic foramina, the
saphenous openings, and, fortunately rarest of all, into the peritoneal
cavity. In some exceptional cases there seems no tendency to
burst at all, the abscess remaining encysted for very long periods.
In the non-puerperal variety it is extremely rare for an abscess
to discharge externally; the evacuation most frequently takes place
through the rectum or vagina, though the fact of the pus escaping
gradually may prevent its being noticed, or it may not be distin-
guished from the other discharges.
Prognosis. — This should always be guarded, as it is almost im-
possible at first to foresee the various contingencies, complications,
and dangers.
Where the patient has previously been in a fair state of health,
the symptoms are slight, and the effusion of serum or lymph is
only moderate in extent, termination by resolution may be antici-
pated, the swelling soon disappearing. When the amount of the
exudation is considerable and the deposit dense, the powers of
locomotion may be impaired for many months, and convalescence
tedious and prolonged. Should pregnancy occur under these cir-
cumstances it is very liable to be cut short, the adhesions inter-
fering materially with the growth and expansion of the uterus. A
more usual result is sterility. The dangers are greater, as a rule,
in puerperal than in non-puerperal cases, abscesses being more
likely to occur, though the danger of bursting into the peritoneum
is greater in the non-puerperal than in the puerperal forms of pelvic
cellulitis. This, however, is only exceptional. Unless suppuration
is very extensive or prolonged, or other complications are added,
evacuation generally takes place either by spontaneous or artificial
opening, and recovery ensues. In some instances the discharge
continues for a long period after the bursting of the abscess, often
through long, inaccessible sinuous tracts, thus wearing out the
patient's powders or proving the exciting cause of the development
of tubercular disease. Where the abscess opens into the colon or
rectum a constant exhaustive dysenteric kind of diarrhoea is kept
up, and is little amenable to treatment. The reproductive appa-
ratus is often irreparably damaged by destruction of the ovaries,
occlusion of the Fallopian tubes, or displacement of the uterus.
Septicaemia may also result, or thrombosis of the veins, with the
risk of pulmonary embolism.
A permanent state of ill-health is often induced, the appetite
and digestion are impaired, the nutrition defective, sleep disturbed,
the temper irritable, and the mind enfeebled. The demand for
opiates in some form or other, and in augmenting doses, increases.
The patient's life is one of constant sufiering, neuralgic pains often
occurring in severe paroxysms during the night.
If the ovaries happen to be involved in the exudation, nausea
and sickness are apt to occur, adding greatly to the patient's dis-
comfort. The bladder may also become aftected by the extension
of inflammation and prove a source of additional suffering. The
346 DISEASES OFTHE BROAD LIGAMENTS.
patient thus becomes a permanent invalid, or finally succumbs to
some form of tuberculosis.
Treatment — Prevention is proverbially better than cure. Much
may be done in this direction by avoiding exposing patients to
the causes already enumerated as most likely to give rise to cellu-
litis. The influence of long-continued pressure of the foetal head
in the maternal passages during parturition was formerly a most
potent cause of sloughing and the formation of vesico- vaginal fist-
ulas. Although unfortunately cases are still allowed to occur,
they are by no means so frequent at the present day. Yet there is
little doubt that the well-being of many a parturient patient is
jeopardized by allowing the foetal head to remain impacted in the
pelvis for many consecutive hours. A timely resort to the appli-
cation of forceps would eflfectually prevent much subsequent risk.
The careful management of the perineum during the expulsion of
the head and shoulders, so as to avoid rupture; preventing the
patient getting about too soon after delivery; or returning to the
marital couch too early after a miscarriage, and many other similar
preventive measures, may well be insisted on by the practitioner
as conducive to the safe recovery of the patient and the prevention
of inflammatory mischief.
In non-puerperal cases the avoidance of surgical operations where
inflammatory mischief of the pehdc organs already exists, unless
some urgent necessity for so doing is manifest; extreme caution
before resorting to intra-uterine medications, whether the applica-
tion of escharotics, the insertion of laminaria or sponge tents, or
the introduction of stem pessaries; and the avoidance of every-
thing likely to set up inflammatory mischief, may serve to limit
the number of cases in which cellulitis often occurs.
Operations that are tolerated shortly after the menstrual period,
if performed just before the period is due, are more likely to be
followed by inflammatory mischief.
AVliere gonorrhoea, either in its latent or more active form, is
even suspected to be present, the mere passage of the uterine
sound or the most trivial operation may prove sufiicient to set up
such an amount of irritation as will take wrecks to allay.
In cases where the symptoms point to an acute attack of pelvic
cellulitis, our first care on the occurrence of a chill will be to put
the patient to bed; to apply warmth to the body, hot-water bottles
to the feet, to administer some warm drink, to w^hich some stimu-
lant may be added if thought requisite; to cover the lower part
of the abdomen with some hot fomentation, either flannels or
spongio-piline, w^rung out of hot water, or with linseed meal or
bran poultices.
When reaction has been established, and pain and general fever-
ishness are the chief indications, a saline mixture of the liquor
ammonise acetatis, citrate of potass and tincture of aconite (n\^ij-iij)
every three or four hours, may be prescribed, or if sickness be
present, an efiPervescing saline may be substituted.
To relieve the pain which is generally at this stage the most
DEPLETION. 347
prominent indication, opium in some form is generally requisite;
a starch and laudanum (n\,xx to n^^xxx) enema, the hypodermic
injection of morphia, poppy-head fomentations to the abdomen,
or better still a piece of linen of the requisite size saturated with
laudanum, placed next the skin, the hot fomentation being applied
over this, will generally answer the purpose. As far as possible,
avoid giving opium by the mouth at this juncture, and even be
careful in commencing hypodermic injections, lest the patient in-
sist on their frequent repetition, wdiich will necessitate personal
attention on the part of the practitioner every four hours.
i^ow wdll arise the question of depletion. General blood-letting
will rarely be indicated. Leeches may be applied to the lower
part of the abdomen, or around the anus, in numbers varying from
three to tw^elve, depending upon the urgency of the symptoms, the
strength of the patient, and the nature of the case. It is better to
err on the side of applying too few than too many, for the bleed-
ing may be encouraged subsequent to the falling off of the leeches
by hot fomentations, or more leeches may be applied if thought
requisite. Temporary relief generally ensues, but in many in-
stances it is a question w^hether this is not too dearly purchased.
The patient wdll need all her powers ; she is probably in a depressed
state of health at the time of the attack, and may have to go through
a very prolonged illness. This should always be borne in mind.
It is rarely ad^dsable to apply leeches to the cervix uteri in acute
cases, because the pain and tenderness preclude the use of a specu-
lum or leeching-tube.
' The next perplexing question the practitioner will have to solve
will be that of whether he shall administer mercury or not. Opin-
ions differ widely as to the propriety of its employment. Some
contend that in combination with opium it seems to act as a direct
sedative to inflammatory action ; to lessen the tendency to plastic
exudation, and to promote absorption. A pill of one or two grains
of calomel with half a grain of opium ; or a combination of gray
powder (gr. iij), with Dover's powder (gr. v-x) ; or blue pill (gr. ij)
with extract of opium (gr. ss) may be given every four or six hours
for the first twenty-four hours, and then every six or eight hours
for another day or tw^o, the effect being carefully watched lest
ptyalism or irritation of the bowels be produced, two conditions
carefully to be avoided.
K considered undesirable to give mercury by the mouth, a mix-
ture of equal parts of mercurial and belladonna ointment may be
smeared on lint and applied to the lower part of the abdomen.
It is comparatively seldom, however, that we shall be called upon
to give mercury with a view^ to influencing the system in the ma-
jority of the cases met with at the present day.
Dr. Emmet, of New York, with a view to cutting short an attack,
advises the continuous employment of hot-water vaginal injections,
continued, if possible, for hours. He says it is the only means we
possess for aborting an attack of pelvic cellulitis, w^hich it will do
if thoroughly employed at the beginning.
348 DISEASES OF THE BROAD LIGAMENTS.
The continued action of hot water is to stimulate the circulation
in the pelvis, so that the local congestion may he relieved before
nature attempts to do so by the exudation of serum into the sur-
rounding tissues. The temperature of the water must be elevated
rapidly from that of blood heat to 110° F., or to as high a degree
as can be borne by the patient. The injection should be often re-
peated. The nozzle of the syringe must be of horn or ivory, or
covered with a piece of india-rubber tubing, to prevent it causing
discomfort by coming in contact with the outlet of the vagina.
In the more chronic and diffuse forms of inflammation, charac-
terized by want of power or of septic origin, it is generally better
to avoid mercurials and depletion altogether, and to rely solely upon
opium, which relieves pain, diminishes the severity of the inflam-
matory process, keeps the bowels constipated, produces sleep and
creates general nervous quietude. Quinine may often advanta-
geously be combined with this.
Where obstinate nausea, hiccough or vomiting occur, it may be
necessary to suspend other remedies for a while until the stomach
grows less irritable, and give small doses of hydrocyanic acid, bis-
muth, pepsine, creasote, ice, soda water, effervescing salines, etc.
Mustard poultices may be applied to the epigastrium, or even a
blister. A hypodermic injection of morphia and atropine may
succeed when other means fail. Should the vomiting prove very
persistent, it may be necessary to administer nutrient enemata.
To allay the thirst usually experienced, potash or soda water,
seltzer, barley water, toast water, or milk and soda water iced, may
be given in small quantities at a time.
In any case the diet must be simple and unstimulating, consist-
ing of milk, broth, beef-tea, jelly, arrowroot, and similar things.
After the first acute symptoms have somewhat subsided, whilst
the effiision is becoming organized, before it passes on to suppura-
tion or to chronic induration, a blister may be applied over the
hypogastrium, or a surface of about four or five square inches
painted over with the blistering fluid and kept open with savine
ointment, or with the French tissue-plaster known as " albespeyres."
Should the blistering tend to provoke distressing and persistent
strangury, as is apt to occur in some sensitive women, it will be
better to resort to the linimentum iodi or other form of irritant.
The bromide and iodide of potassium, combined with some bit-
ter infusion or tincture, such as cinchona, calumba, or quassia, may
now be given.
Chloral, hyoscyamus, or Indian hemp may be tried in place of
opium at bed-time to procure sleep, if the pain be not severe ; but
if this latter be a prominent symptom, some form of opium answers
best.
A vaginal douche of hot water, night and morning, may be of
service in stimulating absorption, a small quantity of tincture of
iodine or of common salt being added to the water if deemed ad-
visable.
Warm baths, or, failing these, hip-baths, will also prove of ser-
TREATMENT OF PELVIC ABSCESS. 349
vice in allaying pain, quieting inflammatory action, and inducing
refreshing sleep.
The bowels will need to be carefully regulated, and the simpler
the means employed the better. i
A little syrup or confection of serja (5j) ; the pulv. glycyrrhizse
CO. (5j in milk); tamar Indian; castor-oil (5j every morning) ; equal
parts of sulphur and bitartrate of potass made into a confection
with honey, of which a drachm or more may be taken when requi-
site ; small quantities of the natural aperient waters, or anything
that is found by experience to suit best, may be taken. An occa-
sional pill of a grain or two of calomel, or blue pill combined with
pil. rhei co., or the coloc3^nth and hyoscyamus pill, or one of aloes,
nux vomica, and rhubarb, is often of service.
If enemas be resorted to they must be given only by some ex-
perienced person, and then with great care, only the simplest and
least irritating being employed, such as a couple of ounces of olive
oil beaten up with the yelk of an egg and blended with half a pint
or so of warm water. K castor-oil be added, one or two table-
spoonfuls wdll be ample.
During all this time the most absolute and perfect rest possible
must be enjoined, the patient not being allowed to sit up in bed for
a single moment on any pretext wdiatever. Apart from any fear
of pulmonary embolism from dislodgment of some venous clot,
there is always a risk of inducing a relapse if the patient be
allowed to get up too soon. She will need also to be extremely
oareful in resting up at what should be, or what is, the catamenial
period, for many months afterwards, to avoid relapse.
Occasional blisters to the hypogastrium, painting wdth iodine,
the continual application of spongio-piline wrung out of hot water,
or poultices, may be persevered with.
Treatment of Pelvic Abscess. — On the first indication of suppura-
tion having taken place, every eiFort must be made to sustain the
vital powers. Animal broths, milk, malt liquors, wine or spirits
if requisite, or even solid food if the patient can digest it, such as
chop, chicken, sweetbread, game, or anything that the patient can
fancy, may be given.
A mixture of quinine and hydrobromic acid, or acid and bark,
or the citrate of iron and quinine, should be prescribed. "Where
cod-liver oil can be taken it proves very serviceable.
Fomentations and poultices will need to be sedulously applied.
A pill of quinine and opium at bedtime, or some other appro-
priate form of opiate, will generally be needed.
As to the propriety of opening pelvic abscesses, opinions differ.
There is no universal rule for practice in this matter, but as rupture
is the only alternative, and this may involve important structures
or even cause death by rupture into the peritoneal cavity, the ex-
pediency of making an opening must be determined by the urgency
of the symptoms, by the progress and duration of the case, by the
accessibility to puncture, and by the probabilities of early sponta-
neous evacuation taking place.
350 DISEASES OF THE BROAD LIGAMENTS.
It will be well in any case where the least doubt exists to em-
ploy the aspirator trocar at first, our subsequent plan of action
being guided by the results obtained. In cases of hard, inelastic
pelvic tumors, due to the thickened, indurated condition of the
cyst wall, where owing to th^ excessive distention fluctuation can-
not be detected, and yet the history points plainly to the presence
of pus, the employment of the aspirator trocar is indicated.
In those cases w^here the abscess is near the surface, and fluctua-
tion can be plainly detected either per vaginam, per rectum^ or in the
lower abdomen, we need have no hesitation in opening it.
If fluctuation be detected at the roof of the vagina, puncture
may be made by a long, sharp-pointed hernia knife, or by a long
trocar. A long curved trocar is very convenient for tapping the
abscess per rectum. If pointing take place in the hypogastrium,
an incision may be made with a bistoury or a Syme's knife.
The insertion of a drainage-tube, to keep the opening patulous
and facilitate the discharge of pus, is sometimes requisite where
the opening has been made 'per rectum or per vaginam. A winged
male elastic catheter or a Sayre's coil drainage-tube will answer
the purpose.
The best point for evacuation will be that to which the abscess
is nearest, or the surface from which it is most easily accessible
and the pus can most readily drain away after operation.
Where a choice exists, the skin over the abdominal walls is possi-
bly the most desirable, failing that, the vagina, and last of all the
rectum.
3Tode of Operating. — If there be no special reason to the con-
trary, it will generally be better to give the patient some anaes-
thetic before operating, in order to secure perfect quietude, more
especially if the opening be made internally. Antiseptic precau-
tions should be employed.
If the abdominal wall is the point of selection, the patient should
be inclined towards that side on which the opening is to be made,
so as to facilitate the exit of the pus.
If the vaginal cul-de-sac be the channel chosen, the patient may
either lie on her back or in the ordinary obstetric position on her
left side, with the hips close to the edge of the bed, depending
upon the convenience of the operator. The aspirator trocar is
then passed carefally along the vagina, guided by the finger until
the point is opposite the site selected for the opening. The trocar
is then plunged in, and any fluid contents aspirated.
Should it be thought desirable to extend the opening to allow
of free exit of pus, a bistoury or long, sharp-pointed hernia knife
may be passed up and the requisite incision made, or a laminaria
tent inserted.
In opening abscesses per rectum, the long curved rectal trocar
may generally be employed. The point of the trocar being with-
drawn in the canula until the spot selected is reached, the point is
thrust suddenly out and the instrument pushed into the sac, the
trocar being then withdrawn and the pus allowed to gain exit.
PELVIC PERITONITIS. 351
After first opening the abscess it is doubtful whether it be a
prudent plan to inject the sac with a view to washing it out, either
with warm water or some disinfecting solution, such as iodine, car-
bolic acid, Condy's fluid, etc., for fear of breaking down any adhe-
sions, and so allow^ing pus to gain entrance to the peritoneal cavity.
Later on, when the sac shows no disposition to close but goes on
pouring out large quantities of pus, which produces much exhaus-
tion of the patient, the injection of some astringent lotions is often
necessary. Of these tincture of iodine (5j-iv ad i5J); carbolic acid
(1 in 40); sulphate of zinc (gr. ij-x ad 5j); chloride of zinc (gr.
ij-x ad .^); or other agent may be injected and allowed to flow
out again.
Where air or fseces gain access to the sac from the bowel, or
urine from the bladder, a counter-opening must be made to allow
the free escape of all accumulations, and other means resorted to,
where possible, to cure the fistulous tracts.
Pelvic Peritonitis (Peri-metritis). — Definition. — Where inflamma-
tion afiPects the peritoneum covering the female pelvic viscera, and
is strictly limited to the pelvis, rarely passing into general perito-
nitis, it is spoken of as pelvic peritonitis.
Frequency. — Although proved by post-mortem examinations to
be a very common aftection among women, it is one that is very
generally overlooked.
Many of the anomalous attacks of cramp, pains, and colics oc-
curring at the time of menstruation, producing a certain amount
of' febrile disturbance, and necessitating a short rest w^ith hot
fomentations and other domestic remedies, are really instances of
pelvic peritonitis.
Pathology. — In the very early stage of the aflection we have
simple engorgement and turgescence of the vessels, producing red-
ness, dryness, and pain. Tbe membrane has lost its glistening
smoothness, it looks villous or granular, owing to intense vascular
injection. It is bright with punctate, stellate, and arborescent in-
jections, and often uniformly red.
In the second stage we find a collection of yellowish plastic
lymph, which is quickly thrown out over the whole inflamed mem-
brane, gluing opposing surfaces together. Serous or sero-puru-
lent fluid is also eflPused. The semi-fluid lymph gravitates into
Douglas's pouch, ultimately becoming consolidated into a firm
dense mass, binding the uterus and its appendages, as well as the
intestines overlapping the brim of the pelvis together. This con-
stitutes the third stage.
A considerable quantity of serum is often poured out in the
spaces left between the coils of intestine and the pelvic viscera,
forming a more or less circumscribed tumor, often simulating a
true cyst, and spoken of as encysted serous peri-metritis. In some
rare cases the contents are purulent, and may remain in a state of
quiescence for very long periods, though as a*^ general rule the col-
lection bursts into the rectum or sigmoid flexure, or possibly into
the vagina, still more rarely into "the bladder, and very seldom
352 DISEASES OF THE BROAD LIGAMENTS.
indeed into the general peritoneal cavity. Perforation of the ex-
ternal abdominal wall is far less frequent in this variety than in
abscess from cellulitis.
Purulent collections are occasionally found in the ovary, and even
one or other Fallopian tube may be distended with pus.
Where septic infection Avas a well-marked factor in the produc-
tion of the peritonitis, the lymph is often of a semi-fluid, pultaceous,
flocculent, or even purulent character, with little or no plastic prop-
erty, the adhesions readily breaking down. Where recovery ensues
the deposit of lymph becomes gradually absorbed, the adhesions
becoming stretched and thinned to allow of the movements of the
intestines; in other cases they shrink and so distort the uterus, by
the gradual traction exerted, or bind the fimbriated extremities of
the Fallopian tubes in such a position that the requisite passage of
the ovum is interfered with, and sterility results in consequence.
Causation. — In a large proportion of cases, pelvic peritonitis,
whether acute or chronic, is secondary to or symptomatic of dis-
eases of the uterus. Fallopian tubes, ovaries, or pelvic cellular
tissue. It may, however, occur as a primary affection, appearing
suddenly, as when irritating fluid escapes from the fimbriated ex-
tremity of the Fallopian tube, as in some cases of intra-uterine
injection ; from bursting or perforation of an ovarian cyst or abr
scess ; from rupture of the uterus or of an extra-uterine gestation
cyst; from eftusion of blood into the peritoneal cavity, as from an
over-congested Graafian follicle, or from regurgitation of obstructed
menstrual blood ; from perforation of the intestine, of a dermoid
cyst, etc. Cases not infrequently occur from sudden impression
of cold, analogous to cases of pleurisy and pericarditis, especially,
after parturition. A knowledge of this fact should make us ex-
tremely careful in resorting to cold-water injections, the application
of ice or the cold douche to the abdomen in cases of post-partum
haemorrhage, or of allowing the patient to remain long lying in the
wet linen, or of exposing her unnecessarily to cold.
In many of the puerperal cases, antecedent metritis or cellulitis^
from traumatic injury, or septic infection, is usually the starting-
point of the pehdc peritonitis.
It may, however, be part of a general peritonitis due to some
zj'^motic poison, as scarlatina or erysipelas.
Gonorrhoea is a very frequent cause, the inflammatory process-
extending from the vagina to the cervical, and thence to the uterine
mucous membrane, passes up the Fallopian tubes, producing sal-
pingitis, thence to the peritoneum. The ovaries are generally in-
volved in the process. It is this form of inflammation that is se
frec[uent in puellce publicce, and accounts largely for the fact of theii
generally being sterile.
Latent gonorrhoea will explain many of the obscure cases of peri
tonitis occurring in newly-married women.
Imprudence during menstruation, sudden suppression from cold
sexual excess just before or after this period, will account for som*
few cases.
PELVIC PERITONITIS. 353
Tubercular or cancerous deposition in any of the pelvic organs
may produce secondary inflammation.
AVliere obstruction to the free exit of the menstrual secretion
occurs, as in cases of stenosis and acute flexions, we may have
reflux of blood through the Fallopian tubes and peritonitis as a
consequence.
In certain states of the general system, unforeshadowed by any
recognized peculiarity, the most trivial operation has been speedily
followed by fatal peritonitis. Even the passage of the uterine
sound for the replacing of the uterus, or the application to the
cervical canal of some escharotic, may be suflficient, or the inser-
tion of an intra-uterine stem, a laminaria or sponge tent.
Symptoms. — These will vary, depending upon whether the attack
is acute or chronic, secondary to some antecedent inflammation of
the pelvic organs.
An acute attack may be ushered in by some feeling of chilliness,
but is seldom marked by a severe rigor, as generally occurs in
cellulitis. There is tenderness over the lower abdomen, usually so
marked as to compel the patient to assume the dorsal decubitus,
the knees being flexed on the abdomen so as to relax the abdominal
muscles, and also to take oti^* the w^eight of the bedclothes, which
is intolerable. The pulse increases in frequency, often to 120, is
â– small and wiry. The temperature will vary with the nature of the
case. It may run up to 106° F. rapidly in simple inflammatory
cases, or may be even subnormal in septic forms of the disorder,
or. may fluctuate irregularly between very high and very low, so
â– that we must not depend implicitly upon the revelations of the ther-
imometer, but be guided in our prognosis by a general considera-
'tion of the various symptoms. There is usually nausea or vomit-
ing, more or less tympanitis, constipation of the bowels with much
;pain on defsecation, except in septic forms where diarrhoea is the
â– rule, frequent micturition, with dysuria or vesical tenesmus.
The features become pinched and anxious, dark areolae surround-
ung the eyes. Delirium is not infrequent.
Some cases from the first assume a chronic or latent form, the
patients going about their usual occupations with merely a sense of
local discomfort, increasing to pain at menstrual periods, accom-
panied by feverishness of an evening, difl&culty in locomotion, and
by a general sense of feebleness and malaise. The symptoms are
frequently so insidious, and the progress of the disorder so masked,
that beyond some slight bladder-irritation there is little or nothing
to make us suspect the presence of the disorder, although post-
mortem examination may reveal the presence of dense, firm adhe-
dons over the w^hole of the pelvic roof, the organs being matted
irmly together.
These cases are most likely to occur when some long-standing
)ut not very severe source of irritation constitutes the exciting
^ause, such as endometritis, ovaritis, etc., but may also accompany
^onorrhoeal infection.
Amenorrhoea is a common result of peritonitis.
354 DISEASES OF THE BROAD LIGAMENTS.
Physical Signs. — On examination, the h^-pogastrium will be found
to be very tender on pressure. If much serum.be effused, a sense
of fluctuation may be detected on vaginal examination ; the uterus
is less mobile than natural, and gives rise to pain if any attempt be
made it push it up ; there is often a sense of resistance or tumefac-
tion, like an ill-defined tumor, in the posterior cul-de-sac or to one
side of the vagina, but there is none of the puflfiness or (edematous
condition met with in cellulitis. The tumor formed by the effused
lymph and serum, and by the agglutination of the pelvic and
abdominal viscera, is often extremely sensitive to touch ; it may
attain considerable magnitude, pushing the uterus forwards, rising
above the fundus up to the pehdc brim, and even occasionally reach-
ing as far as the umbilicus. Local collections of serum may occur
between the folds of the intestines, having all the characteristics of
cysts, or may be mistaken for abscesses. The adhesions formed
over the pelvic roof are often very firm and hard, almost like a
piece of board, fixing the pelvic viscera, and interfering consider-
abW with the calibre of the rectum, or pressing upon the neck of
the bladder.
Where suppuration takes place, the pus is often localized, so as
to form a limited abscess, or a series of abscesses. They may be_
at some distance from the uterus, although the inflammation orig-
inated there.
Differentiation. — The conditions with which pelvic peritonitis will^
be most liable to be confounded are pelvic cellulitis, pelvic hsemato-
cele, and fsecal impaction.
Cellulitis generally occurs after parturition, abortion, or some
operation upon the uterus.
Peritonitis usually results from exposure to cold during men-
struation, from extension of inflammation of the uterus. Fallopian
tubes, ovaries, or pelvic cellular tissue, or escape of some irritating
fluid into the peritoneum.
In cellulitis we have mostly a distinct rigor, followed by high
temperature ; these are less marked in peritonitis.
In cellulitis the pain is more of a bearing-down or dragging
character, there being a sensation of fulness and pressure, vesical .
tenesmus, and throbbing or pulsation.
In peritonitis the pain is referred more to the hypogastrium, th< -
recti muscles being kept rigid on pressure being attempted. Tin
patient lies on her back with the knees drawn up, the features ar<
pinched and anxious, and delirium or extreme mental anxiety ar<
often present.
In cellulitis the swelling is frequently limited to one or othe
iliac fossa, seldom rises much above the pelvic brim, and general!
suppurates.
In peritonitis the swelling is often more central, extends highe
up in the abdomen, the abdominal walls being more movable ove
it than in the case of cellulitis.
In pelvic hsematocele the sudden onset of the symptoms, ev
dence of internal haemorrhage, absence of preceding inflammator
355
symptoms, bulk of the effusion, which is soft at first, becoming
harder later on, and the concurrence of metrorrhagia, will generally
serve to distinguish the one aifection from the other, although the
hematocele usually excites peritonitis, and so we have the two ex-
isting together.
Fffical impaction may complicate either of the forms of pelvic
inflammation and lead to the belief that the inflammatory process
is still active, more especially where opium has been employed for
long periods. Examination per rectum, and the removal of any
accumulation, will soon clear up the diagnosis.
Other conditions have occasionally proved sources of error; they
will be found mentioned under pelvic cellulitis.
Prognosis. — This will depend greatly upon the character of the
attack. After parturition or abortion, if the attack be very severe,
or the inflammation extend to the general sac of the peritoneum,
the prognosis will of course be grave. The occurrence of a septic
factor as a cause of its origin will also influence our opinion, re-
covery in these cases being often very tedious. Where the attack
is insidious and chronic, the result of some peMc disorder, pro-
vided it be not tuberculous or cancerous, or occurs after some
operation in the non-puerperal state, the prognosis is more favor-
able.
Where the formation of abscesses occurs in place of adhesive in-
flammation, there is always the risk of perforation into the peri-
toneal cavity, or the lighting up of a fresh attack at the recurring
menstrual periods, or from some accidental cause.
Course, Duration, and Termination. — This varies considerably. As
with pleurisy we may have effusion, adhesion, and recovery, or
formation of pus, empyema, or pneumothorax, and death ulti-
mately from tuberculosis, so with pelvic peritonitis. It may run
its course unobserved, only being detected post-mortem. It may
come on very acutely, cause severe danger and discomfort, and yet
the patient recover perfectly within a comparatively short time.
In other cases the adhesions may be so dense that the pelvic organs
are all matted together in one confused mass, effectually preclud-
ing impregnation, and rendering the patient a permanent invalid
for the rest of her life.
Abscesses may form in different parts of the lymph deposit,
each new centre of suppuration giving rise to a renewal of active
symptoms.
General peritonitis may result from extension of the morbid
: process from the pelvic to the general surface of the peritoneum,
or one of the purulent collections may burst into the peritoneal
cavity and cause fataj peritonitis.
Results. — These are mainly amenorrhoea, dysmenorrhoea, and
sterility, due to atrophy or abscess of the ovaries, compression or
obliteration of the Fallopian tubes, and fixation of the uterus in
some abnormal position, frequently that of retro-flexion or -ver-
sion, from the permanence of the adhesion or contraction of the
exudation dragging the uterus to one or other side.
356 DISEASES OF THE BROAD LIGAMENTS.
Treatment {Preventive). — Much may be done in this direction, far
more than we might at first be willing to admit.
In those instances termed autogeneiic, where the septic matter
originates within the patient, so that she infects herself, a little
extra attention on the part of the practitioner at the time of partu-
rition, in those cases depending upon puerperal origin, may save
much subsequent anxiety. Great care must be taken not to allow
any portions of the membranes, or of the placenta, or any coagula,
to remain in utero, and so give rise to putrefaction and septic absorp-
tion. The patients should be urged to sit up for a few moments
at a time, to evacuate the contents of the bladder or rectum from
the very first. This will allow any clots in the vagina or decom-
posing lochia to be expelled. The employment of the syringe
daily by the nurse, with some antiseptic fluid, will also have the
same effect.
The foetal head should never be allowed to remain for many
consecutive hours arrested at the brim, or impacted in the pelvis,
sloughing being apt to follow, and septicaemia as a natural result.
So-called heterogenetic causes, the septic matter being conveyed
from without, account for many cases of pelvic peritonitis. Xo
student during the time that he is dissecting or performing post-
mortem examinations should ever be allowed to attend a patient in
labor. As far as practicable the medical attendant upon parturient
patients should avoid going direct to them from any infectious dis-
orders in other patients, such as scarlet fever, erysipelas, diphthe-
ria, or puerperal septicaemia itself. Where operative interference is
requisite, the most scrupulous cleanliness of all instruments should
be observed. Even the use of an imperfectly washed sponge, on
which discharge has been allow^ed to remain and decompose by
some careless nurse, may prove suificient to induce septic mischief.
Strict personal cleanliness on the part of the practitioner should
always be observed ; even the presence of some decomposing dis-
charge on the cuff of his coat, unobserved it may be at the time,
may light up inflammatory mischief in the next parturient patient
he attends. The fact of the practitioner being the subject of ozaena
has before now been the cause of numberless fatal cases of puer-
peral septicaemia.
Treatment. — This is very similar to that of pelvic cellulitis in the
early stage.
Absolute rest is the chief essential, and to ensure this the patienf
must be brought rapidly under the influence of opium. Large
and frequently repeated doses will be requisite. Grain doses oJ
pulv. or extract, opii, or quarter-grain doses of morphia, every twc
or three hours, depending upon the effect produced, may be given.
In strong plethoric subjects, the application of leeches to the hj^o-
gastrium, followed by a large linseed-meal poultice, will often allaj
the pain very materially; but the same remarks apply to peritonitis
as to cellulitis, both as to depletion and the use of mercury, anc
the reader is referred to these to avoid repetition.
The catheter may be employed to empty the bladder. Thr
REMEDIES. 357
action of the bowels should not be encouraged. Milk, beef-tea, jelly
and simple nutritious diet, in small quantities frequently repeated,
must be allowed. If vomiting be urgent, ice to suck, iced drinks,
bismuth, pepsine, hydrocyanic acid, creasote, etc., may be tried,
and where these fail a h}^odermic injection of morphia and atro-
pine will often succeed.
When the inflammatory process has somewhat subsided, counter-
irritation to the abdomen by means of turpentine stupes, mustard
poultices, painting with iodine, or, what is probably more efl&ca-
cious, blistering fluid, may be resorted to.
In ill-defined chronic cases, or where the acute attack has sub-
sided into the chronic stage, every means must be employed to
improve the patient's health as much as possible. She must not
be confined so rigorously to bed, but if weather permit should be
allowed to recline on a sofa, well wrapped up, near an open win-
dow, or even permitted to drive out in a carriage if the pain be not
thereby increased. The diet must be generous, alcohol in form
of stout or ale, wines, and even spirits, being given if deemed
requisite, but milk and animal broths will still form an important
part of her diet.
If she can digest it, cod-liver oil will prove of service. Some
form of tonic containing quinine or iron, or both, or mineral acids
with bark, will also be indicated.
As to the evacuation of any collections of pus or serum, if the
general health seems to suffer in consequence of their presence,
ithe- patient not progressing favorably, and there is evidence of
I pointing, or the collection can be easily reached, it may be well to
' employ the aspirator trocar, enlarging the opening subsequently if
thought desirable, and washing out the cavity w^ith some w^eak
disinfectant lotion, such as one containing iodine, Condy's fluid,
carbolic or sulphurous acid. But in all cases of peritonitic efiTu-
sions or collections of pus, the greatest care must be taken lest
â– adhesions be torn through, and the general cavity of the peri-
toneum opened.
Wliere the abscess points externally, antiseptic precautions should
ibe taken in opening it, a drainage-tube being inserted, or the cav-
fity washed out if necessary, as before indicated.
To encourage contraction of the cavity, the position of the pa-
tient must be attended to, so as to allow of the fluid gravitating
towards the opening. Pads of cotton-w^ool, oakum, tow, or other
similar material, may be also so arranged as to keep up pressure
by means of a bandage, with a view to facilitate the same object.
Evacuation may be accomplished by means of the aspirator
Tocar, by a small trocar and canula, by a guarded bistoury, or
3ther suitable cutting instrument.
Change of air to the seaside should be suggested as soon as the
:>atient is able to bear the journey.
Great care will need to be taken in permitting patients to walk
mtil all active symptoms have subsided, and even then the amount
nust be strictly regulated. Patients who are allowed to take exer-
358 DISEASES OF THE BROAD LIGAMENTS.
cise commit all manner of indiscretions, overtaxing their powers by
too prolonged fatigue, going out too thinl}^ clad, or sitting about on
damp grass.
For many months it will be necessary to carefully avoid all ex-
posure to cold or fatigue, and to keep resting in the horizontal posi-
tion, as far as possible, at the recurrence of each menstrual period.
Marital intercourse, without being strictly prohibited, must be
restricted mthin safe limits ; all emotional disturbances being par-
ticularly avoided at the above period.
Those who may be desirous of studying the subject more in de-
tail will do well to consult the following works, which have been
consulted by the author, and from which many important contri-
butions have been extracted.
Barker, Fordyce, '' The Puerperal Diseases."
Barnes, " Diseases of Women," 2d edition.
Duncan, Mathews, " Peri-metritis and Para-metritis."
Emmet, " Principles and Practice of Gynecology."
M'Clintock, "Diseases of Women."
Priestley, "Articles in Reynolds's System of Medicine," vol. v.
Thomas, " Diseases of Women," 5th edition.
PELVIC HEMATOCELE.
359
CHAPTER XXIII.
PELVIC HEMATOCELE.
Pelvic Haematocele. — ^Various terms have been employed to ex-
press an accidental effusion or collection of blood in the neighbor-
hood of the uterus, either wholly or partially in the pelvis, whether
in the peritoneal cavity or within the connective tissue of the pelvis,
such as peri-uterine and retro-uterine hsematocele, pelvic hsema-
toma, pelvic thrombus, and pelvic haematocele. Of these pelvic
Fig. 127.
Retro-uterine Haematocele. (After Barnes.) a. The Haematocele filling the Cavity of the
Sacrum, bounded above by Plastic Effusions and the Small Intestines. B. The Bladder, u.
The Uterus pushed forwards, r. The Rectum.
haematocele, as proposed by M'Clintock, is probably the most cor-
rect as well as appropriate.
There are two distinct varieties, the sub-peritoneal and the intra-
peritoneal.
The intra-peritoneal is by far the most serious kind. If the effu-
sion proceed rapidly, death may result before coagulation takes
place ; if more slowly, violent inflammatory action is often set up.
Some authors speak of this as being more frequent than the other.
It is true Tuckwell found of forty-one cases examined post-mortem
that thirty-eight were intra-peritoneal. Still this only proves that
the cases were very severe ; the extra-peritoneal form may still be
much more common, though not so severe and not so fatal.
360 PELVIC HEMATOCELE.
In sub-peritoneal hsematocele tlie blood is effused into the cellular
tissue surrounding the uterus, ovaries, and pelvic viscera generally.
Causes. — The p redisp osing causes are the jperi od of ov arian activ-
ity, more especially the period of greatfiat ^exual vigor, "asHbe^ween
twenty and thirty years of age, particularly at the menstruaLepocIjis^
when there is g^enefaThypersemia of the sexual organs; any chronic
ut erine or ov arian ^i^ease, especially if there be any obstruction
of the c ervix u terLoi:^ vagina ; the hsemorrhagic diatilesis or any
diseased condition of me~15Tood, such as~met^ith m zymotic dis-
eases, lead-poisoning, jaundice, chlorosis, purpura, scurvy ; a weak
and -var-icQse, condition ofjthe ve ins in the pelvis and lower ex-
tremities.
The exciting causes are suddeiLSuppresd^n of the_catamenial flow
from ci)id, niental shogji, etc. ; i m m gd er at^ o^oi t u ^ especTally at or
near a menstruaPperiod ; undue,_ex.er,tiDn , over:^^ue, violent
sti^aining at stool or other muscular strain ; any external violence,
such as falls, blows, etc. ; premature exertion after abortion.
Symptoms. — These vary somewhat, depending upon w^hether the
effusion be intra- or sub-peritoneal.
In intra-peritoneal hsematocele the onset is generally sudden, at
or about a menstrual period. The symptoms are those of severe
shock with intense abdominal pain, similar to those experienced
in cases of perforation of the stomach or bowels, with extravasa-
tion of their contents into the peritoneal cavity. The suddenness
and intensity of the attack not infrequently leads to a suspicion of
poisoning. Ma rked anaem ia rapidly ensues ; hieeup and vomiting
are often present! The femperature at first is k)\\ cr than normal,
and the surface of the body pale ancl bl^ngjied. The abdomen be-
comes tender and hard, as well as dull on percussion. Syncope,
with small, rapid, and almost imperceptible pulse, or even com-
plete collapse, rapidly ensues, and death not infrequently takes
place within twelve hours from the commencement of the attack.
In cases less severe than this, where the attack occurs at a men-
strual period, where this latter has not been checked by cold or
other shock, the flow is often much increased and may continue
so for many weeks, if the amount of effusion be not so great as to
preclude further loss.
There is generally also a feeling of fulness, or weight, or bear-
ing-down in the pelvic region, sometimes spoken of as a dull,
heavy aching, at others as acute pain, producing violent efforts at
expulsion as if some foreign body were present, uterine tenesmus
so-called.
The action of the bladder and rectum are also interfered with.
In cases of encysted hcematocele, the sub-peritoneal form, the
haemorrhage is often less profuse and less rapid, the onset of the
attack is less marked, the symptoms being more insidious at the
commencement, the prostration and shock less evident.
There is generally a feeling of weight or fulness about the anus,
with frequent desire to evacuate the lower bowel, although no faecal
matter, but only mucus tinged with blood, may be voided. There
PHYSICAL SIGNS. 361
is often partial or complete retention of urine, at the same time a
frequent desire to micturate, though where the effusion is limited
in extent, this symptom is less marked. Menorrhagia generally
ensues and often persists for many weeks.
If the patient survive the first forty-eight hours or so, reaction
generally sets in ; the pulse becomes more rapid, the temperature
elevated, there is a tendency to chilliness succeeded by a feeling
of warmth and distention, with tenderness in the lower abdomen ;
the skin is hot. Retention of urine is not infrequent. The pain
persists; menorrhagia continues. There is much rectal discom-
fort ; often dysenteric diarrhoea with tenesmus and muco-sanguin-
eous discharge, at other times much tympanitic distention with
constipation.
Later on the febrile symptoms gradually subside, the pain de-
creases, the menorrhagia becomes less. For some considerable
time, however, the patient experiences a feeling of weight and
bearing down, difficulty in defsecation and micturition, pain or
difficulty in walking, and much weakness.
Where the effused blood undergoes disintegration, the symp-
toms of irritative fever supervene. The countenance assumes a
dirty, sallow, earthy hue ; rigors, with vomiting, night sweats, ele-
vation of temperature, and rapid pulse ensue. The abdomen be-
comes more distended, tympanitic and painful. The symptoms of
septicaemia are marked, often accompanied by those of a low form
of peritonitis.
. Physical Signs. — These vary of course with the extent of the
effusion. Within the first few days following the attack we shall
usually be able to detect, on examining per vaginam, a more or less
soft, smooth, tense mass, occupying the pelvis, blocking up the
cavity, communicating to the finger on conjoined manipulation an
obscure sense of fluctuation or elasticity. The uterus is generally
pushed to one or other side, or more often upwards and forwards,
the OS uteri being detected high up behind the pubic symphysis,
against which it is often firmly compressed, occasionally being flat-
tened out into a narrow transverse chink, the cervix itself being
obliterated by the effused blood, the fundus uteri often being de-
tected just al)ove and behind the pubes, if the hand be pressed
carefully over the lower abdomen. The uterine sound may be
employed if necessary. In some few instances the bulk of the
effusion takes place between the posterior wall of the bladder and
the uterus, pushing this latter organ back into the hollow of the
sacrum ; but these cases are comparatively rare. Exploration by
the finger in the rectum should always be resorted to in any doubt-
ful case, the bladder sound being passed into the bladder if requi-
site, to assist still further in the examination.
Where the effusion is great and takes place rapidly, there may
be little or no displacement of the uterus, and even the mobility
of this organ may not be seriously affected at first.
There will usually be detected in these cases a fulness or sense
of resistance in the lower abdomen, more marked to one or other
362 PELVIC HEMATOCELE.
iliac fossa possibly, or extending nearly up to the umbilicus, dull
on percussion, tender to the touch. In some instances the effusion
is so great as to fill up the pelvic cavity completely, pushing down
the posterior vaginal Avail almost to the perineum. This may be
partly due to oedema of the recto-vaginal septum.
Later on the tumor ^:>6r vaginam is felt to become more solid and
tense, of unequal density, more irregular in outline, less resilient,
and there is no longer a sense of fluctuation. This feeling of
solidity depends upon coagulation having taken place, but more
especially upon the formation of plastic effusion, the result of peri-
tonitis, which serves to encapsule the mass. The serum becomes
rapidly absorbed, the mass becoming by degrees more solid and
diminishing in bulk.
In other instances the tumor becomes even more soft and fluctu-
ating, increases in size ; shivering, night sweats, anorexia, and ele-
vation of temperature clearly indicating that suppuration is taking
place.
Source of the Hcemorrhage. — This varies in different cases. It may
be from
1. Rupture of miejof the vessels in the uterine or ovarian plexus,
as the pampiniform plexus, or the bulb of the ovary.
2. Apoplexy and rup ture of the ovary.
3. Ex cessive h aemorrliage on r upture of a Graafian follicle, at
the time of menstruation, into the peritoneal cavity.
4. Reflux of menstrual blood through the Fallopian tubes when
the normal outlet at the os uteri or vagina is occluded.
5. Haemorrhage from vessels of the peritoneum and other sources,
such as false membranes, bursting of an aneurism, etc.
6. Constitutional causes, so-called cachectic hsematoceles.
7. Rupture of the sac of an extra-uterine foetation in the early
months. Rupture of the gravid uterus. Rupture of haemor-
rhoidal veins.
Rupture of a cyst in the ovary or broad ligament.
Rupture of the distended Fallopian tube.
Dr. Barnes speaks of those cases of non-encysted, intra-peritoneal
haematocele, depending upon rupture of the uterus, of tubal or
other ectopic gestation cysts, of the ovary, of sub-ovarian vessels,
or from a uterine varix or aneurism, when blood is rapidly poured
out in large quantities into the peritoneal cavity, looking at the
terrible suddenness and severity of the blow struck at the vital
powers, as " cataclysmic." In these cases the shock and loss of
blood alone may kill the patient without delay.
Differentiation. — The conditions most liable to be confounded
with pelvic haematocele are :
1. Pelvic cellulitis, para-metritis, or pelvic abscess.
2. Retro-version or -flexion of the gravid uterus.
3. Ectopic or extra-uterine gestation.
Other conditions are said to complicate the question and must
therefore be mentioned, but if ordinary care be exercised in listen-
ing to the history and in making a thorough examination, there
EXTRA-UTERINE GESTATION. 363
will be comparatively small risk of mistaking either of these con-
ditions for hsematocele. They are :
4. Fsecal accumulation.
5. Dermoid or other cystic tumors of the ovary or broad liga-
ments.
6. Uterine fibroids, retro-version or -flexion of the unimpreg-
nated uterus.
7. Malignant tumors, enchondromatous or osseous growths from
the walls of the pelvis.
1. In cases of pelvic cellulitis^ para-metritiSy or pelvic abscess, the
constitutional symptoms present themselves in an inverse order
from those of heematocele, febrile disturbance preceding the forma-
tion of tumor, whereas it follows in hsematocele. The skin also
does not become so rapidl}^ pale as noticed in hsematocele. Pelvic
inflammation is more frequent than heematocele, and is more gen-
erally consecutive to abortion or delivery; hsematocele is more
constantly connected with some accidents of menstruation, and
there is generally coincident metrorrhagia. The symptoms of
pelvic inflammation are seldom developed with such sudden inten-
sity as met with in hsematocele. The sw^elling in the pelvis is more
likely to begin laterally than posteriorly, is comparatively slow in
formation, is hard and brawny at first, the fibrinous deposit being
infiltrated through the pelvic tissues, fixing the uterus, often cen-
trally, so that it cannot be elevated or depressed, instead of displac-
ing it, as if soft plaster of Paris had been poured into the pelvis
and hardened there.
Later on, if suppuration occurs, the deposit becomes soft and
fluctuating. The deposit in hsematoeele is more often posteriorly,
retro-uterine, rounded in form, and displaces the uterus from its
natural position, generally forw^ards and upwards. The deposit is
soft at first, and becomes harder later on if absorption takes place.
2. Betroflexion and Retroversion of the gravid uterus are not infre-
quently mistaken for haematocele, in that they may occur suddenly
from accidents, straining, or any violent eftbrts, and lead sometimes
to retention of urine and other urgent symptoms coincident with
the formation of a retro-uterine tumor. Where the uterus is en-
larged to between the third and fourth month of utero-gestation,
and has become fixed or wedged in the pelvis, the diagnosis is often
extremely difiacult. The tumor is found to be circumscribed, sen-
sitive, somewhat mobile, and in some cases can be lifted up above
the pelvic brim by carefully directed pressure ; it may, how^ever,
be fixed by old adhesions, and thus complicate the case considera-
bly. There is also the history of early pregnancy to guide us.
Even if the retroflexion has been suddenly produced, and retention
of urine exist, there are none of the evidences of sudden or severe
loss of blood.
8. In extra-uterine gestation there is usually amenorrhoea for at
least a month or two, in place of menorrhagia ; the mammse show
indications of pregnancy, the cervix and body of the uterus undergo
alterations in bulk ; the condition does not develop suddenly but
364 PELVIC HEMATOCELE.
gradually, and there is an absence of urgent symptoms at the com-
mencement. It should be remembered that the bursting of an
early extra-uterine foetation — tubal gestation — is regarded by many
as a frequent cause of pelvic hsematocele. If, therefore, there be
the least suspicion of extra-uterine pregnancy, the examination
must be conducted with the greatest care.
4. Fcecal accumulatioiis may mislead the unwary. An examina-
tion per rectmn should never be neglected in any doubtful cases.
The finger can be indented in the mass. The history of constipa-
tion will throw light upon the question.
5. Small cystic tumors of the ovary occasionally fall down into
Douglas's pouch, and may even grow and become impacted in the
pelvis, pushing the uterus over to one or other side, or they may
contract adhesions, or become inflamed and suppurate, and thus
cause much difficulty in diagnosis.
They may usually be distinguished by their lateral position, their
mobility, slower growth, circumscribed form, and by their being
elastic or fluctuating. There is also an absence of urgent symp-
toms from the commencement. The aspirator will often clear up
the diagnosis.
Cases are not unknown of haemorrhage taking place rapidly
into the cavity of an ovarian cyst, and causing all the usual symp-
toms of haematocele.
Dermoid cysts are comparatively rare, and would probably not
be suspected until an examination of the contents by means of the
aspirator.
6. Uterine fibroids may generally be distinguished by their slow
painless growth, their density, attachment to the uterus, with
which they move, and by the irregularity of the surface.
Menorrhagia is a prominent symptom in these cases, as in
hpematocele, but there is an absence of any sudden supervention of
symptoms.
Operations for the removal of supposed fibroids have before now
been undertaken, when the case was one of retro-uterine hpemato-
cele. Where there is the least doubt, the exploring needle and
aspirator had better be employed. The passage of the uterine
sound will readily enable us to distinguish a retro- verted or -flexed
unimpregnated uterus. If the sound j)ass backw^ards and down-
wards into the tumor posteriorly, and the fundus uteri cannot be
detected behind the pubes, we may be pretty certain that we have
not a haematocele to deal with.
7. Maligymnt turnorsy mostly encephaloid in character, are rarely
met with in the pelvis. The history of their gradual development,
and the presence or absence of the cancerous cachexia, may pos-
sibly put us on our guard, though, as this latter closely resembles
the peculiar pallor produced in hsematocele, the difficulty of diag-
nosis is extreme. Enchondromatous and osseous growths from
the bony pelvis occur very rarely ; the history, their more or less
stony hardness, the absence of pallor, etc., should guard us from
mistaking them for h?ematocele.
TREATMENT, PROPHYLACTIC OR PREVENTIVE. 365
Course, Duration, and Termination. — The effusion of blood in the
intra-peritoneal form may be so great and so sudden as to destroy
life within a very short time ; such deplorable accidents are fre-
quently associated with the rupture of an extra-uterine foetation
cyst, as met with in tubal gestation. Where the haemorrhage is
less severe, and the patient does not die from shock or collapse,
the effused blood may undergo gradual absorption, an indurated
mass remaining for many consecutive months, gradually decreavS-
ing, and ultimately becoming entirely absorbed. In other cases
the effused blood finds its way by perforation through the vaginal
or rectal walls, bursting into one or other of these passages, and
80 becoming discharged. Secondary rupture into the peritoneal
cavity, when the effused blood becomes disintegrated, is compara-
tively rare, more often it is evacuated per rectum. There is often
a tendency to aggravation of the mischief at the catamenial periods ;
but it has also been noticed that a great stimulus to absorption
occurs at these times, the swelling disappearing as it were by suc-
cessive stages. Perfect recovery may ensue after the lapse of sev-
eral weeks or months, depending upon the amount of effusion,
subsequent amount of peritonitis, occurrence of septicaemia, and
other conditions.
Prognosis. — This will depend a great deal upon the amount of
blood effused at first, degree of constitutional shock resulting, and
the intensity of reaction excited.
Where expectancy is intelligently carried out, surgical interfer-
eijce not being rashly resorted to unless clearly indicated, the
prognosis is generally favorable. Death may occur either from
the extreme amount of blood suddenly withdrawn from the gen-
eral circulation, shock or collapse, peritonitis, septicaemia, or rup-
ture of the encapsulated mass into the peritoneal cavity.
The larger the amount of blood effused the greater wdll be the
risk of septicaemia resulting, or of a low form of peritonitis being
set up from disintegration of the mass. Exhaustion often follows
the process of suppuration, which occurs wheu the blood is dis-
charged by opening into the rectum or vagina, especially if this
opening be valvular or of limited extent.
Treatment [Prophylactic or Preventive). — All cases of obstructive
dysmenorrhoea in which haematocele is likely to occur should,
whenever practicable, be dealt with surgically, and every precau-
tion taken in the way of avoiding unnecessary fatigue, dancing,
exposure to cold, long journeys, etc., just at the menstrual period.
Sexual intercourse near these times should be prohibited, and
strict moderation observed at all times.
Patients who suffer from varicose veins of the lower extremities,
vulva or rectum, and w^ho menstruate very profusely as well as
painfully, should especially avoid all the exciting causes known to
produce haematocele (Priestley).
Where abortion in the early months has occurred, the patient
should be kept in the recumbent position for several days after-
wards, and all unnecessary excitement or fatigue avoided.
366 PELVIC HEMATOCELE.
Where h^ematocele, however slight, has once occurred, the
patient will need to take every precaution at succeeding menstrual
periods not to incur any known risks of exciting a recurrence of
the attack.
Therapeutic Management. — If called in early, our first efforts will
naturally be directed to checking the further effusion of blood,
promoting coagulation, averting the tendency to death from shock
or collapse, and allaying pain.
The patient, if not already in bed, should at once be placed
there, and the clothes removed with as little disturbance as possi-
ble. She must be kept absolutely quiet on her back. A hypo-
dermic injection of morphia will have the effect of allaying pain
and lessening the amount of shock, as well as rendering her less
restless.
If great prostration or collapse ensue, it may be necessary to re-
sort to alcoholic stimulants, such as iced brandy and water, iced
champagne, etc., but opium is a far safer restorative in these cases.
Locally, a bladder of pounded ice may be placed over the lower
abdomen, or iced water injected ^er rectum if deemed advisable.
In patients whose abdominal walls are thin and lax, it is a ques-
tion whether the better plan is not to cover the abdomen with thick
pads of cotton- wool or folded napkins, and exercise as much com-
pression as deemed prudent by means of a broad bandage, extend-
ing from the hips to the ensiform cartilage, which will materially
lessen the capacity of the abdomen, and so exercise pressure upon
the bleeding vessels.
Under no circumstances should hot fomentations or poultices be
employed with a view to relieve the abdominal pain ; they would
but tend to encourage the extravasation, and thus defeat our main
object.
If extra-uterine gestation be known or suspected to have been
present, and rupture of the cyst is the presumable cause of the
hsemorrhage, if this latter be very severe, as evidenced by the effect
produced upon the system, it is quite an open question whether we
are not perfectly justified in making an exploratory incision in the
abdomen and endeavoring to secure the bleeding vessels by liga-
ture or otherwise, ^ay, more, is not the performance of gastrot-
omy imperatively demanded where we have every reason to believe
that, in these days of antiseptic abdominal surgery, the operation
might be done with safety and success ?
Few practitioners will probably be inclined to follow the French
custom of bleeding from the arm, or the application of twenty
leeches to the abdomen, with a view to arresting the internal
haemorrhage.
During the first few days the diet must be simple, unstimulating,
and restricted in quantity, sufficient only being taken to prevent
exhaustion. As little alcohol as possible should be given. The
patient should be kept slightly under the influence of opium ; the
catheter had better be passed about every eight hours. iSo attempt
at relieving the bowels should be resorted to ; if much discomfort
BLADDER TROCAR.
367
Fig. 128.
be present, opium should be administered per rectum. The efficacy
of astringents and haemostatics in arresting the haemorrhage is very
problematical ; sulphuric or gallic acid may be tried if thought
desirable, or ergot may be given by the mouth or subcutaneously.
After the alarming symptoms of the first stage or shock have
subsided, a certain amount of feverish reaction generally sets in ;
the symptoms of peritonitis become marked. Salines, quinine, and
opium maj^ be administered internally, and a few leeches applied
to the abdomen. Any warm poultices or fo-
mentations must be used with great care, lest a
fresh access of haemorrhage takes place. Per-
fect rest must be enjoined, so as to favor adhe-
sions taking place, and the efiJused blood be-
coming encapsuled.
Surgical Treatment. — This has given rise to
endless controversy, opinions varying very con-
siderably as to the expediency of puncturing
the tumor after the more acute symptoms have
passed. " So long as the local distress is not
urgent, so long as the tumor remains hard, so
long as there is no sign of septicaemia or irrita-
tive fever, so long is it wise to follow the ex-
pectant method, observing strict rest, and ab-
staining from all local interference. But when
the tumor softens, when it enlarges immoder-
at,ely, when the pulse and temperature rising
indicate septicaemia, then it is time to consider
the resort to puncture " (Barnes). The usual
site for puncture is the upper portion of the
posterior cul-de-sac of the vagina, where there
is generally marked bulging. In some cases .
the bulging is more prominent in the rectum,
and then it may be deemed prudent to puncture
fer rectum, though this site should be avoided if
possible, as " the irritating and exhausting diar-
rhoea produced by evacuation into the rectum
frequently adds a new source of danger to a
patient already much enfeebled by the previous
progress of the afl:ection " (Priestley).
When the swelling is not readily accessible
by the vagina, but reaches high up into the ab-
domen and there is obvious pointing externally,
it may be safer to puncture through the abdom-
inal walls.
An ordinary bladder trocar (Fig. 128) may be employed if the
effusion be broken down and sufficiently liquid to pass through the
canula. The left forefinger being inserted per vaginam and passed
up to the most bulging point, the trocar is guided by the right hand
along the finger and plunged in the direction of the axis of the
pelvic brim, parallel with the posterior wall of the uterus. The
Bladder Trocar.
368 PELVIC HEMATOCELE.
trocar must be pushed deeply into the sac, so as to penetrate the
laminated coagula forming the outer boundaries, which are often
of considerable thickness. The canula may be left in situ for the
fluid to drain oft', or a drainage-tube inserted.
If the blood be chiefly coagulated and not fluid, it will probably
be necessary to enlarge the opening by means of a bistoury or ten-
otomy knife, or, better still, by the galvanic or Paquelin's cautery
knife, and clear out the clots by the aid of the finger or scoop ; but
it will be better not to attempt too much. Where decomposition
of the contents of the sac arises, the cavity must be washed out
twice daily with some disinfecting fluid, such as Condy's fluid,
carbolic acid, iodine, etc.
If there be signs of fresh suppuration after the use of the trocar,
with renewed distention of the cyst, the laying open by larger
incision will be almost inevitable.
In these cases where no surgical interference is resorted to, the
patient should be carefully watched for many consecutive months.
Absolute rest at the catamenial periods should be enjoined, and
even in the intervals the amount of exertion should be carefully
regulated ; no undue fatigue, long walks, or sexual excitement
should be permitted. The bowels must be regulated, the diet re-
stricted to hght and easily digestible articles. Tonics, such as the
syrups of the iodide or bromide of iron, citrate of iron and qui-
nine, bark and acid, with nux vomica, or other appropriate mixture,
should be prescribed.
Locally, the application of blisters, painting with iodine, or the
employment of mercurial and belladonna ointments, may prove
serviceable.
Change of air, and everything likely to restore the patient to
her former state, of health, should not be forgotten.
/
DILATATION OF THE FALLOPIAN TUBES. 369
CHAPTEE XXIY.
DISEASES OF THE FALLOPIAN TUBES, INCLUDING EXTRA-UTERINE
GESTATION.
Diseases of the Fallopian Tubes. — Salpingitis, or inflammation of the
Fallopian tubes, is generally the result of extension of inflammation
from the lining membrane of the uterus. The acute form ending
in suppuration is mostly observed as a sequel of septic endome-
tritis, or as an extension of gonorrhoea. The pus accumulating in
the tube and not escaping readily by either end forms a tortuous
dilatation of the middle portion of the tube. Sudden and rapidly
fatal peritonitis may result from extension of the inflammatory
process through the fimbriated extremity, from escape of pus
through the same orifice, or from pus being poured into the peri-
toneal cavity through a perforation the result of ulceration or
rupture from undue distention.
Obstruction or obliteration of the Fallopian tube may occur at any
portion of it, in consequence of pelvic peritonitis and the forma-
tion of bands of adhesion which constrict the tube, or if the latter
become twisted or bent it may be bound down by lymph, w^hich
in process of contraction efl*ectually closes the tube. In other cases
the fimbriated extremity of the tube becomes matted together by
lymph. In some instances a small polypoid growth may interfere
with the patency of the uterine orifice of the tube, or the pressure
of an interstitial fibroid may have a similar effect.
The result of obliteration of the tubes, where both are atifected,
is sterility. Ilsematocele may be caused by eftusion of blood into
the peritoneal ca\dty, when rupture of the Graafian follicle occurs
in the surface of the ovary, the ovum not being conducted into
the tube. .
Where the obstruction to the tube is only partial, the impreg-
nated ovum may become arrested and give rise to the most frequent
form of extra-uterine gestation, viz., tubal foetation. Rupture of
the tube generally occurs at a later stage, and death from haemor-
rhage is not infrequent.
Dilatation of the Fallopian tube may result from obstruction in
some portion of the uterine cavity, as at the internal os, in cases
of pronounced flexion. The menstrual blood being unable to gain
exit by the normal outlet, the cavity of the uterus becomes dis-
tended, reflex action is excited, uterine colic or expulsive pains
are produced, and retrograde dilatation of the uterine ends of the
tubes ensues. It is in these cases that the uterine sound occa-
sionally passes several inches beyond the normal distance, though
there is little doubt but that in some instances the point of tlie
24
370 DISEASES OF THE FALLOPIAN TUBES.
sound perforates the softened muscular tissue of the uterus, more
especially within a few weeks after parturition, when the uterus is
in a condition of subinvolution.
As it not infrequently happens that in the class of cases likely
to produce dilatation of the tubes we may have to resort to the
injection of astringent or styptic fluids into the cavity of the uterus,
to restrain hsemorrhage or to check profuse uterine leucorrhoea,
too much care cannot be exercised in avoiding any undue force
and in providing for the return of the fluid.
Uterine contractions being excited, the fluid may readily be
driven along the tubes, and thus cause severe symptoms from
shock or collapse, or set up peritonitis, w^hich may prove fatal.
There is also danger of the menstrual secretion finding its way
into the peritoneal cavity, constituting peri-uterine hsematocele,
or of any collections of mucus or pus being driven backwards and
setting up peritonitis.
In cases of atresia or closure of the uterus, vagina, or vulva,
leading to retention of the menstrual fluid, the Fallopian tubes
often become considerably distended, and may either burst or be-
come perforated, and so allow blood to become extravasated into
the peritoneal cavity. In puellce publicce, where the fimbriated ex-
tremity of the tube becomes closed in consequence of extension
of gonorrhoea, or of those attacks of metritis or peritonitis to
which they are so subject, symptoms known as colica scortorum are
not infrequent.
Hydrosalpinx, or dropsy of the tube, occurs in those cases Avhere
stricture or obliteration of the extremities of the tube takes jjlace.
The secretion gradually accumulating and being unable to dis-
charge itself into the uterus as usual, saccular dilatation of the
tube results, the collection in some instances attaining the size
of the foetal head, or even larger. The distended tube usually
assumes a convoluted form, the outer extremity presenting the
maximum of distention. The fluid contents vary from a yellowish
limpid serum, containing large quantities of albumen, to a thick
muco-purulent or sanguineous fluid. In many instances both tubes
are similarly aftected.
Diagnosis. — Dropsy of the tube may sometimes be distinguished
from a small ovarian cyst, with which it is most liable to be con-
founded, by the following points :
In the case of distention of the tube, the swelling is generally
convoluted, elongated, and cylindrical. Its position is more ante-
rior than that of an ovarian cyst, and can often be felt behind
Poupart's ligament by conjoined manipulation. AflPections of the
tubes, excluding tubal gestation, are frequently symmetrical, when
the uterus is detected in a central position. Where one tube only
is aftected it pushes the fundus towards the opposite side, thus
causing obliquity of the uterus. Examination of the fluid when
drawn ofiT by the aspirator would also assist the diagnosis.
A small ovarian tumor generally falls behind and a little to one
side of the uterus, pushing this latter forwards against the sym-
ECTOPIC OR EXTRA-UTERINE GESTATION. 371
physis, often causing pressure upon the bladder and even retention
of urine. It is usually spherical in shape, and can be detected
readily on examining per rectum.
Treatment — Puncture per vaginam, with an aspirator or small
trocar, and examination of the fluid, will generally enable us to
distinguish between dropsy of the tube, cyst of the broad ligament,
ovarian cyst, and an extra-uterine gestation cyst. As Barnes puts
it, absolute precision of differential diagnosis is not imperative, as
the same indication to puncture the cyst exists in all these cases.
In the first two the cyst is not likely to refill, whereas, if it be
ovarian, the fluid will in all probability collect again within a very
short time.
Fallopian catheterization, by means of a fine whalebone probe,
has been suggested as a method of evacuating the retained fluid
and keeping the uterine ends of the tubes patulous.
Hcemato-sal'pinx^ or distention of the Fallopian tube with blood,
not infrequently complicates hsematometra from occlusion of some
portion of the genital canal, as mentioned under dilatation of the
tubes.
Fibroid tumors or myomas similar to those found in the uterus
may occur in the Fallopian tubes.
Tubercle and cancer have also been observed, but as these affec-
tions are comparatively very rare, and but little can be done in
the Avay of treatment, w^e need not stop to consider them further.
Ectopic or Extra-uterine Gestation,
Although this subject belongs strictly speaking to obstetrics,
and is rarely more tlian even alluded to in works on gynecology,
it will be of advantage to the student if we consider the question
in the present treatise, as a knowledge of it is essential in forming
an opinion in all cases of doubtful or obscure pelvic and abdominal
tumors. It will be needless to enter into the various perplexing
varieties that the zeal of modern obstetricians has elaborated.
The classification of the late Dr. John S. Parry, of Philadelphia,
who recently published a most exhaustive monograph upon extra-
uterine pregnane}^ will be found to include every possible variety.
It is from his graphic description that the following account is,
mainly condensed:
Species, Varieties,
Tubo-ovarian (the germ being arrested in the pavilion, which con-
tracts aahesions with the ovary).
Tuho-ahdominal (germ arrested in the same locality. The tube
may contract adhesions with neighboring organs. If it does
Tubal J not, the chorion may project into the abdominal cavity, with
Pregnancy, j a part of its surface bare).
Tubal proper (germ arrested between the pavilion and that portion
of the oviduct which traverses the uterine wall).
Tvbo-uterine (germ arrested in that portion of the tube which
passes through the uterus).
372 DISEASES OF THE FALLOPIAN TUBES.
Species. Varieties..
{ Ovarian proper (germ contained in tlie ovary, that organ remain-
Ovarian I ing free from adhesions).
Pregnancy. 1 Ovario-tuhal (germ contained in the ovary, which contracts adhe-
i hesions with the paviHon of the tube).
Y , 1 { Primai-y (ovum developed from the outset in the peritoneal cavity).
A iff? ^^* ^\ J S^^^^d^^ (development commences in the tube or ovary, the cyst
omma > ruptures, ovum escapes, and continues to live and develop in
Pregnancy. [ the peritoneal cavity).
For our present purpose it will be sufficient to consider the three
species : tubal, ovarian., and ventral. Of 500 cases, collected by Dr.
Parry, 214 were tubal, 27 ovarian, 29 abdominal, 230 being doubt-
ful ; but even here there are some manifest sources of fallacy, and
as the author himself remarks, " the above statement is of little
value."
The ovum may be arrested and go on developing in any portion
of the oviduct, constituting tubal pregnancy. The weight of author-
ity is in favor of the possibility of ovarian pregnancy.
Facts, while they do not prove that fecundation can occur in the
peritoneal cavity, make it extremely probable that it does some-
times happen ; this constitutes abdominal pregnancy.
Causes. — Pelvic inflammations, peri- and para-metritis, frequently
cause extra-uterine pregnancy by producing constriction and dis-
placement of the uterine appendages. Erratic pregnancy is apt to
occur in women who have become pregnant after having mani-
fested an inaptitude for conception, either primarily, or after they
have borne one or more children — frequently after a long pause in
conception.
Hernia of some portion of the internal genital organs may some-
times cause extra-uterine gestation. It seems not improbable that
some of the ordinary uterine displacements may occasionally pro-
duce extra-uterine conception by preventing the migration of the
ovum along the Fallopian tubes.
Tumors of the uterus and surrounding organs sometimes pro-
duce this accident by obstructing the Fallopian tubes. An unhealed
section of the uterus, made in the operation of gastro-hysterotomy,
has caused extra-uterine gestation.
Moral and mental influences may cause this accident, such as
strong emotions, occurring during or shortly after intercourse, espe-
cially in widows and young girls who indulge in illicit hymeneal
pleasures, as the fear of discovery or fright experienced during or
immediately after the sexual act; but it is to be remembered that
this terrible accident is much more frequently due to pathological
changes in the internal sexual apparatus, than it is to emotional
disturbances experienced at or near the time of coitus.
Any injuries, such as blows, shocks, falls, or severe exertion
during the first few da3'S after conception, may alter the relation
of the tubes, ovaries, and uterus in such a manner as to prevent
the descent of the ovum.
In cases of combined intra- and extra-uterine pregnancy the two
PATHOLOGICAL ANATOMY. 373
ova may obstruct each other in their descent to the uterus, and thus
cause the accident.
Various diseases of the Fallopian tubes may impede the descent
of the ovum, or even temporary flexion may sometimes obstruct
the oviduct, and thus lead to the arrest of the germ. Deranged
physiological action, such as spasm of the muscular coat of the
tubes, due it may be to the violence of the voluptuous sensation
during coitus ; paralysis, too great relaxation and inaction of the
muscular fibres of the canal, have likewise been supposed to cause
it. Ovules produced in Graafian vesicles developed on the margins
of the ovary, and especially upon its posterior, inferior portion,
will be less likely to reach the tube safely than those liberated from
the upper portion and near the centre of the ovary.
Long-continued functional activity of the genital organs, and the
diseases produced thereby, are not without influence on the pro-
duction of extra-uterine pregnancy; hence the accident is more
frequent in multiparse than in primiparae.
Pathological Anatomy. — The uterus after death from rupture in
the early stages is found to be more or less enlarged. It always
undergoes, to a greater or less extent, those changes which prepare
it for the reception of the ovum. The organ is more vascular than
natural, and its cavity is often found to be lined with a decidua.
This is absent only when it has been discharged before the death
of the pati^ent, being rarely retained until the completion of gesta-
tion, and thrown off during false labor. More frequently, if the
pAtient goes to term, it is discharged during the early periods of
pregnancy in small fragments, and Avithout producing pain ; or else
it is expelled en masse with symptoms of miscarriage.
The cervix is filled with a plug of thick gelatinous mucus, pre-
cisely as it is in normal gestation.
The uterus, although prevented from discharging its functions,
prepares to do its work precisely as if the fertilized germ had
entered its cavity.
The corpus luteum is present as a rule, its absence is the exception,
especiall}^ in the early months of gestation. It is a curious fact
that it has been found in the ovary which is on the side opposite
to that occupied by the gravid cyst.
If the gestation is ventral, whether primar}^ or secondary, the
sac is composed of the ovular envelopes of the foetus alone, or con-
joined with an adventitious membrane, formed as the result of irri-
tation and inflammation. In a few instances of secondary abdominal
gestation, the child has been found in the abdomen, uncovered by
any membranes, or surrounded only by an adventitious cyst. Upon
opening the foetal cyst the liquor amnii will be found to present its
normal characters. The umbilical cord is almost always normal in
its formation. The placenta varies considerably in different cases.
It may be attached to any portion of the surface of the peritoneum,
within the ruptured foetal cyst whether it is ovarian or tubal, or
lastly within the uterus itself.
In women who die at term, the womb is more or less displaced.
374 DISEASES OF THE FALLOPIAN TUBES.
It is generally elevated, the cervix being carried towards and above
the pubes. At the same time it is pushed to one side, though it
is sometimes found in the middle line. Though the foetus is gen-
erally developed behind the uterus, it may lodge anterior to the
organ, which is consequently pushed backwards and downwards.
In rare cases even the bladder is found behind the vicarious uterus.
The womb is enlarged in almost all instances. Very rarely, in-
deed, does it fail to undergo some nutritive change, but at term
the organ is not often found larger than that of the fourth or fifth
month of pregnancy, and at this time it rarely contains a decidua;
this has usually been thrown off before death occurs.
The autopsy of women who have lived some time after the death
of the child may reveal characters very different from those de-
scribed. The foetus now either undergoes decomposition, or the
cyst shrinks, the liquor amnii being reabsorbed, and the product
of conception lies quiescent in the abdomen. In the former case
the cyst walls will be found inflamed, and they may be partially or
wholly destroyed. 
