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. ■
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
^^■^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-
■ M vidual case, or can be altered in shape from time
■ ^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
■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 (¥\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.
A¥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-
■ 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-
■ 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
^^^^■^^^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
^■^^^^ 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
■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-
■\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 ■
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
■ 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
► ^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
■conjoined manipulation, the passage of the uterine sound in the
normal direction, the tumor behind the cervix being still felt by the
■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
,■ 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.
■ Numerous ingenious contrivanci^
■ have been devised to overcome the
I difficulty often experienced of keeping
I the uterus straight and the fundus ele-
■ vated. Meudows's Vulcanite Stem and^
I Support (Fig. 84) consists of an intra-
I uterine stem attached to a kind of
^■^^^ ^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
■ 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.
■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 ■
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
'■ 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,
'■ 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
■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-
■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 ■
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-
■: 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
■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
■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 ■
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-
■:. 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
■^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-
■ 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
■ 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- ■
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
■ 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
■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 eminenc 
