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lilSil^i^^ltMilPSIiSl
^
LECTURES
ox THE
DISEASES OF WOM
\
THE AUTHO
The third edition of this 1
out of print. : T^je; work 1
my expectatioM^. ' "It 'fiad j
in America, through two i
less distinguished than tha
lator, and had also been tr
Spanish, Dutch, and Danisl
But in the year 1863 my
mew's Hospital ceased ; and
saying that " no one should
ject which he does not co^i
been present to my mind, a
attempt to edit a fresh editi
Last year, however, my
consented to supply my defi
Thus encouraged, I have om
li THE author's PRKFACK
some five and twenty years ago. I have omitted I
what then seemed to me important ; for ulceratioi
08 uteri has now found its proper place among the i
of uterine congestion, or of the sequelte which
tiehind ; while the arguments which once seemed
against ovariotomy have met an answer which
no reply, and which heaves room only for i
gratolations to him who has been the answe
all woman-kind of whom he has been the bent
Many pages have been rewTitten. I have
I trust imT>i'OKed,. where* the* expef bnc£* of
\* *. ; *^ '* ^ *"*: ' : '::.**.- ^ ^
has enabled mv^ io'clo^s^or north r/gteal tjlai
edition on my professional brethren resets id
made by Dr Matthews Duncan, which ar
!>y l>eing included within brackets,
* CH
61 WiMi'OLE Street, W.,
Jprit 1S79.
DR MATTHEWS DUNCAN'S PREFACE.
When I undertook to aid Dr West in what I regarded as
a highly desirable object, the bringing out of a new
edition of his work on the diseases of women, I antici-
pated the introduction of many more paragraphs from
my own jjen than are to be found in this fourth edition,
and so, I believe, did Dr West. But our mutual counsel
and co-operation have led to such activity in remodelling
by the author of the book, that less than I expected has
fallen to me individually.
It would be almost absurd, in the present growing state
of gynaecology, to look for identity of opinion or view in
any two authors ; and the appearance of my name on the
title-page of this work does not imply any such coinci-
dence. But I esteem that place beside Dr West to be
an honour ; and it does imply entire concurrence in the
tone and spirit of the work.
The literary charact/cr of Dr West's style, the thera-
Viii DR MATTHEWS DUNCAN'S PREFACE.
peutical principles and details, the philosophical and
view of the diseases considered, are such as to render
work valuable to practitioners, and peculiarly fit for
senting to students for careful perusal, with a vi
their earliest impressions of this branch of medicine,
J. MATTHEWS DOT
71 Brook Street, W.,
AprU 1879.
CONTENTS.
LECTURE I.
PAOX
INTROPUOTOBT. SYMPTOMS OF DI8RASE8 OF WOMKN, . , . 1
LECTURE IL
INTBODUCTO&Y. EXAMINATION OF SYMPTOMS, OONCLUDED. MODES OF EXA-
MINATION, 10
LECTURE in.
MENSTRUATION, AND ITS DISORDBIUS. AMENORKHSA 25
LECTURE IV.
DISORDERS OF MENSTRUATION. AMENORRH(EA CONCLUDED. MENORRHAGIA, 48
LECTURE V.
DISORDERS OF MENSTRUATION. DYSM£NORRU<£A, 71
LECTURE VI.
DISEASES OF TUE UTERUS. INFLAMMATION AND KINDRED PROCESSES. HYPER-
TROPHY OF THE UTERUS, AND ACUTE INFLAMMATION, . . . .92
LECTURE VII.
INFLAMMATORY AFFECTIONS OF THE UTERUS. CHRONIC INFLAMMATION OR
CONGESTION OF THE UTERUS. CATARRHAL ULCERATION OF CERVIX. EN-
DOMRTRITIS, 107
tTEUfNE TtJMOrUS ^ND OUTOEOWTUH. MUCOUS, FJBItO-CEU
1>VMJI POLTPL MUCOUS CYSTtt OF tJTEtirs. FlBIllXOUS
LEUTURE XIV.
UTERINE TUM0UE8 AND OUTGKOWTFlJt. FltlllOUS^ TUMOl
TCKEi FATHOLUOY, AXD SYMFTOSJSj ....
LECTURE XV.
UTERINE TUMOURS AND OUTOltOWTHS. FIBROUS TUMOUR
DIA0NO81S, AND PKV NATIONS FHOM OBDINABY StMPTO*
LECTURE XVL
UTERINE TUMOURS AND OUTGROWTHS. FiBROUS TUMOl
TREATMENT,
CONTENTS. XI
LECTURE XVII.
PAOS
FIBU0U8 POLYPI. SARCOMA, OR RECURRENT FIBROID TUMOURS. FATTY TU-
MOURS OF THE UTERUS. OTHER UNUSUAL VARIETIES OF UTERINE TUMOURS.
TUBERCULAR DISEASE OF THE UTERUS, 320
LECTURE XVin.
MALIGNANT, OR CANCEROUS DISEASES OF THE UTERUS : THEIR MORBID ANA-
TOMY, 844
LECTURE XIX.
MALIGNANT, OR CANCEROUS DISEASES OF THE UTERUS, CONTINUED: THEIR
PATHOLOGY, SYMPTOMS, AND DIAGNOSIS, 366
LECTURE XX.
MALIGNANT, OR CANCEROUS DISEASES OF THE UTERUS, CONTINUED: THEIR
TREATMENT, 898
LECTURE XXI.
INFLAMMATION OF UTERINE APPENDAGES, AND OF THE PELVIC CELLULAR
TISSUE : ITS CAUSES, SYMPTOMS, AND COURSE 421
LECTURE XXII.
INFLAMMATION OF UTERINE APPENDAGES, ETC., CONTINUED: EXCEPTIONAL
CASES. TREATMENT OF THE AFFECTION. HAEMORRHAGE ABOUT THE UTE-
RUS, OR UTERINE HEMATOCELE, 444
LECTURE XXIIL
INFLAMMATION OF THE OVARIES THEMSELVES. THE ACUTE AND CHRONIC
•FORMS OF THE DISEASE. DISPLACEMENT OF THE OVARY. CIRRHOSIS OF
THE OVARY. NOTE ON HERNLV OF THE OVARY AND ON SEROUS CYSTS OF
UTERUS, 476
LECTURE XXIV.
OVARIAN TUMOURS AND DROPSY ; THEIR MORBID ANATOMY, . . .495
LECTURE XXV.
OVARIAN TUM0DR8 AND DROPSY. PATHOLOGY OF THE DISEASE FURTHER
CONSIDEUKD: ITS COUKSK AND CAUSES, ill?
m
Xll CONTE^
LECTUKE
OVAKIAN TUM0UB8 AND DROPSY; TIIKIK »
ON FLOATING TUMOURS OF THE AllDOMKN,
LECTIUE
OVARIAN TUMOUErt AND DROPSY; TUEIR
TREATMENT. OPERATIVE MEASURES— TA
LECTURE :
OVARIAN TUMOURS AND DROPSY : THEIR TI
MEASURES. OPERATIVE TREATMKNT. 1
LECTUK
DISEASES OF THE FEMALL RLADDEK.
LECTl
DISEASES OF THE URETURA AND VAGIN
LEC7
DISEASES OF THE EXTKPJ^AL URGAN»<
INDEX,
LECTURE L
INTRODUCTORV,
L a n
r of snbjocta iilitadjr considered in the Lectures on Hiilwifery — Reajiions for
'iiaviug postponed the Stnrly of the Disoiises of Women — Twofold knowledge
requisite fur thinr Ktudy — DangeiB and mistakes uising &om want of it —
IliuMtratiFo cases. Symptoms of these diaeasea furnished by disturbance of
fuiiutioHf alteration of s^uBibility, and change of texture. Symptoms of first
two clatises considered. Importance of not overlooking existence of uterine
diseajie.
jEXTLEMEH, —Some of you, perhaps, remember that I endeavoured,
fat the commencement of my Lectures on Midwifery, to point out
tci you the various respects in which the generative system plays
a more imi>ortant part in the organism of woman than in that of
iie man. I called your attention to its constantly recurring
activity, as displayed in the periodical return of menstruation, to
its fur-reaching influence as manifested in the various phenomena
that attend upon pregnancy and kl»our, and to the impress wliich
the whole body bears of Uie special adaptation of every part for
the most complete performance of its functions. I pointed out to
you, how, as the child grows, the womb grows with it ; how its
luwly organised tissues become developed ; its vessels increase in
size ; nerve-matter is deposited within the sheaths, so delicate as
to have been almost imperceptible before ; and the uterus liecomes
at length what old anatomists have not hesitated to call it, —
Miraculiim Naturae. And next I described to you the means by
I wliich all the dangers and difficulties of partimtion are sur-
^kiountod ; and then told you how, all the grand functions of the
^■aterus beuig thus completed, its tissue undergoes degradation and
^Riecay, its vessels shrink, its ner^^es dwindle to their former size,
all the emunctories of the body bearing their part in the removal
^f the now useless materials ; while, at the same time, nature
ibours to form a new uterus, fitted to go once more through the
ftme marvellous changes, and to answer the same important ends.
AKD DIFFICULTIES
I details, not for the piupofl^
* to lead you to the obvioiis inf
1 must be very apt to become
be your duty, and ought \
jmatAreB with them and their
L to know what is healthful, to cc
» m to render ilk that are uua'
1b» eismiiced, as I trust, of the
im oompleted the examinatia
Hie aei; m 00 far as the reprod
HAItt«« ii^oired, moreover, into
■ek Ae generative orgaus are ]
I of their highest f unction
i llie aieaiig whereby it may
qnlein in woman has fu
I €t tkoM highest offices wlxi
ied^ and becomes
IS not without s
Hie establishment of
i with advancing a
lie eoMtitotion; at botl
fialijlitj to disease, and
I ni Qm rate of mortality. AI
, too^ A tfMMiBnd causes may
of its activit
of the body in
of the sexual functions, tl
^ cm the general health, or a
ne of your attention ; hn*
\ with them most com
i of women will be
wliadi siibeer\'e these functir
these organs, too, are compile
tnons tiflsiies^ but bound togetl
ttsi one pszi cumol be the seat of EuSf
mg together ; and hence it is often m
iBDgfed web of symptoms, and to find
and what it is, to which so many m
due.
OF STPDV OF DISEASES OF WOMEN.
3
II
I
I have deferred till now inviting you to enter on the study of
these affections, on account of the many difficulties by which it is
attended, and on account of the need you will find, in pursuing it,
of that special knowledge which you have acquired while attend-
ing lectures on midwifery, as well as of that acquaintance with
practical medicine which careful observation in the wards of the
hospital can alone supply, Know^ledge of both of these kinds is
equally necessary ; the want of the one or of the other is the
cause of those two errors into which practitioners not infrequently
fall Some men regard the local ailment as everjlhing ; otliers
almost lose sight of its existence, and it is difficult to say which of
these two errors is the more mischievous. A woman applies to a
practitioner who is guilty of the first- mentioned error, complaining
of painful and scanty menstruation ; he at once adopts niechunical
means for her relief. He introduces bougies to widen the canal,
and to remove some, probahly imaginar)% contraction of the cervix
uteri, by which he conceives the escape of the menstrual fluid to
be impeded, and he even incises it to make sure, as he supposes,
of enlarging its calibre. After imdergoing much pain of body, and
much distress of mind, the patient finds herself at the end of these
manipulations no better than when they began ; the cause of her
sufferiugs lay deeper, and was to have been fonnd in the derang-
ment of her general health, which would have attracted the notice
of a better physician, and which well-directed measures would
probably have cured. Let me mention another case as illustrative
of the opposite error, A patient seek* for relief on account of
profuse menstmation, attended with discharge of coagula, but
accompanied \\4th little or no pain. General treatment is adopted,
the patient is confined to the recumbent posture, in a cool and
well-ventilated room, astringents are given internally, cold is
applied locally, and no sign of disorder of the general health is
allowed to pass without appropriate means for its cure ; but yet
amendment does not follow, for the bleeding depends upon the
presence of a poljr^ius, which nothing but careful examination of
the uterus could discover. In the one case, a crass mechanical
treatment was adopted to cure an aflection that depended on the
state of the general health ; in the other, general treatment failed
to remove symptoms which careful investigation would have shown
to depend upon a local cause. But I need not draw upon
EBBORS IN DIAGNOSIS
imagmaiy caaes in order to enforce the caution that I am deg
of impreasing on you ; the records either of hospital or of pi
practice afford illustrations of it in abundance.
A middle-aged woman complained of frequent desire to
water, and of discomfort in voiding it ; she was dj^peptic an<
of health* Her urine waa t^ted, and found to contain albni
and the irritable state of her bladder was assumed to be depei
cm diaeaae of her kidneys. Treatment improved her general h<
but brought no relief to her djsuria. At length careful observ
discovered the albumen to be due to the admixture of vr
dischai^es with her urine — ^a not infrequent source of it in
who suffer from hjucorrhoea ; while examination, which ]
delayed Ujo long, detected a small vascular tumour jui
the orifice of the urethra, to the irrititticm produced by t
aymptoma were due, as waa shown by their immediate i
ance on its removal.
A young lady whose health had never been robust, )
nge of twenty-two to menstruate irregularly and gcf
sufTer at the same time from pruritus of the vulv
symptom various Icm:^! applications were resorted *
than once she underwent the distress of an exam'
discovered nothing more than an increased deg
about the labia and nymphte. At length, with ti
general health, she came under the care of anothe
a8cert4iined that sugar was present in her uri?
like the itching of the urethra in the male subj
sequence and the symptom of the diabetes of wl
eventually died.
A woman was admitted into the hospital a
state of extreme suffering ; her countenance
she lay in bed with her knees drawn up, d
movement ; her alidomen was intolerant e
pressure. She was reputed to have peri
bled for this, as well as abundantly salivatec
yet x^ithout relief. But with all this her si
her pulse was soft, and not increased in f
was, that after vague uterine ailmentF
suddenly attacked by \nolent pain in t'
bearing-down efforts equal in intensity
Of DISEASES OF WOMEK.
subsided, but the pain was referred to the bladder, and desire to
pass water became very frequent. This, too, abated, and the next
complaint was of violent pain in the shoulder, which was
encountered by active measures for the relief of alleged inflam-
mation of the slioulder-joint ; and the pain in the shoulder
suddenly ceasing, the severe abdominal suffering at once succeeded
it A hi»t hip-bath gave almost immediate relief, though the
patient screamed when moved in order to be placed in it ; and a
full dose of opium was followed by some hours of quiet sleep.
The next day no pain was complained of except over the pulses,
and this soon disappeared under the use of anodynes; and steal
and good food completed the cure of a case of hysterical
peritonitis.
Now these cases, to which it would be very easy to add many
more, are aU examples of the error of making too little or too
much of symptoms indicating disorder of the sexual system.
Your general medical knowledge must keep you from the latter ;
it is my special duty to arm you against the former, or rather, as
much as in me lies, to defend you from Iwtlu
With this view I propose to-day to make a few introductory
remarks ujion the si^ji^ and si/mptonis ofdiscdse of ike generatim
organs in the female, and on the means of investigating them.
There are three modes, in some or all of which these aifections
manifest themselves — namely, by causing disturhance of Jmwiicm^
attercUian of sejisibiliti/, or chajige o/icjcture.
The ovaries are the grand organs of sexual activity in the female ;
and during the whole time that sexual life continues, they are
employed in the healthy inth%idnal in bringing ova to maturity,
and then in extruding them at certain periods wlien tliey have
attained a state of fitness for further development, if subjected to
the fecundating influence of the semen. Accompanying this
internal process, the consequence and the evidence of the local
congestion which attends it, we observe a periodical discharge of
blood constituting menstruation. The regular return of menstrua-
tion, its accomplishment within a given period, attended by a
certain average amount of discharge, and by no more than a
certain average degree of discomfort, ai-e regarded by women as
conclusive evidences of the healthy state of the sexual functions.
In every inquiry therefore, with regard to supposed disease of the
SIGNS OF SEXUAL DISORDER.
generative apparatus, the mode in whicli this fimction is performc
must engage your carefid attention. You know meiistmafcion 1
}je merely the sign of a more important process going on dee[N
within the organism. The non-appearance of the discharge, the:
or its suppression, suggests at once many important inqimii
which must he carefully followed up, till you can return to thei
a satisfactory reply. Is the system so feehle that, like an il
thriven plant, its sexual power remains altogether in abeyance t i
are the ovaries themselves diseased ? or does the internal proce,
go on, wliile yet, owing to some mechanical cause obstructing tl
escape of the discharge, its outward manifestation is wanting ?
is its appearance prevented by some disorder of the general syp
or of the uterus, which incapacitates that oi-gan from perfo
its usual office as a kind of safety-valve by means of wh'
congested pelvic vessels are relieved of their superabundar
Or is perchance none of these suppositions correct, and i
eixplanation of the suppression of the menses to be fo'
physiological not in a pathological occniTence, and are t'
toms those of pregnancy, not those of disease ? Su^
important questions which, in every case of suppresses
dmcharge, you must endeavour to answer, and to wh
your own reputation as well as for your patient's wel
of the greatest moment that you should return a c
Or, again, your patient suffers from what she co?
excessive menstruation, her health is breaking do
Whence comes the discharge? is it due to a f
plethora, which nature endeavours to relieve by th
in her endeavours she exceeds the limits of s
hiemorrhage the consequence of aufemia, and
state in which the vessels are so weak that bl
them with dangerous profusion ? or is the h^
neither of these causes, but to a breach of sur^
of the womb from which the blood flows, -
growtli, or forniidahle organic disease, the
rendered more serious just at those times wher
more than usually congested? These, ar
possess a special impoilance at certain epor
for when the sexual powers are on th
especially liable to be set up, and you
DISTURBANCE OF FtTNCTIOK.
menstrual irregularities at that time with closer attention than at
any turuier period.
But there are other subsidiary functions performed by the
generative organs, the disturbance of which ia somctimea the
occasion of mere discomfort, at other times the indication of
serious disease. These organs present a great variety of secreting
surfaces, which furnish matters of various kinds, subserving various
purposes. A slight secretion moistens the interior of the Fallopian
tubes, just as it does that of all viscera, and except near the
montldy periods of sexual activity, it is by little more than a mere
halitus that the cavity of the womb itself is lubricated. The large
mucous crypts or glands about its neck furnish a peculiar secretion
which is generally present at all times, though most abundant
during pregnancy. The mucous foUiclea of the vagina pour out a
somewhat copious secretion upon its surface ; and the two glands
which are seated one on either side of its entrance, and which,
under the name of Duvemey's glands, correspond to Cowper*s
glands in the male, furnish an abundant discharge at the time of
sexual congress ; and, laatly, numerous mucous crypts and
sebaceous follicles on the njnnpkb, tha interior of the labia, and
about the vestibulum, supply a secretion to lubricate those parts.
From any or all of these sources secretion may be furnished,
excessive in quantity, and more or less altered in character. The
secretion may be a mere leucorrhcea, an increased flux from other-
wise licalthy tissue ; it may be a purulent discharge from inflam-
mation of a mucous membmne, or it may be furnished from an
ulcer of the womb ; or it may not be simple pus, but an offensive
sanies from a widespread cancer of the organ, or of some part
&4]CL<^^t^ Your patient may come to you in complete ignorance
aa to which of all these is the cause of the affection under which
she is labouring : she looks to you for an answer to her doubts,
and for reUef to her sufiferings.
Diseases of these organs, however, are associated not merely
with altered function, but also with disordered sensibility^ and that
not only of the part aflected, but also of others more or less
distant. There is hardly any more fertile source of erroneous
diagnosis with reference to the diseases of women than the over-
looking the import of some of these alteiations of sensibility, and
the not connecting with its proper cause the sympathetic aflfection
i
of some, perhaps, distant organ. If a woman complains of a S(
of heaviness in the pelris, of bearing-down pain, of pain in
loins and abont the sacrum, or shooting down the thighs, oi
attention is natnraUy directed to the state of her sexual organl
and we are not hkely, with moderate caution, to overlook the reii
seat of her disease. In many cases, too, something beyond thj
seat of the disease may be learned if we notice the character o
the pain from which the patient suffers, since tliis is usually
one kind if inflammation is present, of another if there
cancerous disease, of a third if there is displacement of the woir
These minutifej too, are of all the moi^ im|>ortfince for us
attend tc», since there are no other diseastis in which that perse
investigation by which so many questions can be at once answ
is attended by so many difficulties, both from the natural r
nance of the patient to submit to it, as well as from the
fection of our means of examination-
But disease of these organs is not sehlom attended 1
whicli is referred not to the real seat of the mischief, but
other, perhsips some distant part. Women may apply to
seem out of hctdth, and in whom you may, perha[>3, at
pect the existence of uterine disease ; but they appear '
inquiries with reference to their sexual functions, or pe.
and with perfect truth, the existence of any pain in tb<
its immediate neighbourhood. Perhaps, however, the
feas to pain in the rectum, especially at the time of d'
may speak of symptoms which they refer to h^emorr'
complain of sciatica, or of hinibago. Always susp
of these sufferings; bear in mind the wide syn
womb, and keep aU your vigilance active ; it is
that these anomalous sjToptoms will resolve then
effects of uterine disease.
Nor are they merely strange and intractab)
ailment which should call your special atten'
and its functions. The pregnant woman suffer
from nausea and vomiting ; her appetite often
and her digcBtive functions! are frequently ill-p
is far from unusual for her to have attacks of
douloureux though she may at other time
iuimimity from all such ailments. But ju
ALTERED SENSIBILITY.
functions of other organs not seldom attends upon the physiologi-
cal prDcessea going on in the womb, so may it follow upon uterine
irritation produced by disetise ; and a large proportion of the most
obstinate forms of dyspepia, and a still larger number of hysterical
and nervous affections, have been excited and are kept up by
disease of the womb. In a great many of these cases, minute
inquiry elicits evidence of functional disorder of the generative
organs, as shown by disturbed menstruation, by leueorrhteal dis-
chai^ges, or by painful sensations, although none of these symptoms
may have been so marked as to have engaged the patient's notice ;
or she may have reganled them as trivial accidents not worth
mention when compared with the other, and to her feelings tho
more inxportant causea of her sufferings.*
Need I guard myself against being misunderstood — against
being supposed to say that, in the management of a woman who
is dyspeptic, your attention is to be turned less to the state of her
stomach than to that of her womb ; or that, if a woman suffi?rs
from neural^a, you are at once to suspect the existence of uterine
disease ? I mean no such thing ; though a statement as extreme
as this has been made by men of good repute j-f but what I do
mean is, that, in the treatment of diseases occurring among
patients of the female sex, you should always bear in mind that,
besides the ordinary causes of disease common to both sexes, there
is another set of causes peculiar to themselves. Whenever,
therefort the ordinary principles of pathology fail to exphiin, or
the ordinary proceedings of therapeutics prove inadequate to cui^
the ailments of any female patient, it behoves you to remember
that in her sex, and in its peculiar diseases, you may perhaps tind
a clue to tfie cause of her present symptoms, and discover indica-
tions whicli may show you how to accomplish their cure.
• la ToL IL of Lbfranc'fl CUniqui Chirur^aU, 8vo, rAria^ 18i2. from p. 182 to
!». 256, are sone remarks, witli niustmtive cams, on errors of diagnosis in uterine
disease, which, tbou^h not free from the charfteteristic faults of that writer, will
yet weU repay tn attentiTe penuml.
t [It 19 of at .oftjit hi!iti>Ticiil interest to note the expfessions of m cntincut a man
as Mayer of Berin. Th« condenmatioa of such imprudent practice requires no
^«xprawioiu lu \h Kliniache MiUheitungen aus d€m OtiieU dor Qjfnacolo^, 1861,
^T«a ft heartroiding description of the reanlts of utedne catarrh, so called ulcer-
, and blames the neglect of practitioners to examine, even in cases when all
oms haTing disappeared, a dangerous confidence has, he says, been estahUshed.
He declares it imfrudent to neglect utertnt emnination in any case whatever of
nervous disease in i female, such aa headachei palpitation, kc]
EXAMINATION OF THE ABDOMEN*
U
8t one department of the art of healing incompatible with the
3ne, and manner, and feelin^^ of a high-bred gentleman. The
iPamilianty which hospital practice begets with these ailments
imong women whose sensibilities are not always as keen as those
[>f persons in a higher class of life, or the circumstance that they
not venture to express the pain which want of consideration
ay have caused thum, leads but too often to carelessness in
respects on the part of men who would yet shrink from the
lea of inflicting a moment's unnecessary suffering upon any one.
am therefore all the more anxious to impress upon you that the
ielicacy with which you ought to comluct all your investigations
ito the diseases of women, is not a thing which can be assumed
the nonce, hot that it must be the halitt of the mind, nnist
iierefore have been acquired now during your pupilage, and in
le midst of your intercourse with the poor»
We make ourselves acquainted with the existence of disease of
|the generative organs, either hy manual cxaminaticm or by ocular
spection; and for the purpose of making such investigations
^with the greater accuracy, we not infrequently employ instruments
of difterent kinds. The simplest mode of examination, and that
which causes our patient the least distress or alarm, is that in
whicli we employ our sense of touch alone, unaided by any
apparatus whatever. It is perhaps scarcely necessary for me to
remind you that, while it is our duty to use every means e«^ential
to the tliorough investigation of our patient's condition, it is no
our duty to make no needless examination ; never to use an
Btrument when we can ascertain all that is necessary without
\i never to resort to ocular inspection when we can feel a i-eason-
iceitainty that by the sense of Umch alone we have arrived at
I knowledge of the disease,
^derive information from our sense of touch when applied
ough the abdominal walls, or by the vagina, or the
^In no case should examination of the abdomen be
omitted, while when any marked abdominal enlarge-
sent, or when the existence of some tumour is
1 examination needs to be made with great care. For
•tient should lie upon her back, with her knees
LI ax the abdominal muscles. It is very seldom
3 hand to the uncovered surface ; the inter-
12
SIGNS OF SEXUAL DISOEDER.
position of the patient's shift little if at all interfering with
accuracy of the examination. In any instance, however, wl
there is a question of a previous pregnaticy having occuired,
value of the presence of the lineas albse and the imporbaj
tlierefore, of seeing the siD'face, must not be forgotten, C
should be taken that your hands are not cold ; if they are, this i
not only annoy your patient, hat, by exciting contraction of
abdominal muscles, may seriously impede your investigafJ
Placing both hands upon the abdomen, you make at first \
gentle pressure, increasing it by degrees as the patient beca
accustomed to it, and trying to engage ber in conversation,
thus to distract her attention, if either pain or alarm should
her to throw her abdominal muscles into action. You thu'
yourself accLuainted with the general contour of the abdor
by examining at either side as well as in the centre, yo\
any ttmiour which may be present there. Supposing a
growth to be discovered, you must examine well its forn
its attachments, its degree of hardness and of mobility
amount of tenderness or pain which meddling with it
Is it due to accumuJation of ftecea in the large int
enlargement of the liver or spleen ; or is it perhaps
result of a general fulness of the abdomen produced '
the bowels, or by fat in the omentum or beneath the
rather than the consequence of any definite dia€
tumour seems to arise from out of the pelvis, it is n
foiTued either by the uterus itself, or by its apper
the former, the chances ai-e that it will be situatec
line of the abdomen ; if by the latter, that it wil'
other side, or at any rate that it will be learned t
that situation wlien first discovered. ^Tiethe:
fluctuating, even or irregular, will l>e other point
make out, and you must then proceed to correct
vaginal examination, the impressions receive
through the abdominal walls.
Even though so minute an examination of tl
is not always called for, yet examination by
bimanual method, or the double touch, should
before the patient ia allowed to turn over ij
usual obstetrical position in this country, nan
EXAMINATION BY TAGDfA AND BECTXJM.
13
'^
^
side. The patient, therefore, being in the recumbent position, you
place one hand over the pubes, while with the finger of the other
hand you examine the condition of the uterus. It is only thua
that you can ascertain the mobility of the uterus, its relation to
any abdominal swelling, and whether, if lower than natural, it is
pressed down from above ; and thus, too, only can you, in many
instances, determine the existence of version or flexion of the
organ, especially anteversion or anteflexion. When you have
done this the patient may now turn upon her aide, and the
va/jinal examination may be continued with special attention to
the degree of pain or discomfort produced by it at every step.
The state of the external organs must be noticed, and, then that
of the vagina — whether it is hot and swollen, or cool and relaxed;
whether dry, or abundantly bathed in secretion. Tlie cervix
uteri is thus reached, and you observ^e whether or no it is tender,
what ai-e its length, and size, and texture; whether the os uteri is
open or closed ; whether its lips are small and even, or rough and
irregular. You will bear in mind that after frequent child-
bearing, the cervix uteri is both shorter and broader than in the
woman who has never given birth to children (changes which are
especially marked in that portion of it which projects into the
vagina, and is commonly called the portio vaginalis) ; and that the
08 uteri is frequently open, so as to admit the tip of the finger
with but little difficulty. In this case, however, the inner surface
of the OS is smooth, and the tissue of the cervix soft and yield-
ing; while if disease exists, the interior of the os may be rough
and uneven, and the substance of the cervix rigid, Sometimes
a peculiar and almost velvety smoothness is presented by the
surface of the os uteri, or the tissue generally has lo3S than its
natural fim^ness ; and any of these peculiarities, or the presence
of any foreign body between the lips of the uterus, should be well
borne in mindi in order that you may afterwards compare the
information obtained by ocular inspection with that previously
gained by the sense of touch. While making this examination,
you notice, moreover, the situation of the uterus, whether it still
retains its natural dit'ection, or has come to lie with it^ axis
corresponding to the axis of the vagioa ; whether it is bent upon
itself, or in any other way misplaced Examiue next whether the
uterus is increased in weight; balance it on your finger, and
14
3IGN3 OF SEXUAX DISOHBER.
appreciate as weD as you can the size and weight of the orgj
When all the above-tnentioned points have been aseertaixii
with as much gentleneas as possible, the vaginal examination
over, and there is nothing more for yon to notice, except it be I
appearance or other characters of the discharge. Now and thl
thou<^h not very often, %vhen the nteraa is lower than natural,!
Ls desirable to appreciate the exact degree of displacement wli|
the patient is erect, and to estimate the extent to which it adml
of being driven down by bearing-down efforts on the part of i
patient, and it may then be necessary to examine her in the stall
ing posture. I may add, too, though it is out of place to mentioa
here, that tliis precaution should not be omitted after the introdu
tion of a pessaiy, in order to make sure that the instrument
firmly placed. Sometimes, too, the same attitude is desirable wh
the uterus is high up, and does not come readily within reach.
It is occasionally expedient to examine per redum as well as y
vaginam ; if either the patient had made complaints of aer'
pain in the bowel, or if you had discovered a tumour sit
behind or to one side of the uterus, or if on any account ^
anxious to examine the posterior part of the pelvis, o^
uterus itself, as completely as possible. The only
specially applicable to examination per rectimi is, tliat
the intervention of the intestine between the finger
wombj that organ feels much larger than it really
which, as the finger reaches less readily to a level witl
uteri when introduced into the rectima than into the '
is some risk of mistaking the cerv^ix for a promi
posterior wall of the uterus, or for a tumour in tha'
for a retroversion or retroflection of the organ, when
morbid condition whatever is present. [The mode
late bold and ingenious Simon of Heidelberg call'
examining the uterus, pelvis, and abdomen, by j
into the rectum, or even higher into the great
requires mention. No doubt it may extend f
some rare cases, and may, in spite of its own pai
usefid. I have resorted to it with advantage an
of old extrauterine foetation. But it is a proce
cation, though certainly within a narrow spb
limits so fixed as to make it a matter of syp
IMFLOYMENT OF THE UTERINE SOUNB,
15
The digital examination of the uterus per rectum is well known
and extensively practised.
The same notes of caution are even more strongly demanded in
the case of the proposal of Noeggerath,* to dilate the urethra with
a view to the admission of the finger into the bladder to examine
the uterus and ovaries.
Thei'e are not the same objections to Attliill's intrauterine
speculum ; but the difficulties of its use destroy its value.]
Of late years it has become customary in many cases to aim at
a greater completeness of tactile examination, by means of an
instniment which is called the Uterine S(/und,. At different
timas, indeed, practitioners have in some special instance
introduced a catheter into the uterus to satisfy themselves of the
size of its cavity, or of the absence of any foreign lx>dy from its
interior ; or have attempted to rectify a retroversion of the uiiim-
pregnated womb, by means of an instrument introduced within
it.^f To the best of my knowledge, however, a Fi'enchman, M.
Lair, was the first person who, some fifty years a^'o, recommended
sounding the interior of the uterus in order to ascertain whether
the cervix is free from aU impediments, and whether the cavity
of the organ generally is in a healthy st-ate. His book is
illustrated with drawings of the instruments which he employed
for tliis purpose ;t and he advised that they should be curved
like a catheter at their uterine extremity, in or<ier to facilitate
their introduction. He recommends, moreover^ that the Sound
should he introduced through a metallic cyUnder or speculum, by
which the mouth of the womb is to be fii-st brought into view ; a
proceeding which, instead of facilitating the introduction of the
instrument, must, in many cases, have rendered it altogether
impossible. The practical defects of M. Lair's plans prevented
their general adoption ; and his recommendations were in
• [See Croom,' ObdUtrical Jmrnal, May 1878, p. 78.]
fThe Ute Professor Oaiand«r, of Gottiiigeii, employed Hs Dilatorium Orificii
Utcirit wliieh is dc«cii1)ed in Roaetunejer^s duisertatioD^ published at GottiugeD ia
I802f on three oocasioiia, to reduce the letrorerted uiiimprrgimtiid womb. Hja
MM were pabliabed in tlie Medicinis^ Chirur^ischs Zcilung for 1308, Accofding
to Sckimttj who refers to them in his Esany, Uehsr dU Zuruckhoigun^ der €hh(u^
mviUr, 8vo, Wien, 1820,
X NouvelU Miihod^ du TrtUUfmeni dea UMret, eic.f d4 VUUrus^ 8vo, Paru, 1828.
Peuri^me 6ditioo, p. 187. The first edition appeared about two years before.
is, the
16 SIGNS OF SEXUAL DISORDER,
consequence soon forgotten* To the late Sir James Simpeoij
belongs the merit, not only of having recalled attention
the subject, but of having also invented an Uterine Sot
admirably adapted for the safe and easy exploration of
cavity of the womb. His instrument ia made of flexible met
and in shape and size closely resembles a sound for the
bladder, having a similar curve, and its handle being flat^
roughened on one side in the same manner. The uterine end i
the instrument terminates in a small bulb, to prevent its injui-i
the interior of the womb, while a notch at every inch serves
inilicate the distauce to which the sound has entered the womb,"^
and thus to mark the size of its canity. A slight prominence at
two and a lialf inches shows the average length oft/te mmti/ of thfl
healthy womb, while a deep depression at four and a half inches^
marks a size, which, except under very special circumstances, the_
»an Iiardly ever exceeds.f
The mode of using the instrument is sufficiently simple,
fingers of the left hand are introduced behind the cervix uter
the patient lies on her back or on her left side, and the sound
slid along the fingers till its point reaches the os uteri, when
depressing the handle towards the perineimi, and at the
time carrying the instrument gently forwards, it will entei
uterine cavity. I need not say, that it must never be empl
when the least ground exists for suspectiog pregnancy j ao
in no circumstances must force be used in its introt'
In the majority of cases the introduction of tlie sounf
some pain, though this is generally by no means severr
almost always of very short duration ; and in no insta^
has come under my observation, have dangerous cor
residted fi*om its use, though awlavaidness and foo
• In a series of papera in Loiulxrn and Edinburgh MoiUMy Journal
t Many modifi,catioos of the CTterine Sound Lave been miggestr
Kiwisch, Hugnier, and etUl more re^^ntly by Dr Kugdmann, of F
h^Jtndl d, Qcscllsdmfif, GehitrUhOl/c, Nor. 1861. ZeiL^hr.f. Otbv
129). Thia last is veiy iugeoioualy contriFed witb a moveable f
on the flotmd itaelf, and indicates at the baDille the distance to
tnent but entered the tjtema, so that the promitietice and the t
fere with the introduction of Simpson'e sountl, are done away
cnlties in tlie em|)loynit'nt of the original instrument are, ho we
simplicity is of such great Falue, that I still prcfur Simpsou'a f
other varieties of the instrument.
EMPLOYIONT OF THE UTERINE SOtTXD.
17
have, I know, done mischief with this, as with almost all iostru-
ments that have ever been invented. The infaruiation which tliis
instrument places within our reach is often extremely valuable ;
and of a kind such as otherwise we could not obtain at aU, or
could arrive at only very slowly, and by frequently repeated
examinations. If, in a patient suffering from frequent haemor-
rhages, we ascertain the uterine cavity to be greatly increased in
size, our immediate conclusion is that the womb may conUxin
some foreign body, as a polypus or fibrous tumour, tlie presence
of which has excited and serves to keep up the bleeding. • If we
doubt whether a tumour proceeds frf^m the womb, or from its
appendages, or from some other part within the pelvis, the sound
enables us to estimate the weight of the organ, and to strengthen
the inference drawn from this experiment^ by completely isolating
the womb from the tumour, and thus ascertaining positively their
indeiiendence of eacli other. Or lastly^ if the uterus is bent upon
itself either forwards or backwards, the diagnosis of tliis condition,
which once was a matter of much difficulty, is now often arrived
at with facility, by introducing the sound with its concavity
directed towards the swelling we detect per vaginam, and observ-
ing whether or no this swelling disappears on turning rf»und the
instrument I will not now go into further detail on the subject
for I shall hereafter have to refer on many occasions to this
valuable aid to diagnosis. The uterine sound, indeed, is not
always applic4ible, nor does it, when used, always clear up our
doubts ; but I do not remember any instance in which a ditxgnosis
based on the information which it afforded turned out aften^^ards
to be erroneous.
[High authority has at least suggested the use of the sound in
the diagnosis of the enlargement of the utenis in early pregmincy;
but it is scarcely necessary to say that, wliile the risk of inducing
abortion is great, such a proceeding is unjustifialjle. Liability to
error in making uterine measurements, from the passing of the
probe into a Fallopian tube or through it into tlie peritoneal
cavity, is not inconsiderable. Every season one or two such case^
occur to me. Several authors in scattered communications in
joomals, especially Lawson Tait, have doubted or denied the
occurrence of tliis accident; but the evidence in favour of it,
including tliat of autopsies, is overpowering* The allegation is
B
18
that the womb is
can scarcely occiir
is carefuL A softeneJ
but while there is no
that a softened uterus i
experiments have shown
cases, it is the peritonei
perfomtion of the uterus by
burgh, I have not access to
ments, but I remember that
probe of about six pounds wa i
force, used in even a rough
violence which the practitiom
required in most cases to pass
into the peritoneal ca\ity is scarce]
to remark that the uterine probe w!
IB. the shops, has, as applied in uterii
in its shaft to bear a pressure producir
pointj but no more, or little more. In
ment, as ordinarily made, is, by its litt
against the misadventure of puncturing
added that even the passage along a tube 3
proceeding not to be lightly considered,
been so unfortunate as to see any bad result
it causes no pain.] ^
The idea of adopting some contrivance by y^
of the uterus might be examined by the eye ^^
unknown to the ancients, though for the most p
ments, of which drawings may be seen in old work
and which received the name of Spemlum Matricis,
dilating the mouth of the womb during labour, r
examining its condition in disease * An instrai
kind, however, appears to have been sometimes ei
investigation of diseases of the uterus and vagina, '
came into anything like general use. The intr
speculum into modern pmctiee as a means of
investigation of uterine disease does not date ^
^ Ewi some remarks and quotation h referring to the ear]
luiu, in Balbimie, Orgmvk Dista&es oftht Wrnnb^ pp, 41-45,
EMPLOYMEOT OF THT? SfECULUM.
the year 1821, when the instrument was first employed by
M- Rt'camier. This, which was merely a cylinder, conical in form,
rounded off a little at its uterine extremity, and bevelled at its
other end, was next fitted with a small handle by M. Dupuytren,
and afterwards a plug was adapted to it to render its introduction
more easy. Various materials have been used in the fabrication
of these instruments, but we owe the greatest improvement in this
respect to the late Sir W. Ferj^usson. Instead of emplojing metal,
which is very apt to tarnish^ and never has a very powerful
reflecting surface, or glass, which though very useful when caustics
are to be applied to the uterus or vagina, since they do not act
upon it, is yet liable to be broken, and moreover, owing to its
transparency, does not reflect very powerfully, he adopted the
following plan :■ — A glass speculum is silvered on its outside, by
which means the inner surface is converted into a mirror easily
kept clean, and on which no caustics can act The speculum is
then enveloped in successive layers of cotton-cloth, each of which
is covered with a solution of Indian-rubber, and when the glass
has thus received a coating of sufficient thickness it is varnished,
and forms an instrument which is now in general usa Its
funnel-shaped termination is intended to pro\ide for the admission
of as much light as possible ; a point of the more importance in
this country, from the almost universal practice of examining
patients on their side, in which posture light has a less ready
access to the parts than if, as on the Continent, the patient lay on
her back. The object of the instrument teing slightly bevelled
off at its uterine extremity, is that the same advantage is thereby*
secured as if the diameter of the cylinder throughout were greater,
This sloping off of the instrument, however, must not be carried,
as some have recommended, so far as to amount to an angle of
forty. five degrees, since by so doing the inconvenience is
encountered of a fold of %^agina falling down in front of the cervix
uterL The specula which I use may })erhaps appear to you of an
unnecessary length ; but you must bear in mind that the vagina
is very extensile, and that when a speculum is introduced into it,
the canal is stretched in length as well as in width, bo that the
ordinary length of the vagina is not to l:>e taken as the measure
for the length of the speciduuL 1 believe the attempt to reach
* ThiA naefdl modification of the specnlmn waa, I belieTe, fint aoggestad by
Dr Warden, Imdm and Edinburgh Mmthly Jourttal^ Bw. 1811
i
the OS uteri fails from tlie sliortness of the speculum oftener thai|{
from ahnost any cause, and quite ngvee with the opiuton of thm
late Professor Lisfranc of Paria ♦ that a speculum ought to hm
seven or at least six inches long, and specula six inches in lengtfa
are to Ije had of all instrument makers.
In spite of the general convenience of the cyhndrical speculum^
however, there are some drawLacks from its utility. Owing to
the entrance of the vagina heing narrower than any part of
canal, it happens sometimes that a speculum sufficiently snu
pass without causing the patient severe pain is not large enoiigl
to bring the whole of the cervix uteri into view. But even thougl
its whole surface he exposed, yet the cylindrical speculum presi
ing the lips of the os together may prevent a good view b
obtained of its interior, and may thus render the examinatio:
incomplete and unsatisfactor}^ To obviate these disadvantage!
specula have been constructed on the principle of the old instm*
ments, composed of two, three, or four blades, and so arranged j
that by turning a screw or by closing the imndlci the uterhiQ^
extremities separate, and thus expose the oa uteri to view withoT'
any enlargenient of the other end of the instrument. The be.
known of them are the- two-bladed specuhmi of M, Eicord;
three and a four bladed speculum manufactured by M. Charrf'
of Paris; and a two-bladed instrument invented by Mr Co^
instrument-maker to University College. M. Kicord's instr
and to a less extent those of M, Charriere, have the inconv
that folds of the vagina are apt to fall down between tb
and thus conceal the os uteri from view. This objection
apply to nearly the same extent to ^Ir Coxeter's instrume
blade ol which being a half-cylinder^ does not leave f
space vacant when it is opened. Two or three different f
of Fergusson's speculum, and a Coxeter's bivalve f
which last it is worth while, for the sake of obtain
reflecting surface, to have electro-plated — are all the
you need for ocular examination of the uterus. Sin
speculum, and Neugebauer's modification of the sami
invaluable as they are in various opemtions on tb
vagina, are yet not adapted to oixlinaiy practice, a
since their emplojrmenfc requires the pi-esence of ar
* Clinigm Chimrgi&ile^ &c. vol. ii p. 272,
Wi^WJUENT OF THE SPECULOI.
21
On the Continent, the posture usually assumed by a patient
when about to undergo a specular examination, is on the back,
with the nates resting on the edge of a bed or table, and the legs
bent up towards the body, or the feet resting on two chairs,
between w^hich the doctor stands. There can be no doubt but
that in this position of the patient the os uteri falls more readily
within the orifice of the speculum,* and that light is (ulniitted
much more thoroughly than in any other attitude; but its
apparent indelicacy is so serious an objection to it, that except
under special ckcumstances, it is desiiuble to introduce the
speculum with the patient lying on the left side. In- this
position, too, unleas the os uteri is directed in a remarkable degree
backvii^ards towards the sacrum, a very good \iew am generally be
obtainedj provided the patient lies with her body directly acroes
the bed, her hips close to its edge^ and her thighs drawn up
towards the trunk ; in the same attitude, indeed, as we shuuld
place a person in, on whom we were about to apply the forceps in
labour. If the patient is not in bed, the same precautions as to
her position must l>e taken as she lies on a couch or sofa, and a
very Uttle care in the arrangement of her dress will prevent any
exposure of her person. The speculum, having been previously
warmed and lubricated, is then to be introduced with the right
hand, whUe with the left the labia and nympha? are separated.
Care must be taken that the end of the speculum is passed
thoroughly within the opening of the vulva, since, if tliis precau-
tion is neglected, a little duplicature of the fourchette is some-
timee pushed before the instrument, and much needless pain is
caused to the patient, or the urethral orifice is painfully pressed
on by the speculum. The great obstacle to the intrndaclion of
the speculum is met with at the entrance of the vagina, and this
must be overcome by gentle efibrt, not by anything appnjaching to
violenca The speculum then passes on with facility, and \Yhen it
has entered for some distance you withdraw the plug, and possibly
find thitt the os utOT is now within view. You miLst, however,
bear in mind that the folds of the vagina sometimes hang down at
the further end of the speculum, leaving a small aperture between
them, which may be mistaken for the os uteri ; though, on moving
the instrument a little, the contour of the orifice will alter, and
the vaginal fulds dispose themselves in a different form* If, a
[IIS
1
although you have mtTOdoced the speculum for some distance, the
OS uteri does not appear, the probabilities are that 3^ou have passed
beyond it, and that the instrument has gone up into the cid'd£-9a£
of tlie vagina, behind the neck of the womb. In this case, \M
gently and gradually withdrawing it, the os uteri will most prc^
bably come into view ; if it does not, you may move the speculum
slightly from side to side, since it 15 likely that the uterus is not
quite in the mesial Mne, and that thence arises the difficulty in
getting sight of it. When once you have the os uU?ri within the
specultim, a little manceuvring will generally suffice to remove any
fold of vagina which obstructs your view; though, if the neck of
the womb ia very large, you may be compelled to examine first
the anterior and then the posterior lip of the organ ; and in this
case you wiU find a bivalve j speculum much more useful than tl
cylindrical instrument.
There are many other little matters of detail connected witli t
employment of the speculum well worth the knowing, but to be
learned rather by personal observation and actual practice than by
any description. Need 1 say that there are some cases, those c"
unmarried women for instance, in which nothing but the w
urgent necessity would justify your employing the specul
others, as the majority of cases of cancer of the womb, in wl
its use would furnish no important addition to your pref
knowledge ; and stni others in which its emplojonent mr
postponed, if not actually interdicted—such, for instance, f
of extreme sensibility of the parts^ of inflammation or ul
of the vagina or of the external organs ? liestrictions t
indeed, such as these, speak to the common sense and ri^
of every one too distinctly for there to be much hes
subscribing to them. But while admitting them, some of
be inclined perhaps to go atiU further, and to inqu
whether, on the whole, the advantages arising from th'
speculum outweigh the evils resulting from its abuse
helps us to so much additional knowledge, or adds so
therapeutical resources, as to counterbalance all the sd
moral and physical, which its employment not
inflicts upon the patient ? Now, if I had a strong c
negative side of this question, I should certainly r
up so much of your time in describing the inst?
u
VALUE OF THE SPECULUM.
difllionest motives to those who use it, but by soberly and honestly
trying to test the value of the information which we derive from
it, and learning to discriminate between those appearances wliich
the speculum discloses that are of moment, and such as are of no
importance. Just as when first introduced into practice the
speculum was used for diagnostic purposes with an undiscriminat-
ing frequency, so the facilities which it affords for topical
medication of the utenia led to an abuse of local treatment from
which there ha^ since been in some respects a healthy reaction
Its use is far too obvious to require being dwelt on ; while t^
iibuse of the instrument is not peculiar to the speculum, but
the natural result of the superficial pathological knowledge I
scanty therapeutical resonities of those who, unhappily for th
selves and their patients, have become epecialists withou*
being physicians. Against the errors proceeding from this a
it will be my duty to warn you over and over again in the r
of these lectures.
LECTURE IIL
IIE^STKUATION, AJJD ITS DISORDERS.
Importance of disoTtli<r8 of niftisrtnuttion ; tlteir thrve varieties — Relation of tardy
puberty to metifftniAl disordor. Menatmation not an evideiice of mtzuid
maturity,
Ali^NORELHOEAf froiD locfll caiiBe«, from congeaital absence or malfonuatiou of
sexaal organs, from ret*?iitioii of menKea owing to impt'dimfnta to tlieir flo-*-.
Cohesion of labia in childhood, AtreBia of vugma, and ojierationa for removal
of tbia and similar eonditioni.
Amenorrbcta, from conititulional canie*— tardy deTclopment, influence of previous
illueas in causing it. Symptom a, ebloroaia whereon it dqienda — state of the
bl ood. Consequences o f am enorrhosa,
Triiatment — principle* which should rega]at« i^^—attention to general bfidth, to
uterine functions. VicarioQs htemorrhagL'S, their im{K>rt, their mamigement
Importance of habit in all ailmcnta of meuistrual function*
I CALLED your attention » in tlie first Lecture, to tbe importcince of
the menstrual function, and io the frequency of its disordera. I
told you that almost every serious ailment of the generative
sjnstem, at least during the period of sexual activity, betrays itself
by some disturbance of menstruation ; and 1 may further add, that
such disturbance is often the first, and sometimes for a consider-
able period tbe only, symptom of even grave disease. But you
also know that disordered menstruation does not invariably
depend on local mischief, that derangement of function does not
always imply altcxed structure, but that a woman may menatiiiate
scantily, painfully, or in excess, and yet no part of her generative
oigans may ditfer in appearance from those of a person in whom
that function has always been performed in the most healthy
manner.
The disorders of the menstrual function, then, being so
numerous, so important, and dependent on such v^uious causes, it
will be our best course to study them first, and aftei^wards to
examine into other diseases of the sexual system,, in which, though
26
DISORDERS OF MENSTRUATION,
disordered menstruation may occur as a symptom, it is yet not
the only one, nor that which calls for the chief consideration in
the treatment of the patient.
There are three grand classes, to one or other of which it has
long been customary to refer the different disorders of menstrua-
tion. Either the menses do not appear at that period of life at
which their occurrence is natimdly expected, or they become sup-
pressed in persons in whom they have already occun'ed ; or their
discharge is attended with extreme pain; or it is excessive in
quantity, or over frequent in its return. I propose to consider in
its turn each of these three varieties of disordered wm^tniatwn^
which have respectively received the names of Amenorrhoea,
Dysmenurriitea, and Menorrhagia.
It is, as you know, wisely ordered that the power of perpetuat-
ing the species is the last of natiu'e's gifts, and one which she
does not accord until the whole system has, in other respects,
attained nearly to its perfection. Of this new power in woman,
menstruation is both the sign and the consequence, indicating
that the ovaries have become capable of bringing to maturity the
germs, which need only to be impregnated in order to become
developed to new beings. In our climate, the date of the first
occiureuce of menstruation is between the fifteenth and sixteen*
year ;* but the changes at puberty in the maiden, like those
dentition in the babe, are not accomplished aU at once, but ey
over a period of several months, during which disease is
frequent, and, as our Tables of Mortality show, more ff
compared witli the male sex, than at any former time,
anxiety with which parents regard the approach of this e
then, not unnatural ; nor is it without good reason t'
anxiety is increased more and more in proportion as de^
in the appearance of the first menstruation, since,
* Dr Wltitehesd, of Manchester, givea fifteen years six and three-c
(ta tbe average deduced from 4000 ca«es, in which he made this poini
IJiquirj'. See p. 47 of hie TrratUc on Ahtwtimi and Btcriliiy, 8vo, J
t Thus MM. Quetelit and Smita, in tbuir work Sur la Jlepradu
ialiti de rE&mme, 8vo, Bnoellea, 1832, show that while in chOdh
of the two MxeJt has been equal, or that of the male has pri^don)
mortality at once rbea between foturleeii and eighteen years r
male death ; jdnMng again in the aucceeding four yean to th
iemalfl to 1 nude death.
^ TARDY PUBERTY. 27 ^^M
menstrual function has been even once properly performed, many ^^M
of the dangers of puberty may be regarded as already passed. ^^B
Dr "Whitehead, of Manchester, to whom the profession is H
indebted fur some very interesting researches into these subjects, ^^H
ascertained that the risk of some unfavourable accident, complieat- ^^H
ing the first establishment of menstruation, is very much greater ^^H
when that is tardy in its occurrence than when it is premature ; H
and that in between a tliird and a half of all cases in which it is H
delayed t«j nineteen years and upwards^ its appearance is associated H
with eitlier local or constitutional disorders — a statement with ^^H
which my own experience coincides** ^^H
The mere circumstance, indeed, of a girl having passed the age ^^B
at which nienstniation usually appears, without performing that H
function, is not of itself a reason for medical interference. The H
date of pulierty viiries ver)' widely, and one woman may men- H
struate at ten, and another at twenty years of age, without the H
health of either being of necessity impaired. Usually the absence H
of menstraation in otherwise healthy young women, is associated H
♦ Mr Wliit^head'a toble, tth. eiL p. 48, yields the following reaulta ;— ^^H
Fkat Menatmation.
Total Number
of Cases.
Number
Unfftvoamhle.
Percentage of
UnfaYourable.
1
From 10 to 14 yeara . .
Between 15 nnd 10 , .
„ 17 and 18 . .
From 19 and upwards .
Total, . , .
lUl
1728
289
224
S24
247
97
19-63
1875
27 69
40-68
1000
892
22 30 aver.
In 586 cases in which I iioeitiiiied the dftte of the firet tDenatniation, either ^^H
exeessive pain, exccswTe diaebiigc, irregularity of ita return , or disorder of the H
geuaml health, occurred with the frequency ahown in the following tahle. The H
coneluaions to which it lead« are the samo as foUow from Mr Whitehead*! more ^^^|
extended teaearches : ^^^|
First Menstzuatlon.
UnfaTonr&blei.
Percentage of
UnfaTourable.
1
Under 15
Between 15 and 17 . ,
17 and 19 . .
At 19 and np wards ♦ »
Total . . .
228
220
92
26
41
83
22
n
171»
15'
28-9
46 1
566
107
257 aTer.
J
28 AMEXORHHfKA
^^'ith the abaence of some of the other signs of puberty, indicating
a generally taMy serual development, just as, witliout apparent
cause, one tree will pnxluce blos.soins and bear fruit later than
another. This, however, h not always the case, and instances am
sometimeB met with of persons in whom pre^^^naucy lias preceded
menstruation ; completeness of sexual power having existed,
though not manifesting itself by its ordinary sign. Such cases
f were a greater puzzle to physicians in fonner days than they a?e
\ to us, who know that the discharge of blood is not the essential
( part of menstruation, but that the maturation and extrusion of ova
!i may occur independently of it One instance of it has come under
I| my own notice^ in a woman who, never hav-ing menstruated,
married at the age of twenty, and immediately became pregnant;
nor did the menses appear till after the birth of the first child,
though she subsequently menstruated regularly, and had a
numerous family. This, however, is very rare, and there would
always be reason to apprehend that a woman who had not mens-
truated before marriage would remain sterile afterwards. Besides,
it is possible that the non-appearance of the menses depends upoa
some congenital malformation, which might even prove a bar tor
sexual intercourse, such as absence of the vagina or its imperfe'"
formation. If, then, your advice be asked as to the propriety
any young person manning who has not menstmated, I shou
advise you to recommend delay j and if still further urged,
withhold your sanction imtil you have ascertained that no ser
defect of structnre is present The pain of such an investif
would fall far short of the distress which would be entailed
all parties, if a woman with some important malformation ♦
sexual organs were to contmct maniage,*
[The commencement of menstruation, important though
a sign of completion of the repmductive power, is not to
as coincident with maturity or nubility. Fitness to be
comes later than regular menstruation, just as tlie cc
pupilage is by law prolonged beyond the period at wl
mental powers have begun to make decided progress
subject it is only a general rule that can be laid dow
that a girl should not run the risk of becoming a mo^
• An impoTtant c««e illttrtnitiTo of thia subject la related bj Dr
of kii) tnuifil&tion of Colombat m Diseases of Feniaks. Sto, FbUf
witn
andH
AS1EN0RRH(EA
that in many instances the organs were present, though in a Terr
undeveloped condition. Somewhat less uncommon are the
instances of absence of one ovaiy, a malformation generally
associated with absence of the other uterine appendages on the
same side, and sometimes also with absence of the corresponding
kidney ; a circumstance which will not surprise you if you bear
in mind the mode of development of the urinary and generative
riftpparatus, and the intimate relation which subsists between them
tit an early period of fue-tal existence. Much less uncommon than
the absence of either ovaiy is the persistence of both through the
whole or the greater part of life in the condition which they
present in infancy and early childhood, with scarcely a trace of
Graafian follicles in their tissue. This want of development of
the ovaries is generally, though not invariably, associated with
want of development of the uterus and other sexual organs ; an<3
I need not say that women in whom it exists are sterile.
[It is not altogether out of place'to merely mention here the ;
occurrence of monsters upon the whole well formed, or, if not well'
formed, at least well developed, in whom there is the physiologi-
cally marvellous absence not only of the whole sexual organs hutiH[
also of the urinary.* Although such creatures have lived and
apparently thriven in utero, their continued life extra utemm i
of course impossible,]
Two instances have come under my own notice in which the'
was reason to suppose that some defect of development of
ovaries was present The first patient was a woman aged f
three, who had been married for twenty years, but had
menstniated, nor had ever been pregnant In her case tbe f
organs were well formed, though the uterus was small, and f
appetite existed. The other case was that of a young gir'
twenty years of age, who was for some time under the car
late Dr Koupell, sufiering from those vague symptoms of
of the general health which so frequently exist i»
appearance of the menses is delayed. She pi"esented tb
signs of puberty, but her vagina was very small, and \
was not larger than that of a young chili I do not 1
became of her eventually, but it is quite possible tha*
tion of her sexual organs, though long delayed, may at
[* Edinburgh Medical Journal^ April 1371, p. ^Z7,[
FROM B4ALF0RMATION.
81
taken place, and have been followed by the due performance of
their functions.
Conditions* such as these which I have been speaking of
interest us rather as physiologists than as practitioners : we can
only guess at their existence, and can do notldng for their remedy.
Though not so obscure, still quite as hopeless are those cases in
%vhich the uterus alone is absent, or, as is more frequently the
case, is represented by one or two small bodies^ of the bigness of
a bean, or even smaller, made up of true uterine tissue, rudiments,
aa it were, of the deficient organ. This absence of the uterus may
coexist with a perfectly natural condition of the external organs ;
the vagina, which is usually much shorter than natural, terminat-
ing in a cul-de-sac. Four instances of this malformation have
come under my notice. The first was that of a young woman of
little more than twenty years of age, wlio had been married but a
few months, and who applied to the late Dr Hugh Ley, in con-
sequence of some obstacle to complete sexnal intercom-se. Her
appearance was that of a well -developed woman, and her external
genitals were quite natural, but the vagina was not aViove an inch
and a half in length, and terminated in a blind pouch, above
which no uterus could be felt, neither could any trace of the organ
be discovered on examination by the rectum.-(- The other three
cases were almost completely identical* Two of them were
referred to me in consequence of suits in the divorce court for a
decree of nullity of marriage, while the third was that of a young
lady whom I advised to remain single on account of the all but
complete absence of tlie vagina. Some years after I saw her
she married, her future husband, as I was informed, having been
told beforehand of her condition. An unexpected answer this to
the poet's question —
•' Who shall to the marriage of true minds
Oppose impediment " ?
• Kmncrons references to caaea of absence of the ovaries or of their imperfect
deTelopment^ are to be found in Chereau, Trai(6 des Maladies des Ovaires, Pans,
18l4t pp. 73-91 ; and Mdssnar, FrauenkrankktiUn, toL iL p. 28 \ &nd Dr
Thndictmi, of London, has published In the Monaitichrift /. OrfmrMkxtndf, April
I85&, p. 272, a very careful analyats of twenty-one cajiea, collected from different
sonices, in which the uterus was either altogether absent, or merely mdlmentary.
t Any one who wishe« to study the subject of uterine roAlformations, in all its
bearings, wiU find ample materials collected in the elaborate work of £«Bsmaul«
Von, dem Mam^l, der Forki^mgrung^ <fee., dir OebUrrMtHer, 8yo* Wiirsbmg^
1859.
■
ind
AMENOERHCEA,
Besides these cases, however, in wliich the non-appearanc^oi
the menses is due to a cause wholly beyond the power of art to
remedy, there are others in wliich the ovariea are pre.sent, and
perform their functions properly, in which the uterus also exbti
and the periodical htemorrhage takes place from its lining ; btfl
the effused hlood finds no means of escape, owing to congenital
closure of the oa uteri, or to the absence or occlusion of the
vagina.
The non-appearance of the menses from any of these causes is
unquestionably very rare, and but two instances of imperforate
state of the hymen, and one of retention of the menses from atresia
of the vagina, have come under my observation. To judge by the
recorded accounts of such cases, however, they all present a |
certain general reserahlance to each other, and are all characterised
by tlie occuxTence at or soon after the ordinary period, of theusuaj^
signs of puberty, the appearance of the menses alone exceptec|^|
While these are absent, the premonitory symptoms, which in
general usher them in, are experienced with even more than
ordinary severity. These symptoms subside, and again recur
after the lapse of about a menstnial interval, till, after many
months, enlargement of the womb becomes apparent, and increases '
by degrees with each periodical exacerbation of the patient's
sufierings.
The history of the patient, the alisence of menstruation lo
after the period when it usually shows itself, and tliis in spite
the occurrence of the constitutioual symptoms which gener^
accompiiny it, when coupled with the progressive enlargeme^
the uterus, lead in the course of time to the cause of the sym
being recognised, and to surgical means being adopted fo
removah Still, tliere are several circumstances which coe
prevent the abdominal enlargement from becoming appa'
early, and from attaining, even after a long lapse of tin
great a size, as might at first have been anticipated. It
matter of general observation that while the enlarged
perceptible in these cases at the lower part of the ah'
general abdominal enlargement is comparatively snialL
any mechanical obstacle exists to the outflow of the r
are almost invariably poured out in far smaller qu
natural — a fact which I shall have again to refer to '
nm MALFORMATION.
89
to speak of some forms of dyamenorrhcea. In the next place, it
must not be suppoaed that the blood poured out into the uterine
cavity collects there nninfluenced by t!ie \atal processes which go
on in the rest of the economy. On the contrary, the absorbents
are very active in getting rid of the effused blood ; and microscopic
examinations show that it undergoes alterations of the same kind
as take place in blood poured out elsewhere, and is removed by a
similar process.^ But besides this, the blood itself seems in some
instances to escape through the fimbriated extremities of the
Fallopian tubes into the abdominal ca\ity, where sometimes it is
absorlmd without giving rise to any dangerous symptoms, though,
in other eases, fatal peritonitis has followed this occurrence."f
One other caution with reference to these cases may not be out
of place here, and that concerns the prognosis which we may
express with reference to the result of any openition for their
cure. Though generally favourable, it yet must l>e borne in mind,
that a fatal result, due to the occurrence of inflammation, has
sometimes followed an operation as simple as the mere division of
an imperforate hj^roen ; and that this has in some instances been
produced by blood being poured through the Fallopian tubes into
the aMominal ca\ity — notwithstanding that an opening in the
vagina existed of ample size to allow of its ready escape in the
natural way^ When the ol>stacle has existed from atresia of the
vagina, it is also important to bear in mind the tendency of the
canal to contract unless special care is taken to guard against that
risk.
[Tliere is a not very rare condition that in children is generally,
at least at first sight, mistaken for atresia ; or, if the clitoris is
* See the mteresting jicconnt, by Dr H. MiiUor, of Jiis eramination of the »-
tiined menstnuLL blood in two cusbb of cougonital atresiA yb^iu^ in Henle and
PfmOeei ZeiiKhri/l, vol t. 1816, p. 140.
t A leriee of pupora, by M, Bemutz, in the ArchitxA de Mideeina for Jane,
Angoit, ftnd Deocmber 1348, and for November 1849, beiir on this sabjiH«t, and
mJiy be oonralted with atlvuntjige, Thesp papers will be found repn>dured in a
more extended form, and with many additional o1>sen*iitioQs, in the first rolnme
of the work, Siir U^ Maladu^ des Fttmnes^ 8vo, Paris, 1860, pnbliBhed by him in
coiyunction with M. GoupiL
$ Aa in a case related by M* Marchand do Maas^, in the ^rrA^fWi 4e Mldeeisu^
July 1851, in aeverd colltwted by M, Bemotx, lib, «<., and in one which came
under my own cognisance at Bartholomew's Hospital.
C
u
AMENORRHCEA
large and pendulous, the sex is mistaken, and the case is
erroneously considered one of h3r[)ospadias. In tliese casea the
labia majora have coalesced, and leave only a small urethral-like
opening in front. The union of the labia is sometimes very
shght* and like the union of the glana and prepuce in some boys ;
and in these cases the parts are easily separated without bleeding.
Sometimes there is slight bleeding ; and I have, among seveml
cases, had one, long mistaken for hjqiospadias, where the va^^ina
and hymen, and thu^ the sex, were not disclosed till the tliick
parts were divided by a knife,
A new nomenchiture is now widely used on this subject. As
tarry and otherwise altered blood is genemlly the fluid
accumulated, so hmma is the first part of the term ; the second
part indicating the seat of the collection- But in some congenital
cases, and in some acquired closures of the cervix (generally of the
internal os) in old women, pus or mucopus is accumulated, then
^0 takes the place of hmma, Wlien the blood filb only the
vagina, you have Imnmiokolpm. When it has dilated vtidely and
filled the neck and body of the uterus, you have hwmatomctra.
When a tube ia filled, you have hmm'aioml^m: ; and there are, of
course, combinations of these, for which very long names may be
formed.
Quite a number of cases has now been published, principally in
German periodicals, where the disease was unilateral. Were such
an occnrrence unknown to the practitioner, diagnosis would >
extraordmarily difiicult These unilateral cases are found wh
there is atresia of one-half of a double vagina or of a do
uterus.
The operation for atresia is performed by the bistoury or guF
bistoury, or Pouteau's trocar. The bistoury is to be ger
preferred, Pouteau's trcjcar is resorted to when a consi
part of the lower vagina is absent, and the sac is pt
sometimes pretty high up per reCtunL This operation is
cases prefemble to vain, painful, and dangerous attempts
the thin tissues between the urethra and rectum to n
maintain a new vagina. Such a proceeding results onl
tion. It is far better for the malformed woman to dL^
hopes of maternity. The artificial passage into the recti
kept open, and the menstrual fluid mns off thi'ough
FBOM CONSTmmoNAL CAUSES.
3S
tuuately a woman who so menstruates (or who meastruates
through the bhuider) is susceptible of impregnation.
The condition of imperforate h3rmen, or of the perineum closed
only by a thin layer of tissues, is easily remedied by a crucial
incision. Wlien this is done the tarry fluid runs ott, and it should
be allowed to do so spontaneously, because clanger comes from
squeezing out or from syringing out The iBtained blood decom-
poses very rapidly, and stinks horribly, and there may be severe
septicaemia; but I have never seen it cause death. In a few days
all is discharged, and the septicaemia, with the high puke and
temperature, passes off. If there should be great urgency, gentle
antiseptic syringing may be used, the distension of the parts by
injected fluid being carefully avoided. Perimetiitis is a
consequence of the operation for atresia, which I have, in one
case, seen.]
Attacks of inflammation of the sexual organs in women who have
already menstruated, and have even already borne children, are
sometimes followed hy amenoiThtea ; either from abiding mischief
inflicted on the ovaria altogether putting a stop to the performance
of tiie function, or from cohesion between the edges of the os uteri,
or agglutination of the walls of its cervix, or from injury to Uie
vagina, sloughing of its walls, and subsequent obliteration of its
canal In some of these cases, as in cases of congenital malfor-
mation, the menstrual fluid may collect within the cavity of the
womb, and require to be evacuated by a surgical proceeding.
Mere obstruction of the passages through which tlie menstrual
discharge ought to flow seems, however, to be sometimes followed
by its complete suppression, I have known the menses cease
permanently after severe labour, followed by obliteration of the
08 uteri and adhesion between the vaginal walls, even though
there was no reason for supposing that either the body of the
womb or the ovaries had been the seat of any serious intlammatory
mischief.
Thougli I have made these few remarks on the non-appearance
or suppression of the menses from causes requiring surgical
interference, I wish to call your attention chiefly to cases of
amenorrlwia from causes which require the vtUer/crence of the
physician.
But before going into any details on this subject, I will once
M
AMINORRHCE^
more remind you, that the mere tmaimo rnensium, or postpone-
ment of the appearance of the menses beyond the time at which
they iisnally show themselves, does not of itself c^ll for
interference, does not even warrant anxiety. Like all the Dther
processes of development, that of the generative system admits of
considerable variations in point of time without of necessity
passing the limits of health. Indeed, just as one child cuts it
first tooth at seven months, and another not till a year old, so one
girl may menstruate at foniteen or fifteen years of age, and
another not till seventeen, without any obvious reason existing
for the early performance of the function in the one case, or for
its tardy accomplishment in the other Mothers are often
anxious about their children, if they do not menstruate till some-
what later than the average period ; or even as that period
approaches, will often attribute to its iniluence the most diverse
symptoms of disordered health ; and will urge on you the
emplo}Tnent of emmenagogue medicines as essential to their
removal
Again, the occurrence of serious illness of nlmost any kind a
few months* or even a few years, before the arrival of the period
of puberty, will often postpone for a long time the manifestation
of its signs, and, in particular, the appearance of the menses.
Sometime since I saw a young woman, twenty years of age, who
had never menstniated, who, perhaps never will» Her health
had been good until she experienced a severe attack of scarl
fever at the age of fifteen. Her recovery from this illness hi
been very slow, and she was dwarfed by it in body, ^
apparently in mind too, and her feeble frame wsis unequal tr
task of bringing her reproductive powers to perfection. In *
with whom the imperfect development of mind is ge^
associated with imperfect development of body, puberty is
always late in its occurrence. It appears, too, from the elf
Report on Cretinism, presented to the Sartiinian Govern
1848, that in extreme degrees of that condition, the rep'
powers are never developed at all ; in less degrees, me
appears late, and continues scanty and irregular thi
while even in cases of the slightest description the av
of the first menstruation is as late as the eighteenth yf
• Rapport ds la Commission cr^ par S. M, U Roi de Sardaifftte
Critinifm, 4to, Turin, 1818, see p. 25.
fioM coNsimmoNAL cAusaa
87
Further, even when tbere is no bodily disease, nor any local
cause rendering impossible the due perfomiance of the sexual
functions, it must yet be borne in mind that those fuDctiouB ore
seldom completely perfonned from the very moment when they
give the first iudication of their activity. It often happens that
afttjr the first menstruation there is an interval, not of one
month, but of two or three, before the menses again make their
appearance ; or» perhaps, that the signs premonit<Jiy of menstrua-
tion are followed by a discharge, not of blood, but of mucus, the
mm8tru€B albm of old writers. We know that such discharges,
though once regarded as morbid, are far from being necessarily
80, If the congestion of the uterus attending the menstrual effi>rt
is slight, thu quantity of blood poured out from the organ will be
but small, and mucua and epitheUum corpuscles will then make
up the bulk of the discharge. In such a case, however, menstrua-
tion may be as really performed, as in the woman from whose
sexual organs luemorrhage takes place with the greatest abundance.
Time lurely huls to bring the function, iu a few mouths, to the
strictest conformity, in all respects, to those laws by which it is
governed in the healthy and fully developed woman-
Still, after every idlowance has been made for cases of mere tardy
development, and for those in which the complete performance
of the sexual functions is accomphshed by degrees, as well as for
otliers in which the activity of the reproductive powers is
postponed almost indefinitely by previous bodily ailment, there
yet remain a number of instances where the non-accomplishment
of the menstrual process, at the time when the changes of puberty
are usually completed, is the protninent sjTiiptom uf disordered
health, and seems to be the chief occaision of aU the various foims
of illness with which it may be associated.
There are iivo dilierent classes of symjjt&ms^ with one or the
other of which the non-appearance of the menses is in these
cases usually associated — symptoms differing widely in their
general characters, but probably for less widely separated in
their essential causes. In the one case the comlitimi is apparently
of pldh^jra in the oihtr of (manmai but the tendency of the
former is to pass into the latter, and this transition often takes
place very rapidly.
A girl, previously in good health, approaches the time of
88
AirE^fORRnCEA
puberty; some of the changes characteristic of it take place, the
form assmnea the cont(Jiir of womanhood, and nothing but the
occurrence of mensfcniatioa is wanting to announce the com-
pletion of the change. The menses, however, do not show them-
selves, but the girl begins to suffer from frequent headjiclie and a
flushed face, frequent backache, pain in the hypogastrium. and
constipated bowels, a furred tongue and a full pulse, and all these
signs of constitutional disorder undergo a marked increiise at
stated periods of about a month. At length menstruation occurs,
though in all probability scantily; and attended with much paiii^
and then for several months together there is no sign of its
return ; or it may be in some rare cases, that when th? pr«]iiTer
period comes round again, the bleeding, instead of taking place, as
it ought to do, from the womb, oecui-s from the stomach or, less
frequently, from the intestines. The general health was at first
probably not seriously disturbed, or at least its disorder was
limited to certain times of peculiar suffering, but by degi'ees the
patient becomes habitually ailing, the appetite falls ofl', the
powers of digestion are weakened, the strength becomes unequal
to ordinary exertion, the pulse grows feeble and frequent, and the
face itself assumes the pallid, sallow tinge whence the term
ddorosis has been selected as the most appropriate designation of
the condition J while the stethoscope detects a pecuUar sound
attendant on the passage of the blood through the ca\^ties of the
heart and along the arterial and venous trunks, and which is
known to be significant of changes in its composition, often of
diminution of its quantity.
In other instances, the signs of plethora have not at any time
been present, but the health, never very robust, fails more and
more as the period of puberty approaches ; the feeble pulse, the
cold skin, the bloodless countenance, the deficient and depmved
appetite come on by degrees, while the outward signs of puberty
appear slowly and imperfectly. The frail child never passes
completely into womanhood, but fades and droops in the transition
stage, through which she has not strength to pass.
In cases of both these kinds there is unquestionably a certain
degree of obscurity, though scarcely more than we shoidd find ^
the endeavour to explain how in infancy the state of the genei
health inftuences dentition, or the process of teething reacts t
IN OPPOSITB STATES OF THE SYSTEM. B9
the general healtk Tlie weakly cbild cuts its teeth painfully,
tardily, iiregiiltirly ; and there seems to be no essential difference
between cases in which the health falls oti' before any teeth have
actually appeared, and those in which the syraptoms corae on
after one or two of the teeth have cut through the gum. In both
cases we look beyond the local phenomena for the explanation of
the symptoms j and we do the same in the girl at puberty as in
the infant in whom the period of dentition has commenced.
In the case of the girl at puberty there seems, however, to be
another element to be taken into consideration— namely, the
composition of the blood. Of all the various processes of develop-
ment wliieh at different times go on in the system, none seem to
make such great demands upon the cii'culating iluid as those
which concern the reproductive organs. liuring pregnancy, even
in a healthy woman, certain changes in the blood (a diminution
of its red particles, an increase in its watery elements) are of
constant occun'ence ; while in some instances these changes are
so considerable as to give rise to disorder of the general health
precisely similar in all its characters to chlorosis.* The growth
of the womb, the development of the fcetus, are, indeed, accom-
plished, for they are subject to a law not easily broken through;
but they are accomplished at the expense of the woman's consti-
tution, and leave her often incapable of suckling her infant, and
probably liable to all that class of inflammatory affections, the
remote cause of which, as of phlegmasia dolens, for instance, is to
be sought in some morbid state of the blood.
To originate a new function, to bring to perfection a hitherto
unexercised power, makes larger demands on the strenjj^th than
are required for its continued activity. The feeble phthisical child
failBy as the time of womanhood approaches, to menstruate, and
the signs of chlorosis gradually manifest themselves in her, w^hile
in spite of advanced tubercuhir disease, the grown woman some-
times continues to menstruate with regidarity, or even to bring
* The merit of the first ob«enratioii8 on clilorosiB in prpgiioocy muiit be divided
betnreea M. Gaxeaox, of Fuia, and the late Profeftaor von Kiwisch, of Pragae,
thoa^ this chums of the hitter appear to be the stronger. The best remarks on
the sabject will be fbtuid in Caseatix, TraiU dts Accouchement^^ Paris, 1850, pp,
291-301 ; Eiwiach, DU Qeburtikundt, Erlangen, ISAl, vol. i p. 227, and vol iL
pi. as ; and Scatmmi, LehrbucK der GdmrUkUfft^ Vienna, 1849, Tol i p. 192,
40
AMEKOERHCEA :
forth children* These however, are, it must be confesaed, excep-
tional occurrences; the tendency of almost all diseases wtiich
orii^dnate in, or in their course produce important alterations in
the blood, ia to disturb, to impair, and at length to interrupt the
peiformanoe of the reproductive functions. In one instance
only * out of all the cases of phthisis among women that form the
materials of M. Louis* great work on that disease, did menstrua-
tion continue up to the time of death ; and it suffices to watch
with modemte care any one suflering from uterine cancer in arder
to feel satisfied, that even though haemorrhage may stUl
occasionally take place from the diseased womb, yet the pericwiical
activity of the reproductive organs ceased when once the cancerous
cachexia had become developed.
There ia another peculiarity connected with the sexual functions
in woman wliich must not be left altogether without notic^3, since
it suggests a reason why their tardy or imperfect development, or
their subsequent disorder, should be associated with symptoms to
wliich we nowhere else find t!ie slighteat analogy. It is a law of
the female economy that for some thirty years of life, unless
interrupted by pregnancy or its resulta, a certain quantity of
blood shall be periodically discharged from the system. Tliis
periodical discharge alone engaged the attention of observers in
bygone times, and various hypothesea were framed, which,
diOering in other respects, yet agreed in this, — ^that they all
regarded the menstrual function as a great depurative agent, a
means supplemental to the lungs themselves, for eliminating
superfluous carbon from the system.^ Though we, with the hght
of modern physiolog)', are able to look deeper than our prede-
cessors, and can see in the discharge of blood from the sexual
organs the outward sign of a still more important process going i
on within, we yet must not forget that it cannot be a matter of 1
indifference to the health of a woman whether the excretion of j
four or six ounces of blood takes place every month, or not ; that]
the arrest of this phenomenon, or its non-occurrenco, cannot but!
* Louis, Bechirt^ mr la FhthisUj deiud&me ed. Svo, FariJi, IS 43 p, 3S4.
f Tb© refleamhea of Andrnl and Gavarrct^ Amml^ de Chiinie, ei de Physique^ 3#|
'flBiie, voL viii, have proved coutilusivelj the ahare which tnunstmatiou bears in [
effectiog the depuration of the Mood, and have changed a plaoaible hypothea
into a certain fact.
rrS EEL.ITION TO CONSTITUTIONAL DISORDERS.
41
be associated with much constitutional disorder. We find,
indeed, that even when, with the lapse of years, the time arrives
at which the discharge naturally ceases, its cessation is almost
invariably followed by a class of symptoms which show that the
balance of the circulation has been disturbed, while many months
are often needed to complete its readjustment. Tbe liver now
has extra work to do in the deptinition of the blood, its disorders
are now more frequent than at other times, and though ha:*mor-
rh^es not infrequently take place which relieve the overti^ked
organ, yet they often pass the limits of health, and become
themselves a fresh cause of Buffering, or even an occasion of
danger.
But the very accidents to which there is a disposition when
menstruation ceases, may also precede its occurrence. If
menstruation is postponed beyond tlie ordinary period, tlie system
sulfers in the same way as it often does at its cessation. The
same double duty is thrown on the liver, the same disposition to
its disorder exists, the same tendency to congestion of diflerent
viscera manifests itself, and frequently the same outbursts of
haemorrhage give temporary i-elief to the congestion, too often also
at the expense of the general constitutional vigour. Xo one who
is faniibar with the symptoms that are often associated with
granular degeneration of the kidney will be at a loss to
understand how local plethora may be associated with an altered
and impoverished condition of the circulating fluid, or will fail to
see how it may sometimes happen that leeches, purgative
medicines, and active exercise, may take that place in the cure of
amenorrhif a which tonic remedies, ferruginous preparations, and
wine occupy in general.
The exact mode of applying these principles in cases where
menstruation has never occurred, must vary much in different
instances, though in all, our chief endetivour must be thrected to
the establishment of that function through the medium of the
general health, rather than by means of remedies acting, or
supposed to act, immediately on the sexual eystem. While, then,
the tardy occurrence of puberty, just as the tartly appearance of
the teeth in infancy furnishes, when unattended by constitutional
disorder, no indication for medical interference, the first question
that in these cases presents itself is, whether the symptoms which
accompany the ainenorrhceii are those of siniple debility or of that;
kind of plethora which may yet lie associated with an altered and
deteriorated state of the circulatiDg fluid
But though the decision of this point, with a view to the
adoption of a suitable constitutional treatment^ claims our first
attention, there is yet another which must not be wholly lost
sight of. T^Tien it^ establishment is long postponed^ the. perform-
ance of the menstrual function generally takes place painfully,
difficultly, and for a long time imperfectly, while, as already
mentioned, it sometimes happens that the blood which is not
poured out from the nterus makes its escape through other B
channels ; such a discharge, too, vicarious of menstruation, some-"
times continues to recur for months together, not merely injuring
the patient's he^ilth, but, through the mysterious influence of habit,
offering a serious impediment to the proper performance of the
menstnial function. How, and why this is so. I will not pretend
|i to explain. Deficient innervation of the sexual organs has been
assumed to be its cause by some ; while others have spoken of
some special density of the uterine tissue, preventing the ready
outflow of bloody or of some peculiar thickness ot the blood fl
itself, which therefore could not escape from the pores that
j otherwise would give it exit. Statements of this kind, however^
j are but the expression of very crude hypotheses; they adilH
nothing to our knowledge, they do not even present it to us in a
J clearer form. What we have to do with is the fact, that there
I are certain periods more or less weU marked in the regularity of
^ their return, when a special disorder of the nervous and vascular
I systems, and various forms of local suffering, referred more or less
j distinctly to the womb or to the parts adjacent, announce a sort
I of imperfect menstrual effort, and that at those times various local
I measures addressed to the uterus are not infrequently succeede
I by the establishment of menstruation, though the same measu'
, if had recourse to at another time, would be altogether unavai"
I or even positively mischievous.
I Treatment, then, resolves itself into what is to be done fc
improvement of the general health, and what is to be doT
special occasions with a particular \iew to the excitement
[ uterine function ; while it follows as a necessary coroUar
when no sign of menstrual effort shows itself, then m
f
PUINCIPLES OF TREATMEOT'.
4S
measures are indicated. In cases where general debility
characterises the patient's condition, tonics in the widest sense of
the term are indicated ; and by them I understand not mei'ely
tonic medicines, or preparations of iron, though they willTalmost
always be appropriate, bnt the tonic inHuence of pure air, Iiealth-
ful pursuits, and exercise short of fatigua In these cases, too,
the one great danger to watch against, is that of the supervention
of phthisis, and a winter's residence at Torquay or Ventnor is use*
ful in many instances, not only as a means of guarding the
delicate lungs from the cold of many inland places, but also
because the warm climate and tlie sea air appear of themselves to
have a beneficial influence in favouring the healthy development
of the reproductive system. The constipated state of the bowels,
which is so troublesome a symptom in these caees, must be
encountered, not by drastic purgatives, but by' gentler ajxTiente,
among wliich the watery extract of aloes has a well-merited
reputfition. In some instances all preparations of iron have the
effect of increasing the sluggish state of the intestines, but this
difficulty can in general be got rid of by combining the iron with
some aperient salt.* At other times the delicate stomach is
unable to bear the mildest fen^iginous preparation, and in these
circumstances, chalybeate mineral waters will often produce good
eflects, far beyond what might be anticipated if we regarded
merely the quantity of the remedy they contain. The waters of
Spa and PjTmont are esiieciaUy suitable to crises of this descrip-
tion ; tlie former being the milder and better borne by patients
whose digestive pov^er is very feeble. Both these waters are very
well prepared at Brighton, but patients of this description benefit
as much by the change of scene, the heallhful exercise^ the sort
of busy idleness of a watering-place* as by the virtues of the
spring to which it owes its reputation.
Even when a state of apparent plethora predominates, much
• (No. 1.)
Feiri SiilpKiitU . ,
. gr.ix
Magneaiie Snljiliatis .
• m
Acid, finlpli. diL .
. Zm
Sympi Auratitii . .
. liy
Aquw Carui, ad . ♦
. Jn-M.
Two tableupoonfula twice ft d«y.
the same kind of treatment is nevertheless appropriate ; with the
exceptioD, however, that the preparations of hon are often not
needed at all, whOe a much more 'active system of purgation is
generally indicated. A nutritious, though not a stimulaimg diet,
the shower-bath, and horae exercise, are remedies of gi-eater power
than any which Apothecaries Hall contaius. The sluggish state
of the liver, which constitutes one of the great difficulties that in
these cases we have to contend with, must not lead us to the too
frequent tise of mercurials, especially of mercurial purgativea
There are some exceptional cases, however, w^herc other remedies
fail to excite a due secretion of bOe, in which the steady employ-
ment of small doses of bichloride of mercury, persevered in for
serefal weeks, while a generally tonic plan of treatment in other
respecta is continued, proves of most essential service.
But while the general health must be admimstei*ed to by means
h as I have just described, the appearance of any attempt at
menstroatioD, as it indicates a different object to be aimed at, so
calls for an immediate change in the remedies to be employed.
The patient should be kept quiet^ and if there is any consider-
able suffering, or much disturbance of the circulation, it is desir-
able that she should remain in bed, while the hot lup-batb, night
and morning, rendered still more stimulating, in cases where the
local pain is not very considerable, by the addition of some
mustard, or the hot foot-bath with or without the addition of
mustard, wiU often have the effect of inducing the menstrual flu:
It is at this time that the stimulant diuretics, such as nitrou
ether, turpentine, spirits of juniper, or the domestic emmenagogi
giu, sometimes prove useful,* and by increasing the congestior
the pelvic viscera, induce a kemorrhage from the uterus
relieve the patient from much suffering. Much care, liowe
needed in the employment of any of these remedies ; wh
violent measures, such as the administration of cantharidef
the oil of savin in lai^ge doses, or of very powerfu'
stimulants, such as vaginal injections of liquor ammonir
with milk, or the introduction of nitrate of silver into tl
cavity, by means of Lallemand*s pirrte-mustiqm, appeal
deserve reprobation, as both uncertain and unsafe, a
• In Scotland, tlie oil of pennyroyal, long fallen into dkujse in this
letaini ita old reputation.
PRINCIPLES OF TREATMENT.
4ff
objectionable on the same grounds as would always dismcline one
from making a vaginal examination in the unmarried woman.
Electricity, applied by means of the ordinary electro-magnetic
apparatus, one disk being placed over the pubes and the other
over the sacrum, has in some cases been of semce, though its
results, just as when employed for other purposes, appear to vary
much and causelessly. It was at one time anticipated that the
eigofc of lye would prove a very valuable emmenagogue, and
indeed it was employed as a popular means of inducing menstrua-
tion long before its introduction into obstetric practice. Though
it has been tried, however, in various forms of powder, tincture,
infusion, and essence, and tliongh experiments have been made
with its essential principle, the errfotim, yet its peculiar power
over the muscular activity of the womb does not appear to extend
to any otlier function of the sexual organs.
In some instances, the pain experienced in the uterine region
with the return of each menstnial jDeriod is very severe indeed j
and in such cases, while stimulating hip-baths are out of place,
the application of leeches to the h)T:togastrium or the perineum
not only relieves the pain, but is often followed by the occunx*nce
of menstruation. The explanation that used to be given of this
fact, founded on the circumstance that excessive congestion of a
secretor}" organ often puts a stop to its activity, is scarcely applica-
ble now that we know the menstrual discharge to be a simple
h«emoiThage, not a secretion. The fact, however, still holds good,
and the practice founded on it is worth remembering.
I have alrearly referred to the occurrence of haemorrhage from
various organs as an oc-casional attendant on amenorrliu'a, and
have suggested an explanation of its cause. Medical writings*
are full of iUustrations of this -vicarious menstruation, as it is
often, thctugh not quite correctly, termed ; and from them it
appears that the haemorrhages may occur, not merely from any of
the mucous surfaces, as the stomach, intestinal canal, or air-
passages, but tdso from any casual wound, from the surface of an
ulcer, from the nipple, from the eye ; in short, from almost any
• Abundant references nwiy be found in Brieme de Boismont, De la MtmatruoHoa^
kc,, 8vOf Paris, 1842, cb&p. vi. p. 374 ; and in Meuener'a Frauenkrankhiiiiitj 8?o^
Leipug, 1845, Tol it p. 860,
46
AMEjrORRHCEA :
conceivaHe part of the body. Now it is no part of my object to
occupy yoiir time witb a cletnil of these mere medical wonders ;
but there are several tilings with lefereocc to them wliich I wish
you to hear in mind. The first is, that after the arrival of the
period of puberty, the non-appearance of the menses, or their
accidental suppression^ is likely to be followed by occasional out-
bursts of htemorrhage, which by no means invariably correspond
with any real activity of the sexual organs, or observe any distinct
periodicity of return. Next, it is to be remembei'ed that such
dischai^es, not being genuine menstTuation, may ne%^ertheless take
place from the uterus, and amenon'hrea iind a seeming
menorrhagia may alternate %vith each other. Such htemoiThage,
too, may be extremely profuse ; and even within my own obser-
vatioB it pro%^ed fatal to a young lady, in whom it succeeded to
long-continued suppression of the menses, and whose uterus, as
far as could be ascertained by examination during life, was
perfectly healthy. Lastly, the occurrence of this haemorrhage
does not in any material respect alt^^r the indications which we
are to pursue in our treatment, or the means by which we must
endeavour to accomplish them. If so profuse as to be hazardous,
the disci large must be checked by appropriate means ; but it is to
the state of the genemi liealth, and the excitement of the true
menstrual fimction, that our chief care must be directed. Habit,
** the memory of the body,"* na John Hunter beautifully terms it,
while it plays a prominent part in many of the functions of the
animal economy, exerts over none so powerful an influence as
over those of the sexual system of the female. The haemorrhage
vicarious of menstruation, in its fi.rst occurrence perhaps the
result of mere accident, needs but to return two or tliree times for
its cure to become difficult. After a time, even though the
general health may be perfectly good, and though the ovaries, as
far as we can tell, perform theii* office properly, yet with each
return of that excitement of the circulation which should relieve
itself through the medium of the uterus, the long-established
hal>it interferes, and bleeding takes place from the lungs or from
the stomach, or from the surface of the body, instead of from the
womb.
But the application of this fact is wider than to the mere
• WorkHf Palmer*8 edition, voL i p, 274*
USE OF EMMENAGOGtJES.
47
determining the prognosis of cases of hiemorrhage vicarious of
menstruation, thouf^b it will at once be obvioua that they admit
of cure easily, or with difficulty, in almost exact propoition to
their duratioiL The piinciple which it involves is to be borae in
mind in the management of all the ailments that disturb the
menstruid fimction. It ia not enough to take precautionB till
menstruation has for the first time occurred ; the period for its
return should, even in the healthiest girl, be watched for, and all
previous precautions should be once more repeated ; and this
should be dona again and again, until at length the habii of
regidar, healthy menstruation is established ; and if this is once
secured, the risks of its subsequent disorder will be veiy much
lessened. Need I say that this truth bears with tenfold force on
all cases in which menstruation has been tardily, painfuDy, or
difficultly accomplished ; for in these the bad habit has to be
broken through, and a new one formed. If this is not accom-
plished during the first few years of womanhood, it will, in all
probability, never be attained.
AMESfORaHOEAf contLtiued— Suppression of the Meneefl — Their premature cefisation
— IrregnLmties before final extmction of fmictiott--^ Various causes suspending
tlie meusefi— Treatmeiit
ICoroRRHAOiA — Its two principal causes — let, coustitntional ; 2d loc^ — illustra-
tians of caoh.
Trefttment of both classes of cases — general precautions — cases Tequiring antiphlo-
guitic meuures— cases requiring t^nicg and astringents — local remedies —
conditioQs calUng for the plug, and for intra-uterine injections.
We were engaged during the last Lecture with the study of
those csases in whicli the menstmal discharge has never made itsfl
appearance, Anatlier, and equally important class, atill remains
for consideratiun, in which menMruatiofi is either inttrrupled or
suppressed. ■
It is of course out of the question to attempt an examination
of all tlie various circumstances that may give rise to suppression ^
of the menses, or that may lead to their permanent cessation; forfl
t very large number both of constitutional disorders as well as of
local diseases tend directly to produce this residU Eeference has
already been made to the remarkable influence of phtlusis in its
more advanced stages in leading to suppression of the menses, J
and many other cachectic diseases exert a similar influence on the I
menstrual fimction ; wliile severe uterine or ovarian inrtam-
mation, various forma of ovarian degeneration or of uterine tumour, I
often suspend menstniation for months together, sometimes put a
final stop to its occurrence, many years before, in the natural
course of events, the sexual powers would lose their \i.gour. ■
But besides those cases in which a definite reason can be ^
assigned for the arrest or cessation of the menstrual discharge, j
there are others occasionally met with, in which it disappears as '
the result of a premature senescence, just as we have obseiTed ?
SITPPRESSION OF THE MENSES.
sometimes to come on late in life in consequence of the tardy
occurrence of puberty. Thus while the average duration of the
menstrual function is about thiity years, and the age of it6
cessation in the majority of instances, at or a little after forty-
five, it has been known to continue less than ten years, and to
cease before the age of thirty, and this, too, without any
peculiarity in the history of the woman suggesting an adequate
reason for so wide a deviation from the ordinary rule.*
To a great extent the date of the cessation of the menstrual
function is, I apprehend, a matter of indifference, and just as
some persons of our own sex retain sexual vigour to extreme old
age, while with others it soon grows feeble or becomes sluggish,
so women may long retain their reproductive powers, or may
lose them ciirly, without their health being better in the one
instance, or leas good in the other.
Cases, however, are sometimes met with, in which a permanent
cessation of the menstrual function is associated with the same
state of health, the same condition of general debility, as I liave
already refeiTed to when speaking of the non-appearance of the
menses, and accompanied with aU that collection of symptoms
which constitute chlorosis. In these circumstances the same
general treatment, the same chalybeate remedies as are suited to
the young girl, find their fit application in the illness of the
matron, and generally with the result of impro\ing the health
and repr^ijducing the menstruation. Sometimes, indeed, though
the health amends under axjpropriate means, yet the sexual
functiuns are never re-established ; a result with which, although
far from usual, it is nevertheless important thot you should be
acquainted.
But there are many instances in which, though menstruation
* Ekborate t&blea showing tli« duration of menstntation, &tid the ag« at its
CMBfttion, are to be found in Brierre de Bt^Umont, op. ct£., pp. 209, 211 ; in Br
Whitehead's Treatise on SUrilUy and Abortion ^ &c., 8vo, London, 1647, p, 150;
and m Dr Tilt's work on the DvaeoMs of Women^ Svo, 2d cd., London* 1853,
pp. 44 and 46. My own obaervatiotia on the subject correspond with these in
showing the dilTerenoefl to be very wide indt?ed in this respect between difftfrent
and apjiurently equally healthy women. In my caBt'R the a^ at ceaaalion of the
menjieB varied from twenty- six years in one instan€e, and thirty-one in another,
to fifty-eight in the in*tftnce in which it continued longest, wliile the actual dura-
tion of the function was only eight years in one person, and extended to thirty-
eight in another, in whom it laaled for the longest time.
3t a^
is not finally arreated, yet the function is suspended for a time;
and this accident ia attended by very vaiious degrees of constitu-
tional disorder. At tlie commencement of sexual activity and
towards its dose, menstruation ia often iiregnlar, in the oiie
instance owing to the organs not having arrived at perfection, in
the other owing to the gradual loss of their power. So fi-equent,
indeed, is this irregular menstruation as a prelude to its final
cessation, thiit women have a homely phrase, the " dodging time/*
by wliich they designate the period of its occurrence, I have
already told you how in the former case you must watch over the
function, and endeavour to bring on by degrees its regular
performance. In the latter, you must confine your attention to
the general heaUli, without endeavouring to re-excite the activity
of organs which are thus giving evidence of their waning powers.
The irreguhir menstruation in the above case is almost
physiological occurrence ; its suppression, in other circumstanc
may be due to a gi-eat variety of causes ; it may be owing to
pregnancy— to pregnancy, unsuspected by the person who seei
your advice. I refer to this cliiefly in order to remind you tha
in every case of causeless suppression of the xnenses, just as in
every case of abdominal tumour in women, you must be^r in
mind the possibility of pregnancy. I do not mean by this that
you are to doubt every woman's word, or to question every
woman's chastity, even in thought, but that, l>earing in mind how
little you can know of the intimate history of many of your
patients, you must not allow your respect as men, your gallantly
as gentlemen, to make you quite lose sight of what may much
import you as physicians.
Independently of pregnancy, however, mere sexual intercourse
not infrequently arrests menstruation for a time, so that
in recently married women, the existence of pregnancy is some-
times suspected for two or three months, till, at the end of that
time, the hopes are dissipated by the un%velcome return of the
menstrual dischai-ge. Habitual sexual excesses, though they
sometimes have an opposite effect, and induce mcnorrhagia, yet in
the great majority of cases suppress menstruation altogether, c
render its return irregular, and the quantity of discharge small,*
• See on this snliject the remajka of M. Farent-DucMtelet. Be to Frostituir
dans Ui Filh de Paris^ vol L p. 228.
RULES FOB ITS MANAGEMENT*
51
Any sudden shock, either acting locally on the uterine organs,
as the application of cold to tho viilva, or through the medium of
the general system, as when a person gets wet-footed, or suffers
during menstruation from exposure to wet or cold, will often
check the menstrual flax. In many of these cases, too, the sudden
arrest of the discharge is followed by extreme uterine pain and
tenderness, by all the symptoms of intense uterine congestion,
sometimes, indeed, by actual uterine inflammation. The mind,
too, reacts upon the body, as we see perpetually illustrated in the
case even of those functions that might be supposed most
independent of its influence, and many instances might be related
of sudden grief, or fear, or anger, at once arresting the menstrual
discharge. But other causes acting through the mind tend, tliough
less suddenly, to diminish the activity of the sexual functions, to
lessen and at hist to put a atop to menstruation ; and a French
physicijin, M. Pidoux,* notices this as a not infrequent occurrence
among members of Eoman Catholic sisterhoods. That, however,
which it imports us more to hear in mind is. that iu young girls in
whom meuBtruation h^a been but recently established, a return
to school or a resumption of lessons at home is not very seldom
followed by an interruption of the function. The accident is in
many cases due entirely to the intellectual effort., not to the w"ant
of physical care ; and this is shown by the fact that the mere
removal from school, unless accompanied with the discontinuance
of study, wUl not suffice to remove the araenorrhtea.
But various though its causes may be, yet the treatment of
suppression of the menses rests for the most part on very simple
principles, and those the same in almost all instances. Two |K)int8
require attention; first, to re-excite menstruation at once, if
possible ; second, to provide for its] re-establisliment when the
proper period once more comes round. If the hot hip or foot
l»ath, or a w^arm bath, bed, and a cordial or diaphoretic, fail to
reproduce the menses when sudderdy checked by cold, or by any
other cause, we must wait patiently till the next menstrual period
comes round, unless indeed urgent s}Tnptoms supervene, betoken-
ing great congestion, or inflammation of the uterus, and tliey may
* Quoted by M. Martlneau, irt hid Traiid Clintqwt des AffeetioMderUUrut, 8vo^
187a, i*. ih
62
MENOHRHAGIA :
require free local depletion, or even veneaecdon, and other active
measures t^j arrest tbeir programs.
With the return of the ensuing menstnial period, the greatest
care must be taken to secure the proper performance of the
function, by the use of all those means whic^h I mentioned in my
last lecture, when speaking of amenorrhiea. The importance of
doing this cannot be overrated, since many cases of habitual
dysmenorrhrea, due probably to a state of chronic irritation or of
inflammation of the ovaries, date back to some accidental suppres-
sion of the menses ; and the suffering has been confirmed by want
of due care at the return of the next few periods.
It is no part of my plan to occupy your time with passing
minutely over frround already often trod before ; and therefore,
in considering the different disorders of the menstrual function, I
shall content myself with prjinting out to you the grand principles
by wliich your management of them must Ije regidated, luther
than attempt to enter into detail concerning any.
This bemg so, we may now pass fi"oni the consideration of cases
in which the menses have been scanty, or suppressed, or have
failed to appear in due time, to the study of disorders of the
menstrual function of an exactly opposite character— to cases of
what is termed inenorrM^., or excessive uicnstruation*
This excess of menstruation may show itself either in the great
profuseness of the ilow, or in its long duration, or in its fi-ef^uent
return. It is, -an you will liud hereafter, by no means a matter of
indifference, in which of these respects the excessive menstruation I
first or chietiy shows itself, since from these variations important
conclusions may often be drawn, both -as to the cause of the
ailment and its means of cure. It must, however, be borne in
mind, that mensh'uatton seldom continues long to be excessive in
one respect alone ; but if the menorrhagia is not si)eedily checked
the patient will menstruate not only in greater quantity, but for a
longer time, and at shorter intervals than natural. f^
Divisions and subdivisions of menorrhagia into many differ
kinds have been needlessly multiplied The only classificat
that seems to me of real practical utiUty is that which recogn^
two forms, depending, either —
1st, On some cause seated in the constitution generally,
2d, On some affection of the sexual system.
I
1
I
CONDITIONS ON WHICH IT DEPENDS.
This distinction should never be lost sight of in practice, though
we may seldom meet with instances in which the actual line of
demarcation is drawn with the same precision as we attempt to
observe in our nosologies.
One caution is, perhaps, worth giving, befom I say anything
more alx^ut menorrhagia* It is, that every excessive ba-mun-hage
from the unimpregnated utems, during the years of sexual
activity, is not necessarily menoirbagia. Women themselves are
apt so to regard all losses of blood during that period of their
life, and practitioners are too often guilty of the same oversight
Menorrhagia is an excess of menstrual discharge, an over-
abundant hsemorrhage, the cause of w^hich, in the first instance,
is that congestion of the sexual organs which att^jnds the
maturation and escape of an ovule from the ovary. As I
mentioned yesterday, outbursts of bleeding may take place from
the w^omb in some cases where the menses have been long
suppressed, affording relief to the system, or even, by tlieir excess,
jeopardizing the patient's wellbeing, and this with no more real
reference to the function of which menstruation is tlie sign, than
exists in a case of haemorrhage from the bowels, or of bleeding
from haemorrhoids. In tlie same way, too, a patient may bleed
to death from a cancer of the womb, or from a polypnis, or from a
fibrous tumour of that organ, and yet such ha?mon^hiige may be
no real menorrhagia.
In this case, again, the distinction cannot always be drawn, for
the incipient uterine disease may at first have betrayed its
existence by the excessive congestion of the sexual system, and
consequent abundant discharge of blood at a menstrual period,
but with the advance of the mischief, bleeding may take jjlace at
any time, and independent of any special occ^ision of uterine
excitement* I need not say that a distinction does not cease to
be naefal because it is not always practicable to make it.
But to return,* Tmnorrim^ia was stated to d*:pe)ul in some
• Premature ni<?nstraatioti, mcnttruaiio pmeoTt haa been classed by some writera
■1 « fonu of mcDorrhiigia. I have preferredt however, passing over the mihjecl,
■ilioe oifles of precocious puberty in cither lex oone^ru the phyRiologitft rather
than the phyaicinn. Two remarks only fltiggest themitclves ils in place here.
Kwt, thtt those ioatanccs in wliich the senw] system has bt^cn stiniulated to
ptvmAtiirc activity by various injuriona mfliieiic«9 both physical und moral, are
&ot g^-Doiucj oastia of precodoufl puberty ; and ftscond, that neither aie ail caaea to
I»
k
instances mi causes acting throufjh th-e viedium of the gene
s^ste^ii. Thus, for instance, some yeara ago 1 saw a widow ladjf"
of about forty years of age, whose time was di\^ded between a
sojouiTi in this country for two or three months at a time aud a
residence during the other part of the year in a somewhat damp
situation in Ireland. Meuetruation w^as always regular in the
time of its recurrence and natural in quantity during her stay in
this country, but for some two or three years her return to
^Ireland had been followed by an excessively profuse discharge at
each menstrual period, and by its continuance for more than twice
as long as usual ; symptoms which subsided once more after a
few weeks' stay in England* How the change of cUmate act^ad
in this case it is not possible to say, though illustrations of a
somewhat similar influence of locality in modifying the uterine
functions are far from unusual.
Cases are sometimes met with in w^hich an altered state of the
circulating fluid, such as even our rough chemistry can detect,
co-exists with and appears to be the exciting cause of menor-
rhagia. In cases of granular degeneration of the kidneysii^
menorrhagia is far from being of uncommon occurrence. The
altered, attenuated blood seems to escape more readily than
natural from the uterine vessels when they are congested at the
return of a menstrual period; and three or four cases olS
supposed disease of the womb have come xmder my notice, in^
which the most careful examination could detect no local cause
for the jjrofuse menstruation, but in wliich the urine waafl
discovered to be loaded with albumen. The hint which this fact
be 80 regnrded in which once, or often er, Rangnineous diachargea have takan place
from the sexnal oi^gans (*f infants and very young female children. ^|
Caaes of genuine precocious puberty, iti which the whole hody haa nndei^ne ia^B
early childhood the varioua chunges that usually take place iu lat^^r years, and an-
nounce the arrival of womanhood, are far ksa common than the numerous refer-
ences to ht" found to their occnrrotice in medical worka would at lii'st le-ad one to
imagine. A rery sound criticism on many of the curlier caaes is to he foond in
Kaegele, Abhandlujigt^nt d^., au3 dent Gebiete der Ehaikhaiimda vmblicJtfn Gench-
Uchtes, 8vo, Mainz, 1812, pp. 312-328. Numerous referenoes^ though aomc of them
are of doubtful authenticity, are to be found in Meisfluer, Frauenkrankheiten, vol*
ii, 8vo, I^eipsig, 1845, p. 723-739 ; and in Busch, Xtaa QeschkchtsMen da Wtibett
voL iv. 8vo, Leipsig, 1843, g 243, pp. 459-465 ; and, lastly, an interesting case,
with very sensihle remarks on many previous histories of ca-^es of premature
menstruation, will be found in a. small tract of 47 pages, by Dr Beutcr, U$l^r di^
Freococitdt der Mmtimaiiont 8vO| Wiesbaden, 1846,
FEOM CONSTITUTIOKAL CAUSES.
B6
suggests as to the expediency of examining the urine, even
though no sjinptom should seem to point to the existence of
remd disease, is worth remembering, and the test tube will some-
times help to clear up an obscure case of supposed uterine
ailment You are not to be specialists, even though chance
should lead you to have most to do with one special class of
ailments, but you are to be physicians, and in proportion as you
learn to estimate aright the influence of the di.sordei's of one part
on the functions of another will you be likely to prove good and
successful practitioners in the treatment even of local diseases.
Somewhat similar in their nature are those cases of monor-
rhagia met with most frequently towards the decline of sexual
activity, in which, with general disi»osition to plethora of the
abdominal vessels, a sluggish liver, and constipated bowels,
menstruation is sometimes irregular in its occurrence, often
anticipates the proper date of its return, and is often excessive in
its quantity. Such haemorrhages are not of necessity menstruah
though they usuaUy take place at or near a menstrual period, the
congestion of the womb which tlien exists favouring the occuixence
of profuse bleeding at that time from the uterus rather than from
any other organ.
A tendency to haemorrhage is a frequent attendant on many
conditions of debility, and we look, probably with propriety, on
some change and deteriomtion in the circulating fluid as
accounting both for the general feebleness, and for the local
gccident. In women whose strength has been exhausted, or
whose blood has been impoverished by prolonged lactation, the
leappearance of the menses often takes place with an undue
abundance of discharge, frequently in such quantity bs to con-
stitute real menorrhagia ; while in many instances the long
duration of the hicmon'hage is at least as trying to the patient as
the profuseness with which it Hows. Here then is anotber
illustration of menorrhagia from constitutional causes.
These cases, indeed, are so frequent in their occurrence, and
often cause so much anxiety, as to claim a moment's special
notice. A woman -who has reached the period at which mens-
truation commonly ceases, finds that, independent of any cause to
which to attribute it, the flow becomes far more profuse than was
its wont It lasts longer, is more abundant^ and often returns
56
MENOREHA.GIA
more frequently than before ; but it is unattended by pain, and iB
not succeeded by purulent or mucous leucorrhcea, tliough a sero-
sanguineoug discharge not infrequently continues in the intervals
of menstruation, or is induced by very slight exertion. The
absence of all local discomfort often leads the patient to postpone
any treatment for mouths, uuder the impression that the ailment
will soon disappear with the spontaneous cessation of menstrua-
tion, until at length the daily increasing weakness, the dyspnoea
on slight exei-tion, the swollen ankles and impaired digestion, urge
her to seek relief from symptoms which even then she scarcely
connects with the perpetually-recurring bleeding. Such patients
come to the out-patient rooms of hospitals, or even present them-
selves in the consultiug-room of the practitioner after long delays,
with the worn aspect, the pale and sallow countenance which at
once raise the suspicion that they are suffering from mahgnant
disease. This suspicion, too, is not infrequently strengthened by
the statement that the discharge is occasionally fcctid— a con-
dition by no means unusuid in cases of long-continued haemor-
rhage, if the blood is not w^ashed away from the vagina by daily
sjTinging. In every instance of the causeless occurrence of
menorrhagia in advancing life, the probable existence of cancer
must not be lost sight of, since to that, or to the presence of small
fibrous tumours or pol}^i, the haemorrhage is oftenest due. In
these special cases, however, no uterine disease exists, though
sometimes, from the perpetual afflux of blood towards it, the
womb is increased in size. Often the organ is no larger than
natural ; it is not hard, nor in any respect unhealthy, and one
feek at a loss to account for such grave functional disorder with
such complete absence of local mischief.
But though in cases such as these the sexual system is not the
part firat in fault, yet no serious disorder of its functions can take
place, still less can recur frequently without being accompanied by
some sign of uterine ailment, A sense of weight in the pelvis, a
feeling of bearing down and syinpathetic pains in the back, tell
that the uterus is heavier than natural, and that its vessels, from
habitual congestion, ate overloaded with blood ; while the mucous
discbarge w^hich persists in the intervals between the menstrual
periods is but the effect of the same condition, which, increased
at the time of each ovarian excitement, gives rise then to the
TBOM LOCAX CAT7SGS.
6T
profuse outflow of^ blooA Moreover, since the menstrual effort
returns every twenty-eight days, the congested womb hag not
time to recover itself between each perioA The blood has
scarcely ceased to flow before it is again determined to the organ
by a renewed ovarian excitement ; and, its tissue being looser, its
vessels more dilated on each succeeding occasion, allow more and
more readily of the escape of blood, till at length no interval ia
left at all» but the How goes on constantly, and menstruation is
marked only by a lai^ger htt^morrhage than takes place at other
times. The influence of habit, too, to which I referred when
speaking of amenorrhcea, is not less marked in cases of menor-
rhagia, tending to pei-petuate the evil, and to render its removal
ditticult, long after the cause to which it was originally due has
ceased to be in action*
Some inferences applicable to practice may be deduced from
what has already been said*
l«i» The importance of determining whether the cause of the
menorrhagia is to be sought in the state of the general system or
of the sexual oi^ans,
2d, The necessity of bearing in mind that even when the
ailment depends on a constitutional cause, it ^vill yet be attended
by certain local symptoms; and further, that the latter may
persist long after the removal of the former.
3d, It follows as a corollary from the two preceding statements,
that it is essential in every case of long-continued menorrhagia to
determine by careful exaruination the presence or ateence of local
disease; and tliis the mtlier since the early stages of organic
uterine aflections are not only often accompanied by menorrhagia,
but also are often imattended by any other symptom.
But there is a semnd class of cases in which jmiwrrhfu/ia occurs
as the result of some cause a4:lin^ directly an th£ sexual system. We
meet sometimes %vith instances of what^ seems like a special
susceptibility of^ the sexual system, in which any sudden excite-
ment, even though unconnected with the sexual functions, is
followed by haemorrhage, lasting perhaps only for a few hours, or
for a day, but sometimes continuing longer, and even passing into
regular menorrhagia ; while in all patients who are liable to this
accident, menstiiiation is almost invariably profuse. A similar
effect is produced by causes acting directly on the sexual system ;
#
p
^
^
and hence, while in some cases we find tlie unaccustomed stimvi^ff
oi sexual mtercourse lead to 8ux)pres3ion of the menses, we also
observe it in otLer instances followed by their excesa Menstrua-
tion in these cases generally continues to observe its proper
periods of return, but lasts on each occasion much longer than
natural; while abstinence from intercourse for a season, and
moderate use of it afterwards, are almost always followed by the
menstmation resuming its natural character. More difficult of
cure, however, are those cases in which, from some cause or other,
the marriage is sterile, and especially those in which, from dis-
parity of years, or from constitutional feebleness on the husband*3
part, the act of congress is but imperfectly accompUshei In these
circumstances a sort of chronic ovarian irritation and chronic con-
ge!5tion of the womb are kept up, which lead to a degree of
hypertrophy of the uterine substanco and to profuse bleeding from
its lining membrane. Menorrhagia, too, not seldom occurs in
prostitiited from the constant over-excitement of their sexual
otgims, and its cure Ls almost impossible by any means short of
the complete abandontaent of their habits.
Tlie local causes, however, which may give rise to menorrhagia!
are manifoLl Whatever produces undue ovarian excitement,
whatever causes undue uterine congestion, is likely to occasion it,
while any circumstance that renders the womb larger, its texture
looser, its vessels of greater size than usual, by just so much
facilitates its occurrence. Premature exertion after delivery is
often followed by liiemorrhage. If this hi^emorrhage is not speedily
checked by treatment, and its return guarded against by watchful
care, it soon assumes the menstrual ty|>e, and soon also becomea
excessive in quantity, from the very circumstance that it tak<
place from an organ in which the processes of involution are
yet ineomiilet<3, aod whose vascular supply is much more abundani
than it would be if menstruation were delayed till the lapse of the
ordinary ])eriod after dehvery. From a similar cause the founda-
tion of menorrhagia is often laid in a want of due care at the time
of the first ai>pearance of the menseB after a miscarriage ;
occasion, by-the-bye, on which you should not fail to impress
your patient the need for what may seem to be almost exaggerated
precaution. This condition of the womb, too, sometimea persists
for long periods after the delivery or the miscarriage to which it
i
les
4
ntV
be
la-
o^
FKOM LOCAL CAUSES,
was originally due ; or in weakly persons exists even independent
of any appreciable cause, and this to so great an extent tliat the
uterine sound may sometimes discover the length of the uterine
cavity to vary as much as half an inch within the course of a
single week. Tliis state of relaxation of the tissue of the womb
likewise coexists very frequently with a granidar. abraded^ or
ulcerated condition of tlie os uteri ; local all'ections which, slight
though they may seem, yet help to keep up an habituid conges-
tion of the womb, and thus furnish an ever-present occasion of
menorrhagia.
Other causes still might be enuniemted as giving rise to exces-
sive menstruation, such as blows or other injm-ies inflicted on the
uteruB during a menstniol period. Misplacements of the uterus,
as retroflexion or anteflexion, are often associated with it, and
various organic diseases, as pol^^us, fibrous tumour, or canceti
which eventually produce consttmt haemorrhages, at first manifest
their existence in many cases by an increased flow of blood at the
ordinary menstrual period. Inflammation of tlie uterus, e^i^cially,
I believe, of its lining membrane, has this effect in very many
instaacea, and not only produces it on a single occasion, but gives
rise to a state in which menorrhagia often becomes haViitiuih It
has also been alleged* that many cases of obstinate menorrliagia
are dependent on a morbid state of the uterine lining raembmne,
in which it becomes the seat of minute polypoid granulations
whose removal, by scraping away the membrane itjself , is essential
to the patient's cure. There can, however, be no doubt but that
the frequency of these granulations haa l>een greatly overrated ;
their existence is not referred to by Pichard in his table of
examinations of 8U0 uteri ;f Eokitansky does not allude to them,
and they did not come under my notice in any one of seventy
uteri which I examined carefully some years since at St Bartho-
lomew's Hospital. There is no doubt, however, of their occasional
existence, or of their identity in structure with the ut*irine mucous
♦ Pinrt dawTil)ed by M. R^camier in the Jmimalik Chirurgk for 1S48» M. Nonat,
who embmces M, BecAmier's opiaiouA, &tid adopts hia pmirtiee, gives n »k«;tch
oi the litemture of the imbject at p. 193 of bk TmiU da Maladk$ da VUUrui^
8T0p Paiia, 1S60.
t Appended to his book, Des abua de la oamUrimivmf cle,, dans k$ maiadm d$ la
matHce^ Pans, 8vo, 1846.
membrane itaelf,* though, while thej have been found in the uten
of women who had never suffered from any form of hirmon'hage,
there is no evidence to show that they have any necessaiy con-
nection with the occurrence of menorrhagia, or tlmt menorrhagia,
when associated with them, is distinguishable by any peculiar
symptoms. The supposition that it is possible to distinguish them
by exploring the uterine cavity with the ciirdte m ridiculed, fairly
\ enough, hy M. Aran,-!- who criticises the hazai-dous proceedinga
which their presence has been supposed to justify, and on aecount
of which I make this reference to a pathological condition in itself
I of no great importance*
I Lastly, various affections of the ovaries are attended liy the
same result ; and misplacement of those organs, their inllanima-
tion, and more rarely their degeneration, may be characterised by
abundant and over-frequent menstruation. Each of these causes
of menorrhagia, however, as well as aD the different affections offl
the uterus itself, must engage our attention at a future day, and
may therefore be passed over now without further notice.
In entering on the consideration of the trtalimnt of menorrhagia,
it is almost superfluous to observe that this can be by no means
uniform, but must differ almost as widely as the vai-ious causes to ^
which the excessive loss of blood is due. f
In every instance, however, we have to fulfil two indications, of
whicli sometimes the one sometimes the other \b the more urgent,
namely, to arrest the present haemorrhage, and to remove the
cause on which it depends. The principles which must guide us
in endeavouring to accomplish the latter are too obvious to need
more than a brief reference. In those patients, for instance, in
whom the menorrhagia is but ssign and a consequence of general
debility, the tonic remedies and ferruginous preparations which
tend to invigorate the health and to improve the composition of
I
* See the account of tlieir microscopic fltructore by M. Hobin, iu the ArMv^
d^Midecine, 1847. vol xrii. p. 411.
f In hill Lc^is sut lis Maladies dt F UUrus, 8vo, Pari», 1S5S, p, 475, * ' What V*
says he, " do they serioaaly pn>f««« to be ahk to distinguish by meatiB of the
carette^tbflt is to say, at the end of a stem a foot in It iigth— these fuugositte
which meaaune in every direction three or four mlllimetreH, and which scarcely
project one or two millimetres beyond the surface of th« mucous membrane ; anr
thii, too» in Bpite of their extreme softness, and of their continuity, without ar
diatinGt line of demarcation^ with the healthy mucous membrano I **
r
INDICATIOKS FOR TREATMENT.
SI
the blood, will of themselves have a most powerful influeace in
checkmg the excessive dischai^e at the menstrual period. In
some of these cases, too, the menstruation is excessive relatively to
the patient's strength, rather than absolutely, compared with the
quantity of blood lost by women in general at a menstrual period.
This is so not infTeqnently with women in whom menstiiiation
appears during suckling ; and in such circumstances, it usually
sufiBces to wean the child, and to give some simple tonic, in order
to effect the patient's cure. Less amenable to treatment, of course,
are those cases in which the alteration', in the circulating fluid
depends on some deep-seated cause, sucli, for instance, as exists in
cases of granular degeneration of the kidney ; though in such it is
at once obvious that our attention must be directed chiefly to
something more than the mere suppression of the present
heemorrhage,
Again, the excessive haemorrhage that occurs in connection with
a state of general plethora of the abdominal vessels, showing itself
in a disposition to haemorrhoids, a sluggish action of the liver, and
a constipated state of the bowels (a condition most frequent
towards the decline of the sexual powers I, admits less of remedies
immediately addressed to the suppression of the bleeding than of
attempts to remove it by indirect means. These are the cases in
which a carefully regulated diet, whence all stimulants should be
banished, great attention to the bowels, with the habitual employ-
ment of small doses of saHne aperients, such as the sulphate of
magnesia, the potassio-tartrate of soda, or some of the aperient
miDeral waters, as the PuUna water, for instance, continued for
weeks together, wOl seldom fail to be successful in restoring the
general he^dth, and in tliereby removing the tendency t<^ mcnor-
rhagia. We trust, too, to similar indirect means in the case of
young girls in whom menstruation, even from the commencement
of the function, shows a tendency to be over profuse, an evil
which, if not corrected by judicious management, ia succeeded in
a year or two by a state of amenorrht^a and chlorosis, Similar,
too, in the indications for their management, are in many respects
those instances of meuorrhagia which are not seldom met with in
comparatively young women of indolent and self-indulgent habits,
who are ailing but not ill, and who require for their cuje
discipline of miiid and body rather than what is commonly
understood by medical treatment. Such patients are met with
in all clagnes of society except the pooi'est; most fret|iiently,
perhaps, among childlesB married women of the middle diies,
whose social position does not force on tliem the necessity for
exertion which in some form or other is imposed on the higher
ranks, while half an hour suffices for the performance of the
domestic duties of a wife whose husband is absent at business all
j. day long. Such persona, with few or no mental resources to
l| occupy their time, soon give up exercise of body when the daily
\ walk has no object, while they eat and drink, not in excels, but
I'r as people do on ship-board, for want of something else to do. In
I a few years they grow fat, but not robust ; become subject to
^ flatulence, dyspepsia, and haemorrhoids; menstruate iiTegularly,
the discharge sometimes postponing for a week or two, then
returning with a profuseness which exhausts the strength, and
i does but confirm the patient in the indolent habits to which her
condition was originally due. In them, as in the other ctises, it
is to the management of the patient in the intervals of men-
struation that attention must be directed. In them, too, if the
periods still return with regularity, an active aperient given
just before their expected occurrence will often have a most
remarkable influence in lessening the excess of the menstrual
ilow.
There are, of course, certain precautions which shoidd be
observed in the case of all women at the menstrual period with
whom there is any disposition to menorrhagia, such as the
horizontal posture strictly maintained from first to last, the cool
clothing, the mild and stimulating diet But while these rules
are of universal application, the treatment during the period itself
is not tlie same in all conditions, and the strong astringents m
which are of use from the veiy first in cases of passive luemor-
rhage, are far less appheable in those to which special reference
has just been made. In these latter cases a plan similar to
that which has been pointed out as indicated in the inter
vals may still he continued mth advantage during the periot
and small doses of sulphate of magnesia mth sidphuric aeii
and a Uttle tincture of henbane, or the nitrate of potass wi'
INDICATIOlfS FOR TREATMENT.
fiS
tincture of digitalis, will restrain the bleeding within moderate
limits.'
In these circumstances, indeed, and especially in that form of
apparently causeless hsieDioiTliage which occurs in women towards
the time of the cessation of the menses^ dij[,dtalis sometimes exerts
remarkable powers as a ha.'mostatic. I do not imderstand its
mode of action, for my own observation has not confirmed the
statement of Dr Dickinson, who introduce it into practice as a
remedy for menon-bagin^-f that it produces distinct muscular
contraction of the womb. At the same time, however, its
intluence is not exerted specially through the medium of the
circulation; for though a diminution in the freciuency of the
poise was always observable, yet those cases in which the
peculiar power of the drug over the heart*s action Wiis most
marked were by no means the instances in which haemorrhage
was most checked, while sometimes, though it became neces-
sary to suspend the remedy altogether, the bleeding continued
unabated. I have been accustomed to give 5iv of the infusion of
digitalis every foiir hours, the patient remaining in bed, and being
cautioned at once to discontinue the medicine if it produced
faintness or dizziness. In most instances when it proved of
benefit it gave some earnest of this within twenty-four hours
from its first employment, while if no effect were produced
within forty-eight hoiirii, I have always discontinued its further
administration; and in no instance have I continued its use for
longer than between three and foui- days.
The existence of a very considerable degi^ee of exhauRtion, and
the necessity for giving wine or brandy, do not contm-indicate a
trial of digitalis, though in ctises of great feebleness I generally
b^gin with only 5ij instead of 5iv of the infusion for the first few
dosea. The medicine has seemed to me of Uttlo or no utility in
E
• (No. 1)
E Hignesife SulpliAtia . . 5^
Acid 6u1ph. aromat , . 5li^
Tine. Hyodumi . . . ^uj
Sympi Zinzibi^riii . » , Jiv
AqUK CiuDiimomi . . . 3^
AqvLst pune t*d . . . . "^vi
M. ft. niut, two taljle-spoaafuls
every four bottis.
t Mtdico-ChirurgiciU TrcmMdions^ toL mix, p, 1.
(No. 3,)
PotasBse NitmtU . . . 3^
TiDct Digitalia , . . . m iO
Syropi Linionmn . . . ^xt
Aqax pums ..... jvt
M. ft. mint, two tttble-apooiiftila
every four houn.
•
caa88 where tlie hfemorrhage depends on tumour or other organic
disease of the womb, but in other circuoistances I know of no
means by which we can determine beforehand, with any con-
siderable certainty, whether it will prove successfuh In spite of
all these drawbacks, however, the digitalis is a very valuable
medicine in cases of menoiThagia; in no instance have I seen any
serious mischief result from its employment, and in many cases
it has certainly effected great good.
It can scarcely be necessary to add that precautions taken and
remedies employed during one attack of menorrhagia do not
suffice to prevent its return. Both must be repeated for two or
three successive times, and even for long afterwards a much
greater degree of care should be taken at the return of each
menstruation, and in the intervals, than many woman like to
observe.
The cases hitherto dwelt on have been those in which the
menon^iagia was not of that purely passive character in which the
one obvious indication is the direct suppression of the bleeding by
the use of astringents. In them, indeed^ the long-continued loss
of blood will bring the patient into the second category, namely,
that of passive haemorrhage, in which our aim must be to check
the bleeding as promptly and by as direct means as we can.
Absolute recumbency, light covering, cool drinks, are essential ;
and often the employment of cold locally to the vulva, and even
the use of cold enemata and the introduction of ice into the
vagina are of much service. Sometimes, how^ever, cold used
locally in any way provokes pain without restraining the hiiBmor-
rhage, and it must then of course be discontinued.
Of internal astringent remedies the two most generally eflBca-
cious are the gallic acid and the ergot of rye, Tlie latter is
specially serviceable in those forms of menorrhagia which occur
after previous abortion, or in cases where there is a degree of
imperfect involution of the uterus, or where, as in some delicate
women, there is a deficiency of contmctile power in the womb ;
while the former, as well as the mineral acids, alum, lead, and
matico, are most useful in the menon^hagia of young unmarried
women, or of patients generally ansBmic. The most convenient
form for administration of the eigot of rye is that of the liquid
extract, of which drachm doses may be given eveay four hours,
I
ITS TREATMENT,
65
either alone or in combination with small doses of tincture of
Indian hemp, if there m mnch nteriiie pain* The ^\ic acid from
its insolubility is best taken rolled up in wafer paper, or in the
syrup of preserved ginger. Next in value I should rank the
matico, while the mineral acids, lead and alum, though they may
all lie tried, appear to me to have far less influence over uterine
haemorrhage than they exert over haemorrhage from other organs,*
In the great majority of instances the observation of precau-
tions and the emplojTaient of internal remedies such as I have
recommeoded, suffice to restrain the loss of blood within safe
limits, and it then remains only by judicious treatment in the
interviil to guard against the recurrence of liEemorrbage at the
next menstrual period. But now and then we meet with cases in
which these measures prove nearly useless, or in which the loss
of blood on former occasions has already been so considerable, or
80 often repeated, as to render each ounce of almost inestimable
importance for the maintenance of the patient's health, possibly
even for the preservation of her life. Earely though it happens,
you must yet bear in mind that women sometimes ilie' from loss
of blood at a menstrual period, and tins wholly independent of
uterine disease. Two instances of this occurrence have come
under my notice ; 1 1 have already referred to one case, and the
second was even more important, since the person was not only in
previously good health, but an examination after death ascertained
that not only her uterus, but every organ of her body, w^as free
from any sign of disease. She was a young woman who, havijig
* (No. 4.) I (No. 50
^ AlammiA • > < <r • 3J^ ^ Flumbi AcetatiB . , . * Jm
Solve in ' Aceti destilkti . . . . |ij
Aquffi pum Jv Tioct, OpU . . . . TTl ix
Addie Syrupi Fapov. alb. . . . 5^^
Tinct Clnnamomi ca Af|ii8e puiw, iid , * . . f vj
Sjrapi Papav. alb, aa . Jiv M. ft mist
Iff* ft mist Two tabk-spoonfulA every four Lovtra.
9wery thr«e or four bonis.
(No. 6.)
a Fob Piperis AuguitifoliiE (Matico) . . Jsi
AqurR ferventiB Ji?j
macera per boniA tj et cola.
E Liqnor. colati ,.....,.. ^vsi
Tinct CanL co Ji'^
M, ft. iniat A wiue-glassfiil every four hoars.
Two table-spootifala
JfENORRHAGIA :
been senteBced to transportation for some offence committed in
Scotland, was sent by sbip during a stormy season from Edinburgh
to London, Menstruation appeared during the voyage, but her
exhaustion waa not unuaturally attributed in great measure to
sea-sickuess. She improved on being landed, and thougli meu^_
struation continued profuse, yet she made no complaint to th^|
oSicers of the prison. At length, having fainted one dtiy, she was
removed to the infiruiary of the institution. No profuse loss of
blood took place during the three or four days tbat she was there,
but only a slight draining, which went on in spite both of astrin-
gent remedies and of cold applications, and under which she sank
exhausted. A small coagiilum was found within the uterus, but
nowhere was thei-e any trace of disease. ^M
Now the bare possibility of any such occurrence happening is
reason enough for watching moat anxiously every case uf very
profuse menstruation, and for being ready with appropriate means
to combat the symptoms as they increase in urgency. One of the
first and most obvious means of checking bleeding from any part
consists in the application of cold. After the menses then have
continued for two or three days, pro\dded they do not show any
disposition to abate, the loins and vidva should be sponged every
few hours with cold water, and the patient should besides have
an enema of about four ounces of cold water night and morning.
If in spite of these means, which, however, are generally
successful the loss of blood sliould still continue, wet cloths must
be applied to the vulva, and astringent injections thrown into
the vagina, for which purpose I know of nothing better than the
infusion of matieo.
If even these means should fail, there remain then but twc
resources, the plu^ng the vagina, and the injecting the cavity of
the uterus itself. The expediency of resorting to either of these
measures must be determined by a careful consideration of the
patient's general condition, quite as much as by tlie mere amount
of tlie hiemoniit^e. It is not indeed in general while blood is
flowing profusely that the necessity for their employment arises,
but at a later period, when, with gi-eat depression of the vital
powers, blood still drains away in quantities so small as at
another time would be of no importance,
I need give you no special directions as to how to plug th
he J
of*
ITS TREATMENT-
67
d, except to remind you that you will find the speculum of
service in enabling you to introduce a considerable portion of the
tow, wool, or whatever material you may employ, much more
speetlily, and with much less irritation of the va^anal walls, than
would otherwise be practicable.
The injection of the uterine canity, though a powerful means
of repressing htemorrhage, is yet a proceeding of much hazard,
which has given rise, in many instances, to severe inflammatory
s}fTnptoms. Its use should therefore, I conceive, be limited to
cases (and these are of extremely mre occuri-euce), in which,
though haemorrhage may for the moment be restmined by means
of the plug, it yet returns so soon as that is withdrawn, while
remedies fail to exercise any influence on its flow.
Such a case was that of a woman aged fifty-one, who was
admitted into the Middlesex Hospital under my care on
September 21st, 1848, Her health had been good till about a
year before, when her menstruation became irregular and over-
frequent, and in the previous April she had an attack of haemor-
rhage, for which she was treated with advantage in University
College Hospital, though bleeding returned soon after her
discharge from that institution, and had ever since recurred
frequently.
On her admission, her appearance was extremely anaemic, her
pulse small, and her voice almost inaudible. She complained of
constant pain in the lumbar and right iliac regions, increased
after each attack of flooding ; but a vaginal examination dis-
covered nothing wrong about the uterus, except that it was
somewhat larger and heavier than natural. The whole cliisa of
astringent remedies and astringent injections were employed
with varying result till I^ovember 16th ; the bleeding sometimes
ceasing for a day or two, and then again returning. On that day, '
however, the disch^irge was so profuse that it was considered
Beoesaary to introduce the plug. This means arrested it; but at
11 AJi. on November 17th, the plug having been removed for six
homs, heemon-hage again returned, and git?at!y exhausted the
patient After being reintroduced, and allowed to remain for
twelve hours, the plug was once more withdrawn, and no return
of haemorrhage took place; the infusion of matico, which the
patient began to take about this time, appearing to restrain the
68
MESOBRHAGIA :
I
bleeding very effectually. During the remainder of November,
and the first few days of December, hnprovement continued, but
the patient now again experienced frequent returns of luemor-
rhage, either in the form of a draiJiing away of a pale sanguineous
fluid, or in that of frequent sudden gushes of profuse bleeding.
Previous to any profuse gush, she comphiined of pain in one or ■
other fliac region, most frequently the right, Eemedies soemed f
to have completely lost all influence, and on Dec^mbf^r 18th,
though the haemorrhage was not at that moment veiy pi'ofuse,
yet the patient was reduced by it to a state of extreme
exhaustion, her pulse was scarcely perceptible, her voice a mere M
whisper, and her stomach rejected everything. The os uteri was
open wide enough to admit the finger as far as the first joint, but
its tissue seemed quite healthy, and under the speculum the
appearance of the os was perfectly natural About three
drachms of a mixture of a scruple of galhc acid in an ounce of
water were now thrown into the uterine cavity, and no con-
siderable pain was excited by the injection. At the some time
pure brandy was given to rally the patient's powers, and as soon
as her stomach could bear it, the infusion of ergot of rye was
administered every few hours. It is needless to detail the dfdly
treatment adopted fram this period, for convalescence, as might
l>e anticipated, was tardy. From the time of the injection of the
uterus, however, the haemorrhage completely ceased, its* place
being taken by a puriform discharge just tinged with blood, and
DO haimorrhage reappeared until the 26th of January, when it
was neither excessive in quantity nor of long duration* At
intervals of rather less than a month haemorrhage recuri'ed,
though it was always readily controlled by treatment, and on
April 10th she was discharged from the hospital, well, though
still rather weak ; her life ha\dng to all appearance been saved,
when in most imminent peril, by the injection into the uteiin©
cavity.
I have no experience of the employment of turpentine as an
injection into the uterine cavity in cases of uncontrollable
haemorrhage. I should fear to employ such an agent, which
indeed, has been followed,* when thus used, by violent inflamma-
• See a case r©lat4id in AibweU's Trealise'oH Di^ases of Womertt 8to, ISi-*
p. 156.
i
I
1
ITS TREATMENT.
69
tiott of the womb. The infusion of matico, a solution of gallic acid,
or a mixture of one part of the solution of the perchloride of iron
and nine parts of water, would appear to me to be safe remedies.
The distressing symptoms which have not seldom followed the
employment of intra-uteriae injections are probably, in most
instances, due to the irritation of the mucous membrane itself, and
are by no means invariably dependent on the passage of the fluid
into the peritoneal cavity. There can be no doubt, indeed, but
that this accident has occasionally happened, but recent oljserva-
tioDS and experiments seem to prove that the chances are
considerably against its occurrence. The precautions suggested
by ^L Guyon * who has most recently investigated the subject,
ought, however, never to be omitted. These consist in intro-
ducing the tube of any syringe which may be employed only a
very few lines within the cervical canal in those cases in which it
is wished to limit the action of the injection to the neck of the
uterus. Whenever it is intended to throw fluid into the cavity
of the womb itself, the tube of any syringe must l>e very
niUTOw, so as to admit of the ready and immediate outflow of the
fluid ; the quantity injected must be extremely small, not above
forty minims in the ease of a person who has never been
pregnant, and a little more than a drachm into the uterus of a
woman who has borne children.
Lastly, I wish to add a word of caution with reference to the
scraping of the mucous membrane of the uterus with a gouge, as
a means of arresting menorrhagia — a proceeding which, while
falling into disuse in France, has recently met with strong
advocates in this country.-f- I own that I have not practised it
myself, but that my conchiaions with reference to it ai^ drawn
partly from the adnussions of its advocates, partly from the
arguments of its opponents, I reproduce, therefore, as perfectly
cODciIusive to my own mind, the observations of M. Aran on the
subject^ — a physician whose premature death has been a loss not
only to his own friends and his own country, but has been felt
by all who are engaged in the cultivation of medicine, and who
* £imU mr U$ CamUs da TUierm 4 VEtal ds Vacuity in ''Journal de Pby
aiologiif.'* ToL iL 1859, S«6 p, 413,
f Pr* RoutU in Ohatftriml Tran^cthns^ voL ii. p. 117.
%<^^^ Tol L pp. 472-481.
k
can ill afford to lose thus early one of the most diligent, most
acute, and most honest of their fellow-lahourers. " I am surprised,"
says he, in words which I am merely condensing, "that the
advocates of this operation have not made a few experiments on
the dead subject. They would then have found that the curette
does not act equally on all points of the uterine cavity ; that
while it easily reaches the posterior and lateral walls of the organ,
it can scarcely he applied at all to the anterior surface and the
vicinity of the tubes, though these are the very situations where
the vegetations are most frequently met with. They would
faith er have found that these little bodies, varying in size from
a millet-seed to a pea, can be scraped out of the cavity of any
uterus, since they are neither more nor less than little bits of
epitheliimi frayed from the mucous membrane by the actian ot
the instrument It is not, indeed, that I absolutely deny tliat in
some few cases genuine vegetations may have been detached by
its means, but what I maintain is, that that is nothing more than
a lucky accident, and that one cannot raise to the mnk of a
regular operation a proceeding which is nothing moiie than a ^t
of blindfold shooting at a mark."
M. Aran then suggests, in explanation of the success which Fas
sometimes followed this mode of treatment, the probability that it
acts, as do such proceedings as the cauterisation of the interior of
the uterus, by exciting the womb to very \igorous contractions ;
while further it is possible that some modification may also be
produced by the inflammatoiy action induced in the mucous
membrana He concludes by stating that three instances of
death have come to his own knowledge where the operation was
resorted to by some of its most skQful advocates ; that he believes
similar occurrences have come under the observation of other
practitioners ; and that he retains a painftil recollection of " the
numerous instances of perforation of the uterine cavity, some of
them followed by death, which M* B^camier communicated to
the Academy of Medicine a few years since, and which produced
a general impression of surprise and regret/*
What the exact import of these granulations is, and the
dependence on a condition of inflammation of the uterine mucoi
membrane, will be more fitly discussed when we have to spe
of cmimneCritis, among the inttammatory affections of the worn'
LECTURE V.
MENSTRITATION, AND ITS DISORDERS.
DrxMEVOERirou — its three varietica — tieumlgic, congestiTe, mecbanic&L Sjinp*
tonia of neuralgic form ; of congeutire form, sometimea attended with expulsiim
of a membrane. Relatton of congestive dysmenorrho^ to rhifuioatic, or gouty
diA^esiaL Mechanicai dysmenoirhoBO, from contraction of eerrix uteri, & rare
occtirpence.
Tk«atmeiit of the neuralgic form ; varioua sedatiyes, and their comparative results ;
of the eongi?*rtive form ; depletion, and how to apply leeches— treatment of
the rhfuraatic variety — of the mechanical form ; cautions with reference to ita
treatment
I FEAR yon may think that I am uttering a very superfluous
truism when I remind you that almost every function of the
body, if ill performed, is performed with an unusual amount of
pain. The feeble stomach is pained by the presence of the food
which it is unable to digest ; the eye whose vision is imperfect,
is pained by the effort to decipher even the most legible
' characters ; and the head of the convalescent aches on the first
' attempt to resume his ordinary mental occupations.
Just so the menstrual function when deviating from its most
exact performance, either in excess or in defect, m almost always
attended by suffering far exceeding that discomfort by which, in
the case of healthy women, it is usually accompanied. Amenor-
I Tbo?a and menorrhagia are both almost invariably assoeiated with
suffering, and in the case of the most various disorders of the
sexual organs, an undue amount of pain at each menstrual period
is a symptom scarcely ever absent. But besides these instances
I in which the pain is but one among many ills for which the
[patient seeks our aid (and probably even in her estimate by no
[leans the gravest), there are other cases where the sufttiring of
I menstruation is so intense in its severity, or so importunate from
|its continuance, as to constitute a dtstinct aff'ection, and to claim
I in our nosologies as dystnenorrhmi.
NEUIIALGIC m
It has been castomary to recognise three different varieties of
this dysmenoiTliiva, or painful nienstnmtion ; and the distinction
of neuralgic, congestive, and mechanical dysmenon-ha^a, terms
which interpret themselves, seems to me to rest on good grounds,
and to merit being generally adopted.
There are some instances in which pain alone, unattended by
any other symptom, is the only important respect in wldch
menstruation differs from a healthy state. This ^leurai^
di/sme7wrrh(^u occurs most frequently, and in its simplest form,
in young women whose sexual system has not been developed till
a comparatively late period, and who have not begun to
menstruate till a year or two after the average date. The pain,
in such cases, precedes menstruation for a day or two, generally
reaches its greatest intensity in the course of the first thirty-six
hours of the cataraenial flow, being sometimes so intense that the
patient writhes on the floor in agony, and then by degrees
subsides, though it does not cease entimly till the period is over, ■
Though severest in the uterine and pelvic regioiL^, the pain is not
in general limited to those situations, but is experienced also in
the back and loins, is referred to either groin, or rather to each
ovarian region, and shoots down the inside of the thighs. The
pain, too, is aggravated at inter\^als, and becomes paroxysmal,
like that of colic or of labour, while the whole abdoraitial surface
is so tender as scarcely to bear the slightest touch. In addition
to these jiains, all radiating more or less obviously from the
sexual organs, there is often much suffering in other parts.
Intense headache is very frequent, often confined to one side of
the head, or presenting the well-known characters of clavus
hystericus ; or, in other cases, the stomach is disordered, and the
patient distressed by constant nausea or frequent vomiting. In
many instances, various other hysterical sjrmptoms manifest
themselves, often, indeed, with peculiar int-ensity ; and I knew a
patient in whom an attack of hysterical mania ushered in on
more than one occasion a menstrual period. This neuralgic
dysmenorrhtea, however, is by no means invariably associated
with a hysterical temperament, and patients who suffer most
intensely during menstruation, sometimes manifest no symptom
of hysteria, but, on the contrary, are remarkable for quiet self-
possession and well-regulated minds.
I
I
CONGESTIVE DY3MEN0RHI1CEA.
n
In some instauceSi it seems as if the disorder of tlie nerves
extended to the whole system, wliile in others it ia limited to
tboi9e which supply the sexual organs, and is then usually of
shorter duration, though not by any means of necessity shghter in
the suffering which attends it than when the sympathies which it
awakens are more extensive. Even when pain has altogether
subsided aft-er the cessation of a menstrual period, any excitement
of the sexual system will, in very many instances, suffice to
reproduce suffering. In married women affected witli tliis form
of dysmenorrha?.a, sexual congress is almost invarialdy extix^mely
painful, while pregnancy is attended by more than the ordinary
degree of local discomfort, and the pain of parturition amounts to
intolerable anguish.
I have referred to this neuralgic dyamenorrhcea as occurring in
its simple^st form in young women in whom there was a tardy,
and perhaps an incomplete development of the sexual system.
It ia, however, by no means limited to such persons, but some-
times comes on after years of healthy and comparatively painless
menfltruation, I have known menstruation become painful
during convalescence from some serious illness wholly uncon-
nected with the sexual functions, and continue so long after the
patient had, in other respects, regained her usual healtli. In
other cases, the sudden suppression of the menses by cold, or
some other accidental cause, is succeeded by obstinate dysmenor-
xfaiOBa; and this although no obvious uterine ailment had followed
the accident At other times, inflammation of the uterus, after
delivery or miscarriage, ia followed by painful menstruation,
which persists long after every trace of inflammation or of its
consequences has completely disappeared.
But there is another form of dysmenorrhoea which has been
termed the cmi/fesiite, from the peculiar circumstances that attend
it UnUke the purely neuralgic variety, it is less frequent at tlie
commencement of sexual vigour than as an acquired condition
at an after period of life, A sense of weight about tlic pehis,
and a tendency to heemorrhoidal affections, generally exist in the
interval between the menstrual periods; and these symptoms
increase considerably a few days before the discharge comes
on. During the first twenty-four or thirty*six hours of each
menstruation, the dischaige in general is but scanty, and the
74
OOirOBSTIYE DTSMENORRHCEA ;
pain is very severe. At the end of this time, however, some-
times even sooner, the hjemorrhage often becomes abundant, i
as the blood flows the pain abates, and then ceases altoget
The congested womb ached till nature bled it, just as the :
achea, when the brain is congested, till the cupping-glasses or
the leeches have relieved the overloaded cerebral vessels. Somc-
timea in these cases the menstrual flux at no time becomes
abundant, and consequently the relief which natm« gives is very
partial. Wlien this is so the womb continues to ache and throb
during the whole of the menstrual period, and is left afterwards
tender and painfuL When this is not the case, however, the end
of the menstrual period generally leaves the patient in a state of
comparative comfort. For the next week or ten days she
continues to enjoy a comparative immunity from suflering ; but
then the symptoms gradually return, and reach their climax of
severity with the commencement of the next nienstmation.*
In some instances of this form of dysmenorrhcea, not only is
the amount of blood lost at a menstrual period insufficient to
relieve the congested womb, but it is absolutely as well as
relatively scanty. In some of the cases the discbarge, having
continued for a few hours, ceases, and then comes on again j
while, though scanty, it is intermixed with &mall coagida, owing,
probably, to the blood having been poured out so slowly as to
allow of its coE^ulating within the uterine cavity ; an] occurrence
prevented during healthy menstruation by its comparatively rapid
flow into the vagina, where its fibrine is at once dissolved by the
* I aptpcod here a note of mj nble Froncli tt&nalator, Dr. Mauriac, from p. M o
hU edition of the hook i—
*' One may refer to the congestive fonn of dysmenorrhrayi that variety to whk
Simpaon haa applied the name of ovarkin, because the excessiTe congestioD whic
occasioTiH the pain is seated im the ovaries rather than in th« utenia, Thia vari^
may also depend on another cause indicated by Scanssooi — * If one heara in m?
aays this antbor^ * the well- ascertained fact, that the rapture of those QTf
TMdclea, which aro situated in the deeper layers of the ovarian tissue, t
nquirea « greater h)'penEmia of theae organs^ and takes place more slowl
that of the more snperficial veaiclea, and that it consequently involves tl
tinuance of the menstrual congestion for a longer time, it is not unreason
fluppoflo that dysmonorrhtBa la somfetimes de£)en(3ent on the maturation '
seated vesicles, and on the long-continued and undue hjrpcnemia whicl
panies their rupture/ In ovarian dysmenorrbcBa the pain is referrod chiel
or other iugainal region.**
%viTH EXPULSION OF muauunE.
7S
^
agulating property
¥
acid secretion of tliat canal, and its
destroyed.
In others of these cases we find intermingled with the
menstrual discharge, slireds, or strips, or distinct laminae of mem-
brane, or even a small membranous sac, which is seen, on careful
examination, to form a complete cast of the uterine cavity. This
occurrence sometimes takes place only once, but oftener it
reappears during a long succession of menstrual periods. The
discharge of the membrane is generally associated with very
considerable tiggmvation of the patient's suffering; sometimes
with distinct periodical pains, like those of abortion ; and when to
them profuse hfemorrhage is superadded, an occurrence which is
fi'equent, though not invariable, unfounded suspicions have in
gome instances been entertained with reference to the chastity of
women who have had the misfortune to present this combination
of s}Tnptoms.
In the ignorance which tiU lately prevailed generally with
reference to the real structure of the uterine lining membrane, it
was customary to speak of the dysmenorrhoeal membrane lis the
product of inflammation, or of some process akin to it We know,
however, that during menstruation the epithelium of the uterine
cavity is thi-own off in greater or less abundance; while an
examination of the membrane suffices to show that what has
occurred in its formation and detachment is merely an exaggera-
tion of the process wliich to a leas degree takes place at every
menstrual period.* The membrane is smooth on one surface,
rough, almost villous, on the other, and presents the remains of
* Thia opinion as to the identity in characttr of dysmenorrliceal membraBc and
d«cidua ia now altno^ universally entertained, Iwth in this coimtry and on tho
continent In this country the first to reassert this identity were, I believe, Dr.
Qldham, in Med. Ows,, April 16, 1846, and Dr. Siraiwon, in Edhi, MofUhltf
Jimrmdt S«pt,| 1846, of which, however, neither W, Hunter nor Bjiillie was
%D<iranL [For copioiua and elaborate liiatorical details, aee two papera by HauBs-
mftiiii^ in the Berlin BeUr&ge Zu OtburiahOtfe und Gi/n^ikologie, h Band. a. 155,
1872, and II. Band* a. 263, 1873. The student muat also i)eru8e the valmbk paper
UWyAet {Arekiv. fUr Gifndkologie, xiii Band. L Heft 1878). The structure of
tndometritic, and especially of so-called dysmenorrhteal membranea, is there entered
Upon ; and references will be found in it to other valuable contributions to this sub*
J ©d Besides the well-known occurrenoe of extravaaa tioM of blood and their in II uenco
on theaepaiation of menatroiil membrane, when in an inMomed or abnormal state, and
the well-known detachment and diacharge of infiamed or dysmenorrheeal
w
CONGESTIVE DY9MEN0RIIHCEA.
numerous dilated uteriDe glands ; characters that prove it to be
the analogue of that decidua wliich, under the physiological
stimulus of conception, passes thi-ough a more complete developi^
ment to serve important purposes**
I scarcely needj say that it is not a matter of iudiflTereBce, in
practical point of view, whether or no you enteitain correct
opinions with reference to the structure of this memhnme. To
regard it as a layer of plastic lymph similar to that which is
poured out in croup^ at once suggests the employment for its
removal of active antiphlogistic measures, such as experience
would by no means jnatify. Reasoning, however, even indepen-
dent of the actual observation to which I have appealed, would
suffice to show the fallacy of this opinion. It is utterly incon-
ceivable that a mucous membrane so intlamed as to become the
seat of deposits of lymph should in a few days return to a
perfectly healthy condition, and yet periodically undergo the
same intense inflammation issuing in the same deposit, and this
with no serious injury to its functions and no permanent change
of its stnicture.
Allied to this congestive dysmenorrhoea, are cases of painful
menstruation dependent on constitutional causes, especially on
the gouty or rheumatic diathesis; though I cannot pretend to
say why in women this peculiar ailment should residt from it so
much more frequently than the ordinary forms of those disorders
with which we are familiar in the male sex. Such cases, how-
laembranes in patches, not in complete uterine moulds, Wyder points oijt & means of
diutin^iabiug menstrual^ that ia, endometritic or dy»nnjQorrhceal membrane, from
decidual membrane, that ia, the hy pertropbied mucous aiembmne of pregnancy, Tbif
U done by microscopic examinfttioti of tbe epitbeliam, the tubes, and especially of th
inteT-glandular tissue. Tbe meDstruai membrane ahowB here only small oella
while those of decidual membrane are m great as to be eadlj diHtinguiBbed. Thi'
and other differcncea between menBtrual and decidual membrane were not dreamt
by Hunter and Uaillie oud their followers. It is on extremely valuable diatinc*
if it comes to bo shown to be thoroughly reliable. Wyder not only maintaina
it is 80, but that it ia available in cases of extrauterine aa well as of n
pregnancy »]
• All membrancin, however, expelled daring painful menstruation are not i
products. l>r, A Farre, in a paper published in Beale's Archives of Met
No. Il.f 1858, shows that occaaionally the mucous membrane of the vaf
foliat«a in layers forming even a complete cant of the canal Their expa^
accompanied in »ich of the caaes related by much imSering, though, aa n
expected, referred more to the vagina than to the uterus.
CONdESTITE DYSMENORBHCEA.
I
ever, are by no means rare in any class of society; and whenever
they occur, they are chronic in their course and difficult of cnre,*
A casual attack of cold is iu some instances referred to as the
occasion of the patient's illness^ while in other cases the ailment
comes on by degrees, and with no definite exciting cause. Men-
struation begins to be more painful than was its wont, often more
scanty ; an unusual degree of constitutional disturbance attends
each period ; the pulse at those times is very frequent, the skin
hot though perspiring, and lithates abound in the m^ine. In the
intervals, profuse leucorrhteal discharges take place; the pain,
though less intense, is yet severe, and is aggravated by trifling
causes, or without any obvious reason. The pain at one time is
most severe in the back, at another is refeiTod to one or other
iliac region, shooting down the legs in the course of the crural
nerve, or, like sciatica, affecting the back of the thighs ; whOe
occasionally, in addition to these abiding discomforts, the patient
is kept in bed for a day or two at a time by slight feverish
attacks, accompanied by wandering pains in the limbs, though
seldom attended by inflammation and swelling of any of the
joints.
The seat of the pain in these cases is no doubt the muscular
tissue of the utems ; and the suffering from this cause sometimes
oatlaste that time of life during which menstruation takes place,
though the cessation of tlic periodical congestion of the womb
which occurs so long as the sexual system retains its activity, is
followed by a great diminution of the patient's ills. In the worst
cases of this disorder, the woml>, though presenting no appreciable
alteration, is so intensely tender, that the slightest movement
causes intolerable pain ; and many instances of an affection
which the late Dr Goochf described with all that graphic skill of
which he was so great a master, and for which he proposed the
name of the Irritahk Uterus, may be referred to this category. I
shall presently have a few remarks to make on the treatment of
• The obiervations of Dr. Totitl on the stibject in section ix. of PrtKHeal Eemarha
9K Omd^ MhemncUi»jfh Fever, <£x\^ 8vo, London, 1843 ; and those of Dr. Rigby, in hin
work on Dyfmenarrhaea, published in 1844, bavo more especially caUisl attention
to thiB snbject.
f On the More TrnportarU Biaeasta of Womai, 8vo, 2d ed. London, 1831,
p. 332,
78
MECHAKICAL DYSMENOREHCEA*
this ailment ; Just now, I will add only that relief for it is to be
sought by measures directed to the constitutional cause, and not
by any form of local medication.
Such then, are the two principal forms of dysmenorrhrea : the
one the neuralgic, the other the congestive ; while often we meet
with cases presenting the mingled chaiucteristics of both varieties.
It is probable that in all of these cases a temporary constriction
of the internal orifice of the uterus plays a more important part
than has commonly been supposed in the production of the
symptoms J that not merely ia there a non-effusion of the
menstrual fluid, but that, even after it has been poured out, a
condition either of tm-gescence or of spasm at the internal os
uteri prevents its escape, and keeps up or aggravates the suffering
of the patient But there are other instances in which the
influence of mechanical obstruction is both more obvious and
more abiding- Such are those in which the painful menstruation
is associated with some organic disease of the uterus, as fibrous
tumour, or with some malposition, as anteflexion, or retroflexion,
or in which the canal of the cervix, or either orifice, is
permanently contracted, Tlie existence of any of these con-
ditions can of course be ascertained only by a careful vaginal
examination, and this should not be omitted wherever the
dysmenorrhrea continues for several months in spite of treatment
calculated to remove it.
Of late years special attention has been directed to this
so-called fmchmikal dymieTmrrhmi, in which the patient's suffer-^
ing are due to some abiding obstacle which interferes with the
escape of the menstrual fluid. This forai of dysmenorrha^a is
characterised not only by pain, but also by the slow escape and
scanty amount of the blood discharged, which also, for the most
part, escapes in small, imperfectly formed coagula* Tlie late Dr
Mackintosh, of Edinburgh,* was, I beUeve, the first person who,
in the year 1823, directed attention to it, and in 1826 he advised
the mechnnical dilatation of the os uteri by bougies for its relief.
The impediment may exist either at the external oa uteri, or at
some limited part of the cervix, and was erroneously supposed to
be especially frequent at the internal oa, where the body and
♦ In Ma Pradicc of Phyak, Ath. ed, Sfo, LoudoD, 1836, toL ii pp. 431-436.
MECHAjriCAL DYSJIENOHRHCFX
79
neck of the womb commimicate, or it may involve the whole of
its canal. It appears^ iu some instances, to lie attributable to
ioflammatiou, and probable ulceration of the cervical canal, as
in the case of a woman once under my care, the canal of whose
cervix was at one point so nearly obliterated as not to allow the
passage of the finest cat-gut bougie, and who refeiTed her sufifer-
ings to the eflfects of a labour twelve years before. In other
instances, where the dysmenorrhciea is habitual, the mechanical
obstruction is seated at the external os uteri, and is then
generally associated with some congenital defect of uterine
development, and with a peculiar conical form of the vaginal
portion of the neck of the womb.*
An impression has of late years been gaining ground that
mechanical dysmenorrhcea is very common^ and mechanical
means of treating it have accordingly come very much into vogue,
to the neglect, it is to be feared, in many instances, of those
internal remedies, by which painful menstruation is in general
niuch more appropriately treated. One circumstance, which I
believe to have much contributed to the suppoi-t of tliis opinion,
I is the fact, that on introducing the uterine sound an obstacle is
very often encountered at the internal os to the pa^ssage of the
nstrument into the ca\aty of the womb» That this obstacle,
however, is in reality perfectly natural, can be readily ascertained
on the dead subject, since even after the removal of the uterus
from the body, a bougie which passes wuth ease along the
I cervical canal will there encounter a resistance such as can often
f be overcome only by considerable effort, or, perhaps, not at all
though a smaller bougie will pass at once with perfect facility,
and the uterus, ivhen laid open, will l;»e found to be perfectly
liealthy. The constriction in this situation, which is found to he
80 considerable even after death, was doubtless in these and
many other instances tar greater during life, and yet, in spite of it,
I the history of such persons often gives no account of difficult or
f painful menstruation.'f Nor, indeed, need this surprise us, for the
• I believe attentioQ w.-w first caUed to this condition by Dr. Barnes in Ms work
OntheDitfefueso/ Wmrun, 8vo, London, 1873, p, 222,
+ The fuet of the natumJ couBtrictioa of the uterine <."anal at the aitaation of the
mtemal o9, wwi very clearly as8t;rt43d by Dr. Henry Bennet in \m work on /»-
ilkm of ihc Uterua. See p. 3 of the 4 th edition.
80 MECHANICAL DY8MEN0RRHCEA.
discharge takes place during menstruatioD, not in a continnaug
stream as the urine flows frrjin the bladder, but oozjes from the
interior of the womb, the blood escaping drop by drop from the os
uteri If the aperture at either end of the cervical canal is so
small as scarcely to allow this to take place, mefistniation no
doubt may be rendered veiy painful ; and just as when atrictui-e
of the urethra exists, or a congenital phymosis, or an extreme
degree of smallness of the opening of the prepuce interferes with
a child passing water, the bladder, and ureters, and kidneys become
irritated and disturbed in the performance of their functions, so it
is quite conceivable that a similar state of the channel may exert
the same influence on the function of the womb, and render the
menstrual flux scanty in quantity and morbid in character, as the
consequence of the difficulty in it^ discharge. The natural con-
striction oi the internal uterine orifice is probably often heightened
by functiona! disorder, and thus becomes the occasion of a great
increase of the patient's sufferings, and the same result must
follow if the external opening is preternaturally smali It by no
means follows, however, that all cases in which symptoms of
obstruction are present raquire mechanical treatment, any more
than that every case of croup or laryngitis is at once, and irrespec-
tive of other measures, to be dealt with by the performance of
tracheotomy.
The development of what has been termed the " mechanical
system of uterine pathology " has also of late years brought into
great prominence the dependence of dysmenorrhcea in some
instances on flexion of the womb at the junction of the body with
the cervix. By this means it is alleged that an obstacle to the
outflow of the menstrual fluid is produced far more considerable
than if the cervical canab or either of its orifices, were contracted ;
for in that cixse the passage is merely narrowed, while when the
womb is bent on itself the cbaimel is aU but occluded ; and it is
further contended that to this cause by far the greater number of
cases of dysmenorrhtea are to be attributed. The importance of
uterine flexions will call for careful consideration hereafter ; but
the practical deduction from the opinions to which I have just
referred is that in the vast majority of women of whatever age,
and whether single or married, in whom menstruation is painful,
a vaginal examination is to be made, and the virgin of seventeen,
TREATMENT OF DYSMENORRHCKJL
81
is to be treated without a Dioiiient's hesitation by the Temoval of
the alleged invariable Hexioii of her womb, and by wearing for aii
indefinite pericd some form or other of pessary to prevent the
return of the misplacement
I demur to the accuracy of these statements, and dissuade you
from the general adoption of the practice fco which their acceptance
would lead. At the same time, I do not deny the possible
occurrence of dysmenorrhcta with scanty menstruation, or in some
rare cases where tlje uterus has been enlarged by previous
pregnancy, with excessive menstruation occurring in intermittent
gushes of blood and coagula, in connection with a state of extreme
flexion ol the womb* I believe such cases, however, to be as rare
as some conceive them to be frequent
And this brings me to notice the treatment of dysmenorrhoea,
which must vary just as its forms are various. In the dysmenor-
rhoea of young girls in whom menstruation is not yet completely
established, our efforts must chieily be directed to bringing about
the regular performance of the function as speedily as possible,
and there is reason to hope, that in proportion as this is effected,
the pain will by degrees diminish. If, however, the suffering is
ao seTere as to require the employment of remedies specially
directed to its mitigation, they will in the majority of instances
be such as are applicable for the relief of nervous dysmenorrhfea*
One of the most serviceable of these is the hot hip-bath, which
may be had recourse to on the first threatening of pain, and even
twenty-four or thirty-six hours before the date at which the
eommencement of the menstrual discharge is expected. To
obtain the full benefit from it the patient should remain in it for
half or three-quarters of an hour ; the temperature of the water
being maintained during the whole time at 96° or 98*" ; while the
bath may often be advantageously rendered more stimulating by
the addition of mustard to the water. If pain again returns with
severity, the bath may be repeated twice or three times in the
twenty- four hours, while after its employment the patient should
always retire to bed, and remain there until, with the establish-
ment of the menstrual flux, the pain has in great measure
subsided. It will, however, still be wise for the patient to remain
during the whole period in her apartment, and to avoid all
exertion, as w^eU as all changes of temperature.
I
«2
NEURALGIC DYSMEKOBRHOiA :
Besides the tath there are other local means which often give
great rehef ; such m the hot spine hag to the sacrum, and the
apphcation of wannth to the lower part of the ahdonien. A
warm linseed poultice with the addition of a small quantity ot
laudiiiiuni, or of mustard in the proportion of one part to three,
or a thiuuul wrung out of hot water and sprinkled with chloroforiii,
or the chloroform liniment, or even pure chloroform will some-
times relieve pain, and if local applications suffice, they are of
course far preferable to internal remedies.
Still if the pain is very severe other measures must be a<iopted,
and first stands the old women's panacea, gin and water very hot
and very strong. In many instances this gives almost immediate
relief, acting, I suppose, in the same way as ether does, which in
the neuralgic form of dysmcnon^hii^a is often of much service ;
the compound spirits of ether in half draclun doses being, from
its stimulating properties, more efficacious than the spirits of
chloroform. I have not found that in the attack of severe pain
much is gained by the bromides, though when, as is sometimes
the case, pain continues on and ofif for a large part of the
menstrual period, the bromides of pottossium or ammonium, in
doses of 15 or 20 grains four times in twenty-four hours,
combined with five grain doses of camphor and 20 minims of
spirits of chloroform, have a decidedly soothing influenca
When pain is very severe, the inhalation of chloroform or
ether, though its effects are but transitory, yet sometimes exerts a
permanent influence. The remedy, however, is seldom applicable,
since it is too hazardous to be entrusted to the patient or her
friends, and hence we are usually compelled in tJiese circum-
stances to give some sedative medicine. Henbane or belladonna
may be tried in the iirat instance ; and their combination with
camphor seems decidedly to increase their activity. M. Bemutz,*
no mean authority in these matters, speaks of hemlock as ha\ing
a specifd power in controlling uterine pain ; but by mere accident
I have used it less than henbane or belladonna The hydrate of
chloral, so valuable as a soporific, does not seem to have much
power in annulling pain; but a very useful remedy, and free from
many of the inconveniences of opium, is the Indian hemp. The
uncertainty of its influence on different persons is, however,
• Quoted by Matiriac m the French tmnsktion, p. 106, note.
ITS TREAniENT.
83
dmwback from its use, and bearing this in mind, you should
always begiu with a small dose not exceeding fifteen miniras of
the tincture, till you have ascertained its effect on your patient.
If none of these means give relief opium becomes our last
resource ; but there are many reasons why it is undesirable to
have recourse to it, until the niilder sedatives have been tried and
found inefficacious. In many instances opium dei-anges the
digestive functions seriously^ and inflicts on the patient a very
distressing headache, or equally troublesome sickness, for hours
after its first soothing influence has passed off. But a still more
serious objection to its use is furnished by the fact that young
women not seldom become habituated to the drug from having
had recourse to it as a sort of domestic remedy for deadening the
[pain of menstruation, and so report to it on every occasion of even
triSing ihseomfort. When opiates become unavoidable, tlie Dover's
powder, morpliia, tlic sedative solution of opium, and the black
drop, are all of them in these cases to be preferred to the simple
tincttire, because they generally occasion less sickness or headache,
and are less apt to produce constipation of the liowels. Sometimes
medicines giveo l>y the mouth seem unavailing, or the severity of
the pain induces us to seek for a remedy that shall be more rapid
in its action, and in these circumstances an opiate suppository, or
an opiate enema, the bulk of w^bich must of course be very small,
will often afford speedy relief; or in the hypodermic use of
morphia youMiave a speedy and almost unfailing means of con-
troUing even the severest attacks of pain»
I do not tJiink it will be out of place if I here very strongly
advise you to look on every case of dysmenorrhcea in young
women as of importance, and not content yourselves with giving
a few general directions, or with writing a prescription for your
patient, if the pain from w Inch she suffers should chance to be
very urgent. There is always much greater risk of the attacks
becoming habitual, and tbm rendering your patient's future life
miserable, than there is reason for expecting the popular behef to
be realised, and that the ailment of the girl will spontaneously
cease when she attains to full womanhood. Every precaution
which I have suggested is of the greatest moment ; the confine-
ment of the patient to her room, the absolute rest, the repose in
bed during the early part of the menstrual period, are indispens-
able with each return of menatruation^ go long as the tendency '
dysmenorrhcea continues, and I believe are much more important,
as far as eventual pennanent recovery is concerned than is the ^
employment of remedies to relieve pain on any single occasionJ^
Your cure, moreover, must not cease with the cessation of the
attack, but your attention must be most watchful during the
menstrual intervals, to correct anything wrong in the general
health, and to invigorate the patient's system, wMch in these cases
i& almost always feeble* One other caution yon must allow me to
add: tliere is a popular impression that when the highest
fuuctions of the sexual system are brought into play, many
ailments previously troublesome are likely to cease, and it is j
beyond a doubt that, in some instances, marriage, and pregnancy, V
and child-bearing are followed by these desirable results, I fear,
however, that the chances are the other way ; that the girl who
suffers from dysmenorrhtea will be likely to suffer more from it^
after marriage than she did before ; that the extreme seD3itive-J|
ness of her uterine organs will render marriage, in all sexual
respects, a very painful condition ; that conception will be less
likely to occur than in another woman, and that if it should, preg-
nancy and labour will be attended by far more than the usual
amount of distress. If this be so, however, you must see how
cogent the reasons are for treating dysraenon'hcea more gravely
than may at first sight appear necessary. Good taste and good
feeling will not fail to guide you in selecting the best way
of conveying your opinions to your patient and her friends,
and you will most likely find a ready acquiescence in your direc-
tions so soon aa the grounds on which they rest are clearly
understood
In the coTt^estive form of dysmenorrhcea, anodynes no longer
furnish the ready resource for the relief of present suffering which
they sup|ily in the neuralgic variety of the affection. The uterup
and the pelvic viscera generally are overloaded with blood, and it
is only by its iibst motion that we can relieve the patient. Thi
application of leeches to the hj^pogastrium, the anus, or the uter
itself, are the means liy which this end is to lie accomphshed. "
great benefit of leeching the h^T)ogastric or iliac regions seen
l)e confined to those cases in w^hich the pain, refeiTed especia
.the sides of the pelvis, indicates the ovaries to be its seat ; I
ITS TliEAUrENT,
«
$
other cases it is decidedly inferior in efficacy to the application of
leeches to the anus. These modes of abstracting blood can be
reaoited to at any time, even just before menstruation or during
the presence of the discharge ; leeches cannot, however, be applied
to the uterus iti?eli within three or four days of an expected
menstruation witliout conaidemble risk of disturbing the regularity
of its return*
When depletion has been resorted to, the tepid hip-bath will
generally affoi'd some relief, while afterwards the patient slrould
remain in Ijed, and take some diaphoretic saline, such as the
liquor ammonia? acetatis, combined with small doses of henbane
or of opium, or of the tincture of aconite, the eliicacy of which
remedies wiE in severe cases be much increased by combining
them with nauseating doses of tartar emetic. In some cases of
this description the direct narcotics in any form or combination
are ill borne, exciting much constitutional disturbance, and reliev-
ing the pain but little or not at all. Ipecacuanha in grain or half-
grain dowSes, every boor till a decided nauseating effect isproduced^
is in these circumstances sometimes of very great ser\ace, afibrding
much relief to the pain, and also lessening the amount of
discTiarge, which otherwise not infrequently becomes over-profuse
about the second or third day of menstruation.
The treatment of the patients at the menstnial period comprises,
however, only a small part of what is needed to bring aljout their
cure. Though relieved for a season by the flow of blood, as is
generally the case, the syniittome by degrees return before the
next period comes on. It is during this interval that so much is
gained by local depletion of the utenis; a proceeding which,
although abundantly simple, I may, perhaps, as well stop for a
moment to describe to you.
Leeches, when applied to tlie womb, generally pi-oduce a much
greater tlow of blood than follows their application to any external
part ; and four, or at the most six, are tlierefore as many as it is
desirable to put on at one time. Metallic tubes, iie.rfyrateti with
holes at one end, and capable of b^ing closed l*y a plug at the
other, and some other similar contrivances, are sold in instrument-
makers shops, and are very useful for servants or niirs^,
whenever they are entrusted with the operation of leeching the
womU I prefer, however, to employ a speculum, and generally
CONGESTIVE DYSMENORRHCEA :
use one of Feiguaaon'a reflecting glass speculums, by wLich you
can both ascertain more exactly the part to which to apply the
leeches, and also, if the os uti^ri is at all open, have the oppor-
tunity of inserting into it a little bit of cotton wool, in order to
prevent the leeches biting within the canal of the cervix ; since
that accident always gives most acute pain, though otherwise the
operation is attended by very little suffering. The speculum being
introduced and adjusted as the patient lies upon her left side, the
leeches are put into it» and then pushed up to the uterus by means
of a little cotton wool or lint, which may be withdrawn in five or
ten minutes, the leeches having generally bitten by that time.
Now and then a leech, cra^^ling out of the speculum, will make
its way down between the instrument and the vaginal wall, and
fixing on the external parts, will cause much pain ; but a little
care will enable you to gnaixl against any such mischance. I
W'Ould not have taken up your time with details which may seem
80 trivial, if it were not that in the country you may he unable to
command the services of a class of women who in London get a
very good living by leeching the uterus under medical direction.
After the leeches have come away, a warm hip-bath is generally
a comfoii to tlie ]>atient, and, unless the bleeding has been very
profuse, is desirable as a means of promoting it, on the same
principle as we often put on a poultice after the application of
leeches externally. The evening is generally the best season for
applying leeches to the womb, in order that the rest and sleep oi
the coming night may relieve the patient, jaded and w^earied by
the discomfort of the operation.
I may jimt add, that it has been advised, as a more expeditious
and less irksDme mode of depleting the utenis, to scarify its lips
through a speculum by meana of a sharp lancet affixed to a long
handle. Such scarifications are by no means painful, and in some
instances wliere the mucous membrane covering the lips of the
uteras is the seat of undue vascukrity, and presents a peculiar
granular, abraded appearance, 1 have seen much benefit result
from it, just in the same manner as scarification of the palpebral
conjimctiva sometimes does much good in strumous and other forms
of ophthalmia, We cannot, however, abstract by this means any
considerable amount of blood ; and whenever there is much con-
gestion of the vessels of the uterine substance, which we are
i
ITS TREATMENT,
iBft
anxious to relieve by depletion, leeches to the part are always to
be preferred*.
Depletion, attention to the bowels, a nutritions hot nnstimu-
lating diet, and all those little precautions which come under the
somewhat vague denomination of attention to the general health,
must in all of these cases engage our care during the intervals be-
tween each menstrual period. When to this I add that the back-
ache, if not relieved by a plaster, generally yields to the employ-
ment, night and morning, of a liniment of belladonna and
chloroform, or of a croton oil liniment, sufficiently weak not to
produce a troublesome pustular eruption, and that small bUsbers
in one or other iliac region usually mitigate the pain referred to
the situation of the ovaries, I think I have given you all the special
directions which are applicable to cases of this description.
I ha\e* however, referred to some instances in which the painful
menstruation is associated with various evidences of a rheumatic
or gouty diathesis, and such cases are both peculiarly painful and
pecnliarly intractabla Colcliicnm is often of much utility, and
during the paroxysm twenty or thirty minims of the tincture in
combination with small doses of laudanum and of antimonial
wine, m]l often give more relief than any other remedies, and
prove especially useful when large doses of narcotics will be of no
service.
The treatment during the menstrual intervals is of particular
importance to this class of patients, and yet so various are the
eymploms in difterent caaes, that it is impossible to lay down any
definite plan as applicable to all So long as the bowels are very
constipat^^d, as the tongue is foul, and the urine loaded with
lithates, colchicum may be given two or three times a-day, com-
bined with tlie sulphate and carbonate of magnesia, and a small
dose of blue pill or grey powder with the extract of poppy or of
henbane at night. When the constipated state of the bowels has
been overcome, the acetous extract of coIcMcum may still be con-
• [Spiegplberg ntid othera liiive Tiecently reconmieiided the xuse of what may b«
etXXed puiicturea by bayonet, imitea*! of the old icarificjttions. If they are iwed,
tare must be taken to keep them anpeHicial, and then tht-y will be no more cffec-
tire thin scarificxitiona. When the bayonet wounds go aa dwp as a quarter of sn
inch, either iat*utionally m accidentally » a coniiiderable vessel is liable to b«
wounded, and alarm in j|; hemorrhage may persist ao long lU to roqairu the QM of
•typtics or of plugging.]
"^ 88 MECH JLSnCAX DYSMENORRHCEA :
tinued at nigbt, while during the day some niild tonic is given,
such as the niiromuriatic acid with extract of taraxacum, or the
liquor cinchouie and taraxacum ; for with the disposition to local
plethora and congestion there ia almost always associated a general
want of power in the system. "VMiOe the tonic plan is generally
pui-suei, any increase of pain, or irritability of the bladder, or an
increased deposit of lithates in the urine, will call for a return to
the use of the colchicum and its employment with greater
frequency. The pei'sistence of the sjinptoms and the presence of a
profuse leucorrhceal discharge, as well as of an haljitual excess of
lithates, indicates the employment of the iodide of potassium,
which is often of great semce when the colchicum has already
disappointed our expectations. The dysuria in these cases is
frequently much relieved by the patient drinking Vichy water
instead of spring water ; while the form of tonic that in geaeral
suits test is the citrate of iron in doses not exceeding five grains
twice a-day, for which the Vichy water, sweetened w*ith a little
syrup of omnge-peel, is a very agreeable vehicle. Lastly, when
this condition has existed for years, it becomes, I fear, almost
incurable. The waters of Carlslmd and of Wiesbaden do, indeed,
effect something towards the alleviation of the patient's siifTennga,
sometimes, perhaps, even bring about a cure, but at the best
slowly, uncertainly, and leaving behind a great disposition to
relapse. Hence the wealthy lose heart at what seems to be a
never-ending treatment, requiring to be renewed year after year,
and imposing, a*s the price of even moderate success, strict self-
denial, and precautions which almost exclude from society those
who observe them. The poor, unable to afford the luxury of
ilhiess, are at least as unfortunate, and endure a hfe of wearing
pain, all the more intolerable, perhaps, from its depending on no
dangerous disease, and tending but httle to shorten an existence
which it yet renders extremely miserable.
With reference to the laM form of dysmenorrha^a — namely, that
dependent on a mechanical impediment to the escape of the
menstrual fluid — I have already expressed my conviction of its
rare occurrence, and am far from being alone in this opinion.* It
is doubtful, indeed, whether this form, to which attention was for
a long time almost exclusively directed, is not of all the least
• See with inifeivnce to this very pointy the rem arks of M. AtiHj op, cU.^ p, 324,
5
ITS TREATMENT,
89
frequent; and with the change of opinion the heroic measnre of
incision of the supposed stricture has fallen into almost complete
and deserved discredit How carefully soever managed, the
operation was by no means devoid of risk, and severe haemorrhage
at the time, and dangerous pelvic cellulitis afterwards were not
very rare results of the proceeding. But over and above this, the
operation in not a few instances fails altogether to give relief, and
in many more the relief obtained is only temporary. The first
period or two after the operation were indeed usually passed with
far less sutt'enng than before; but the old symptums almost
invariably returned, whether as the result of the reproduction of
an actual stricture, or of the wearing out of the profound imjiTes-
sion made by this severe interference on the \ntality of tlie organ,
I cannot say, but of the fact itself there is no doubt. The dilata-
tion of the cervical canal, and of both uterine orifices by bougies
on the principle advocated by Dv Maekint-osh, is free from danger,
though the same cannot be said with equal certainty of the use of
sponge tents. The intluenoe of either, however, whether
mechanical or, as I liave suggested with reference to the incision
of the cer\ux, more far-reaching, is equally temporary, and it is a
grave question how far the monthly examination, and passing
instruments into the uterus of young unmarried women, is justi-
Hable on moml grounds, nnleaa the physical suirering is very
severe indeed, and the relief obtained very remarkable. The
division of the external os uteri, as advocated in such cases by Dr
Barnes, seems less open to criticism, though it must not be
foigotiexi that in these cases the narrow opening is but part of a
general condition of imperfect development of tlie w^omb. It is
indeed probable that the removal of an obstacle to tlie outflow of
the menses may favour the development of the uterus and of the
sexual oi^ns generally, and that thus in a married woman
sterility may, as has been alleged, be remedied indirectly by the
means which cured the dysmenorrbcea.*
• [F«T special writingu on tliis aubjt'ct by Br Matthews Dnncim, Teferenc« is
ttittde to " I>yam<moTTha*a," Edinburgh Medical JmLmal, May, 1872 ; *' Hi!a«!arche«
on the Mecbttuicftl Dilatation of the Cervii: Uteri, muX the Appliauces used for tlte
Ptiri>ow," BHtUh Medical Jmimal, Nov. &, and Nov. 16, 1872; and "The
Orifir^n of the Unimpregnated Uteras and their Sorgicol Treatment, '^ British
Uidiml Journal, Maruh S, 1873.]
I
MECHAl^ICAL DYSMENOREH(EA :
How uterine flexions are to be treated will come under our
notice hereafter. I will but repeat here the expresaion of my
scepticism as to how far flexions, pure and simple, in the unmanied
woman are capable of producing all the results attributed to
them ; and doubt therefore very much whether the uterine sound
will often be needed to reduce uterine flexions for the cure of
dysmenorrhcea in the virgin, or a pessary to prevent the return of
tJie tUsphicement, and the painful meustruation. It is not, indeed, M
always easy to resist being led away by plausible theories, "
especially when they ai-e of a kind to receive ready acceptance
among our patients. Kon -professional persons cannot understiind
the reasons which induce us to adopt one course of medical treat-
ment instead of another; but they can quite comprehend the
popularised pathology which tells them that they menstruate with
pain because the passage of the womb is too narrow ; or because
the organ is so bent upon itself as to close its channel^ and in the
hope of a cure will readily submit to almost any amount of
mechanical treatment; and will probably draw comparisons
between the doctor who is resorting to veiy needless interference,
and the less oflicious person who did no more than the necessities
of the case ret] uired— comparisona, I scarcely need say, very
unfavouralile to the latter*
And with this caution I should leave the subject of dysnienor-
rha^a, merely reminding you once ng^iu of the necessity of being
physicians first before you are specialists ; but of late a new and
most efiectual remedy has been proposed, which consists in
nothing less than the reheving a woman of the sufterings
incidental to her sex by unsexing her altogether. There may be
conditions of very rare occurrence in the male sex which would
justify castration, but the reasons for it must be cogent indeed,
and the cases in which it was perf oimed would always be regarded
as purely exceptional, and would furnish no precedent of general
application. Widely different is the proposal which it has
recently been sought to force into notoriety for spaying women in
oases of obstinate dysmenorrhcea, and w^hich, in spite of an
admitted mortality of one in five of those who submitted to it, is
spoken of with intense satisfaction by its advocates as a great
therapeutical discovery of no very narrow application. *' Have a
ITS TREATBfENT. 91
care," says Hufeland, " that your remedy is not worse than the
disease/' and to my thinking tina, like other mutilations of women,
is as objectionable on moral as on physical grounds. Bespect for
the sanctity of womanhood seems to me as essential for him who
professes to treat the diseases of women, as medical skill, or
manual dexterity.
LECTURE VL
DISEASES OF THE UTERUS.
Immediate results of pregnancy and delivery not treated of, tliougb tlieir remote
effects AVG numerous and imjKirtant.
lNflAMMATi(*Ni, and kindred processes.
llYrERTROPHY QF THE Utebt78 from deficient involution after delirery or abortion,
from nteriiie irritation. IllaBtFatiTe cases, and treatment. Partial hjqwr-
trophy airecting tlie cervix ; ita e^cta* Treatment, removal of enlai^gdd
cervbt, dangers of hiemorrhago,
Ikplammation. Acut;e Inflammation ; ita rarity, its causes, symptoms, and
reaulta. TreatmeDt
A COUHSE of lectures on the diseases of women, in which it is
not proposed to include the ailments either of the pregnant or of
the puerf>eral state, must needs present much that is defective in
arrangement and incomplete in execution. These defects, how-
ever, appear to me to be a smaller evil than would he the
occupying much of your time with the reconsideration of subjects
such as puerperal fever, or phlegmasia dolens, which have already
come before your notice in the lectures on midwiferj^, and wiiich,
besides, have engaged, and to such good purpose, the attention of
many writers both in this country and on the continent.
Sacrihcing, therefore, accuracy of nosological arrangement to
practical convenience^ I shall leave unnoticed alike the special
diseases of pregnancy, and the morbid conditions which follow
immediately on deUvery* We shall find, however, over and
over again, that conception, pregnancy, and dehvery, are among
the most frequent exciting causes of disorder of the sexual
functions, and of diseases of the sexual organs, and also that
many ailments which come under our care, days, ot weeks, or
even months afterwards, admit of being traced back uninter-
ruptedly to their commencement in a miscarriage, or a severe
I
INFLAMMATION A CAUSE OF UTERINE DISEASE.
csonfinement, or in some interruption to the changes that slaould
occur in the puerperal state. This is especially the case with all
the diseases which are the result of inflammatimi or of kindred
processes, such as pelvic abscesses, hypertTophy of the uterus,
induration of its cervix, or ulceration of its orifice, with all the
varied forms of menstrual disorder and of leucoirhoeal discharge
which attend upon them.
The active forms of inflammation of the sexual organs, which
Uireaten life soon after delivery, are not, however, those whose
sequete most freqiiently present themselves to our notice in
hospital practice, or call for our attention in private. In many
of these the local mischief is but a part of the disease, one of the
consequences of that altered condition of the blood in which the
essence of puerpicral fever consists, and contributes only in a
secondary de^ee to imperil or destroy the patient's life. In such
cases, if the patient survives the constitutional malady, the local
mischief is slowly but surely repaired during the course of her
tedious convalescence, and the sexual organs, restored to their
integrity, resume in time the healthy performance of their
fanctioDSL In other instances, where the affection has been from
the commencement purely local, the severity of the attack and
the intensity of the suffering usually lead to corresponding
activity tmd decision in the treatment, while the sense of past
danger inspires in the patient and her friends the observance of
most minute precautions until her health is completely re-
established! Hence it results that the great majority of cases of
inflammation and enlargement of the womb, of inflsimmation of
the uterine appendages, or of suppuration in the pelvic cellular
tissue, wliich date back to pregnancy, miscarriage, or delivery,
weeks or months before, are not only chronic in their course, but
were attended from the very outset by symptoms of compar-
atively slight severity, and manifested themselves by a state of
ailing rather than of serious illness ; or succeeded to a sort of
imperfect convalescence, for the incompleteness of whose
character no adequate cause appeared for some time assignable.
One result of inflammation succeeding to miscarriage or
delivery is to check that process of involution by which th^^ tcmnh
migld to be TfMored in a few weeks to the size and condition
which it presented before pregnancy began. If you examine the
94
tTTEEINE DISEASE
body of a woman who died of uterine inflainmation after
delivery, one of the first things to arrest your attention will be
the large size of the womb, which, after the lapse of four or five
daya, will be found to be as large as the healthy womb when
only twenty-four or thirty-six hours have passed since the
completion of labour. This increased size of the uterus, too, is
not due simply to its natural contractions being arrested, nor to
the unusual afiiux of blood towards it, nor to the efl'usion of the
products of inflammation into its substance, though possibly all
of these causes may in various degrees contribute to it ; but is in
a great measure owing to the mere supjiression of those changes
wliich ought to occur after deLiver^^ and with whose natui'e the
microscope has made us in some measure acquainted. In a
perfectly healthy condition, a large amount of the blood
previously supplied to the uterus is at once cut off by the
powerful contractious wluch either completely close the vessels
distributed through its substance, or at any rate gi'eatly diminish
their calibre. Its tissue having performed the function for
whicli it was raiaeil during pregnancy to ao high a degree of
development, undergoes, as other tissues do previous to removal,
a process of degradation or fatty degeneration ; and having thus
become more readily susceptible of removal, is either absorbed, or
is discharged with the lochia from the interior of the womb. For
some three or four weeks, little else goes on besides this process
of degradation and removal, and this is much more active during
the second week* after delivery, than either before or after that
period* Tliere next begins a process of I'econstruction of the
organ ; and nuclei, and caudate cells, and elements of new fibres
are formed, which await only the stimulus of a fresh conception
to attain the same perfection of structure as was manifest in the
former uterus. Observers are not altogether agreed as to how
soon tkis reparative action begins ; whether it is quite secondary
to the removal of the elements of the old uterus, or w^hether, as
se^ms indeed moat likely, removal of the old and construction of
the new go on actively at the same time. The interior of the
uterus undeigoes changes as considerable as those which take
place in its substance ; and it is not until its lining membrane,
• According to Henchl, Wicimr ZeUa^iriJt, and Schmidt, Jahrh&cficTf vol Isxvii.
1853» p. 341,
I
I
I
ROM INTERRirPTED PUERPERAL CHANGES,
95'
with the exception of that of the cervix, has been several times
reproduced and then cast ofl" in a state of fatty degeneration, that
it resumes the same condition as before impregnation,*
The occurrence of indammation appears to internipt these
processes, for though fatty degeneration of the tissues takes
place, yet the remnval of the useless material is but imperfectly
itccomplished, while the elements of the new uterus are them-
selveSf as soon as produced, subjected to the same alteration, and
the organ remains, long after all active mischief has passed
away, increased in size, and at the same time composed of a
tissue inapt for all the physiological proce^sses of conception,
pregnaucy, and child-bearing* I cannot pretend to tell yon the
intimate nature of the changes which the uterine substance in
these cases may afterwards undergo, for the microscope here
leaves us for the present at faidt, and many circumstances will
always render the investigation of the effects of inflammation,
and of its kindred processes when seated in the womb, particu-
larly difficult It must, however, be at once apparent, that after
inflammation has passed away, its effects may mmain in the
laiger size and altered structure of the womb, and that the very
nature of these changes will be such as to render the repair of
the damaged organ botlt unlikely to occur, and slow to be accom-
plished, and must leave it in a condition peculiarly liable to be
aggravated during tlie fluctuations of circulation, and alteniationa
of activity and repose, to which the female sexual system is h able.
It must also be obvious that for these results to be produced, it is
by no means necessary that the inflammation be veiy severe in
character, but that a degree of inflammatory^ action for short of
what is requisite to endanger life or to occasion much suffering,
may yet interpose a great obstacle to the complete involution of
the womb.
The importance of this condition is due less to the symptoms
* The best microscopic obsenratioiig on thia aubjoct ire those of the late FrRiis
Killan m Hc'Dle's Zeiisehri/t, toL tiiL p. B3, and vol. is. p. 1, with which those
of Ht'm:hl, toe. eit, generally correspond, though there are some differenct* between
their atatementa in points of detail. Dr Simpson waa, 1 believe, the first to cnU
ftttention to the practical bearings of thu subject See bis Cmxtribuiwna to OhsUtrie
Faiholoffyt ToL L. p. 26. [For a rucent account of this Important subj«;f:t ivfiTence
is here made to a paper by Serdukolf, ** Contributions to the Det«rmination ot the
Diniiuniion of the Utenui after Delivery/' Edinkurfh Medical Journal^ May 1875.]
96
EjnARGEMENT OF THE UTERUS
to which it gives rise, so long as it remains uncomplicated, than in
the circumstance, that complications of some kind or other are
very apt to occur ; that the heavy uterus is very likely to become
prolapsed or otherwise displaced or bent upon itself, or the enlarged
uterus to become the seat of permanent congestion, or to be
attacked by chronic inflammation* A sense of weight in the pelvis,
more or less bearing down, and a disposition to excessive and over-
frequent menstruation, are seldom absent when any considerable
uterme enlargement exists, and in general the size of the womb and
the severity of the symptoms are in direct proportion to each other.
One of the best marked instances of this dsjidi^nt mvolutiou of
the uterus which I have met with occurred in the person of a
woman aged thirty-one, who had been married twelve years, and
had given birth to five children at the full period, and had also
miscarried three times. Her last abortion occurred at the third
month, six weeks before her admission into St Bartholomew's
Hospital Since this abortion she had suflered from shooting
pains at the lower part of the back and in the aMomeu, from
bearing down pain during every* effort at defiecation, and from a
constant sanguineous discharge by which she had been much
exhausteti The medical man under whose care she had been,
told her tliat she had a tumour in the womb. On examination
the utems was found low down, completely retroverted, the os
uteri being directed forwards, and only a short distance from the
vulva. Almost immediately behind the os, the uterus swelled out
into a globular tumour of the siije of a small apple, elastic to the
toueli. The canal of the cervix was open so as to admit the finger
without difficulty. On introducing the uteriiie sound, it passed,
with the concavity turned backward, for a distance of five inches
and three-quarters, and on turning it round, the tumour previously
distinguished completely disappeared.*
* Dr Matthews Dancan has described, in EdMiO'gh MojUhlt/ Journal, June
1S56, p. 1057, aome oases ia which he WlleTes tlmt, independently of may disease
of the atcni8, there exiisted n state of unnatuml patency of the FaUopian tube on
one side, udndttii];g of the [lussage of the utt^rine sound along it for sevemi incliea.
Such a state, howcTer, which h probably one of considtTable rarity, is oot likely
to be confounded with instances of enlsrgeiiient of the womb itself, aince an ordi-
nary vagiual eianjination would at once iufurni us whether or no that organ
liirgtr and heairiei and leas moveable than natural, conditioDs which were
in the inatouceB that Dr Duncan relates of dilated Fallopian tahe«
I
»rgan U M
i absent I
FROM DEFECTTVE IXVOLUTIOK.
AT
The patient was kept quiet in bed, was allowed a little wine and
meat diet, and the harmorrbage ceased, and tbe canal of the cervix
contracted under the iiae of the ergot of rye, though no sensible
uterine action was excited by the remedy. She afterwards took
preparations of iron, and began the employment of the cold ilouclie
to the uterugi by which she was already much benefited, though
the uteruB was not much diminished in size, when the outbreak of
small-pox in the ward compelled nie to discharge her eighteen
days after her admission. I saw her three months afterwards ;
her health was much improved, but she complained of profuse
menstruation, returning every fortnight, and her womb was re-
troverted, though it was much smaller than before. At the end
of rather more than three years she again came under my notice,
having in the interval miscarried several times at an early period
of pregnancy. Her uterus was still retroverted, and the abortiuns
were probably due to the organ having been bound down by
adhesions in tlds unnatural position. It had, however, greatly
dinunished in size, and was now little if at all larger than the
healthy womb.
Besides this form of uterine enlargement from defective involu-
tion, there is another, occasionally, though much less frequently
met with, in which the cnlarffcment of the wmnh takes place
independent of previous pi^egnancy, and is //«; rcmtU of a mart
genuirve h^fperirnphj. Cases of this kind, wliich I have met with
exclusively in women who have lived for a longer or shorter time
in childless marriage, present themselves in most instances
without any definite clue to their history ; a sense of weight in
the pelvis, pain usually of a burning character, and hiemorrhages
having gi-adually come on, and forced themselves by their
slowly-increasing severity (sometimea not till after the lapse of
years) on the ptitient's notice. Excessive or intemperate sexual
intercourse does not produce it. though that leads to its own train
of evils ; but there has, in many instances, seemed to he good
reason for associating the condition with the imperfect perfor-
mance of that function, and sometimes the evidences of this
being the case have been CGUclusive,
Some years ago I saw a lady, aged forty-three, who, during
thirteen years of married life, had never been pregnant She had
always menstruated painfully, and rather profusely ; and both
o
EKLARGEMEKT OF THE UTEEUS
these ailments had by degrees grown worse, and this especially
during the kst few months. She complained of sense of weight
and dragging immediately on making any attempt to walk, and
induced even by remaining long in the sitting postnre. The
bowels were constipated, and defalcation was difficult. Menstru*
ation was very profuse, accompanied by discharge of coagula,
while at uncertain intervals daring its continuance most violent
paroxysms of uterine pain e^me on. On examination, the
enlarged uterus was distinctly felt above the symphysis pubis as
large as the doubled fist, and per vaginam the whole organ wa«
found much enlarged and much heavier than natural ; the cervix
large and thick, but not indurated; ths oa uteri small and
circular ; and the hymen was entira
Eest, attention to the bowels, local leeching every fortnight,
continued for several months, together with the careful employ-
ment of preparations of iron combined with small doses of the
iodide of potassium, were followed by the gradual suppression of
the menoiThagia, by great diminution of all the patient's painful
sensations, and by marked lessening of the size of the uterus. I
l)elieve, too, that in most cases, a similar plan of treatment,
coupled of course with temporary separation from her husband's
bed, will be followed by improvement, and, if long enough
persevered in, by complete recovery of the patient. In the
instance I have just related, the patient's age and the number of
years that she had already been married put aside all question as
to the possibiHty, or^ at least the probability, of her becoming
pregnant. A somewhat similar state of things is> however,
sometLmes observ'ed in younger women, and witliin a few months
after marriage ; and the state of the hustwind's virile powers will
be a 7»oint concerning which it will be your duty in these cases
to make some inquiry, and perhaps even to off*er some suggestioiL
You must bear in mind that not only the old rake, but also the
hard student, or the man who has long led a life of perfect
chastity, often 1ms but feeble sexual power. Such a person
marries : anxiety for children, or some of those complex feelings
which at once come into play in all matters concerning the
generative functions, lead him to over-frequent attempts at sexual
congress. The act is incompletely performed ; nervous apprehen-
sion leads to its still more frequent attempt and its more
FROM TRUE HYPERTROPHY.
99
incomplete perfoi-mance ; and unless by good fortune pregnancy
has taken place very soon after marriage, a condition of
permanent uterine congestion is induced, which leads to
h^Tjertmphy of the organ, and the wife becomes as inapt for
conception as the husband is for procreation* But I have said
enough concerning a matter which I would gladly have left
unnoticed ; yonr own good sense will suggest to you what advice
to give» and your good taate will dictate to you how best to give it
Over and over again in the course of these Lectures, I siiall
have to speak of hypertrophy of the uterus as a secondary result
of many other ailments of the organ, and as greatly increasing
the difficulty of their cure. If fibrous tumoui-s form within ita
substance, the uterus increases in ^ize ; and this in a measure
proportionate to the intimacy of the relations between the foreign
body and the tissue of the womb. If the organ sinks lower down
than natural, the result of the unaccust^^med irritation to which
it thereby becomes exp)sed is to produce its enlargement, and
thus to increase the difficulty of cure of the prolapse* In short,
whenever the uterus is exposed to unusual irritation, it increases
in size ; not necessarily, nor I believe generally, as the result of
inflammation, but because the organ is composed of formative
mat-erial, which excitement of any kind will call into active
development, though it is only under the stimulus of pregnancy
that development goes on to any useful end, or attains its full
perfection.
There still remains mitfor^n of simple uterine hifpcrtmphy to
which I must refer before passing on to other subjects. It is one
in K^hirh Ihc enlargement is limited to ike Ticfk of the w&mh,^ and
sometimes even involves only one lip, generally the anterior. In
the latter case it is usually consequent on child-bearing, and
fierhaps is, strictly speaking, rather the result of a partial
deficiency of involution of tlie uterus, than the ettect of a genuine
hypertrophy of the part.f When affecting the whole of the
• Though noticed before by continental writers, Dr. Evory Kemiedy wiw the
ftrat in this counir)- to caU attt-ntion to tbis ftflt'ction, in a paper publkhed in the
Dublin Medical Journal for 1838, Since then the ttaaay of M. Hugnier, published
m the Mimoirea de VAcademie deMddeeine for 1859, has exhaiut^ aU that remaina
to be said on the aabject
f There are two other fctrnis of hypertrophy of the cervix uteri which I flhall
i^onsidet hereafter f one in which the elongation of the neck of the womb is m
100
HTPERTEOPHY OF CERVIX UTEia.
cervix it haa, howetver, not appeared to l^e traceable to any such
cause, since I have met with it not only in aterile women, but
even in those who were unmarried The ailmeDt seems to consist
of simple overgrowth of the part, the neck of the womb being in
all respects healthy to the tooch, and the 00 uteri free from any
trace of disease. The chief increase ia in length, the portio
vaginalis, instead of being half or three-quarters of an inch long,
measuring an inch and a half, or two, or even three inches. In
those instances in which the elongation of the cenix is most con-
siderable, the uterus sinks down in the pelvic cavity, so tiiat the
08 uteri sometimes comes to lie just witliin the orifice of the
vulva, or even projects lieyond it, giving rise to many of the
symptoms of prolapsus, and being often taken for it by the
patient
The symptoms, as just mentioned, are those of prolapsus, and
consist of a sense of weight and bearing down, aggravated by any
exertion, and increased also during the increased afflux of blood
towards the pelvis at each menstrual period. The condition
presents also a mechanical impediment to sexual intercourse, and
once or twice discomfort in the act haa been the patient's chief
reason for applying for relief. I beheve the state also to be an
occasional cause of sterility, probably from the male organ not
coming into contact with the os uteri, and from the consequent
difficulty in the access of the fecundating fluid to the womb. For
this effect, however, to be produced, the hypertiTvphy must needs
be considerable.
I know no cure for this aflection, except the removal of a jwrtion
of the superfluous gi-owth. The icrascvr has done away with the
formidable risk of hfemoirhage ; which I have known nearly
prove fatal ;* but it has not done away with the danger of peri-
tonitis, though I do not know of any statistics sufficiently
accurate to enable one to estimate tliem exactly. But it seems to
me that as the condition is one productive of inconvenience rather
than of serious evil, and as the removal of a portion of the cervix
secondary result of prokpsvis of the vagina ; tlie other in which the hypertrophy
is Umitedt or nearly so, to the idqcoub membrane, and in which the outgrowth
a!ii}ume4f the fonn of n irolyjius, and has been described under that name. See 1
Lectun?H on ProlapBUs aud on Polypua.
• With referenco to which ^ s«e the remarka by M. Pauly^ at \\s^ 473 of hi«
Maladu4 dc rVUrm, kc. 8to, Piiris, 183G.
INFLAMMATION OF THE UTERUS.
101
uteri is by no means devoid of risk, it is the wiser course to leave
the smaller degrees of hypertrophy without interference Even
though the desire for children should prompt your patient to sub-
mit to it, I should advise you to be very guarded in the promises
you make with reference to this point, for it is quite possiJde that
there may be some deeper seated reason for the woman's sterility ;
one which no mechanical proceeding can remedy.
From the study of simple errors of nutrition, leading to the
increased growth of an organ, the transition is easy to the
examination of the eii'ects produced on it by ifiJiammdliofL In
the case of the uterus, however, there are many circumstances
which render this study peculiarly difficult. Though we regard it
as a single organ, it is yet made up of parts difi'eriiag widely in
structure and in function, and having very diflerent tendencies to
disease, while these tendencies vary at difierent times according as
the highest functions of the sexual organs have been rec^ently
exercised or have never been called into activity, or as the period
for their performance hjis already passed. Moreover, the evitlence
of pathological anatomy^ which corrects so many errors in other
departments of medical inquiry, is little available in the ease of
diseases, which like the inflitnimatory atfections of the unimpreg-
nated womb, liardly ever lead to a fatal issue ; so that we are in
constant danger of mistaking pseudo-morbid appeamnces for serious
alterations, or of exaggerating the importance of real ehanges of
structure. Besides, the office of the uterus in the unimpregnated
condition is so humble, and its functions are so few, tliat there
must needs be great sameness iii the s}T3iptom8 which attend upon
its disorders ; and disturbance of menstruation, and increase or
alteration of the naturally scanty secretion furnished by its mucous
membrane, arealike met with in the most diverse affections. Our
means of examining the condition of the womb are also very im-
|jerfect, compared with those that we possess forinvestigatin;^ the
state of other organs ; and hence the question often arises,
whether the signs of disease which we discover are the cause of
the symptoms, or whether they are the index of other aud more
impoitant changes, or whether they are neither the one nor the
other, but mere casual concomitants of graver ailments, concerning
whose nature and degree we can from them deduce no conclusion.
From these circumstances it has arisen, that the int]amm»tory
102
AClfTE TKFLAMMATION
diseases of the uterus have been and still are the siibjeGl 0ii
llicting opinions, though much lass so now than in former years.
Before entering on debateable gn>und, however, I may say a few
words concerning acide inflammation of the unimpi-egnated uterus,
an aihnent universally admitted to he of rare occurrence. I have
seen it come on with great severity in the course of gonorrhoea,
and beUeve that not only in this case, but also in the generality
of instances, the inflammation begins in the interior of the womb,
whence it extends outwards, though it involves the mxiscular
substance of the uterus to a much less degree than its lining
membrane. The tendency indeed of inflammation of the uterine
mucous membrane to extend along the Fallopian tubes, and to
attack the peritoneum, is much stronger than to afiect the sub-
stance of the organ ; and though abscesses sometimes form as a
secondary result of the disease, they arc yet almost always
situated in the pelvic cellular tissue, or at the base of the broad
ligament, and scarcely ever in the utenne wall itself.
The affection is not only infrequent in its occurrence, but it is
still rarer for it to endanger life, and the only instance which I
have seen after death, of the unimpreguated uterus in a state o(
acute inflammation, was in the case of a lady w^ho died of
peritonitis, for the superv^ention of which no cause could l^e
assigned during her lifetime. On examination, however, her
uterus was found to be much enlarged, and a fibraus tinnour of
the si7.e of a hen's egg w^as imbedded in its posterior widl Both
the tumour and the thickened uterine walls were of a bright rose-
red tint, and presented a remarkal>le degree of succulence. The
cavity of tlie organ was dilated, and contained at least an ounce
of pits, which seemed to be retained within it by the flexure of
the body upon the neck of the oi^an, while its lining niend>rane
had exactly the appearance of bright red velvet, though it after-
wards quite lost tliat character by long immei'sion in spuit
1 have referred to the extension of gonorrhceal inflammation as
one cause of the aflection ; sudden suppression of tiie menses may
likewise occasion it; while after one attack, the uterus is oft'Cn
left in a condition in which comparatively shght causes will suffice
to reproduce it. The symptoms by which it is attended are a
sense of pain and weight in the pelvis, with a feeling of heat or
throbbing, and much tenderness over the pubes. The pain
OF THE UTERUS.
103
extends down the thiglia, ia aggravated by exertion, by sitting on
a liarJ seat, by defecation, or by any attempt at sexual inter-
coui-se ; while in this, as in many other aftecfcions of the utems,
there is often more or leas irritability of the bhtdder and deaire to
pass water frequently, the nrine being generally high coloured and
sometimes voided with pidu. Another syniptum, not peculiar
indeed to this affection, though observed during its course in a
very marked degree, is the occun-ence at irregular intervals of
paroxysmal exacerbations of pain of very great severiiy, lasting
for an hour or two, and then subsiding, to recur again, equally
causelessly, in twelve or twenty-four hours. Con])led with these
attacks of pan:)xysmal pain» or sometimes occurring independently
of them, though usually associated with much su Bering, are
seizures of diarrhcea, during which the patient has ten or twelve
watery evacuations in as many hours, and the bowels then become
constipated, and remain so for two or three days. At the com-
mencement of the attack there is no vaginal discharge, but in a
day or two au abundant puriform or suro -purulent secretion is
poured out, often ollensive to the smell, and not i!ifret|uently
slightly tinged with blood. On examination per vaginam thei^e is
always increased heat of the parts, witli tenderness amounting to
sevei-e pain on touching the uterus, whdetbe vessels of the cervix
may be felt pulsating with great force, and the uterus is found
heavier than natural, and in many instances obviously increased
in size. The tenderness of the organ has always led me to abstain
from any attempt at meiisuring it by means of the uterine sound ;
but I can readdy l.>elieve the statement of the lata Professor
Kiwisch, who states that be has found its cavity from six to ten
lines longer than natural*
The amount both of constitutional disturbance and of local
auflcring varies greatly in ditlerent cases, though, except when the
peritoneum becomes atfected, it is unuBoal for the symptoms to
be so severe as to warrant any grave apprehension as to the
patient's ultimate recovery. There are, however, two other risks
besides that of the occunence of peritonitis, against which it
behoves us to be on the watch during the whole course of this
aflTection. The one is that of the ovary, or of the broad ligament,
being attacked by inllammation, an accident very likely indeed to
* KUnueh€ FaHtiigt, &c., lit yo1.» 4tU edition, Prague, 1S&4, p. b7B, f 2id.
104
TKEATMKNT OF
issue in the formation of abscess ; tlie cjther is of the acute evil
passing into a subacute or chronic stage» in which the suffering is
much leas, but the prospect of permanent cure less also; and to
this hitter result all cases of acute uterine inflammation, if let
alone or inadequately treated, seem naturally to tend.
The ifraimmi of these cases is abundantly simple, the indica-
tions are very clear, and the mistakes which are made seldom
consist in doing what is wrong, bnt rather in pursuing the right
end by inadequate means. Some rules are so simple, and the
necessity for them is ao obvious, that it seems almost superfluous
to insist upon them. Eest in bed in the horizontal posture, a
simple diet, and antiphlogistic regimen, and, I scarcely need add,
abstinence from sexual intercourse, for, indeed, that is usuaUy far
too painful to l»e attempted, are essential to the patient's recovery.
Palliatives, however, do not suffice for the patient's cure, but the
ioHammation must be at once attacked enei'getically, and deple-
tion can, I believe, never, be dispensed with. It is not, indeed,
usually necessary to resort to general depletion, but local bleeding
is invariably indicated, and in spite of the tenderness of the parts,
which makes the patient shrink from the iutroductiou of the
speculum or of the leech tube, much more relief is afforded by tlxe
application of four or six leeches to the litems itself than of four
times that number to the hypogastrium or the groins. Still,
whenever the constitutional disturbance is considerable, or the
local suffering very severe, I think it will be your wiser course to
take a small quantity of blood from the ann before you have
recourse to local bleeding. I dare say you may have seen the
application of leeches to the abdomen appear to aggravate the
symptoms in one case of peritonitis while it entirely removed
them in another, and may have found on inquiry that in the
latter case the leeching had been preceded by genend bleeding,
while in the former an attempt had been made to employ local
depletion as a substitute for it. Just the same thing I have
ohsen^ed in cases of uterine inflammation, and have known the
application of leeches to the womb induce a paroxysm of almost
intolerable suffering, though the same measure would have
relieved a less severe attack, and even in that very instance per-
fected the patient's cure after general bleeding had been employed,
In any case in which you find severe pain coming on during the
ACUTE ENFLAMMATION OF UTERUS
105
application of leeches to the u tenia, I would advise you to remove
the leeches, and to withdraw the tube as soon as possible, A
perseverance in the attempt will issue only in a violent attack of
paia In any case, too, in which violent pain has been induced
by local depletion from the uterus, it is expedient not to venture
on it again soon, but to substitute for it the application of four or
six leeches to the anus, which dmw much more blood, and afford
far more effectual relief to the organ than double the number
applied U) the hypo{^astrium, or to the groins.
After depletion, the tepid liip-bath and anodynes are the
remedies on which we must mainly rely. I will not now repeat,
with reference to the cnmparati%^e merit of different remedies of
this class, the remarks which I made when speaking about
dysmenorrhcea, but there is one very serviceable raedicine^ —
belladonna, tliat I did not then mention. It is well, as the
strength of the extract varies considerably, to begin with a small
dose, m a sixth or a quarter of a grain, in combination with three
grains of camphor, and t^ repeat it every four hours, increasing
the doge if no injurious effect is produced by it You will also
bear in mind the suggestion of M, Bernutz which I mentioned
the other day as to the great utility of conium for the alleviation
of uterine pain, i\nother means of alleviating pain, which in
cases of this description has sometimes proved extremely useful,
consists in the application of a linseed poultice, into which an
ounce of laudanum has been stirred while it was mLxing, and this,
if covered over with oiled silk or gutta-percha, as all poultices
should be, will keep warm for many hours, and afford much of
the etise which a dose of opium would procui'e, without its
unpleasant consequences.
That irritable state of the bowels which gives rise to occasional
attacks of dian-bani is best controlled by small doses of Hydrarg,
C Cret4 and Ikiver^s powder twice a day, while the attacks
themselves, as weU as the paroxysms of uterine p^ain, are most
speedily arrested by opiate enemata.
It is not possible to lay down any rule as to the repetition of
depletion, or as to the extent t^j which such bleeding must be
carried, since these questions must in each case be determined by
the urgency of the symptoms. If the pain is seated in one or
other iliac region, and still more if there is any distinct swelling
ACUTE INFLAMMATION OF UTERUS.
or even a sense of fulness in that situation, it may be assumed
that the ovary haa hecome the seat of intlamniation, and leeches
must then l)e ajiphed externally to the number of eight or twelve,
and repeated once or twice at intervals of a day or two, till all
acute pain and all considerable tenderness have disappeared,
Afterwai'ds, the application of a succession of small blisters over
the affected part has seemed to me very useful in removing all
pain and tenderness, and has, I believe, the further good effect of
reducing the size of the enlarged ovary. With the same view I
have sometimes employed ao ointment of six drachms of
mercurial ointment, two scruples of camphor, and two drachms of
extmct of belladonna, which is rubbed upon the atftictcd side
twice a day; though usually I confine the use of mercurial
remedies to cases where the ailment seems altogether passing into
a chronic state, in wiiich permanent enlargement of the womb
and induration of its tissue are apt to supervene. In these
circumstances a carefully conducted mild mercurial course is
often very beneficial, the bichloride of mercury being preferable
to other prepanitions of tliis drug, from its not readily irritating
the bowels or allecting the gums, and from its being quite
compatible with the generally tonic plan of treatment which the
patient s state usually requires.
In conclusion, two other remarks may be made. TJie first is
that a considerable degree of uterine tenderness is often left
behind for many weeks when the organ has been the seat of
infiammatiou, and this not infrequently renders sexual intercourse
very paijiful, sometimes almost impossible. This does not,
however, warrant anxiety, for it tends by degrees to disappear;
and with this assurance you must comfort your patient* The
other is, that you cannot, after an attack of uterine infiammatiou,
watcli your patient too carefully during the next one or two
menstrual periods. It is at these seasons of congestion of the
sexual organs that the great danger exists of the fire, which
perhaps was merely smouldering, being rekindled ; while if your
patient passes safely through that process, you may feel confident
that not only the recent evil is removed, but also that no ill
consequences have remained behind.
LECTURE Vlt
INFLAMMATORY AFFECTIONS OF THE UTEEUS.
I'hronic IxFLAMaATiON, OR CcJKGESTiON. Oft^Ji, but Hot alwiiys, Lu>anected with
pT«vioiw pregnancy and labonr. Peculiarities of uteras fnvour it* occurrence*
FrepouderaDce among uiamed women.
Body of uterus most affected* and why, Symptomsi, reaulta of examinatioUi
State of cerrix-nl^eration.
Trmtrnent of Ihe fj^ueral eonditinu ; of the local ulcemtmti.
Catarrhal tTjxERATiON of Ckrvix. Its diameter. Treatment ] imp of rino
alum. Caution as to possibility of malignant character of aonje ulcerations
Endometritih. Imperfection of our knowledge of it. Sui>erv«nlioo in course of
fever, Pumleut Endometritin with thinning of ut<3riiie wall in the ag*.'d and
in others. Hiemorrha^'c Endometritis ; its character and symptoms. Treat-
ment of purulent fonm*, of bieniorrhagie and hypertrophic fumis.
I RUNTED out to you iH the last Lecture how favourahle the
conditions are in whi€h the uterus is left iniuiedtiit-ely after
delivery, or after miscarriage, to the occurrence of congestion, to
the ane^at of the pniper involution of the oi^an, and to the
supervention of chmoic inflammation, the effects ol which may
pei-aist for liiaiiy years, disturbing the functions of the orgau,
altering its structure, and outlasting in its effects even the
period of sexual vigour.
But such results are by no means limited to seasons when the
uterus has just Ijeen engaged in the performance of its highest
functiona ; hut a predisposition to tliem remains long afterwards.
Nor only so, but morbid processes, such as are most commoidy
called into activity by the incidents of pregnancy and parturition,
may yet originate in the woudj which has never dischai'ged its
highest offices.
That this aliould he so, indeed, will not surprise us, for were
there no other reason for it, we must remember that for thirty
years of life the womb is the great emuncU^ry of the female
system, with sympathies so wide that its disorders react upon the
108
PECULIARTTIES OF UTERUS
whole OTgaBism, and are reacted on by it; and it is scarcely
necessary tliat you slioiild be reminded how the excess of blood
in the system, or its deficieDcy, or its altered quality, may induce
menorrhagia, or may render the menstrual flow scanty, or how
other more complex aOments may have a similar effect, or may
cause the function to be performed with an unusual amount of
fiufTering. This greater liability to functional disorder than is
presented by any other organ in the body brings with it as a
necessary result a greater tendency to various forms of local
ailments, and a more frequent occasion for local treatment
It wonld not, indeed, be easy to imagine a state of things more
favourable to the occurrence of aihnents dependent on venous
congestion, or in which these ailments would be more difficult to
remove, or more apt to return, than is observed in the case of the
uterus during the whole period of activity of the generative
powers. The return of blood from the organ, which is rendered
difficult by its situation at the lower part of the trunk, is still
further impeded by the absence of valves from its veins ; while
every month, for several days together, this organ and it5
appendages are the parts towards which blood flows in
superabundant streams. During this period, the natural secre-
tion from the uterus and Fallopian tubes is much increased ; the
epithelium covering their surface is detached, and reproduced
again and again ; haemorrhage breaks out along the wiiole tract,
— and it is not until this has continued for some days that the
congestion ceases, and the parts subside once more into their
former state of quiescence, — the uterus remaining, howe%^er, for a
short time heavier, and its tissue looser, and more abundantly
supplied with blood than it was before. I need not stop to tell
how a slight cause may protract this haemorrhage, or how some
accident may check it ; nor need I labour hard to prove that in
either case there must be a general distmbance of the functions
of the oi^an — a general impairment of the health of the
individual : exhausted in the one instance by loss of blood,
broken down in the other by the suffering, both general and local,
which the return of the periodical excitement of the generative
organs, unrelieved by their customary depletion, cannot fail to
bring with it In what organ of the body does one And a parallol
to this series of occurrences ?
I
I
I
I
PREDISPOSING TO DISEA3E,
Again: the uterus is held in its position by supports whicli
allow to it a large meiusure of mobility, and whose power is
generally diminished by the very causes that increase the weight
of the body they have to bear. Hence it is very apt to beeuine
displaced, and to be displaced in a downward direction, or pro-
lapsed. And such prolapsus not only brings with it a variety
of painful sensations due to the womb dragging upon its liga-
ments, but the moment the organ ceaaes to be suspended
in tlje pelvic cavity it becomes exposed to shocks of various
kindu, to irritation from sources from which it w^as pre-
viously safe. The neck of the womb, even when that descent
is not very considerable, becomes a sort of stem on which the
organ rests upon the floor of the vagina. In this position it is
liable to disturbing causes almost numberless ; sitting, riding,
exertion of any kind, the very passage of the faeces along the
rectum, produce pam, keep up congestion, and favour that slow
increase of size which seldom fails to occur in parts the seat of
loiig-eontinued irritation, and which oilers one great impediment
to the cure of many affections of the WT»mb,
Another peculiar and fertile source of disorders of the womb is
furnished by the changes that attend upon conception and
jmrturition, and their frequent interruption. With these changes,
even in the healthy state, our acquaintance is at present too
imperfect for us to appreciate with accuracy the nature of the
mischief that may result from their disturbance. We know,
indeed, mauy tilings concerning these processes of wiiich oui'
predacdssors were ignorant; but our increased know^ledge is aa
yet only sufficient to show us the difficulties of the problem, not
sutlicient to furnish its solution. The growth of tlie pregnant
womb is not, as it was once supposed to be, a mere increase in
size and unfolding of texture of the muscular fibres already
present there, but is as much the result of a new formation as is
that of the foetus contained within it ; its tissues going through
tlie same development from a rudimentary condition to high
organization. Cells elongate into caudate bodies, these unite into
tibrilhe, while the mucous membrane increases in vascularity,
grows in thickness, and becomes developed into decidua. The
small, dense, lowly-organized uterus becomes the large, vascular,
powerful muscle which we see it to be at the end of pregnancy^
110
PKEGNANCY AND LABOUR
when, having served as the reaidence of the fcetws, and aa the
medium through which it derived its support, the organ accom-
plishes in the act of parturition the last of that wonderful series
of processes of which for forty weeks it haa heen the centre-
But even before this period hag arrived, indications of decay have
manifested themselves in the changes that have taken place in
the deciduaj while no sooner is the child born than all the
tissues of the womb evince the commencement of similar
alterations, which go on with a rapidity such as is observed in no
other organ and in no other circumstances. The muscuhir fibres
undergo fatty degeneration, and to a great extent disappear;
nerve-matter ceases to be apparent within the sheaths which had
contained it, while even the fibres of elastic tissue interwoven
with the muscular substance of the womb lose their distinctness,
or become entirely absorbed. The old uterus has doiie its work
and is removed ; but in the midst of its decaying fibres the
elements of a new organ are developed, and the microscopist tells
its of a new generation of spindle-shapK?d cells wliieh he cau
discover in it^s tissue, just like those which existed in the organ
before pregnancy began, and which remain stationary at the same
low stf^e of formation, till in their turn excited by impregnation
to go through higher phases of development
In these changes the body of the uterus, and the lining of its
cavity, bear a far greater part than either the substance of its
cervix, or the mucous membmne which lines that canaL The
mucous membrane of the body only is developed to the decidua,
and it alone Ls thrown off after delivery ; the lining membrane of
the neck undergoes much slighter alterations, and is not
deciduous. It is in the body of the uterus that its muscularity
is most evident ; firm fibrO'Cellular tissue predominates in the
cer\"ix, wnth which are interwoven here and there bundles of
narrow, smooth, muscular fibres ; and the stimulus of pregnancy
which works such changes in the former situation, brings to pass
far slighter alterations in the latter.
Though our knowledge is still but imperfect, we yet know
something of the results which often succeed to ueeidents that
interrupt the course of pregnancy, and originate the processes of
degradation of the uterine tissue prematurely ; or which follow
on disease succeeding to delivery at the full period. Some of
I
I
I
CAUSES OF UTERINE DISEASE.
Ill
these results were pointed out to you in the last Lecture, when I
was speaking of deficient involution of the uterus, and of the
evila that may follow in its train; while I referred to other
ailments of a somewhat similar character which may come on
independent of pregnancy, as the consequence of some form of
irritation or excitement of the womb.
In nearly fifty per cent of the patients who applied at St
Bartholomew's Hospital for the cure of uterine ailments
independent of organic disease, marriage, pregnancy, or delivery
was assigned as the cause of the patient's symptoms ; and it m, I
think, fair to assume that in this large propoition of caaaq the
disuitler was local in its origin, and that the constitutional
afifection was hut the secondary result of its intensity or
persistence. Plausible, indeed, as the argument appears, that the
performance of functions for the discharge of which any organ is
expressly constituted cannot be likely to produce disease of that
organ, you yet must not forget those peculiarities of the uterus
which render it a probable exception to such a rule^ while the
fact is also not without its significance, that of 425 applicants for
the relief of non-organic uterine ailments, 404 were manied
women or widows, and only 21 unmarried.*
It is in accordance with what these facts would lead us to
expect, that we find in the great majority of cases that the body
of the womb is the more affected in cases of chronic inflammation,
that its enlargement precedes in almost alt instances that of the
neck, and that thou^^h the two are frequently associated, yet in
general inflammatory enlargement of the neck is secondary in
order of time, and subordinate in point of importance.^*
• It is not yHifviible, from the statifltiea of the oot-yiAticnt dejiartmeot of a haspital
to dedot-e aiiythiug like a correct estimftte of thi? comi>arfltiv'e frequency of dilfor-
ent diseaaes ; nnd the sources of error are jitiU more numerous in the caae of any
di*paitm«nt of a hospital devot€*<l to the cure of a special claiu of diaeaaos ; since
th« morti serious of those alfectiona are sure to prRsent theimselvca at it in a very
undue proi>ortion. The statemeDta in thti text, then, are not intended to repn:-
ae&t the absolute frefjuf'ticy of primar)' uteriiie diae«ae, in oomparijon with casei
in which the disordt-r of the womb is secondary to constitutional ailment, but
merely to guanl against the assumption that th<^ uterine affection i«, in almost all
inatancea, s^^'ondar)' in point of time and anbordinate in importance,
t It is not without interest to observe how sj^eedily deltat^s which ae«m«d otiee
of great moment, and very hard t<j ««*ttle, find their solution. It hm been so with
refereucu to the imporUiut:*; of uli^eration of the o* and inllamniatiou of the uerviJt
112
CHUONIC CONGESTION OF tTTERUS :
i
Few tilings are more difficult than to aketch correctly the
history of a chronic local ailment, especially when the organ
affected is one of complex structure, whose difibrent parts have
tlitrerent functions to perform, and whose sympathies are so wide
that the whole system ahai-es in the sufferings of the part, and
shares them, too, in a manucT which may outlast the local ill
wherein they originated.
The history of such cases is uaiially something of this sort ; —
an aching is felt in the groins, a sense of weight in the pelvis,
and hearing down, a pain referred to the sacrum or to the last
lumhar vertehra, which rest relieves but does nut remove,
llenstniation at the same time becomes more painful than it was
before, and a day or two previous to its occurrence the local
discomforts are aggravated, while when the flow really begins,
]>ain3 like those of uterine contractions are often experienced,
which cease when the period is fully established, to return again,
though in a less degree, as the discharge passes ofi". Menstruatioa
itself varies in quantity in these cases. At the C(*iumeuceraent
of the illness it is often increased (so much so indeed sometimes
as to amount almost to flooding), and its occurrence gives tem-
porary relief, but this alleviation becomes by degrees lees con-
siderable, even though the loss of blood should continue
undiminished. For the most part, however, the discharge grows
scanty sb the illness continues, while, whether scanty or profuse,
the pain attending on menstruation becomes severer, and lasts
during the whole of the period, which at last is a time of uninter-
uteri, whkli T made the theme of my Crooiiian Lecturcn in 1854, published after-
ward, under the title of Jn hiquirif ijito the FaUiolmjkGl Impfjrkuicc of Ukeratioii
of the Ob Ukri. 8vo, London, 1864.
I may, however, be [^wirJoned if I refer here to the endor^m^ot of my opiniona
some tcD years later hy Professor Scaiizonj of Wiirzbiirgh, whose large e]ci>erieiic«
leada bim to say :—
** Awy unpn^Ju diced observer must come to the conclmmon tbjit tbe importance
of the flo*called inflammatory nftectiozis of the neck of the womb has been too
tntich over-estimuted in the course of the last twi^iity years ; that many a discomfort,
ranny a symptom of dbease, haa been attributed to these conditions, without the
slightest proof of any real connexion subsisting between tliem,
**Wc, for our part, are firmly convinced that the fjathological changes of the
upper portion of the uterus are of much greater moment, both locally m well m»
with reference to the disorder which they produce in distant orgnns, thuji the
recently so highly estimated swellinp, hypertrophies, grwmlationB, and ulcerations
of the cervix."— Z>w Chronuche MdritiSf 8vo, Wien, p. 53, 1863.
ITS SYMPTOMS.
113
rnpted and intense suffering. In the menstrual intervals leuoor-
rhai'ii IB present, at first mucous, then puriform and sometimes
slightly blood-stained, then yellow and purulent, or intermixed if
the cervical glanis participate in the affection, with an albuminous
secretion which may be so exceedingly tenacious as to be with
difficulty withdrawn through the speculum from the mouth of the
womb which it occludes.
In this condition it scarcely need be said that sexual intercourse
is intensely ptdnful» and pregnancy most unlikely to occur, while,
if it should happen, it is almast certain to end in an early mis-
carriage, attended with great suffering, and followed by much
aggravation of the ailments. Defteeation is painful, and the
bowels, partly in consetiuence of the discomfort which any
attempt to empty them produces, are almost always constipated,
while the bladder is generally irritable, and micturition often
painfid. The aching in the groin becomes constant and more
severe, and stabbing pain is often referred to the womb; the
whole hypogaatrium is tender, the tenderness bein^^ usually more
intense in one iliac region than in the other, though often so con-
siderable over the whole lower part of the abdomen that the
patient cannot bear the weight of her own hand to rest upon it.
The general health cannot hut suffer from the local ilL The
api^etite fails, and digestion is disturbed ; pain pi'cvents sleep, the
tired nervous system gives w^ay, and all kinds of hysterical ail-
ments become superadded to the direct results of the disease.
Appropriate treatment, and absolute rest for months together,
bring at length an amelioration of the symptoms, and the patient
passes through a tedious convalescence to a condition of imperfect
health. Often, however, some slight imprudence, a little over-
exertion, a cold caught at the menstrual period, the occurrence of
pregnancy, even a return to the mamage bed, suffices to rekindle
the old tire, which is once more extinguished only by a rej^ietition
of the same irksome treatment as was needed before, and con-
tinued for a still longer time. At length, when fifty yetirs have
been attained, the sickly, aUing nervous invalid piisses, to the sur-
prise of all her friends, into the robust woman who complains of
neither ache nor pain, who is equal to all exertion, for she has
laid aside her sex's weakness with her sex's functions.
Wliat we may next ask is the condition of the oi^an when
E
I
^-m
CHHONIC CONGESTION OF tTTERUS :
disease has brought with it such grave resalta ? To the touch it
is found tender, often intensely so, a condition shared m by the
yagina, and frequently by the vulva generally, so that the patient
shrinks from the gentlest touch. But how great soever may be
the teiidei*nes3 of the passages, that of the neck of the womb
is invariably greater, and pressure upon it, nio\dng it on the body
of the organ, or touching the posterior surface of the body, or
passing the fingers np on either side of the womb, is attended by
intense suffering, and suffering all the greater in propoiiion as
the movements of the examining fingers are sudden and jerking;
The organ is usually lower than natural in the pelvis, though
at the game time it is enlarged, and often sufiiciently so for its
fundui? to be felt by the hand pressing above the pubes, provided,
that is to say, that tenderness does not prevent the experiment
being made ; or that a retroverted or retroflected condition does
not withdraw the fundus from reach. One or other of these
latter states is, however, extremely common, — the overweighty
fundus sometimes tOting tlie whole organ backwards, at other
times bending the body of the womb upon the neck and thus
causing retroflexion; malpositions which, just as when they
occur in other circumstances, often outlast the conditions in
which they originate.
In the earlier stages of this condition there is generally an
increase of heat in the affected parts, though with the lapse of
time the temperature in general becomes natural Almost
always, too, leueorrhoeal discharge is present, the amount and
character of which depend in a measure on the presence or
absence of ulceration or abriiaion of the os uteri, and on the
degree to which the cervical folUcles are the seat of irritation,
though some discharge is almost invariably furnished from the
interior of the womb.
And this brings us next to the inquiry into the condition of
the neck of the womb in these cases. As a rule it participates in
the changes of the body, and like it liecomes thickened,
indurated, and enlarged ; and the more lowly organized tissue of
the cervix, when once it has undergone these changes, seems to
revert less slowly even than the l>ody of the womb to a healthy
state. In many instances, too, though not in all, the surface of
the uterine lips becomes the seat of those abrasions or i
I
I
I
I
U
TOLERATION OF OS AND CERVIX.
115
to which what is bow regarded as an undue importatice wa«
formerly attached, ad though they were the cliief factors in the
production of that state to which the name of chronic inflamma-
tion, or chronic congestion, has been given, and of wliicli I have
heen endeavouring to descrihe to you the main features.
These ulcerations are for the most part mere superficial
abrasions of the epithelium investing the lips of the 08 uteri, the
surface of which ia then seen of a vivid red colour and finely
gmnular. This granular appearance seems to \*e due to the
papilla:' that beset the uterine lips having become denuded ; while
the lai^er and more distinct granulations, which frequently bleed
readily on being touched, are these same papilla^ not merely
deprived of their epithelial investment, hut actually hypertrophic*
In other cases, in which the absence of epithelium is less
complete, the surface seems beset by a number of minute
superficial aphtlious ulcerations, between wliich the tissue
appears healthy, or slightly redder than natural. The ulcerations
of tlie OS uteri seldom or never present an excavated appeamnce
with raised edges as ulcers of other parts often do ; hut either
their surface is smooth, or it projects a little beyond the level of
the surrounding tissue. They are usually, but not constantly, of
greater extent on the posterior than on the anterior lip, are some-
times confined to the former, but very rarely indeed limited to the
latter. They app ar to commence at the inner margin of the os
uteri whence they extend outwards and sometimes, though by no
means invariably, the short extent of the cervic^ canal, which
ean be brought into view by the speculum, appears denuded of
its epithelium. The adjacent parts of the cervix uteri vary
considerably in their api>eamnce ; sometimes their natural pale
rose tint is preserv^ed up t43 the edge of the abrasion, which is
marked by a distinct well-defined line, while at other times the
whole surface is of a much more vivid red than natural, and the
line of demarcation between Hie abraded and the healthy surface
ia irregular and indistinct, the one encroacldng on the other*
The orifice of the uterus is generally more open than in a state
of health, and the disappcamnce of the abrasion, which always
takes place from the periphery towards the centre, is aecom-
• See tlic nocount of tbeir microscopio rtnicture in the clHlxirat4» work of Heimig p
At Katarrh dcr weibliehtn OMchUehUihHle, 4to, Leij>2ig, 1862, i>. 61
116
CHRONIC CONGESTION OF UTERltS :
panied by the gradual closure of the previously patent orifice;
The state of the tiasue of the o& and cervix varies ; sometimes
there is a very market! softness of the parts, the condition
resembUng tliat of the uterus soon after aliortion or delivery,
while at other times it is much harder than natural ; but it
certainly is not at all a common occurrence for extensive
abrasion of the os uteri to co-exist with a condition of the organ
such as would seem healthy to the touch. The secretion from
the surface varies cooeiderably in difTerent ciLses, and the chief
part of the leucorrhceal discharge from which the patient
suffers is derived from within the canal of the cervix, or from
the cavity of the womb, not from the aljrasion itself. Still, in
some instances, those especially in which the idceration presents
a very marked ^rranular character, the discharge derived from this
source alone is far from inconsiderable. The degree of sensibility
which the ulcerated surface possesses also varies greatly ; now
and then the shghtest touch is extremely painful ; but in the
majority of cases, the ulcerated siu-face is not more sensitive than
the adjacent parts, nor is the neck of the uterus whose os is
abraded by any means constantly more tender to the touch than
the same part of an or^an entirely free from that affection.
I have for convenience sake described together the two comli-
tions of chronic coiigostion, or chronic intiammation of the womb,
and ulceration of the os uteri. I must, however, remind you that
the two states are not of necessity associated ; that you may not
only meet with affection of the body of the womb unassociated
with any ailment of the cervix ; but that ulceration of the os, or
chronic catan'hal inflammation of the cervical canal, is of still more
common occurrence as an independent disorder. The remarks
which I may make, therefore, on the treatment of ulceration of
the OB uteri will be understood to apply to it whether it is met
with alone or in combination with affection of the body of the
womb J though, in the latter case, recovery is naturally slower, and
treatment of necessity more protracted.
We will, however, consider first the trenlment of chronic inflam-
mation of the body of the womb. This, as you will readily
understand, diflers widely, according as the symptoms have any-
thing of an active character ; or, on the other hand, are purely
chronic, though in both cases the indications to be met are but
I
rrS TREATMENT.
117
few, and the meanB to be employed abundantly simple. So long
as acute symptoms are present, or whenever tbey reappear in the
chronic stage of tlie disorder, local leeching generally affords more
speedy and more decided relief than any other remedial means.
The leeches should l^e applied to the uterus itself; not above
four in number at a time ; nor is it in general expedient to repeat
their application above once in a week or ten days. Another
precaution to which your attention has already been called, con-
sists in never leeching the womb within four or five days of a
menstrual period, lest the regularity of that function Ije disturlied,
either by being brought on prematurely, or (which, however, is
much leas frequent) by its occurrence being postponed for several
days. The pidn which is left iKjhind after menstruation in some
of these cases — in those, eapecially, in which the disebaige is
scanty — is often very greatly relieved by the application of a few
leeches as the period passes offi Next to the alietraetion of blood,
the mitigation of suffering by direct sedatives claims our attention.
After what has been said in former Lectures on this anliject, I
will now merely remind you that, when sedatives may be long
needed, the milder the preparation, and the smaller the dose, the
less will be the risk of injury to the health from their continuance.
The baek-ache is often relieved by couDter-irritation to the sacrum,
wiaich is usually moi*e efficient than plasters of opium or bella-
donna, while its gimd effects, also, are in general less transitory.
As suitable a preparation for this purpose as any is a croton-oil
liniment, composed of one part of croton oil to ten of the simple
camphor*Uniment, which should not be rubbed into the sacrom,
but merely applied with & sponge twice a-day ; and while thus
employed will somewhat irritiite the skin, but without producing
any troublesome pustular eruption.
The same means as relieve the uterine pain, seldom fail to
diminish the irritability of the bladder by which it is oft-en
attended, and which, after the first more acute symptoms have
passed away, is ver}^ generally associated with abundant phospha-
tic deposits in the urine. Small doses of hydrochloric acid, with
tincture of henbane and the extract and decoction of pareira, are
then most serviceable. So long as there is much pain or much
uterine tenderness, no local applications nor vaginal injections
will be of service, except such as are simply soothing^ as tepid
118
CHBONIC CONGESTION OF UTERUS ;
water ; and for the same purpose the tepid hip-bath raay be found
of benefit Wliile these measures are emphiyed, absolute rest for
a time is needed, though it must never be forgotten, in the treat-
ment of uterine ailments, that there are certain positive evils to
which prolonged rest exposes a patient, both by the general inter-
ruption of her health, and also by the almost inevitable direction
of her thoughts, during the days of seclusion from her ordinary
pui-soits and ordinary amusements, to the seat of suflering. At
the same time much prudence is necessary in breaking through
restrictions ; and even for months after the patient is convales-
cent, the approach of a menstrual period, the presence of men-
struation, and the first few days after its cessation, are seasons
when every precaution must be most strictly obsei'ved.
If promptly met, the symptoms sometimes pass away gradually,
hut umnterruptedly ; tliough the tendency to relapse, which each
menstrual period brings with it, or which some very slight impru-
dence suffices to occasion, is one of the most disappointing
features of these cases. In these relapses, too, the mischief some-
times extends to the peritoneal investment of the womb, and hence
those adhesions by which the organ is sometimes pemianently
boimd down to the rectum, or confined in a position of abiding
retroflexion or retroversion.* After several such misadventures,
we Ond the uterus not only enlarged and less movable tlian
natural, but its tissue generally feels harder. Leeches will still
do something in many instances towards removing this condition ;
though it is in general inexpedient to apply more than two at a
time, and the result of their employment must settle the question
as to the frequency of their repetition. In these cases the
bichloride of mercury, steadily employed for many weeks, has
seemed to me preferable to any other remedy, exercising a decided
influence in reducing the enlargement and diminishing the
induration of the organ, while it neither irritates the bowels nor
affects the mouth, as other mercurial preparations do ; nor disordei-s
the digestion, nor produces sleeplessness, both of which evils are
incidental to the employment of iodide of potassiuuL I prefer
giving it in the form of pill, with a few grains of extract of hemlock,
and if this is taken in the course of dinner or luncheon all risk of
* It ia U) these which Mftdame Boirin refers in her little tract, Sur une det
pauses dc V AvoriaiieiUf etc., 8?o, Faria, 1828.
I
ITS TREATMENT^
119
irritating the digestive organs is avoided, a matter of no sliglit im-
portance, where, as in these cases, the appetite is fickle. Some
kind of tonic is often needed, and few are so little hkely to disagree
as the liquor einchonre. If the bowels become constipated, or the
liver gets out of order, accidents very apt to happt^n ; sui5f>e.n8ion
of the tonic for a day or two, and an aperient with two or three
grains of blue pill, or a pill containing a gi'ain and a half of gi'ey
powder, of watery extract of aloes, and of extract of henbane, will
usually remove the symptoms.
Pain ill either iliac region is a very frequent attendant on this
condition. A smdl bhster will genemlly effectually reheve it ; or,
if the pain is scarcely so severe as to necessitate the employment
of a remedy from Mdiich patients usually shrink, a liniment of
belladonna, aconite, and soap liniment, may be employed
instead.*
Long after other symptoms have passed away, or have at least
been very greatly mitigated, there remains a disposition to excessive
menstruation, and also to profuse leucorrha?al discharges, due, I
believe, to the [>er9Lstence of congestion, not of the uterine substance
only, but of the lining membrane of the womb in particular.
This is a state of things for which chalybeate preparations are
generally the best remedy, and 1 know none better than the eum-
pound of sulphate of iron, sulphate of magnesia, and sulphuric
acid, which I mentioned some time ago.-f" Another remedy which
I have tried with advantage on Dr Tyler Smith's recommendation,
88 specially adapted to cases where menorrbagia is a prominent
symptom, is a oompoimd of alum with sulphate of iron. He
speaks of a compound salt* which he has employed for his hospital
patients ; but, even in the rough form of extempore prescription,
it has seemed to me very useful
But, besides internal medicines, various external remedieSi
• (No. r.)
A Extr. Bftlbdotinie . . 5as
Tinct Aconiti (Fleming^) . 3'*'
Liu. Saponin, co. . , Jjaji — M. ft. Linimeotum.
For this very asefol formula I am indebted to a pftper of Dn OldhiLm'6 ** Oti the
IJte of BichJoride of Mercury in Hypertrophy of the Utems^** Ouy's Hospital
Jtej»ri$f 2ut! Series, vol vi. pt. i. p. 16L
t Sec Fonnnlft No. 1, p. 43.
t Th4 Falhology and Treatment of LeucorrhcBo^ 8to^ 1655, p. 19S,
120 CHKO^nC CONGESTION OP UTEBUS.
such aa hip-baths and vaginal injections, may be employed with
advantage in the more chronic stages of this affection. It is true
that we who now believe the main source of the discliarge in
these cases to be not the vagina, but the uterus, cannot anticipate
80 much good f^m their use aa was reckoned on by our
predecessors, who imagined that the fluid injected into the vagina
came into direct contact with the secreting surface whence the
leucorrhceal discharge was furnished. Still, mere purposes of
cleanliness furnish one veiy obvious reason why injections should
be employed in every case of abundant leucorriura ; while, in
adchtion, it may be borne in mind that almost always, when the
ailment is of long standing, a part of the discharge is poured out
from the vaginal walls, and some also from the folhdes of the
cervix, on both of which it may be expected that the medicated
fluid will act more or less energetically. The injection also will
serve to give tone to the relaxed vagina, and thus tci counteract
the disposition to prolapsus, which is an almost constant sequela
of uterine inflammation, while, if fluid is used abundantly, or
its injection continued for several minutes at a time, it is also not
without decided influence on the body and cavity of the womb
themselves.
For any such ends to be gained, however, it ia essential that
injections be employed efficiently. The patient must place
herself in a recumbent or semi-recumbent position and employ
one of Kennedy's or Higginson*s syriogea, washing out the vagina
with tepid water before employing any medicated lotion, and
ob8er\dng that a weak lotion abundantly used is likely to be more
serviceable tlian a strong lotion used sparingly.
Still more eflicacious is the douche, which indeed I am
accustomed to employ very generally in hospital practice, in all
cases where the uterine cavity appears to be the source of the
discharge. Tlie only drawback from its use is, that there is a
kind of fuss in getting it ready, which induces me, in private
practice, usually to substitute for it the hip-bath. By dissolving
a quarter of a pound of alum in the water of the bath, a very
good astringent is obtained. If the patient is apprehensive of
taking cold, the bath may at first be warmed to about 70'' j and
by degrees its temperature may be reduced till it is taken quite
cold. The morning is the most convenient time for using it, and
TREATAfEiTT OF tfLCERATlONS OF CERVIX.
121
the patient should remaiii in it at least ten minutes, in order to
derive any iniportant benefit.
With reference to vaginal injections, the point of most
importance in their composition is, that they should be
inexpensive and readily prepared by the patient herself. The
dilute lead lotion, which can be readily made from the Croulard
extract, lotions of zinc, or of alum, all have their advantages ;
while two drachms of tannin, and half an ounce of Rlum dissolved
in a quart of water, form as powerful an astringent as the
decoction of oak-bark and alum lotion^ which requires much time
for it8 preparation.
Though, in the great majority of instances, these measures
suffice for tlte gradual recovery of the patient, yet to this rule
there are occasional exceptions, and local applications are
sometimes necessary to bring alwut the healing of an ulc-erated
or abraded condition of the os uteri, wliich may have persisted,
unaffected or hut little modified, by the general treatment \ or
which, AS has been stated, may exist a& a cause of troublesome
leucorrluea, and an obstacle to conception, independently of any
affection of the body of the womb.
The vivid red appearance of the os uteri, associated with more
or less extensive abrasion of its surface, and a slightly granular
appearance which is not infrequently met \iith, for the most part
altera its character^ leases ita vivid colour, and finally disappears
under the local depletion which the state of the ut^^rus generally
calU for. Sometimes, however, it continues, its granulations
become large, soft, very vascular, and bleed easily, wliile the sur-
face furniBhes a very considerable quantity of glair}^ discharge.
In this case the os and cervix uteri are usually tender, sexual
intercourse is painful, and ia often followed by a little bleeding.
This condition, hke that swollen and granular state of the palpe-
bral conjunctiva with which we are familiar in the purulent
ophthalmia of young children, is generally much benefited by
extensive scarifications, which may be followed l»y the daily
application of powdered alum on a piece of cotton vvool or by the
introduction of a piece of cotton wool soaked in a strong solution
of alum. By means of a piece of thread tied to the cotton wool,
it can be removed by the patient herself in the course of a few
hours, though it must always be introduced tlii-ough the speculum.
122
ULCERATIONS OF OS AJJB CERVIX UTERI :
la the greater Tiumber of iusttincea, the state of the os wten
becomes so miicli ioiproved in four or ^ve days that this mode ut'
treatment may be then dispensed with, nud the sedulous eiupK>y-
ment of strong astringent injections will usually suffice to complete
the patient's cure. When this is not the Ci^se, but the morbid
condition still continues, more powerful appUcations may be
needeiL The nitrate of silver is not in general suitable in these
cases, for its application is often followed by piiin and also by
bleeding. The acid nitrate of mercury, both in this instance and
also whenever a strong caustic is required, has seemed to me the
most uscfid application; and with moderate care its employment
is unattended by risk, Wlien it is used, however, the patient
must lie on her back, and one of Coxeter s bivalve speculums
being introduced so as thoroughly to expose the os and include
the cervix, a little cotton wool must be carefully disposed all
round the edge of the speculum, so as to absorb any of the super
flous acid, and to prevent it from running down outside the specu-
lum, and thus injuring the vagina. A brusli can easdy be extem-
]jorized by trimming a little piece of cotton wool after it is placed
in the holder, and the whole diseased surface may then be painted
over with the caustic, wliich immediately forms upon it a white
eschar, A piece of dry cotton wool now pressed against the part
will absorb any sufiertluous caustic; the little strips placed
around the edge of the speculum may then he removed and the
sj)eculum withdrawn. An additional precaution, however, w^hicli
it is w^ell to take, consists in introducing, before the withdrawal of
the speculum, a piece of moistened cotton wool up to the os uteri,
wlience it may he removed in the course of a few hours by the
patient It is seldom that either pain or bleeding follows this
application ; and at the end of a week the eschar will usually be
separated, the surfsice will be found to have lost its fungous char-
acter, and cicatrization to be commencing at its edges. A zinc
lotion of about five grains to the ounce, or the black wash employed
as a vaginal injection twice a-day, will now genemlly be sufficient j
but sometimes the surface puts on an indolent character again,
and it may then be expedient to touch it once or twice with the
nitrate of silver, and I have occasionally found it necessary to
repeat the application of the nitrate of mercury.
Another state wdiich I have but rarely met with, but which
THEIR TREATMENT.
123
seems usually to call for caustic applications^ is one in which the
OS iit€ri 19 tilt; seat of a distinct ulcer, with sharply cut edt^es, its
surface apparently a little depressed below the adjacent tissue,
partially covered by a thin layer of dirty yellowish lynipb, but
red and bleeding on its removal This condition has usually
come under my notice in women whose previous history afi'urded
evidence of syplLilitic infection some months before, and it has
generally disappeared rapidly under one or two applications of the
nitrate of mercury.
Ifesides the two above-mentioned conditions of the os uteri,
which are those that oftenest seem to call for caustic applications.
1 have in other instances employed them almost empirically,
where I have found ulc^n-ation or some allied morlud eonditiun of
the OS uteri to exist independent of any appreciable disease else-
where, or where a morbid state of the oa has persisted after the
other symptoms of uterine ailment have been subdued. Neither
the one nor the other of these cases has, however, seemed to me
of frequent occniTence.
Although I expressed my dissent from the opinion that the sole,
or ind'jed, in the majority of instances, the principal source of
leuconhceal dischai-ge, is the follicular structure of the cervix
uteri, it yet must not be forgotten that a very copious secretion
may be poured out from that part, and that, in some instances, as,
for example, in pregnancy, the discharge may be almost
exclusively derived from it The whole glandular apparatus of
the cervix uteri undergoes a remarkable development during preg-
nancy, and exercises its secretory function with an activity which
contrasts remarkably with its non-gravid condition ; and then also
many of the mucous follicles, attaining an unusual size without
opening and giving exit to their contents, form those bodies which
are usually known under the name of the Nabothian bodies.*
But, besides pregnancy, there are soma other conditions, not
* Further incident&l rumarks on the much debated qa^tioo of tlie natiine of
tbede N^botbUn bodies will be found in Lecture XII L, under the he^i of
** Ol&ndulAr Polypi, nnd Huoous Cytts of the (J tenia.'* It may suffice now, how*
er«r, to state that the retfons for regarding them u the obstnicUMJ uiqcoue follicles
of the cervix, which are aaaigned by M. Huguier, at p. 258 of hia paper **Sar lei
Eyaleade la Matrice/' &c., in vol. L of the Mimoirtade la SocitUds Chirurgie^
Mam to me quite concltuiTe. The aame view of their nataro ia taken ako hy Dr.
Hannigi op, ciL p. 63.
124
CHRONIC CATARHH OP CERVIX UTERI :
very clearly understood, though generally, I believe, connected
with some previous irritation of the body of the uterus itself » such
as miscarriage leaves behind, or aa may be produced by habitual
sexual excesses, as in the case of prostitutes, in which the cenical
glands become enlarged, and pour out an abundant transparent
albuminous discharge. In some instances, the discharge collects
within the cervical canal, and escapes in gushes at short intervals.
In other cases the dischaige is continuous, and may be seen issu-
ing in great abundance from the os uteri, which is usually found
open, its lips large but soft, and not tender, and a granular or
abraded condition of their surface as often absent as present, while
the body of the organ is in general quite movable, and not larger
than natural Between this condition and that in which there la
a positive cyst formation in the substance of the cervix uteri, the
difference is, I believe, rather of degree than of kind. The dis-
tinction betM'een leucorrhoea from this source, and that which is
furnished from higher up in the uterine cavity, is furnished by
the abundance of the discharge in the former case, its peculiar
transpai^mcy and tenacity, and the frequent presence of the
Nabothian t^odies on the lips, or about the edges of the os. In
this ca.se too, in spite of the long continuance of the leucorrhcea,
it is generally uoaccompanied by the graver forms of functional
disorder of the uterus, such as menorrhagia, dysmenorrhoea, and
ovarian pain ; while it is not infrequently associated with a stata i
of imtation of Cowper's glands, which pour out an increased dis-"
chaise, or even with obliteration of their duct on one or other side,
and accumulation of their contents so as to form a small encysted
tumour at the inner and lower part of the labium,
I believe this ailment, which is essentially chronic in its course,
to be of rare occurrence. It certainly, in its severer forms, is very
difficult of cure, and though rather an annoying infirmity than a
serious disease, I have seen one case where the complete failure of
a patient's health seemed to be due entirely to the abundant
secretion, which no means succeeded in checking-
The treatment which these cases require is almost entirely local
Something may be done by astringent lotions of various kinds, and
especially by such lotions, when employed by means of the
douche ; though you must not foiget that the douche is inappli-
cable whenever a suspicion is entertained of the existence of preg-
U
ITS TRKATMEXT*
125
nancy. Astringent hip-batbs, too, are of service ; while, during
the persistence of the discharge, it is expedient that sexual inter-
coiose be hut rarely indulged in.
I have found benefit in fiome cases from the introduction of
dossils of cotton wool steeped in a solution of tannin, or covered
with powdered alum, and applied by means of the speculum to
tbe OS uteri ; but I have made less use than perhaps I ought to
have done of the injection of astringent fluids into the cervical
canal itself, A very convenient contrivance for this purpose,
consisting of a very small elastic Ijottle attached to a curved silver
canula, is to be had of all instrument-makers. In some obstinate
cases I have cauterized the whole of the interior of the cervix
with nitrate of silver, by means of Lallemaud's porte-caustique,
but without advantage. It seems as if in these cases the action
of the nitnite of silver were expended on the copious secretion, and
scarcely reached the cervical follicles themselves. Something
may pKibably l)e done to avoid this evil, by the employment of
the douche, or of very abundant vaginal injections to clear the
canal of the cervix to some extent just before the caustic is em-
ployed, I am dispijsed to think, however, that in the most
obstinate cases it may be expedient to adopt a suggestion of M.
Huguier, of which I have but small experience, tliough I have
followed it with benefit on two or three occasions. He is
accustomed* to scarify the interior of the cervical canal with a
small, curved, narrow-bladed, blunt-pointed bistouri before intro-
ducing the caustic. The previous scarification exposes the more
deep-seated follicles, which would otherwise altogether escape the
action of the remedy ; and, while M. Huguier states that he has
never knoiATi any niischief follow this proceeding, he has by its
i-epetition two or three time^ efteeted the cure of caaes that
i-esiatetl every other mode of treatment,
[The late Dr Skoldtergof Stockholm introduced the use of sticks
of zinc-alum for chronic catarrh of the interior of the cervix uteri,
and they are now extensively employed, Tliey are made by
fusing together equal part^ of the sulphates of zinc and alum, and
are generally about half as tliick as an ordinaiy stick of nitrate of
silver* Their advantages are that the sticky mucus of the cervix
• See the third of bit ** Lectaret on Uterine CaUrrh,** in Qaz. des ff^pilaux^
126
CATARRHAL mjOSBLkrim OF CERVIX UTERI.
does not interfere with their caustic action, and that they'caiiterize
more deeply than nitrate of silver, and inore uniformly than most
of the more powerful sort. A atick about an inch in length is
passed through a speculum into the cervix, and made to keep its
place there by a plug of lint or cotton to wMch a string is
attached. The patient is directed to withdraw the plug by pull-
ing the string, two or three hours after the insertion of the caustic
stick, and then to irrigate the vagina by passing through it with
a syringe at least twelve ounces of tepid water* Many, indeed
most causes are readily cured by one application. But it may be
necessary to repeat it or to resort to other means.
It has already lieen fully stated in this chapter that the catar-
rhal ulcerations of the cervix are rather more or less superficial
abrasions than destructions of tissiie, with raised edges surround-
ing the diseased part. When such ulcers are seen on the cervix
as are evidently not mere abrasions, then there is good reason to
suspect their character. I have seen several such terminate
fatally as cancer of the womb, where, in an early stage, there was
only a genuine ulcer on a flabby large cenlx, that presented no
induration, caused no pain to the patient, and produced only
a yellow glairy laudable discharge- In such a case the disease
should be treated by strong cauterization at once. The same kind
of cauterization is occasionally required in cases where there is
great, and often somewhat nodular and indurated hypertrophy of
the cervix, and where mild treatment has proved inefhcacioiis.
In such cases, which are far from common, the actnnl cautery,
or the caustic potass, or the Vienna paste may be used. To the
actual cautery its formidable character starts a great objection
which is now very much modified by the neat and ingenious
thermo-cautery of Paquelin. In the meantime I prefer this to
any other treatment. Of course a wooden or ivory speculum is
required ; and, while the instrimient should be kept only a short
time within the speculum, a cooling lotion should be thrown in
immediately after its withdrawal ; and iK^fore the speculum is
finally removed, an emollient ointment should be smeared over
the cauterized part, or a plug of lint soaked with oil should be
temporarily used. The precautions required in using a stick of
caustic potass to destroy pretty deeply the ulcemted or abraded
surface are much the same as those described for acid nitrate of
IINDOMETBITIS.
127
mercury* But, in addition, the free use of diluted vinegar to
neutralize the alkali is a matter of course. Besides throwing it iu
as a lotion after the cauterization, it is usual to have a little pool
of it dnring the operation, in the end of the speeulum, just helow
the cervix uteri.
Chronic inflammatory disease of the cer\ix, prohaUy commenc-
ing in the mucous membrane, sometimes, though rarely, leads to
enormous indurated hypertrophies,' vith or without ulceration.
Tliese caase great suffering from uterine ailment and constitu-
tional disturbance; they also cause great alarm, for they are
likely to be regarded as of malignant character, and time alone
can complete the diagnosis. They are quite different from the
elongated simple or healthy hypertrophies of the cervix, which
retain a certain likeness in form to the healthy oigan. Two cases
have recently come under my notice in St Bartholomew's
Hospital One was in a woman who had suffered from sj^jhihs ;
the disease affected chieiiy the anterior half of the cervix, and did
not project into the vagina* It was superficially ulcerated.
Energetic and repe-ated treatment by themio-cautery reduced its
size to very moderate dimensions. In the otljer case, both lips of
the cervix were affected, and they projected deeply, each as big as
the half of a hen's egg. MaUgnancy was suspected, and the state
of the woman's general health confirmed the idea. In this case
tlie thermo-cauteiy proved ineffectual Both lips were removed ;
one by knife and scissors, the other (after being reduced in size by
cautery) by tlie tonsil guillotine. Both women have returned
lately, many months after the treatment, in a state satisfactory to
me, and themselves cheerful and satisfied.
This, too, is probably the fittest place for noticing the condition
of mdameirUis, to which casual reference was made in the lecture
on Dysmenorrhtea. The term is understood to imply acute or
chronic intlammation of the mucous membrane of the body only
of the uterus. It is a disease oar knowledge of which has made
ver>' little substantial progress. The state in which it was left
by Ki^camier, Nehitou. and Trousseau, and in which M. Aran found
it, was most unsatisfactory. The disease is generally not dan-
gerous to life, and the treatment by the curette was of a haphazard
character and imperilled life, as its promoters admitted and
illustrated by fatal cases. On this subject valuable practical
128
EXDOMETBITTS :
remarks have recently been made by Dr Keiller* in a criticism of
a new curette introduced to notice by Dr JIuude. It liaa been
widely felt that heroic treatment is, at least till lately, not justified
by the state of our knowledge*
Various important and not rare forms of endometritis occur
during pregnancy, and lead to abortion, adherent placenta,
haemorrhage, and perhaps other accidents. In this work these
forms do not fall to be described ; but, as it is impossible to keep
altogether separate the departments of obstetrics and diseases of
the oniinpregnated woman, I think it desirable to mention that I
have seen two remarkable cases of hj^erti-ophic endometritis
coming on in women suffering under typhoid fever. Eecamier
and Nelaton mention the occurrence of endometritis in
unimia^egnated women suffering from cholera. Vircbow describes
it i\s pseudo-menstruation with oophoritis ; and still more exactly
is it descritied by Slavjaosky,"!* both in cholera and t}T)hoid. In
my cases the disease attacked women in the early months of
pregnancy. Both women recovered from the fever, and were
regaixled as convalescent when abortion came on. The cases
were in most respects very much alike, but one proved fatal ;
while the other recovered, after being utterly despaired of by four
medical men in cousidtiition. She was a young woman recently
married to a physician ; and since her recovery has home two
healthy children. The following notes are furnished by the
husband :— First symptoms of fever on June 26, Crisis on July
17. Thereafter convalescence progressive tiU abortion on the
24th July. The placenta w^as removed eight hours after the
fcKtus, which was about four inches long. The third month of
pregnancy waa held to be completed on July 2L After abortion,
pulse generally very quick, 130-160. The temperature kept
high. When I saw her on July 27 the pulse was 160 and the
tempemture 104. Stimulants w^ere freely used, and a niixtnre of
nitric acid and sweet spirits of nitre ; also mild opiates in the
form of morphia suppositories. Her recovery after this was slow
but steady. Before my arrival her physician had removed a
large quantity of soft fleshy substance wdiich could be felt within
the uterus by tlie finger passed through the cervix. By the
linger and by forceps I removed also a large quantity, more than
• Edinburgh Mediml Journal^ October 1878.
t Jnhiv, /ilr (fyfkEkoloffUf IV. Band. a. 285.
L
ITS BIFFEREKT FORMS.
129
could be lifted in a table-spoon ; and desisted from the operation,
the patient being weak and excessively exhansted, aa soon as the
uterua was cleared of the thicker and more prominent masses.
These decidual masses came away in pieces of various sizes,
generally of the size and thickness of a field bean. Some
presented on one side a smooth, and on the other a ragged,
surface. Many had small ecchymoses in their substance. Veiy
little bleeding accompanied the operation.
Purulent endometritis may be so termed because its chief
feature is a copious, sometimes profuse, secretion of laudable or
sexous pus. The pus is sometimes tinted with blood, and
occasionally there are bleedings, which may even be severe ; but
the loss of bloud in any shape is only an accidental occurrence.
The discharges are occasionally putrid. Pain in the region of the
womb and around it are frequently, not always, complained of.
This disease of the body of the uterus has, aa a feature, distension
of the cavity, whose walls are, in the aged, reduced in thickness
and covered internally with a pyogenic-like membrane which
extends over it all or only over parts. The disease is well
illustrated by cases of the occlusion of the internal os uteri in
elderly women, when pyometra oceuj's. I have one such where
the uterine wtdl is not above 1 line thick, and where the cavity
filled with pus is of the size of 2 inches in diiimeten An
extraoniinary case of this kind was recently published in the
Obsteiriail Tratisacliwis by Dr (lalabin* Cases somewhat similar
are rarely seen in congenital atresia.
As purulent endometritis occurs characteristically in women
past the cliild-bearing period of hfe, and as there may be pain
with purulent bloody and ielid ilischarges, it is natural that
malignant disease of the body of the womb should be suspected.
The subsequent liistory of many originally doubtful cases verifies
the suspicion. But tlie Idstory of others is encouraging, and
treatment crowns the practitioner's efforts with success. There
can be no doubt that, in a long-continued ease, malignant
degeneration is very liable iu supervene ufjon disease that was
long of a curable kind. At present 1 have two cases under my
care, where there is no ground for suspecting mahgnancy. One
of them is in a woman aged sixty-four, and in whom the
discharge has lasted eleven years,
I
tso
Ein)OMETOITIS :
Purulent endometritis is not confined to elderly women. I
have more than once actually seen an inverted uterus in a young
woman — thick, spongy, and secreting profusely, the inflammation
being aeeompanied by pain and tenderness not of an intense kiniL
In these cases the disease was traumatic, produced by the
mechanical interference used with a view to reduction of the
inversion. Cases of purulent endometritis of still another kind
are not verv^ rare. In these, the disease is caused by morbidly
retained and decomposing ovuline and uterine structures, and
may last for a year or more. For examples, reference may be
made to my Researches in Obstetrics (p. 281). Lastly, I have
seen purulent endometritis with profuse fetid discharge come on
in childbed and last beyond the puerperal month. In one
carefully investigated case there was no doubt left as to its
simple character, and there was no retention of any discoverable
tissue. The patient had absolutely no suffering, and, except loss
of appetite, little constitutional disturbance.
If the uterine neck is opened up in these cases, and the finger
passed, the whole mucous membrane may be felt thickened and
velvety ; or only a part of it is in this condition ; and in this last
case the difference between the healthy and unhealthy parts is
easily made out.
The commonest and best known form of endometritis is
sometimes, and not inappropriately, called haemorrhagic endome-
tritis. It is the disease of Eecamier and his followers, and we
owe our beat account of it to Olshausen of HalM.* In his
description and in some others there is a tendency to neglect the
slighter forms of the disease and to consider only the mere
prolonged and severer, where hypertrophy of the mucous
membmne occurs. This hypertrophy is general, or exaggerated
in parts which project into the enlarged tender cavity of the
uterus, like polypus or molluscum ; and this gives some of its
various names to the disease — endometritis polyposa, vel tuberosa^
vel fungosa. But the majority of cases are comparatively slight,
and uterine h\"pertrophy may be inconsiderable or al>sent When
uterine hypertrophy is present, it is owing to and caused by the
growth of the mucous membrane, which can be easily felt to be
• Arehiv. ftir Oynmkolo^k, Band. tuL See also Biii<!liofr, Correspondens-BlaU
/. iMti'cis. Aerzte, 1878,
I
I
I
ITS DIFFERENT FOEMS,
in
morbid, soft, tLiekened, and with prominences of various sizes if
the cervix is dilated by a tangle- tent to admit of the passage of
the finger. Earely bits of decidua are found hanging semi-
detached, and post-morteni examination shows the mucous
membrane to have many disseminated little extravasations.
Tlie disease has no definite painful symptoms, its main
characteristic being an oozing of blood or of bloody and more or
less purulent serum, which is long continued rather than profuse;
but, even when slight, produces at length a condition of decided
ansemia*
The commonest cause of endometritis is abortion and natural
delivery. In such cases, however, especially when occurring
within a few weeks after the discharge of the ovum, the disease
may be simulated by the persistence of an undetached tag of
decidua, or by the pressure of blood causing an oozing tlirougb the
only partially restored membrane or through open venous sinuses
M^liose closure and disappearance has been delayed. The use of
intra-uterine pessm-ies is frequently a cause of the disease, and I
have seen this illustrated in the post-morrtmi examination of a
young woman who died of pleurd-pneumonia. The mucous
membrane was thick, spongy, and engorged with blood, and at
tlie fundus was a rounded deep ulcer, where the upper end of the
stem of the pessary pressed The disease associated with ovaritis
is common in consequence of gonorrhoea, of cholera, or of typhoid
fever. Besides, it is fouud without apparent cause. It occurs in
the unmarried as well as the married, and in the latter it is often
associated with sterility. The neck of the womb may be
unnaturally patent and softened, but it may present little devia-
tion from its healthy state; and this is its ordinary condition
in the slighter cases.
The earlier descriptions of this disease as offering granulations
on the mucous surface, or projections of the size of a millet seed,
I have never verified. But I have repeatedly felt, what has beep
also often observed in post-mortem examinations by myself and
others, the mucous membrane as it is fotmd in a menstruating
woman, or stiU more thickened and almost hanging in folds, or
witli various sized projecting masses.
The irmttftrnt of the disease is aided by a due regulation of the
exercise, diet, and bowels,— for the last, salines to be preferred, it
132
ENDOMETRITIS :
any laxative is required. If there is good reason to suspect tlie
retention in utero of any detached or semi-detached piece of
decidua or ovuline stnicturej it must he searched for through a
cervix dilated by tangle-tent, and removed. In such cases, the
neck of the utems heini^ sufficiently opened, irrigation by antisep-
tic lotion is all that is furtlicr required. For tliis purpose an
instrument like a male catheter with double tube is to be used,
and the operation performed with utmost gentleness. In the
purulent endometritis of old women I have been often and soon
successful, by injecting through a hollow uterine probe a drachm
or thereabout of solution of nitmte of silver, 30 grains to the
ounce. No other treatment has, in this form of the disease,
afforded me so good results. These cases should be early treated,
for I am satisfied that if the disease is allowed to last long, it
degenerates into malignancy and incurability in a considerable
proportion of instances.
The treatment of the catarrhal or h^emorrhagic form of
endometritis is at present a burning question, and nothing conclu-
sive can be declared regarding it. There can be no doubt that
the slighter forms are easily and quickly remedied, or get well
spontaneously. It is the hypertrophic or moi^ aggravated and
chronic forms that are difficult to manage. Besidejs ordinary
uterine antiphlogistic care, the free and continued use of ergot of
rye is the most serxdceable remedy. Xot unfrequently the bene-
ficial result is e\idently favoured by the previous dilatation of tbe
cervix, which has been made with a\iew to diagnosis. Thus, the
completion of the diagnosis, in addition to the medicine, did what
the medicine alone could not efi'ect.
In the hj^rtropliic form I have treated, by avulsion of the
pulpy masses by the uterine dressing forceps, T\ith satisfactory
results. I have occasionally used the curette, but have formed no
decided opinion as to its special utility. There are many objec-
tions to it, and these are better illustrated by the writings and
practice of its introducer than by any other. On the other hand,
Olahausen and Bischoff, to whose works we have already referred
as most valuable, inculcate its use. In this country caustics are
more in favour than the curette. I have repeatedly used the
strong ferri perchloride solution. It brings away a cast of the
uterine cavity such as comes away in some cases of dysmi
I
I
inenoF- I
ITS TRIL4TMENT.
133
tlicea; and, except the rare occurrence of temporary adheaive
perimetritis, I have nothing but good to say of the plan, from my
experience. At the same time I would add a caution against the
use of this salt if there are any distinct indications of malignant
ulceration or of the existence of considemble open vessels, I
have seen a fatal result follow the injection in one case in which it
was used in the treatment of malignant ulceration of the ho;ly of
the uterus.* Dr Attliill recommends the use of fuming nitric acid,
Dr Playfair uses carl>olic acid, and the reader is referred to Dr
Barnes' work on the diseases of women for an account of the use
of a great variety of remedies, including caustics.
In conclusion, it may he remarked that this di&ease is at present
not to be distinguished from adtnoma of the same structure in its
early ste^; for, in both, the microscopical appearances are closely
alike* The adenoma grows to form large masses, more or lesa
polypoid, and is genei-ally of malignant character. Tliis adenoma
has now been extensively observed and described, especially in
German works. There is another intra*nterine mollusc urn -like
growth which falls to Ije mentioned here. Bischoff describes it,
and I have examined some specimens. They are found alone, or
in uterine cavities dilated by the peculiarities of growth of a
uterine fibroid. Their peculiarity is that they contain no glandu-
lar structures, and they seem to me to have liad almost a
mechanical origin, growing to fill up otherwise vacant spaces in
the uterine cavity.
[As a result of chronic inflammation, thereniay occur com-
plete atrophy, producing, of course, incurable sterility, for the pro-
per histological structure of the membrane is utterly destroy ed-f]
• See Edinburgh Medical JmtmtU, Febniiry 187&.
[t See Mayrhofer, BUlroih*s Handbuch der I^u^nkranJtheUen^ II, Abscbnitt
6. 47, where references are ^veu to BokiUQ&ky, £leb9, ScanxoDii Schroeder, and
Gnmewaldt]
LECTURE VIII.
MISPLACEMENTS OF THE UTERUa
pROLAPHUR UTEBt. Reasons for tbe mobility of the uterus, and consequent variety
of uiispldcementB to which it is liabk. Vnrious degreca of prolapsus, ajxd
arrftiigements by wliiuh its occurrence Is opposed ; its causes, teodeMcy to in-
creaaer chiuiges in the uterus, aud in ai^ac«ot parts. Complete Prokpse, or
ProoidentiA.
ProlAP8£ of the Vaoina ;^itH relation to prolapse of the womb — may occur in
eonuexion mth hyi>ertrophy of walbi of canal ; peculiaritiea of thia form, and
hypertrophy of €«rvii uteri which it produces. Prolajise of anteiior, and of
posterior wall, with descent of bladder and of rectum : its causes, character,
and mode of production.
Amono the many wonderful adaptations of means to an important
end with wliich the study of anatomy makes us acquainted, not
the least remarkable is the contrivance by which the uterus is
suspended in the pelvic cavity, so movable as to escape any rude
shocks from withont, or any inconvenience from the varying con-
ditions of the surrounding viscera, and yet so tethered to its place
as to insure its enlargement going on, if pregnancy occurs, in such
a dii-ection as shall avoid needless discomfort to the person, or
pressure upon, and disorder of, the functions of other organs. But
this very mobihty, without which pregnancy would be a season of
uninterrupted suffering, and even sexual intercourse almost
impossible, naturally exposes the womb to the risk of changes in
its position, such as may theoaselves become the source of incon-
venience, and as call more frequently than almost any other
uterine ailments for medical interference.
It is obvious enough, that an organ suspended within a capacious
cavity by means of supports which are themselves yielding, must
be very likely to be displaced by comparatively trivial causes. In
the case of the uterus, too, the risk of its displacement is
increased by the circumstance, that ita w^eight and size are si
I
;es. In ■
further I
subject I
PBOLAPSns UTEKL
135
to variations, and that the very causes which tend to render it
heavier and larger than natural, have often the further effect of
diminishing the power of those supports by which it is retained in
its natural position. The tendency to misplacement, too, ia
further encouraged hy the pressure from above of the superin-
cumbent viscera, and by all those muscular exertions which a
person cannot avoid making in walking, in liftinfr weights, or evnn
in efforts at defalcation.
All these causes, indeed, tend to produce displacement in one
direction — namely, downwards ; and accordingly, in all but some
very rare instancea of uterine misplacement,* the organ is thrown
lower down than natural^ though there are some causes which
likewise incline the fundus of the uterus either backwards or for-
wards, and thus produca its rUrcmrsion^ or afUeverd&n, instead of
its simple proifipse.
Prolapse or de^-int of the womb is so much the most common
form of misplacement of the organ, that I will first notice it and
those aUied conditions in wluch either the rectum or the bliidiler
becomes pmlapsed, dragging in some cases the uterus with it, and
will afterwards call your attention to those moditications of its
situation in which its fundus is either bent or thrown backwards
or bent or tilted forwards.
Prolapsus of the womb, then, which is a common result of any
cause that either increases the weight of the oi*gan or diminishes
the strengtii of its supports, may exist in three different degrees,
for which different names have been proposed, but which it w^ill,
I think, be most convenient to designate simply as the Jirst,
Becomi, and thiTd degrees of prolapse.
In prolapsus of the first degree, the organ is merely situated
lower than natural, but still preserves its proper direction, its axis
corresponding with that of the pelvic brim, and this even though it
should l)e so low that its cervix rests upion the floor of the vagina.
In prolapsus of the wxyrid degree, the uterus is situated with
its fundus directed backwards, its orifice forwards, so that its long
axis corresponds with the axis of the pelvic outlet.
• The preternatuml tUteUUm of the uterus Is not only a rare comUtiob, but nXao
one which of ita«If givua rise to no peeaUar or chttractoristic aym|it^iti», Som^
remarks on its ditigaoatii^ import in iloubtrul caaei of Affection of the uterus or iU
apptrodag1^!i will be found in Lecture XIL
186
PBOLAPSUS UTERI i
In prolapsus of the third degree, or, as it is often termed,
procidentia of the uterus, the organ lies more or less completely
externally, Imngiocr down beyond the vulva, though it generally
admits of being replaced vrithin the vagina, if not of beitig
alt-ogether restored to its natural positiou*
Now the first question that suggests itself to us with reference
to this accident, concerns the manner in which it ib brought
about, and the mechanism which uiust be disordered before its
occurrence becomes possible* The off-hand reply that the womb
is maintained in its natural situation by its ligaments, and that
their weakening and stretching are the cause of its prolapse, is
neither minute nor correct enough to be of much service to us in
practice. The ivomb is not merely suspended in the pelvis by
the duplicatures of peritoneum within which it is contained, but
is also supported in its place by the vagina, on which it rests as
on a firm though elastic stem. The vagina is yielding enough to
allow of the voluntary efforts depressing the womb to the extent
of half an inch or an inch, but immediately these efforts cease, the
organ would in the healthy state resume its former position,
while any fuiiher descent of the womb would be at once resisted
by the duphcatures of peritoneum, which would be put on the
stretch. In the healthy virgin, however, the support afforded by
the vagina is very considerable ; for instead of being a wide
canal with membranous walls far distant from each other, as it
appears in so many anatomical drawings and preparations, its two
walls lie in close contact with each other, and thus form an
almost solid stem for the utems to rest upon» The curved
direction of the vagina further lessens the chances of misplace-
ment of the womb, while at either extremity the v^ina is
strengthened by its connexion through the medium of the pelvic
fascia with the bladder and rectum above, and by the sphincter
which surrounds it below, as well as by the other muscles of the
pelvic floor, and by the perineal fascia between the two layers of
which those muscles lie.
By these arrangements the very beginning of prolapsus is in
the healthy virgin altogether prevented; but let habitual
leucorrhcea relax the vaginal walls, or frequently recurring
menorrhagia diminish their resistance, just as the loss of blood
robs all tissues of their natural resiliency, and you will at
once ■
MEAKS BY WHICH IT IS PRETKNTED,
137
see that the first step towards the production of prolapsus uteri is
already taken. Wliile all things were in a state of health, the
connexion of the vagina with the rectum, and thereby with the
posterior pelvic wall, would have been the first to offer resistance
to the further descent of the womb. If the parts, however, are
lax and yielding, this slight resistance wdll soun be overcome, and
the anterior attachments of the vagina not affording any more
serious obstacle, the upper part of the canal will become inverted
as the uterus descends, and will readily allow it to ocL'U})y a
position from an inch to an inch and a half lower than its natural
sitoation. In many instances the organ remains in this position,
its cervix a little above, or even resting on the posterior vaginal
wall, for its further descent is oppased by the various duplicatures
of its peritoneal iovestraent. First, the posterior part of the broad
ligaments, and the utero-sacral ligaments, mnst be put on the
stretch, and then the middle part of the broad ligameuta, before
any considerable stress will be experienced by the utero^vesical
ligaments, or by the anterior fold of the broad ligaments ; and it
is to the circumstance of the posterior attachments of the uterus
tying it down so much more closely than the anterior that we
must in great measure attribute the tendency of the fundus uteri
to fall back into the hollow of the sacrum in every case of prolapse
of the organ. Tlie round ligaments of the uterus have no share in
preventing descent of the womb ; their office seems to have
reference to the development of the organ during pregnancy rather
than to its situation in the unimpi*egnated state, and the organ
must not merely be prolapsed, but must be procident far beyond
the external parts, before the round ligaments can be at all put
on the stretch, or can be in the least affected by its changed
position.
As has been already mentioned, descent of the uterus is not
often the consequence of mere weakening of its supports, but in
the great majority of instances the same cause as diminishes the
resistance increases at the same time the superincumbent weight
The leucorrho^a or the monorrhagia which deprives the vagina of
its tone, is often associated with actual uterine disease, and the
oi^n, enlarged by chronic intlammation or its consequencea, is
more prone than in a healthy person to sink below its natural
positioiL Such is the history of moat of the cases in which pro-
138
PROLAPSUS UTERI :
lapsus uteri takes place in uumurried women, or in tliose wha
have not recently given birth to children ; and in such cases, with
the cure of the inflammation and the reduction in bulk of the
hjrpertrophied organ, the vagina will once more regain its proper
tone, and the womb, which had been situated only an inch or an
inch and a half from the vulva, will, aa it were spontaneously,
resume its proper position high up iu the pelvic cavity.
In most cases, however, it is not io single but iu married women
that prolapsus takes place, and in them it very generally succeeds
to abortion or to labour* Everythiug in these circumstances con-
spii'es to favour the occurrence of the malposition, for the womb is
greatly increased in weij^ht at the very time when the vagina has
lost most ol its power of resistance, while the duplicatures uf the
peritoneum have been so recently put on the stretch by the
distended uterus aa to be but little able to prevent even the more
advanced degrees of misplacement. In not a few in,stances» too,
the tendency to this accident is still further increased by the
perineum having been lacerated, and by the whole posterior wall
of the vagina having thus been deprived of its natiu-al support by
the tearing of the fascia and muscles of the perineum, an accideut
which has the additional etfect of giving to the canal a perpen-
dicular instead of a curved direction.
The general rule of the co-existence in cases of prolapsus uteri
of increased weight of the organ with diminished power of its
supportSi is not, however, without occasiootd exception, Ev^en
in a previously healthy person, a sudden and violent effort, such
as the attempt to lift a iieavy weight, may sometimes cause the
uterus to prolapse beyond the external parts, just as in auother
person, or in the other sex, a similar effort might produce a
hernia. But while such cases call for no further remark, the
occasional occurrence of prolapsus of the womb in old age, in
spite of a healthy or even of an atrophied condition of the organ,
and in the absence of any exciting cause, requires some
explanation. This explanation, indeed, is not far to seek, for it ia
furnished by circumstances peculiar to that period of Ufe. With
the advance of years the fat and cellular tissue which give
their rotundity to the labia, and which form a sort of cnshion
about the entrance of the vagina, become entirely removed ; and
instead of the vulva being closed, it is scarcely concealed by the
ItB VARIOUS CAUSES.
139
shmokeu parts. The fat of the perineum is removed ; the
levator ani becomes atrophied and ftieble, and the vagina grows
shorter as well as smellier, while it losea its muscularity, and the
peritoneal duplicaturea lose their resilience. The womb may now
almost spontaneously become prolapsed, since, though shrunken^
instead of being increased in size it has almost completely lost
the support which kept it in its proper position.*
This somewhat tedious explanation of the different conditions
iinder which prolapsus of the uterus is commonly brought about,
shows, I think, clearly why it is that the fundus of the wontb is
so disposed to fall backwards, why every prolapsed womb is to a
great extent retroverted also. You see that the anterior uterine
ligaments do not tie the orgiin so closely in its place as the
posterior, and that consequently the liability of the womb to
retroversion must always be mucli greater than to antevcrsiom
You see also how it comes to pass that the uterus, when once
prolapsed, i-? always extremely likely to remain so. The vagina
having once yielded so as to allow of the descent of the womb,
can hardly be expected to i-ecover its tone while the patient is
going about her ordinary avocations, and the uterine ligaments,
subjected to daily stress, can scarcely do other than yield. But
not only is the spontaneous cure of a prolapsed uterus thus
rendered very unlikely, but the condition has a constant teudency
to pass from bad to worse, and for this simple i-eason that the
pressure of the intestines from above is always iielping to
increase the descent of the uterus, always filhng up the space
which that descent leaves vacant in the pelvis. The prolapse of
the posterior wall of the vagina, if at all considerable, is daily
aggravated by the efforts at defiecation, and thus the womb
pressed on from above by the intestines, is at the same time
drawn downwards by the vagina. The close connexion between
the cervix uteri and the neck of the bladder is a temi>orary
obstacle to the complete descent of the womb, while at the same
time it favours the retroversion of the organ; but if at length
this yields, the urine accumulating in the bladder distends its
fundus and the anterior vaginal wall into a pouch which drags
* By far the best aocoant of ths mechMUsm of prokpaus uteris mid wluch I have
followed in the text, is given by KiwUch, Klinische Fartrdgt, 3d edition, vol L
p. 17L
140
PJIOLAPSUS UTERI :
down the uterus in front just as the prolapse of the rectum dlfgH
it down behind ; and the organ now soon comes to lie beyond tlie
external parts ; the case being thus converted into one of proci'
dentia of the uterus, or of prolapse in the third degree^
But this misplacement of the womb does not happen, or at
least occurs comparatively seldom, unaccompanied by other
alterations both in the organ itself and in the surrounding parts.
The womb, subjected to constant and unusual irritatiou, obeys the
law whicli we observe to be exemplified in ahuost all the
affections to which it is liable, and increases in size by a process
of simple hyi>ertrophy, that differs from the enlargement of
pref^nancy only in the somewhat greater density of the tissue.
The neck of the womb is the part in which this alteration chiefly
takes place ; for it is the neck which is exposed to the most, and
the most constant, irritation. This enlargement, too, occurs both
in length as well as in thickness ; so that the neck of the womb
may not only be found nearly of the thickness of the wrist, but
also greatly elongated, and the 03 uteri be thus approximated to
the pelvic outlet, not simply by the general descent of the womb,
but also in great measure by positive growth of its necL The
lips of tlie uterus become enlarged, together with the rest of the
womb ; and the small transverse aperture which in women who
have borne children should represent the orifice of the womb, be-
comes converted into a wide opening, situated deep m between
projecting lips, whose surface, irritated and excoriated, presents,
in paits at least, a vivid red, finely granular surface, covered by a
copious albuminous secretion. How much this enlargement of
the womb must lessen the chances of the oi-gan resuming its proper
situation in the pelvic cavity, is obvious without any remark of
mine.
There are limits, however, to tliis increase of the womb, which
Beems to be most considerable while the organ, though occasionally
or partially procident, yet admits of being replaced in the vagina ;
and in these circumstances I once found the neck of the womb
measure 8 inches in circumference, an inch above the os uteri In
this instance, however, the patient had nine months before given
birth to a child ; and the uterus, both at that time and also for
thi-ee years previously, had been occasionally procident ; so that
its enormous enlargement was probably partially due to the
CHANGES WHICH RESULT FROM IT.
t^
imperfect involution of the organ after delivery. At first it seems
almost impossible that so enormous a mass could pass out of the
vulva, and be replaced without difficulty, unless the perineum
were altogether destroyed. In not a few cases, however, of pro*
cidence of the uterus, the whole fieivic lioor corapletelj loses all
power of resistance ; so that, thou^^h quite uniojured, it offers not
the slightest obstacle to the misplacement or reposition of the
womb* — an occurrence which, as might be expected, is most
frequent in cases where the accident has followed soon after
delivery at the full period, when the parts are already stretched
and weakened by the passage of the fcetus.
In the course of time the occasionally protruding womb comes
t-o lie constantly beyond the vulva, though this procidentia may
still for years continue to be only partial; the fundus and a
]ioTtion of the organ remainiog within the pelvis, while the neck
and lower part uf its body are external In most instances,
liowever, so considerable a degree of descent of the womb is before
long converted into its cr>mplete procidentia ; the vagina becom-
ing inverted^ and forming the outer walls of a tumour, at the
lower part of which the womb is situated So long as the pro-
cidentia is incomplete, this tumour is somewhat pyrifomi in shape,
its base being directed upwards ; but afterwards, as it increases
in size, it assumes an oval form, owing to more or less of the
IJadder being drawn down into it in front, and of the rectum also,
in many cases, behind. Its bulk is also further swelled, in
numerous instances, by the small intestines sinking down into ihe
sac, and thus adding to its size tiU it equals or exceeds that of the
adult head. In a preparation now in the museum of St Bartho-
lomew's Hospital, the external tumour measui-ed 7^ inches in
length by 13 inches in circumference, and was found to contain,
in addition to the uterus and its appendages, the bladder, and a
jjortion of the rectum, no less than 5 feet 8 inches of the small
intestines.
The uterus itself, as the above-mentioned case w^ell illustrates,
forms in many instances only a comparatively small portion of
the large external tumour which often exists in cases of complete
procidentia. The susceptibilities of the organ seem indeed t*j be
much diminished, and with them its disposition to hypertrophy
when it has come to reside habitually out of the pehic cavity.
142
PROCrDENTIA UTEHT.
Sometimes, indeed, as in the case just referred to, the womb
appears actually diminished {it measured in that instance less
than 2 inches from its orifice to its fundus), and I believe that the
difficulty which may be experienced in the replacement of long-
standing procidentia of the uteins seldom if ever arises from the
size of that oi'gan. The bulk of the tumour, and the difficulty of
its replacement, depend chiefly upon two causes. Of these the
one consists in the enormous hypertrophy which the vaginal walls
undergo, Not only does their mucous membrane lose its ordinary
character, and become covered by a layer of cuticle like that of
the skin, t-o protect it from the various sources of irritation to
which it now becomes exposed, but th^ walls themselves attain a
thickTiess of as much as half an inch, and present a dense muscu-
lar structure. The other cause of the bulk of the tumour, and of
the difficulty of replacing it, arisea from the presence of the
intestines in the sac, which seldom reside there long without
inflammation of their peritoneal covering being set up ; not of so
acute a character, indeed, as to produce formidable symptoms, nor
even as always to call for treatment, but matting their different
coOs to each other, and tying them firmly to the interior of
the sac. This latter cause of difficulty in the attempt to return
a procident uterus must not be lost sight of, even though no
intestines should seem to have descended into the external tumour
itself^ for the same slow form of peritoneal inflammation may glue
them to each other and to the walls of the pelvic cavity, and
thus eflectually close up the way against all endeavours to
replace the womb.
In the cases which we have hitherto studied, though the point
of departure of the whole evil consisted in a weakening of the
vagina, yet that step once taken, the prolapse of the womb might
be regarded aa a primary occurrence, the oi^an in its descent
dragging down the vagina with it. There are, iiowever, other
cases in which the displacement of the womb is entirely a
secondary accident, following on a giving way of the anterior or
posterior vaginal wall, which becomes prolapsed, and in its
prolapsus draws down the uterus. It is thus, for instance, that
prolapsus uteri is sometimes brought about in cases of ascites, the
pressure of the fluid gradually distending the rccto-vnginal pouch,
till it may even cause the posterior wall of the vagina Uy protrude
PROLAPSUS OF YAGINA.
143
externally. A Bimilar effect is sometimes produced in cases of
lonf^'-cnntiniied coTistipatioB, in whicti the accumulation of faeces
in the rectum by degrees distends the intestine into a pouch
wluch pmjecte into the vagina, while still more frequently the
anterior vaginal wall gives way from the retention of urine in the
bladder, and thus produces in the course of time a similar descent
of the womb. There is, besides, a fonn of vaginal prolapse due
apparently to hypertrophy of the walls of the canal, in which the
position of the adjacent viscera is not alt-ered, though the os uteri
is not infrequently found lower down than natural, owing to the
prolapsed vagina dragging at the cervix, and exciting the part to
overgrowth by the constant irritation w^hich it thus maintains.
Strictly speaking, these difierent affections of the vagina should
be reserved for our consideration by and bye ; hut there is such a
general similarity between their symptoms and those of prolapsus
of the uterus, and so close a coiTespondence between the
principles of treatment applicable to them, that we may very
well sacrifice systematic arrangement to practical convenience.
First, now% with reference to prolapsus of the vagina unaccom-
panied by misplacement of the otlier pelvic organs, I have already
mentioned that it seems to depend in the first instance on a sort
of hypertrophy, as the result of which it cannot well be contained
within its p^roper limits, but a fold of it comes to f>rotnide beyond
the external parts. Such a hypertrophy of the vagina takes
place during pregnancy, for not only does the womb grow* to keep
pace with the development of the foetus, l>ut the vagina grows
too ; longitudinally, to allow the womb to ascend high up above
the pelvic brim ; transversely, to aflbrd space for the passage of
the chEd in labour, room for which could not be obtained by any
mere stretching of a membranous canaL Wlien labour is over,
the vagina, in common with the uterus, ought to diminish in^size
by a removal of much of its old material Sometimes, however,
just as we have already seen in the case of the uterus, this
involution is imperfect, and the vagina then remains longer and
wider, and with its walls thicker than they should be. and as
soon as the patient begins to move about again, or to make any
exertion, a portion, often the wdiole cylinder of the lower part of
the vagina, hangs dow^n outwardly, an accident all the more hkely
to take place if the perineum has been injured, or if the levator
144 PROLAJPSUS OF VAGINA :
ani and the fascia at the pelvic floor have lost, as they are wont
to do, much of their power of resistance by frequent child-
bearing. Why it is that sometimes the vagina continues thus
hypertrophied while the involution of the uterus has gone on
properly, I cannot say, though of the fact itself there can be no
doubt; for one meets occasionally with cases in which the
uterus, still suspended by its ligaments and by the folds of
peritoneum, is little if at all lower than natural, and little if at
all altered in size, while the vagina is so wide as readily to admit
several fingers, and its folds hang down loosely to, or even
beyond, the orifice of the vulva.
Although this prolapsus of the vagina is usually a primary
affection, and attributable to the consequences of pregnancy and
child-bearing, yet this is not so invariably. The prolapse of the
vagina appears to be in some iostances consecutive to descent of
the womb,* but the affection being neglected, the tissue of the
protruding portion of vagina may become hjrpertrophied, and the
ailment, which was secondary in importance, may by degrees
become of greater moment than the misplacement of the womb,
and more difficult to remedy.
Though not quite constant, yet the exceptions are but few to the
rule that considerable or long -standing prolapsus of the vagina
will produce hypertrophy of the cervix of the uterus ; not of that
portion only which projects into the vagina or portio vaginalis, as
it is termed by (Continental writers, but of the whole uterine neck,
of which a specimen (Series xxxiL 30) in the Museum of St Bar-
tholomew's Hospital affords a striking illustration. Even more
remarkable instances of this kind are on record, one of the first
of which was described by Morgagni ;"(• and attention was drawn
some few years afterwards to their practical bearings by LevretJ
* Remarks made by Professor Eiwisch, Klinische Vortr&ge, toL iL 2d edition,
1862, p. 418.
t Morgagni, De Sedibuset CauHs Morborum, folio, Venetiis, 1761, 2d toL, Epist.
45, Art 11. p. 204. Morgagni regarded the hypertrophy of the cervix in this case
as consequent on the prolapse and hjrpertrophy of the vagina. ' ' Evidens est, vaginie
adeo crasscB pondere deotsom tractum fuisse uterum, c^jos fundus aliquanto
inferior fuisset, nisi cervix jam inde ab initio, ut puto, ea esset laxitate, ut se prss
cseteris distrahi, distendique in raram istam longitudinem sineret"
X Jmrnal deM6decine, ChirurffU, etc., parM. A. Bouac, vol. xl. Oct. 1778, p. 852,
'*Sur nn allongement considerable qui survient quelquef ois au col de la Matrice/'
Attention was called to this state with a completeness of detail which leaves but
ITS INFLUENCE ON THE UTERUS.
He clearly pointed out the differences between those cases in
which the approach of the 09 utari to the vulva is mainly due to
overgrowth of the cervix, and the others in which it is entirely
the reault of the descent of the womb. His remarks, however,
were lost sight of, and it was with no previous knowledge of them
tliat Virchow/ some lew years since, described this occurrence as
a peculiar form of prolapse, under the name of prolapsus uteri
without descmit of the fundfus. Still more recently the subject has
been brought into undue prominence by the assertion of M.
Hugmer,t that prolapsus of the uterus is a condition that scarcely
ever exists ; hut that cervical hypertn>phy has been almost
invariably mistaken for it, and that consequently not the support
of the womb, but the removal of the elongated cervix, is the pro-
ceeding to which one ought to have recourse. Like most extreme
statements, this of M, Huguier is contradicted by general observa-*
tion^ Still it is well for you always t^ bear in mind, not only
that hypertrophy of the uterus tends to favour its prolapse, and
that the prtjlapsed uterus tends to enlarge still more, but also that
long-standing prolapsus of the vagina is almost always associated
with a condition of the cervix uteri which closely simulates
ordinary prolapsus, but which, as you will hereafter see, must be
clearly distinguished from it, since those attempts at mechanically
roctif>nng the supposed malposition which would be of service in
true descent of the womb must here he useless, and sometimea
may even aggravate the sufferings of tlie patient.
Of much more frequent occurrence are those cases in which the
prolapse of the vaginal wall is partial, involving its anterior or
posterior part only, and deriving, in the great majority of
little to be added, by Prof. Stoltz of Straaburg, in Journal HthdomndMrt^ ?oL vL
June 10, 1S59, p. 356, where, however, by & misprint, the dftte of Lerret'^ paper is
gireti 1775 instead of 1773.
• Virchow, in Ferkandl der Gesdl$cha/l /, OehurUh, in Beriin, vol ii. 1847,
p. 905.
t In » memoir read before the Academy of Medidne on March 8, 1869, and
pQbliahed in voL xxiiL of the M^moirts de rAead4mi€—**Sw lea allongementa
hyjK'rtro phi lines* da col de Tot^rua/'
t See espeoiallj the disoassioos to which this paper gave riae, as reported in the
BuUtUn tU VAeadtmit, vol. xxiv. p. 672, 727, 771, 794 ; a paper by ScaiuEonl, at
p. SS9 of the 4th foluroe of his Beitr^e tur Oelntrtukunde ; Aran, c»p. cii, p. 1034 ;
M*aintock on Diaeates 0/ Womm, 8vo» Dablin, 1863, p, 58 ; und Mayer, KUnitchs
MiUhtili^ngm out dm dsMeto dbr GyfMoloj/ia, 4to, 1 Heft, Berlin, 1881, p. 83.
146
PROLAPSUS OF BLADDER
instances, its chief importance from the altered position of the
adjacent organs, which descend int«3 the pouch thus formed, and
constitute %vhat have been termed by many writers vaginal
re^tocde and vaginal cystoceh.
In those cases whei-e the anterior vaginal wall gives way, form-
ing a pouch into which more or less of the blatider descends, it is
not easy to say what is the first step in the occurrence ; whether
the vagina draws down the bladder with it, or whether the
distended bladder pushes before it the vaginal wall. It is an
accident, however, which in the unmarried is even more rare than
prolapse of the womb, and its occurrence is traced back, in by far
the majority of those who sufifer from it, to a miscarriage or a
labour ; to a time, in sluirt, at wdiich all the parts were loose,
and had lost the power of resistance, while the vagina as well as
the uterus wag hypertrophied, and had to imdergo that process of
post- puerperal involution to which T have had such frequent
occasion to refer. Sometimes, indeed, though rarely, the patient
gives a history of the sudden formation of a swelhng at the
anterior part of the vagina during some unwonted exertion, just
as the womb itself occasionally becomes prolapsed in similar cir-
cumstances ; while it is easy to understand how a comparatively
small prolapse may be converted into a large one duiing some
violent effort when the bladder ia fall, and consequently exjjosed
to all the force of the diaphragm and abdominal muscles pressing
downwards.
The union* is so much more intimate between the anterior
vaginal wall and the bladder, than between the posterior vaginal
wall and the rectum, that we scarcely ever find the vagina alone
becoming prolapsed, and dragging itself away from the bladder
in the same manner as, in prolapse of its posterior wall, it often
becomes separated from the rectum. Further, that part of the
bladder which adheres to the vagina includes the orifice of both
ureters and the whole of the trigone, extending, indeed,
somewhat beyond its limits on either side, so that the urine, as
soon as secreted, collects in this situation, and tends constantly
to distend it into a pouch, whose dimensions increase aU the
• The exact relationfl of these pai-ta are nowhere so won descrilifid us by Duboifs
TmiU dc VArt de$ AccouchmfTit% pp. 190-190, mid pp, 284-243 ; nor so weO dv
Ime^tedasby Kohlraiiscli, Zur Amtomk, itc, der BwJccnorifanef 4to, Ltipsic, 1S54.
I
I
I
ITS MODE OF PRODUCTION,
147
more rapidly since its enlargement is not opposed by the weight
of the superincumbent intestines and the antagonigm of the
abdominal muscles^ both of which have to be overcome as the
distended bladder rises out of the pelvic cavity,
A slight pouch then is first formed in the anterior vaginal
wall, scarcely perceptible when the bladder is completely empty,
but tense and elastic when filled witli urine, though admitting
even then of being partially or completely removed by firm
pressure upon it, and disappearing altogether if, while this
pressure is being made, a catheter is introduced into the bladder.
In the course of time the small tumour, whose anterior border
was felt a little behind the symphysia pubis, enlarges, now and
then forming a kind of diverticulum * with a nmTow neck and
long pedicle, but oftener producing a globular swellings which fills
up the canal of the vagina, and projects more or less beyond the
external parts, when it becomes covered by the same investment
of ordinary skin as clothes the tumour in prolapsus of the uterus
or vagina. The weakening and gi^^g way of the anterior
vaginal wall, however, seldom attain any very great degree
without producing likewise some prolapse of the uteiiis, though
the extent of this is by no means constant. Wlieuever the
nterus does not readily yield to the traction made on it by the
prolapsed bladder, the anterior lip of the organ liecomes hypertro-
phied, and projects far beyond the posterior, in a similar way,
though not to the same degree, as we have already observ^ed to be
the case with the whole of the neck of the womb, in coses of
prolapse of the whole circumference of the hypertrophied
vagina.
The dragging of the prolapsed portion of the bladder upon, the
neck of the organ naturally interferes with the functions of the
part, and produces frequent desire to pass water, as well as in
many instances inability to retain it. Another evilf which
occasionally results from it (but which I have failed to observe
in the few cases where I have been present at a post-moritm
examination of women who suffered from prolapsus of the
* As in A case describctl by MNdimie I,achiip«lte, Pratique dta Ae^mtchtm^enU, voL
iii p. 387, in whiuh the pToUpj»«il bladder was driven dovrn in ihi» form before tlx«
fecial b«id, aod Heyoud the external parts.
t K«ferr<sdto, both by Kiwbcb, lib. cU. vol. il. p. 422 ; aud by Virobow, loe. dL
p. 20fi ; by ibe ktter of whom it is more fully described.
PROLAPSUS OF RECTUM.
Madder, probably from want of dii-ecting .special attention to the
]»oint), consiats in a degeneration of the kidneys themselves.
The ureters being not only drawn down and stretched, but also
in some instances even pressed upon as the pouch of prolapsed
l>ladder projects under the symphysis pubis, the urine with
difficulty Hows along them ; and both they and the pelvis of the
kidneys theuiselves become dilated, with a correspondiug atrophy
of the secreting substance of these organs.
Prolapse of the posterior vaginal wall is in its slighter degrees
of more common occurrence than prolapse of the anterior, and
when the perineum has been torn in labour, scarcely ever fails to
take place. It does not, however, constantly bring with it
prolapse of the rectum in the same manner as the giving way of
the anterior vaginal wall is constantly associated with prolapse ol
the bladder, since the loose celhdar tissue wliich connects them
allows of a tolerably ready separation between the two canals, and
the rectum may still retain it-s natural situation. If, however, the
laceration of the perineum has been considerable, or if, independent
even of any such condition, the bowels have been habitually
allowed to be constipated, the lower part of the rectum bulges out
into a cid'de-sm, in which fiecal masses become retained and in-
durated, causing, in addition to the ordinary annoyances of prolap-
sus, much discomfort, sometimes even much suffering, in the act
of deftecation. It is to the influence of constipation in producing
this ailment that must be attributed the comparative frequency
with which it is observed, independent of pregnancy and child-
bearing; and its importance arises in great measure from its
aggravating that state of the bowels to which its original occur-
rence was mainly due.
LECTURE IX.
MISPLACEMENTS OF THE UTERUS.
PaoLAFSUB Utebi. Spuptomi of its first and second st&ges ; pain, its ca,nses and
character, disorder of uterine functions, and of general health. Symptoms of
third stage ; influence of mkplacenient on adjacent orgam ; difficulty of return
of long-standing procidentia. Pwjaliar symptoma of prolapsus of bladder and
rectum described and explained.
Treatment of Prolapsus variea according to ita cat^o and degree* Oiaea requiring
or not requiring mechanical 8upi>ort, distinguished ; petsiriea, their iiaes and
TaHetiea ; external supports and bandages.
ItatiagetaeDt of Pit>cidentia ; cautions as to replacement of uterus ; treatment of
ulcemtion of ita surface. Operations for its pennan«;iit cure considered. Irre-
docible procidentia ; extirpation of womb.
After the study of the manner in which some forma ot muplftee^
ment of the uterus and part^ theremth connected are produced*
we come next to inquire into the spnptoms to which those
misplacements give rise. Theae symptoms depend partly on the
changes in the relations of the various organs produced by their
altered position, or by the altered position of the womb itself ;
partly on direct disturbance of the uterine functions ; and partly,
too, on the sympathy of distant organs with the ailments of the
womb itself. None of these symptoms, however, are. constantly
proportionate in severity to the degree of misplacement, so that
one woman will suffer most acutely from comparatively slight
descent of the womb, while another will pursue laborious avoca-
tions, apparently little distressed by a prolapsus so considerable
that the utenia is with difficulty retained within the canal of the
vagina.
As a general rule, the patient suffers most in those cases in
which the occnrrence of prolapsus has been somewhat suddeii, and
in which it does not succeed to previous delivery or miscarriage.
The reasons for this are obvious enough ; the dragging at the
L
150
rnoiArsxjs uteri :
uterine ligaments and duplicatnres of peritoneum must be much
more painful when they have been suddenly stretched, than when
already loose and yielding, they give way under the weight of the
utems which they are prematurely called upon to bear. Hence it
is that comparatively slight prolapsus in the unmarried is often
attended by far more distress than a much greater amount of dis-
placement in women who have given birth to cbildreu, and that
the degree of auffering which is sometimes experienced after a
night's dancing, or a fatiguing ride on horseback, seems to point to
an ailment far more serious than slight descent of the womb.
Women designate the peculiar pain which they experience in
cases of prolapsus uteri by the expressive term bearing'down — a
sensation as though the pelvic \7scera were about to fall out ; and
to this is often added, on very slight exertion, such as in walking,
in lifting anything, or on altering the posture, a sharp pain, due
to a momentary increase of tension of the uterine ligaments, which
compels the person to stand still, and often to bend slightly
forwards, so bj3 to remove as far as possible all pressure from
above, and thus to await the cessation of the pain. The effort at
defaecation ia often extremely painful, from the very circumstance
that it puts all those hgaments upon the stmtch ; while, when the
womb has descended eo far that its cervix habitually rests upon
the tioor of the vagina, there is frequently superadded a sense of
desire to emjity the rectum, a sort of tenesmus which is very dis-
tressing. The uterus, too, becomes now exposed to shocks from
various external causes from which it was before defended ; and
sitting on a hard seat, or placing herself in any posture in which
the perineum is pressed on, causes the patient extreme pain, so
that she is compelled to study her attitudes, and carefully to
adjust her position. With these discomforts tliere is almost
always associated more or less of that pain ^in the t>ack which is
the nearly constant attendant' upon uterine ailments of every
kind ; and in some instances there is also an extreme degree of
tenderness or sensitiveness in the hypogastric region, which is not
aggravated by slight pressure on the surface, or by gentle friction
over it, but on the contrary is often much reUeved by it. This
abdominal pain is no more special to prolapsus than ia the lumbar
pain, but both seem due to the radiation of painful sensations
from the uterus itself, along the different nervous branches and
ITS SYMPTOMS.
151
twigs with which it is either directly or indirectly connected ; and
hence we find it in many cases of uterine cancer, as well as in
dysmenorrhcea, and in very many otlier chronic ailments of the
uterus. Another very distressing sensation often experienced
quite in the early stage of uterine prolapsus, and before tliere is
any interference with the position of the bladder, is a very
Crequent desire to pass water, which the patient is comf^elled to do
every half hour, though with very httle relief. In unmarried women,
when the uterus has descended so as to lie in the uxis of tlie pelvic
outlet, there is besides much distress produced by the os uteri
pressing agaiust the hjTuen ; Imt all of these discomforts are miti-
gated, many of them cease altogether, when the patient lies down.
Pain, however, is not the only symptom of prolapsus of the
womb. The organ thus misplaced is irritated, and leucorrhteal
discharges are an almost invarialde attendant upon the ailment,
while, from the same cause, the menstrual ilux Iteconies more
profuse, lasts longer, or returns more frequently tiian naUirah
The blood Hows back from the misplaced womb witli more than
ordinary difficulty, a state of habitual congeBtion is maintained,
which in some instances relieves itself from time to time by
profuse losses of blood, though in spite of them the Irritated
congested organ tends to increase in size : and the womb, tlius
larger and heavier than natural, becomes less and less likely to
resume its natural situation.
The disorders of the general health that accompany prolapsus
of the womb have nothing in them that is characteristic, but
consist of that chiss of symptoms which attend upon so numy
uterine ailments, and among which dyspeptic disorders have a
very large share, owing to the peculiar sympathy that subsists
between the stomach and the womb. Constipation of the tiowels
may, however, be mentioned as an almost constant attendant ujion
prolapsus, due in part to the distress which in the eiirly periods
of the aflection accompanies the effort at dehii'cation ; in part also
to the mechanical impediment which the pressure of the cervix
uteri on the rectum frequently ofifers to the passage of the faeces.
In the upper classes of society, the symptoms of prolapsus are
almost invariably met by appropriate treatment in tlie early
stages of the atiection, so that in them it seldom passes the first
or second degree of misplacement* There may, however, be
152 SYMPTOMS OF PEOLAPSE,
exceptions to this rule, in eases where tlie perineum has been
extensively torn, and the vagina has consequently been very
much and permanently weakened* The atrophy of advanciiig
age being equally incidental to all, the utenis may even in the
wealthy mme down so low as to protrude partially beyond the
external parts. Now and then, too, even in young women, the
perineum after child-birth seems so completely to lose its
resiliency as to afford little or no support to the vagina, A small
knuckle of the posterior vaginal wall soon becomes prolapsed, so
as to project between, though not beyond, the lalda ; it here
becomes irritated ; and irritated, it soon becomes hyper trophic d.
The edge of tlie yielding perineum is dragged down by the
vagina, or if an examination is made, is easily carried before the
fingers, and seeming thus to constitute a part of the vaginal wall,
the sensation of the perineum having been nearly destroyed, is
most deceptive ; and sometimes the eye alone can determine
whether this is so or not Now, in this case the vaginal support.
of the uteiiis being completely lost, though the mischief is not
irreparable, as it must bo when the perineum is torn, external
prolapse of the uterus may take place.
The sudden occurrence of external prolapse, or procidentia,
when it happens durmg some violent exertion, or when it takes
place all at once during some change of posture a short time after
parturition, or in the etTort at defecation, is attended by much
local distress, and much constitutional disturbance. In by far
the majority of cases, however, the womb becomes procident only
very gi-adually ; at first but a small part of the organ pmtruding,
and that only occasionally ; and then more of it coming down, and
for a longer time, till at last the whole womb Hes usually, or
constantly, beyond the external parts. With this change of
position of the organ there is a change of symptoms ; of ten »
indeed, a marked remission of some of those which were the most
distressing; for the sensibilities of the womb appear tt> be greatly
blunted when once it b*iComes an external organ, and injuries and
interferences which it could not bear while in its natural situation
seem to be of but small importance when it has left the pelvic cavity.
The aUeviation of the patient's symptoms, however, owing to
the cessation of the vaginal leucorrhoea, and the gradual blunt-
ing of the uterine sensibiUties, is generally more than counter-
AlfB PROCIDENTIA UTEBL
153
balanced by the supervention of stiffering Imm other sources.
With the increase of the procidentia of the uterus, the posi-
tion of the other pelvic oi^ans becomes more and more dis-
turbed ; the bladder is drawn down into the pouch in front ;
and the natural relations of the urethra are often so altered
that the canal runs perpendicularly downwards, instead of in a
horizontal direction. This misplacement necessarily brings with
it much difficulty in emptying the bladder, while accompanying
it there is generally a frequent desire to void the urine, and by
these two symptoms the patient's life is rendered miserabla In
a similar manner, though not so invariably, the rectum h drawn
down behind, and ditlicult defalcation is thus superadded to the
other symptoms. Nor is this all, but the descent of the email
intestines int-o the pelvic cavity to occupy the space which the
uterus and adjacent viscera have left vacant there, disturbs their
proper functions, and gives rise to various sensations of pain and
diacomfort in the abdomen, and to these is not infre{|uently
added the distress from inHammation of the peritonenm, a
chronic form of which seldom fails to he set up.
The external tumour is itself the source of much distress. In
spite of the thickening of its tegument, the irritation product by
exposure to the air, and by all the forms of external injury from
which it is impossible to shield it, as well as by the passage of
the urine and faeces, seldom fails to produce ulceration of its
surface. This ulceration genondly occurs in large patches upon
the most exposed parts, — as, for instance, at the sides where the
tumour is exposed to friction by the thighs ; below, w^here it is
rubbed when the patient sits or lies; and at the upper part,
where it is apt to be made sore by the passage of the urine*
The ulcers are seldom deep, but are usually iri^gular, with raised
edges and an indolent surface, and are very indisposed to heal.
The 03 uteri, too, from its position at the low^er part of the
tumour, and its consequent exposure to irritation, as w*eU as from
the delicacy of the membrane in this situation, is almost always
the seat of an ulcer or excoriation. This ulceration is oft«u of
considerable extent ,* not simply from the circumstance that the
• Thin fact, of the coireL'tnc as of which any one dm roftilily satisfy himself, wm,
to th(^ best of my know lot l^i% flrat noticed by gcanzoni, tu » Dt)te at page 178 of
thd 4th edition of voL I of Kiwiech'a Kliniaeke Vorirdgt,
154
SYMPTOMS OF PROLAPSE OF UTERUS,
lipa of the os partaking of the general hypertrophy of the womli,
present a lai-ge surface, but also because the eontiiiual di-agging
of the iBveTted vagina tends to draw the lips of the uteina
upwards and apart from each other, and thus produces a very
considerable eversion of the mucous membrane of the cervical
canal, whicli soon becomes excoriated. The replacement of the
utei-ua restores the parts to their natural relations, and the large
external ulceration passes almost out of sight into the canal of
the cer\ix.
The existence of prolapsus uteri, though no bar to conception,
often renders pregnancy a period of very considerable sufl'ering.
The slighter degrees of descent of the womb, indeed, are often
cured by pregnancy, since the uterus as it enlarges gradually
ascends in the pehis ; and the temporary reUef thus alTorfled
may be rendered permanent by care during gestation, and a long
observance of the recumbent posture after delivery. When the
misplacement, however, is considerable, and especially when the
uterus has already l*en partially procident, the etlect of the
enlargement of the wuinb is to make it descend still lower, so
that a considenilile portion of its lower segment, as well as its
greatly enlarged cervix, protnide permanently during a great part
or the whole of pregnancy. All the synijttoms to which prolap-
Bus ordinarily gives rise are experienced in these cases in an
aggravated degi-ee, and miscaiTiage not infrequently takes place,
partly owing to tlie disturbance inseparable from the misplace-
ment of the womb, partly owing to the want of space in the
pelvis for the further enlargement of the organ, which is unable
to rise as it ought to do into the abdominal cavity. In some few
instances, however, pregnancy runs its course undisturljed, in
spite of a great degi"ee of prolapsus; and cases are on record in
which the uterus has descended further and further till a great
portion of it hung down between the thighs ; but the development
of the ftetus ha^, nevertlieless, gone on in this unnatural posilion ;
and others, still stranger, in which coitus has been practised
immediately through the os uteris and impregnation and
uudiaturbed gestation have followed^ in spite of the existence of
irreducible procidentia.
The causes have been explained which tend "to oppose the return
of any long-existing procidentia of the uterus ; and the same
AND OF THE VAGIKA,
155
causes, though operating io a less degree in simple prolapsus, yet
often interfei'e with the couipl^te rtistoration of the womb to its
normal aituation. By degrees, indeed, a w^oman nut infrequently
gets habituated to the discomforts of her j^osition, till at length
she seems to be but little inconvenienced by them, and this even
in cases of external procidentia of the womb. To this, however,
there are many exceptions ; and the ulcerations of the surface of
the procident organ sometimes become very extensive, assume an
unhealthy condition, and partial slonghings of the integument
take place; or the mass having been unretumed longer thsm
usual, it becomes swollen, tense, and painful, and all attempts at
replacing it prove unavailing. The extreme pain, which in Siime
of these cases attends upoo any endeavour to replace the womb, is
often due to some degree of inflammation having been set up in
the peritoneum lining the pouch into which the intestinCvS descend,
at the upper and back part of the prolapsed womb, or of the peri-
toneal investment of the intestines themselves ; and death may in
these circumstances take idace, with many symptoms of the same
kind as attend upon fatal stmngulated hernia.
Of the two varieties of vaginal prolapms in which its posterior
or its anterior wall is displaced, the latter gives rise to by far the
more important symptoms. Some degree of prolapsus of the
posterior vaginal wall exists, indeed, in very many cases of lacera-
tion of the perineum ; and a jpainful dragging seiLsation on assum-
ing the erect jKJstui^, leucorrhteal discharge, and discomfort from
the pr*3Jectiou between the labia of a small pouch of vagina, tire
generally experienced, though by no means in a measure always
proportionate to the amount of misplacemenl To these are
supenidded all the inconveniences of constipation, and the distress
arising from the impaction of scybala in the rectum, whenever the
lower part of the intestine itself becomes dragged down and
prolapsed ; while, whenever the ailment is of long standing, or
considerable in degree, the uterus is usually drawn down also out
of the projter position.
The prolapsus of the anterior vaginal wall, attended as it is by
descent of the bladder, is accompanied by a peculiar dragging
sensation at the umbilicus, which is distressing in proportion as
the bladder is fuE ; is lessened, or ceases altogether, when that
viscus is completely empty. This sensation has been referred.
156
PROLAPSUS UTERI :
and proLably correctly, to the stress upon the auBpensory
ligament of the bladder, which must be dragged on more and
more in proportion as urine accumulates in the prolapsed pouch
of the organ. The patient experiences, moreover, a constant
desire to paaa water, which very fre<|uent micturition fails to
relieve, unless pressure be made from below against the pouch of
prolapsed bladder, so as completely to empty the organ. To this
becomes supemdded in many instances, in the course of time,^
an altered condition of the urine, which is turbid, ropy,
sonietimes oflensive and loaded with phosphates ; owing, in part,
to its reteutiou in the pnnlapsed pouch of the bladder ; in part,
also, to irritation projjagated to the kidneys themselves. It can
scarcely be necessary to say that in these cases the ordinary
syntptoms of vaginal prolapse will not be wanting ; while
reference has already been made to the peculiar effect of descent
of the bladder in causing hypertrophy of the anterior lip of the
womb, and afterwards in occasioning the organ to prolapse
The characters of prolapsus of the uterus or vagina are so well
marked, that with the most ordinary care it must be nearly
impossible to mistake their import. We may therefore pass at
once to the examination of the treatment best suited to effect its
cure.
Here, however, we at once meet with very contradictory
opinions and assertions, for while some WTiters advocate the
general employment of mechanical means to ketip the misplaced
organs in their proper position, others deny their utility, and
allege various arguments against them. Without entering iuto
the controversy, we must bear m miod, what the disputants have
too often forgotten, that prolapsus of the womb occurs in very
ditlerent circumstances ; and that its treatment, to be appropriate,
must differ too. Sometimes it is the result of causes which add
to the weight of the uteriLs, and thus render its ordinary supports
unequal to maintain it in its proper position ; while in other
instances a weakening of the supports themselves, by accident or
disease, is the first step towards producing the misplacement ;
and according as the one or the other of these conditions
• To tliifl canse of alteration of tlie iiriTie attention waa first called by the latfl
Dt GoldiDg Bird, m a paper pubUshed in Medkal Tbnca and OasetUf 1853| Jru. 1,
J. 11.
ITS TREATMENT.
157
predominates mill the use of mechanical means be expedient or
nnde^irable. Thus, for instance, time and care, and judicious
management generally, suffice to remove that form of descent of
the womb which succeeds to miscarriacre or to labour; wherein
the as yet imperfect involution of the organ, and its consequent
increase of weight, are the main causes of its misplacement ;
while mechanical contrivances are always needed when the
support which the vagina should afford has l>een destroyed by
extensive laceration of the perineum, or greatly enfeebled by the
atrophy of old age.
The first inquirj^ then, which we ought to make in every case
of prolapsus uteri concerns the cause to which the misplacement
of the organ is due ; and we must therefore endeavour to
ascertain the precise condition of the patient's health previous to
the occurrence of those symptoms for which she now seeks our
help. In married women we shaU often find the commencement
of the evil referred to some miscarriage or labour; in the
unmarried, to exertion too severe or too prolonged at a menstrual
period, and subsequently aggravated by a Uke want of care at
each successive return of the menses. Eest in the recumbent
position, strict attention to the condition of the bowels, the cold
hip-bath, and astringent vaginal injections, will usually suffice for
the cure of such cases ; and as the hypertrophy of the womb
gradually subside^s, so will the organ by degrees regain its proper
position. Neglect of due precaution at the menstrual periods,
leading as it often does to the miBor degrees of uterine prolapse,
becomes associated, also, with enlargement of the womb, which
diaappears, together with the malposition, under the same treat-
ment as is appropriate in those cases where the ailment succeeds
to delivery. Here, however, especial care is needed, at the return
of each menstrual period, to counteract the tendency of the womb
to become again dispkced— care, too, which it is often very diffi-
cult to Induce our patient, who probably feels but little discomfort,
to observ^a It ia by such care, however, rather than by much
positive treiitment, that we can beat succeed in putting a stop to
that over-profuse menstruation which is very frequently associated
with even the minor degrees of prolapsus. The misplacement of
the organ exposes it to irritation ; the irritated and congested
oi^n becomes somewhat increased in size ; and from its yesaels^
158
TREATMEKT OF PROLAPSUS UTERI :
larger and more numerous than when the organ was in its natural
position, blood flows more freely ; and all the more so if the
patient retains at these times the erect posture, or pursues her
ordinary avocations.
] n many other conditions the uterus grows larger and heavier
than natural, and in some of them, the disposition to prolapsus is
even greater than when the size of the organ is due to the incom-
pleteness of its puerperal involution. The womh, though left
after delivery much larger and heavi|^r than natural, is not the
only part hjpertrophied ; hut its supports, albeit overstretched
and consequently enfeebled, have grown too, and are larger and
more powerful than in the unimpregnated state. If, however, the
increase of the womb is due to some other cause, such as the con-
gestion of habitual menon'hagia, or the enlargement which attends
upon chronic inflammation, prolapsus of the organ will be still
more likely to occur, since its increase of weight will have lieen
unassociated with any corresponding development of those parts
by which it is retained in situ. The prolapsus here is purely
secondary ; the enlarged womb may even require local depletioii
to reduce its bulk; and tiU this end has been attained, the pro-
lapsus will tend to increase, wliile attempts to retain the organ
mechanically in its proper position will increase its irritation, and
thus prove positively injurious.
If to these cases we add another large class, in wldch the
descent of the utenis is but slight, and is either one result of a
general loss of tone in the parta, attendant on a state of debility,
or the conse€[uence of some accidental and temporary cause, such
as the over-exertion of a long wallc, or excessive fatigue, we may
conclude that the employment of mechanical support for the mis-
placed womb is not necessary nor suitable :
IsL In slight degrees of uterine prolapse.
2(L In cases where the descent of the womb, still comparatively
recent, is due to the persistence of the state of puerperal hyper-
trophy, owing to imperfect involution of the organ after abortion
or labour*
3rf. In cases where uterine disease of whatever kind was the
occasion of tlie misplacement of the organ, such disease being still
in a stage calling for treatment
I
USE OF MECHANICAL SUPPORTS.
159
On the other hand, mechanical means of some kind or other are
generally appmpriate :
1st. In all coses of external prolapse, or procidentia of the uterus.
2d, In cases of long standing prolapse in the second degree,
associated with much relaxation of the vagina, and consequent
weakening of the uterine supports,
3d. In all cases of extensive laceration of the perineum, and, for
a Bimilar reason, in cases of prolapsus in the aged.
4^A. In cases of the minor degrees of prolapsus which are
accompanied by extreme distress or violent pain.
5tfL In all cases of considerable prolapsus of the vagina, with
or without descent of the rectum or l>ladder ; and in all eases in
which the uterine prolapsus is secondary to any of those other
forms of misplacement.
The supports which are used in these cases are intended either
to keep the womb in its proper position, or to afford relief to the
painful sensations that accompany its niisplacement.
Thejr are either internal or external, the latter being various
descriptions of bandages which exert counterpressure in different
ways on the sacrum, the perineum, or even the pubes ; while the
former act immediately on the displaced organs themselves. The
internal are called pessaries, from tlie Greek ^itftfto/ ; the ancients
being acciLstomed to introduce medicated substances for various
purptjses into the vagina.*
There are two different kinds of pessaries ; namely, those which
when introduced are maintained in their position by the vaginal
walls themselves, and those whose support is external to the
vagina, and supplied by means of a bandage or some similar
contrivance to which they are attached by means of a stem.
• It was for the medicinal virtuet of tbdr composition, not for their mechanic*
tttaitj, that these peasariea were employed by the ftiicivnts. Thus, for iosCaiMSO,
m the Htppocratic oath the canilidate vows to abstain from the use of petttriee lo
destroy the f*j tus ; and it is to the aupjxased remt'dial virtues of their constituent!
tlmt CelsuB refurs in the twenty-first chapttsr of his fifth hook. Thftir nnuie it de-
rived by 9ome from th«'ir supposed therapeutiesil i>ower, quasi -irtatrtiv mollirt ; but
by others from wf<rx^* the iiktn of an animal with the wool on it, in which the
mutt^nala of the p^sary wt^re wrapjwd previous to being introduced witlxiu the
vulvi. Theae }^>essAnes were csnployed iu caa«ii of prolapsus utorii btit as a means
of applying astringent reme«lies, rather than of mechanically retaining the utenii
in it« positicm ; and it ia ouly within the past two centuries that their mechanical
Utility hat como to be chiollyj if nut exclusively regarded.
160
TREATMEXT OF PROLAPSUS UTERI :
Each of these kiads lias its advantages in certain cases, while
obviously we have no choice but to employ the latter in many
instances where the perineum has been so torn as greatly to
enlarge the orifice of the vagina, and thus to render ita walls
incapable of retaining the pessary.
A pessary ought to be light and smooth, in optler that by it«
w^eight it may not further weaken the lax and yielding vaginal
walls nor increase leucorrhn-al discharge by its irritating quali-
ties. It is also desirable that it should not press unequally,
nor upon a very limited extent of the vaginal wall, but that
the support it gives should be uniform, and distributed over a
tolerably large surface. Now these conditions are best fulfilled
by a pessary of a globular or slightly oval form, and made of
wood or some other material to which a perfectly smooth surface
can readily he given. Hollow metallic pessaries have been re-
commended by some writers, and whenever it is expedient for
them to be habitually worn, the lightness, perfect cleanliness, and
unirritating qualities of a thin glolm of electro-gilt silver render it
by far the best pessary that can be employed. The expense of
emplo}T.ng any of the precious metals must, however, always be
a bar to their general use ; while pessaries of box-w^Dod answer
every important purpose when a temporary support only is
needed, Indian-rubber has many advantages in its softness and
elasticity, but it is by no means so cleanly as wood, and is easUy
acted on by the vaginal seci'etions. The globular pessary is
especially useful in cases of prolapse in the first degree, where
the descent of the womb, so that its cervix rests upon the floor
of the vagina, causes much local suffering, or much sympathetic
disturbance, A small globular pessary introduced into the ml-
de-sac behind the womb, suffices to keep the OT^n off the pelvic
floor, and often affords the patient a degree of comfort equally
grateful and unexpected, and removes symptoms such as we
could scarcely persuade ourselves that so very slight a degree of
misplacement of the womb should have produced. The large
globular pessaty is also very useful in cases of considerable and
long-standing prolapsus of the uterus, in which the organ is close
to the external parts, or even protrudes beyond them, while the
whole of the vaginal wall is in a state of extreme relaxation. la
some of these cases, indeed, as well as in others where the
MECHANICAL SlTPFORTS, AND PESSARIES,
161
perineum has been extensively torn, it may be necessary to retain
the pessary by means of an external bandage with a pad pressing
on the perineum. In every instance of considerable prolapsus of
the vagina, and in all cases where the rectum or bladder is pro-
lapsed, an oval pessary is absolutely needed to prevent the
increase of the ailment, and to briojr about its cure. The globu-
lar pessary, however, Ls not free from some disadvantages. Unless
it be very small, or unless the patient leam to introduce and
remove it for herself — ^a matter, indeed, seldom of much difbculty
— it not only interferes with sexual intercourse, but also with
such an efficient use of vaginal injections as is necessary for pur-
poses of cleanliness. It is partly with a view to obviate the
difficnlties which a person sometimes experiences in the introduc-
tion and withdrawal of the pessary, that air pessaries have of late
been invented, com jjosed of ba^of v^canized indian-nibber, with
a tuhie attached to them ; through which, having been introduced
in the flaccid state, they may be distended wiih air by means of
a sjTinge. They are expensive, and apt to get out of order, but I
know of no other drawback from their utility. In some instances
there is a very considerable degree of tenderness of the uterus and
VBgina, so that an ordinary wooden pessary occasions much pain,
and when this is the case the indian-rubber air pessary will be
found extremely serviceable. Besides the more costly form of it,
which IS inflated by means of the syringe, there is a less expensive
kind which resemV»le3 an ordinary fn'ssary, except that it is dis-
tended with air, instead of being stutled with horse-hair or any
other material
I ought, perhaps, to say a word or two about the use of
pessaries made of sponge, and which, though less employed than
they once were» are not without their application in some
instances. The ernplojuient of globular pieces of sponge enveloped
in oiled silk, to render tbem iniper\^ous to the vaginal secretions,
has now fallen into disuse, owing to the superior advantages of
in<lian-rubber pessaries. WTien used now, therefore, the sponge is
introduced either mthout any covering, or enclosed in a piece of
UneiL The advantages of the sponge pessary consist in the facility
of its intnxluction, which the patient can always manage for her-
self, and in the circumstance that it expands so as effectually to
keep the uterus in situ, and that astringent vaginal injections may
L
162
TRIATMENT OP PBOLAPSUS UTEBJ :
he used without its removal. The objections to it are, that its
rough surface is always apt to irntate the vaginal walls, while by
iuibibing the discharges, it grows rapidly veiy olfensive and pro-
portionally more irritating. On these accounts, therefoi^e, it is
never to be employed among the poor, whose circumstances ore
likely to interfere with the most scrupulous cleanliness, nor in any
case where there is difficulty in retaining the uterus in its place ;
while, wherever it is used, the sponge ought to be withdrawn
every twelve hours and another substituted for it, and no sponge
should be re-introduced tiU after it has been soaked for twelve
hours in water. The only cases, then, in which sponge is advis-
able as a pessary, are cases of the minor degi'ees of prolapse,
where we are fearful lest the evil should be increased by the
patient's ordinary pursuits and exercise, whUe the use of a pessary
is a precautiouiiry measure, which there ia good reason to expect
that we may in a short time be able to dispense with altogether.
Another kind of pessary, not so generally applicable as that of
a globular or oval form, but yet having advantages that render it
very* useful in some crises, is the disk pessary. This, as its name
implies, is a Hat disk of wood, or sometimes of some light
material, such as hair or wool covered with indian-rnbber, or, still
better, a solid ring of vulcanized indian-rubljcr, or an indian-rubber
cushion inflated with air, which, being introduced into the vagina,
is placed transversely across between the spines of the ischia, so
as tx> form an artificial floor to the pelvis, and thus keep the utems
more nearly in its natural situation. These pessaries are all
perforated with u central openiog, whit'h is not merely useful in
facilitating tlieir removal, but also allows the ready escape of the
menstrual lluid, and even admits the possibility of conception tak-
ing place, while they are still worn by the patient. The central
aperture, however, has sometimes been the occasion of consider-
able discomfort to the patient, owing to the cervix uteri passing
through it and becoming swollen, and partiidiy strangulated by
its edges. This inconvenience is easily avoided by the precaution
of haring the central aperture made either too small for the
cervix: to pass through it, or too large for the possibihty of its
strangulation occurring ; and, as a general rule, the former mode
of construction is preferable to the latter. A less remediable
objection to this kind of pessary is furnished by its extreme
I
I
I
I
MECHA.}nCAL SUPPORTS, AUT) PESSARIES.
163
liability to become displaced, owing to the circumstance that it is
in contact with only a comparatively narrow band of vaginal
waU, instead of being embraced, as the globular pessary is, by a
large extent of surface ; while, though a woman possessed of very
slight dexterity may learn to introduce and remove the globular
pessary for herself, she must always be dependent on a medical
man for the proper adjustment of a disk-shaped pessjftry.
The ready displacement of the disk pessary is limited to the
wooden one, the cheapness of which will probably always compel it
to be retained in hospital practice ; but the soUd indian-rubber ring
pessary is free from tliis tlrawhack, and moreover can always be
introduced by the patient herself if she is possessed of ordinary
dexterity. One dLsjidvantJige, however, attaches to the use of
indian-rubber pessaries, namely, that the material is apt to irritate
the vagina, and so to produce a troublesome leuconhrea, which
can sometimes be prevented only by the withdrawal of the
instrument at night, and its re-introduction in the morning.
[It is worth while to note that young women rarely sutler from
acute vaginitis caused by wearing a pessarj\ They may, and
often do, have slight vaginitis with muco-punileut dischai^ j
and ulceration, which may be deep, may be discovered at a point,
for example, behind the cen^ix, where the pessary has pre^Lsed too
strongly. Old women, that is, women who have passed the
menopause, besides being liable to all that befalls the younger,
are specially liable to a vaginitis which is acute in every sense, or
acute merely as causing profuse discharge of pus. In such
women the vagina has not the appearances prcvsented by that of
younger women similarly affectetl The absence of ruga? leaves
room only for a uniform redness* Of course, in such aise^, the
pessary has to be removed for a time ; and ordinary treatment
soon removes the intercurrent affection,]
Various attempts have been made of late years to improve
uterine supporters so as to avoid irritating or distending the
passage, wliile yet funaishing a support which shall be both
light and not easily displaced. Some of these requirements were
met by a very ingenious instmment invented some years ago by
Dr Zwanck.* This consisted of two wings, in the shape of
* He publiihed a dfsoription nnd dniwuig of th« iBstnunent in the Monatsachrift
/. OthiwUkmd^ Botia L Heft 3.
184
TREATMENT OF PEOLAPSUS UTERI :
castanets, each perforated with a central aperture, and connected
hy a hinge with a central st^m ; so arranged that while
introduced closed, the wings were easily expanded and secured by
a connecting screw with the stem in an ofien position. It
answered the purpose of supporting the uterua very well^ and
was of special aervice in cases where the perineum had been
extensively lacerated. It had, however, the gi-eat drawback of
distending the vagina, while in cases where the patients were
inattentive the circumscribed pressure that it exerted sometimes
produced serious ulceration of the canaL On these accmmta it
is now much less employed than formerly ; though I believe that
in cases where the perineum has been extensivaly torn it will still
be found of much service.
One of the most generally appUcable internal supports for the
uterus is the lever pessary in one or other of its modifications, for
the idea of which we are indebted to Dr Hodge of Philadelphia,
whose name it most properly bears * Every one is now bo
familiar with it that it scarcely calls for description. It is a par-
allelogram of flexible metal, coated with vulcanite, curved at
either end,^ — the curve at the one end larger than at the other ;
while the nature of the material admits of the curve being readily
modified by pressure with the finger. It is introduced so as to lie
with its convexity in the hoDow of the sacrum, the end with the
larger curve resting as high as possible behind the pubes, while
the other occupies the cui-(k-3m between the uterus and rectum*
The mode of action as a support to the uterus cannot be better
described than it has been by Dr Barnes, whose words I quote.-f
" During inspiration or exertion, the intestines driven do^vn upon
the uterus and bladder cause the anterior wall of the vagina to
descend. The lower limb of the pessary being applied to the wall
is carried down with it ; and the upper limb necessarily rises in
the opposite direction, lifting the roof of the vagina and the uterus,
and keeping the fundus of the uterus inclined forwards. So long
a^ the body of the uterus is maintained in anteversion it can
hardly sutler prolapsus. The average action of the pessary is also
gi-eatly aided by the posterior wall and floor of the vagina. This
* Oti. Diaeagea Peculiar to Wotneri, Svo, Philadelphia, IS SO, chapter vi
|i. 830-350.
t Clinical Eisiory of the IHseases of fForMn^ 2d ed. 8to, 1878, p. 655.
I
I
MBCEAXrCAL SUPFOETS, jLND PESSABIEB,
165
at the lower part forms a thick, elastic, and muscular structure,
wliicli, partlj by its contractile property and partly under atmo-
spheric pressure, is normally kept in close apposition to the
mnterior walL giving it material snpport, and thug constituting
one of the greatest impediments to prolapsus* The pressure so
exerted of course will bear upon the upper limb of the pessary
which is embi-aced in the vagina. The sphincteric action of the
vuWa also cornea in aid. This contracting the outlet helpa to
support the instrument above it/*
This instrument has undergone various modifications, into the
particulars of which it would be tedious to enter ; and in practice
you are sure to lueet with cases which no existing form absolutely
suits, and in which your own ingenuity will be called into play to
meet the peculiar needs of your patient. Need I say, do not
therefore fancy yourselves great inventors or rush into print to
describe your new contrivance. It will probably be as useless in
sine eases as you have found it serviceable in the tenth.*
There is another large claas of pessaries in which the instru-
ment is retained in its position by some support external to the
patient, not by the mere counterpressure of the vaginal walls
and pehic floor. The principle of all such instruments consists
in the emplo}Tnent of some kind of belt surrounding the hips, to
which eitlier a stem is attached bearing the uterine supports, or
strape are connected with it which serve to hold the internal
support in ita proper position. The great practical drawback from
their employment is this, that the belt or spring surrounding the
pelvis is unavoidably liable to changes of position, by which the
vaginal stem is sometimes brought to press painfully on the orifice
af that canal ; or the uterine support tecomes misplaced, so as to
allow of the descent of the womb taking place by its side. This
circumstance, together with their much Uglier price. leads to their
being comparatively seldom employed, though you may nie^t
with caaes, those especially in which the perineum has been
extensively torn, in which one or other modification of this kind
of apparatus will be of service.
♦ *• I find," KLji Dr Fordycc B&rker of New York, in his addtuis to the Gynat-
oolcgioal Society in 1877, '* that aince 1845 one hundred and two men have sought
immoitfdity by devising new Jbnns of pesaaries, descriptiana of which h*ve been
166 TREATMENT OF PROLAPSUS UTERI :
One source of comfort to the patient, from the employment of
some of tliese external supports, is derived from the couuter-
pressure on the pelvis which the helt exercises, and which
relieves very many of the painful sensations experienced in cases
of uterine prolapsus. Two bandages which seem to me extremely
well adapted for this purpose, are Hull's utero-abdominal
supporter, and a bandage know^n hy instrument-makers a*s Dr
Ashburner's bandage. Each of these tightly embraces the liips,
while the former is furnished with a large padded metallic plate
fitting over the pubes, and the latter with a similar one adapted
to the upper part of the sacrum^ The chief utihty of these
metallic plates is that by their firm and yet gentle counter-
pressure they relieve the sympathetic pains referred t^ the back
in one case, or the dmgging and distress in the region of the
ovaiies in another. To both of tliem a strap passing between
the legs, with a perineal pad, is adapted, and though it can be
dispensed with at pleasure, will he found of great service in all
cases of cousiderftble relaxation of the vagina, with disposition to
actual procidentia, when used either alone, or in combination
with some form of internal support. The strap and perineal pad
have the disadvantage of heating the parts, and thus of keeping
up leucorrhffial discharge ; but without them the instrument
cannot be so well adjusted. Of the two, that of Dr Ashburner,
with its sacral pad, has seemed to me the more useful, greatly
relieving the back-ache, and being found indeed by some persons
almost indispensable to their comfort in walking or making any
kind of exertion.
It can scarcely be necessary to say much with reference to the
manner of introducing pessaries, or the precautions to be
observed by those who wear them. Even in cases that most
require their employment, it is always presupposed that they are
not used so long £is any considerable tenderness of the parts exists,
or as there are any remains of inflammation or of considerable
congestion. These conditions being removed, the patient l}^ng
on her left side, the uterus is carried as nearly as possible into its
natural position, and the pessary covered with oil, or some M
unguent, is introduced, not without attention to the direction of
the pelvic axes, and placed either Ijehind the cervix uteri, or
simply in the upper part of the vagina, if the relaxation of the
I
MECHANICAL SIJPPORTS, AKD PESSARIES.
167
Vaginal walls is very considerable, and the prolapsua has passed
the first degree. Whenever the relaxation of the parts is great,
it will be essential to choose at first a pessary so lar^'e as nut to
be introduced through the orifiee of the Yulva without some little
difticulty, for the vagi Da is always more capacious near to its
upper part than close to its orifice, except in old wouien not
sufi'ering from prolapsus, and in whom the ordinary ati'ophy of
age has taken place j and besides^ if the introduction uf the
inatrument were ver}^ easy, it would be almost sure to become
speedily displaced. In the greater degrees of prolapsus, and
when the perineum is torn, an external bandage with a perineal
pad is required to keep the inatrimient in its place*
When the di.sk-pessriry is employed, the instrument is introduced
edgewise, and is carried up in the vagina as far as possible in that
position. It is then fixed by turning it round so as to bring it t<>
lie tranfiversely between the iscbiatic spines, when it forms a sort
of artificial pehdc lIcKjr, on wliich the uterus rests. The lever
pessary is likewise introduced edgewise, and as soon as it has
passed the orifice of the vulva it is turned round with its con-
vexity downwards, while as the finger presses one end upwards
► toward the pubes, the other passes of necesaity into the eni-de-sfw
behind the uterus. Whatever kind of pessary is used, l*ut
especially when the disk or kver pessary is employed, we should
not leave our patient after its introduction until she hiis walked
two or three times across the room, and thus ascertained tliat the
instrument stiU remains in its proper position. Its small lialnlity
to misplacement is, as I have already stated, one of the great
advantages of Zwanck*s instrument
No pessary should be allowed to remain for many weeks in the
vagina, whatever may be the precautions used by frequent
employment of vaginal injections to prevent the deposit of the
secretions upon it. One of the great advantages of t\w j^lobular
or cylindrical pessary, and also of Zwanck's instrument, consists
in the possibility of its being removed by the patient herself
every night, and replaced before she rises in the morning, by
which means not only can it l>e kept scrupulously clean, hut the
vagina can bo washed out by the copious use of water, or of some
astringent lotion twice in the twejity-four hours. Ctises of most
serious mischief, arising from the neglect of this precaution, are on
168
rREATMEKT OF FROLAPaS
record, in wliich inflammation and ulceratioo of the vagina have
been produced, or the pessary has even made its way into the
bladder, thus entailing on the patient aU the miseries of vesico-
vaginal fistula. But another reason for the frequent removal of a
pessary is, that in many cases we employ it purely as a temporary
expedient, as a meaiLS of keeping the womb in its place^ while the
vagina and the dnplicaturea of peritoneum are acquiring that
power which may enable them permanently to retain it thei*e.
We hope that aft^r a time the pessary may l>e altogether dispensed
with, and as a preliminary step towards this, we change the
pessary occasionally, and substitute a smaller instrument for that
which was previously worn. It is indeed comparatively seldom
expedient to do away with the use of the pessary all at once ; but
it is in general more prudent to employ one or more instalments
of smaller size before discarding their use alUigether.
In cases of prolapsus of the rectum, it is important to give the
patient special cautions as to the necessity of attending to the
state of her bowels, and as to the probability that a few weeks of
neglect in that respect would reproduce all her former symptoms.
When the bladder has been misplaced, something may be done to
cure the slighter degrees of the accident, or after the removal of
the pessary to prt^vent it« return, by the patient pressing with her
fingers against the anterior vaginal wall whenever she passes
water, so as to ensure on each occasion the complete emptying of
the bladder.
In all eases of procidentia of the uterus, as well as of external
prolapse of the vagina, the first point to attend to is to return the
parLs within the pelvic cavity, and to keep them there by the
employment, if necessary, of Ashburner's or of some other well-
adjusted bandage with a perineal pad In some instances, when
the procidentia has been of very long standing, this is all that can
for a time be att'Cmpted, since the amount of hypertrophy of the
womb and of the adjacent parts is not infrequently so considerable
as to leave little room for the employment of a pessai-y. It is
remarkable, however, with what rapidity such hypertrophy
dimiuLslies if the patient is kept for two or tlu^e weeks perfectly
quiet in the recumbent posture, w^hile care is taken that the
pr<dapsus does not become again externaL The presence even of
very considerable abrasion about the os uteri does not in any
AND PKDCIDENTIA OF UTEHUS.
169
tncasiire contmindicate the immediate return of the organ, nor do
in general the large and indolent ulcerations which form epon the
surface of the inverted vagina. The healing of such soi-es,
though always tardy, yet usually goea on much more rapidly
within the body than external to it ; while, if cicatrization does
not advance satisfactorily under the use of simple vaginal
injections, such as the letid wash, or the lotio nigra, the patient
can be directed to protrude the uterus externally by occasional
bearing dowTi eflbits, in order to enable us to touch the edges or
surface of any ulcer that may require it with the nitrate of silver.
To this rule, however, there are occasional exceptions. Some*
times the exposed surface has become extensively abmded, and is
very painful, or the ulcerations upon it are large, numerous, and
unhealthy. In such circumstances the endeavour to replace the
uterus Would l»e very painful, while the ulcerations may n^qiiire
more direct treatment than would be practicable if the organ wei*e
returned within the pelvic cavity. Wlien this is the case I am
accustomed to keep the patient for a few days strictly in the
recumbent posture, with the hips niised, and the uterus itself
supported on a pillow, and enveloped either in simple water
dressing or in a weak lead lotion, or if the abrasion of its surface
is very extensive, and the discharge from it very profuse, in cloths
aoaked in a lotion composed of two scruples of the oxide of zinc,
auflpended by means of two drachms of mucilage, in six drachms
of water. If the sores are very indolent they may be dressed
with an ointment of two drachms of Peruvian balsam to an ounce
of spermaceti ointment, while their edges may require daily
touching with the solid nitrate of silver. Tliese measures,
however, are to be continued only so long as the state of the
procident parts absolutely requires it, for the sooner they can be
replaced the better it is in all respects. Two other conditions
require caution in the endeavour to replace the womb, or delay in
attempting it. When the utenis has long been external, the
int-estines, as already explained, fall down out of their proper
situation into the pelvic mvity. They may grow so habituated to
their new position that considerable discomfort may be experienced
by the patient when the womb is replaced. In these circum-
stances it will be advisable to return the organ for a short jieriod
only every day, so as by degrees to accustom the parts to the
170
TEEATl^IEKT OF CHRONIC PROdDENTIA UTERI :
disturbance of what has now become, by the lapse of time, almoat
their natural poaifcion, Tlie discomfort, however, that the patient
experiences, may be further due to the circumstance tliat
adhesion has taken place between the intestines themselves, or
between tliem and the margbis of the sac of the prokpsus, thus
offering a positive mechanical impediment to the replacement of
the womb, and calling for much care on our part, since not
discomfort only, but dangerous peritonitis, may result from too
forcible efforts to return the womb, or, when replaced, to keep it
constantly within the pelvis. In all cases, too, of very large pro-
lapsus, in which the intestines have descended into tlie sac, much
caution is necessary in any attempt at replacing the womb. If
there is much tenderness of the mass, it may be expedient to
apply leeches to it, and to keep fomentations or water dressing
upon it for many days. But even in the absence of any such
symptom it is yet expeihent, unless the masa is retmned with
great facility, to content ourselves for a time with raising the
uterus by means of a pad, and applying a T bandage to prevent
its further descent; for if by gentle means w^e can gradually
diminish the prolapsus, we may hope in the course of time safely
to remove it altogether. By an opposite course of proceeding, so
much violence will almost invai'lably be done to the uitestines as
to excite their inflammation; and I have seen death on one
occasion result from this want of precaution, %vhile in another
instance, though no excessive violence was used in replacing the
organ, peritonitis supen^ened, from which, however, the patient
happily recovered.
The vaiious contrivances for the relief of prolapsus of the utenia
or vagina which we have hitherto examined, are confessedly
merely palliative measures; bringing about a cure, indeed, in
many instances, but doing so indirectly by preventing any increase
of the displacements, and thus giving time and opportunity for
nature gradually to remove them. In the slighter degrees, and in
comparatively recent cases of prolapsus, these means seldom fail
to accomplish much good ; but there is nn uncertainty about their
results when the accident is of long standing, or very considerable,
which has led not unnatumlly to the endeavour more speedily and
more surely to accomplish a cure.
Numerous oiterations have therefore been devised, having in
OPERATiyi; PROCEEDINGS.
171
view either the diminution of the orifice of the vulva, and the
consequent prevention of external pmlapsus, or the contraction of
the vagina itself, and thereby the removal of one of the cliief
causes on wliicb the prolapsus depends. There can, probably, be
no difference of opinion with reference to the propriety of per-
forming an operation in some of these cases. In those, for
instance, where extensive laceration of the perineum has been
followed by prolapsus of the vagina or rectum, and by consequent
descent of the uteniB, it is obvioms that all mechanical con-
trivances for keeping the womb in place will accomplish but little
in comparison with what we may hope to do by restoring the
perineum, giving to the vagina once more its proper support, and
bringing the parts again into their natural condition. Between
this, however, and the artificial contraction of the orifice of the
vulva there is a very wide difference. The restoration of the
natural perineum gives back to the pelvic organs the support of
which accident had deprived them, and is thus essentially a cura-
tive measure ; the partial obHteration of the vulva does no more
than mechanically cIcjsc the opening through which the prolapsed
oigana bad esc^iped from the pelvic cavity ; while it leaves all the
other evils of the accident unmitigated, and even less amenable to
palliative measures, and to such aid as mechanical contrivance can
afford, than tliey were before. In spite of these obvious draw-
backs, however, the difHculties attendant on the application of
pessaries and other mechanical supports, the discomforts inseparable
from their employment, and their insutliciency, in some instances
at least, to answer even that limited purpose which alone they
can fultih led to the suggestion hy Mende* of one operation, and
to the performance by Frickef of a somewhat difi'erent one, with
the object of retaining the uterus within the vagina. Mende*8 opera-
tion, which was intended to retain the womb by forming an artifi-
cial hymen, was never practised, but the attention which has been
excited in tliis country by the performance of an operation identical
in principle to that of Fricke renders it desinible to enter somewhat
more into detail concerning it than would otherwise be expedient.
• Dui Ge3chl4i*'hUtrankheiUn des IVcibc^, Gottingen, 1834, vol ii p. 51,
t Annaleii, etc., rol. il 1833, p, 142 ; wbeiice a minute iicootmt of the operatioti
is extmcted in KiUaii*s Opcmttotutlchrc^ 2d fid. vol- iii. 1861, f. 96 ; and in Sonth'i
edition of ChcHusj 1847, toL ii. p. 114.
172
TREATMENT OF PROLAPSUS UTEEI :
!Fricke*s operation consists in the removal from the edge of each
labium of a portion of its substance of two fingers* breadth ; the
incisions being begun about an inch below the superior
commiesure on either side, and uniting in an arched form half an
inch behind the frenulum ; in doing which a special caution is
given not to be too sparing of integument The haemorrhage
having ceased, the edges are united by sutures, of wliich ten or
twelve are sometimes necessary, and the operation is completed.
The union thus obtained waa incomplete in many instances, but
even then a sort of bridge of integument was formed which it
was believed by M. Fricke would prove amply sufficient to retain
the uterus in its place. The operation, too, was speedily adopted
by others, and DieETenbach lent the gi'eat weight of Ids reputation
in its support. But nevertheless, ** though the proceeding had
apparently taken firm root in surgical practice, and though it had^
been most carefully performed by dexterous hands, the lapse '
time sufficed to moderate the high-flown expectations which had
been euteiiaiued concerning it, and a calm judgment succeeded
wliich we," says Professor Kilian, " after having performed the
operation five times, pronounce without the least hesitation. It
may be regarded as established — 1^^, That the operation in some,
though very rare cases, is of permanent service ; 2dj that in not
a few other caaes it is Hkewise of temporary utility, sufficing to
retain the womb for some weeks, possibly even for some months^
but allowing of the eventual return of the procidentia as the
orifice of the vagina gradually dilates ; and 3d, that very oft^en it
either fails completely, or its success is extremely imperfect. In
the face of these evils, Fricke 's proceeding was unable to maintain
itself in practice, and the various attempts made to improve and
to modify it have proved altogether unsuccessfuL*'*
Nearly simultaneously with the abandonment of this operation
on the Continent, an unconscious modification of it was intro-
duced into this country by Mr Baker Brown, in which tiie
general integument is left untouched, the mucous membrane only
being removed from the inner surface of the labia from a point
on a level with the urethra, and from the posterior surface of the
vagina, and the parts being then brought together by sutures, the
orifice of the vagina is thus contracted, and the perineum
• Kilimi, op, cU. p, ©0.
OPERATIONS FOR ITS CUHE,
173
elongated. Tliis proceeding is certainly much less severe than
that adopted by Fricke, but at the eame time it must contract
the orifice of tlie vulva to a much less extent than the other
operation by which the integument is ao freely removed. When,
therefore, we find Fricke's operation, even as modihed by
Malgaigne, who carried his incisions much deeper, and removed a
considerable extent of mucous membrane at the oriJice of the
vagiDa, in order to include a still larger surface in the suture^
abandoned on account of its not being followed by permanent
success, we hesitate to pronounce an opinion on the alleged
successful result of almost every one of fifty cases in which the
modified operation was performed by one surgeon,*
Frequent as is procidentia of the uterus among the poor, cases
in which the condition proves rebelliona to rest and well-
contrived mechanical support are, I believe, of very rare
occurrenca It ia surprising how much the size of the procident
womb is reduced after its return within the vagina by a month's
rt?st in bed, how completely a long-standing ulceration of its
oriEce heals, and how effectually the organ is retained afterwards
within the pelvis by a bandage. If in the majority of these cases
an operation were performed, a similar result would doubtless be
obtained ; the month's compulsory rest in bed would be followed
by the same diminution in the size of the uterus, and the
elongated perineum would answer for a time at least the same
purpose as the perineal pad of an ordinary bandage ; while by
slow degrees the ligaments in the one case as in the other might
regain some measure of power, and the womb might cease to fall
down externally. If, however, the operation be limited to cases
of sficcial gi^vity, and to such I apprehend it ought to be
confined, I doubt whether any higher commendation can be
bestowed on it than is contained in the Hippocratic axiom, which
pronounces a " doubtful remedy to be better than none at alL"
In the only case of mine in which, the perineum being intact, the
• AfedieeU Times, November 21, 1857- The valui? of the stat^nipnt is Hkstnitod
by tho f»ct, that of forty-one crises reported in the 2d edition of Mr Brown's work
on Dismaa of Women, yp. 101-111, while oao only is un iidniitt«d failure, and one
ftUowed to be an ijicomplete success, thers ftrebttt thn^e of the remainder concem-
iog which any information ia given after the diachargo of the patient from the
hospital. The permanenct of the cnre ia the teat of tho value of the operation j
tovr&Tdfl catabliaiLiDg that, these thirty-six casea are aboolutely worthless.
174
TREATMENT OF PROLAPSUS UTERI :
operation seemed requisite, it failBd completely to retain the
wombj and within two montlis from the patient*a lea\ing
the hospital the procidentia was as bad as ever. The patient was
a young unmarried women, twenty-six years old, whose spine
was much distorted by lateral curvature, and to w^hom, on that
account, no bandage could be adapted- Sir James Paget
performed Fricke's operation ; the union of the parts was com-
plete, and the elongation of the perineum was earned further
than would have been expedient had the woman been married.
The cicatrix yielded to the pra^ure from above ; for a time the
uterus distended the new perineum, then bit by bit it dilated the
orifice of the vulva, till at length it projected exteraally as it bad
done before,
A verdict not more favourable must be pronounced on a
kindred though somewhat ditierent operation, which has some-
times been practised either in addition to that for naiTowing the
vulva, or independently of it, and which consists in the en-
deavour to contract the vaginal canal, cither by the removal of
strifts of its mucous membrane, or by the emplojTnent of the
actual cautery, or of strong caustics, so as to produce cicatrices in
its walls, and consequent shrinking of its calibre, or by the
insertion of sutures in its tissue in a peculiar manner, witli
the view^ of obtaining the same result The first of these proceed-
ings suggested by a French surgeon, M, Gerardin, but actually
performed thirteen years afterwards by Dr ^larsball Hall, and
modified by Professor Dieffenbach of Berlin, has been practised
more frequently than the other operations, and with considerable
tempomry success. The actual cautery employed by M, I^ugier,
and afterwards by Dr Kennedy of Dublin, and the use of the
strong nitric acid resorted to by the late Mr Benjamin Phillips,
have proved less successful ; while Bellini's operation by means of
the suture is difficult, complicated, and has therefore been
abandoned The objection, and, to my mind, the fatal objection,
to these as to the other surgical proceedings for the cure of
prolapsus uteri, is furnished net merely by the imperfect nature
of the cure wliich they accomplish, and the new discomforts and
inconveniences which they substitute for those before experienced,
but still more by the want of permanence in theu' result, even
when their issue is most fortunate, and this objection seems to
OPERATIONS FOR ITS CURE.
175
me all the more serious since failure in this respect appears to be
the rule, success the rare exception/ I think, too, that if we
consider the circmustances in which prolapsus either of the uterus,
rectum, or bladder takes place, we can scarcely expect that the
result of thti operation should be other than temporary : that the
cicatrix tissues should fail to yield to the pressure from above ; and
that all the other causes remaining unremoved, misplacement of
the organs shouhl in most instances recur.
The operations already referred to seemed to deserve rejection
rather on account of their inadequacy to effect a permanent cure
of the evils for the removal of which they have been suggested,
than on account of great difficulties or great danger in their per-
formance. The removal of a large portion of the neck of the
womb, however, m recommended by M. Huguier^ merits condem-
• Professor Sciinxoiii, in a note at vol L p. 205 of tbt* fourth edition of Kiwiach^i
work on Diseases of Womei\ and at p. 124 «f bis own Lehrhuck dtr Krankkeiltn dtr
itriblkiieii Sexualor^jie^ 8vo, Wien, 1857, in&ke« some remiirks on ihia subject,
liSAed on Ms own experience at Prague, which amply bear out the stutcments in
the text, And corroborate the verdict that I have quoted frum rrofcasor Kiliau.
He myn that of five cases in which the orifice of the vnl v^a wm contracted by opera-
tion, aU were unsnccesafhl, either failing from the first to retain the womb, or the
newly -formed perineum stretching by degrees till at lenj^h the orifire of the
Tulva widened so m to allow the womb 1^ protrude jnmt as it had done b^jfore the
operation was undertaken. The reault of thirteen cases, in wliich it was t-ndea-
▼oared to produce contractioo of the vagina, was still more unsatLsfactory, ainee in
every one the utenis within n few wi?eks protmdcd a» nuich as ever. It is almost
«iperf!uons to add anything further in condemnation of proce*'diiig8 whicli are
falling into disrtse by their own inutilitj^ I cannot, however, refrain from adding
the opinion of Dr Gu^t«v Simon of Darmstadt, no mean authority in all questions
of this kind — Mmiaisschr. J\ Otburisk. 1859, vol. j^iii. p. 284. After relating an un-
■QcecMrul case on which he himself operated, he adds that he hoa frequently
watched its performance by other Rurgeons, and Ix'lieTea a pernumtnU cnr» of pro-
lapsoa to be very rarely brought about. ** These slender results of episioraphy/*
mjn he, ** an operation which, moreover, is not unattended by danger, led to other
means being devised for the relief of prolapsua. Recently, indeed, such well-
contrived pe-s8drie>* have been invented (tboee of Boaen and Bi.'anzoni, of Zwanck
and Eulenberg) that it can very seldom ha[>i3en for a cane to occur in which the
far more uncertain and more hazardous operation is indicated. In not a single
one indeed of the rather numeroua iostftiicea ol uterine prolapse n which have come
under my care, since the |ierformanoe of the operation which I have related, have
1 found it necessary to resort to episiorapby, for in every one suitable peaaaiifle,
geoeroUy that of Zwanck, retained the pro1n|FSUs just as well as the moat flocoess-
ful oijeration could have done,'* I may a<ld, that cluring the hwt three years of
my conncHition with St Bartliolomew's Hospita!» I did not meet with a single case
of prolapsus which a Zwauck*s pessary failed to retain*
176
OPERATIONB FOH CURE OF PROLAPSUS UTERI :
nation on diiferent and more serious grounds. The excision of the
portio vaginalis of the uterus, which M. Huguier employs in some
casea of descent of the organ, is an operatiou, as I have already
stated ^ by no means free from danger ; and additional experience
does hut confirm surgeons in their view of it, as a proceeding not
to be Hgbtly had i-ecourse to.* M, Huguier*s special operation,
however, adapted, as he behoves, to cases of elongation uf the ueck
of the womb above its connexion with the vagina, is of a far
more formidable kind, and "consists in taking away, together with
the upper extremity of the vagina, the whole length of the necJc,
and, if necessary, the lower part of the body of the litems, remov*
ing it by an incision slanting from without inwards^ after having
previously detached the bladder from the part to be exciaed/*-f-
This statement of the nature of the operation loses nothing of its
formidable character if one reads the details of its mode of perfor-
mance, or looks at the illustrative plates, or considers the very
needful cautions given by M. Huguier as to the means by which
one may best avoid opening the peritoneal pouch behind and the
bladder in front, while the ht^emorrhage, always profuse, can
scarcely fail in some instances to endanger life.
Moreover, the very conditions in which the need of relief is
most urgent, are those wliich, according to M. Huguier, forbid the
perfoimance of the operation, inasmuch as he says, that "a
capacious pelves and a large opening of the vulva, more or le^
laceration of the perlnenm, and considerable relaxation of the soft
parts at the pelvic floor, absolutely contraindicate if I 1 would
confidently ask, how many are the patients suffering seriously from
the symptoms of uterine prolapse, in whom some one or more of
these conditions are not present, and in what persons but those
whose sufferings are most severe, should we be justified in setting
their life upon the cast by the performance of an operation which
rests on a false hypothesis, which is not proved to be permanent
in its results in many of the cases where it has been performed, and
which can be but moderately perilous only iu the hands of those
who may be possessed of the exceptional dexterity of M. Huguier? §
* See some recent cmaei referred to in the discussion on M, Hngoier's paper, bj
M. Bepanl, BiUkiin d& rAcatUmie, toL x^r. pv (}S2.
t Op. cit p, 160. t Thid, p. 166.
§ The ertticisma of M. Depanl in tbe discnsaion at the Academy of Medicine,
those idruady refijired to by Scanzoni in vol iv. of his BcUrage on this and the
EXTIRPATION OF PROCIBENT UTERUS.
177
The annak of medicine contain the history of aoine few extra-
ordinary cases in whicli the uterus, having long been procid^int,
hein^ quite irreducible, and having been attacked by iiiflanimation
which terminated in gangrene, has been removed with no ill
effect by means of the ligature and knife. I have no personal
experience of such cases, thougli a patient was once sent to me
at St Bartholomew's Hospital to have the procident uterus
extirpated. The procidentia, however, was not irreducible ; the
uterus was not the seat of any dangerous inflammation; and the
woman within the previous year had given birth to a child. 1
need not say that the operation was not performed ; but the
womb, being replaced within the pehis, was retained there by
means of an Ashburner's bandage, and the patient was sent back
to the country in a state of comparative comfort.
I do not know, however, but that instances may occur
justifying this proceeding ; and further, would remind you tliat
the womb, when long misplaced, loses much of that sensibility
which characterises it when in its natural positioiL The inveited
womb has on many occu.sion3 been safely removed by ligature,
and one of the few instances of successful extirpation of tho
cancerous uterus was that recorded by the younger Langenbeck,
in which his father performed the ojieration on a womb tliat for
years had been procident beyond the external parts.*
There would be two great risks to be avoided in such a
proceeding, — the one would be that of opening the peritoneum ;
the other, that of wounding the liladder, which viscus in almost
idl cases of considerable or long-standing prolapse, descends far
down in tlie front of the tumor, aud without much care would be
very likely to be injured.
[There are rare accidents in the way of procidence which may
be mentioned, because acquaintance with tlieTu may aid diagnosJ!^
or at least prevent mistakes. Vaginal hernia is i-are, and is not
within the scope of these lectures ; but Dr Fordyce Barker has
written a valuable paper on the subject^f Cases of procidence
mttalogotifl opemtion of Profcaaor Braiin of Vienna, and in tbe 3d edition of bis
Lehrhuch^ pnUisb<'d in 1863, pp. 1 45-1 47j may b« coasalted by an j one who ia
de»tnjus trt parauis tbis sulject furtber.
• De totiitJt ukrl cjrlirfMUiov/'^ aiictore M, Laugcobeck, 4 to, Gottinge, 1842.
[t Ameri^'an Journal of ObslttricSf 1876 J.
178
BARE VARrETTES OF PROLAPSUS VTmh
or hernia of the posterior wall of the vagina in a pouch-like form
are aonietimes produced by distension of the abdominal cavity.
The Huid is pressed into Douglas's space, and pushes the
peritonenm before it, sac-like, into the vagina, T have seen a
case which, during life, had been taken for a procident utems.
The protrudin^r vaginal hernial sac was tilled with gelatinous
matter escaped from a larger ovarian cystoma. It miglit well
have been taken for an ordinary vaginal cyst, which indeed it
closely resembled. I have seen such a cyst protruding from the
vulva, and regarded as a falling of the womb. Sometimes the
womb, as it is forced down, is pushed not through the vaginal
orifice, but through tlie anus, and of this I have seen an example.
When the uterus is procident in a child, or before the
establishment of menstruation, the procident mass presents
peculiarities. These mv seen also in the cases of some old women »
in whom the procidence has taken place after the atrophy of old
age has occurred, or in whom the atrophy has come daring the
procidence. Other great changes may take place during procidence.
among which one of the most interesting is the change of an
elongated tive inch uterus into one of ordinary dimensions, the
body of the uterus being dragged down by the continuously
acting tension. TJie peculiarities referred to are absence of the
enlarged cervix or entire absence of the infravaginal portion, with
an OS uteri of ordinary size or preternaturally sraall. Tn some
such cases the os has to be searched for, so small is it.
As already described, the bladder is all but invariably dragged
down by the cervix uteri to which it is closely attached, — the
sound in the bladder being easily felt near the most dependent
part of the anterior iip af the procident cervix. I have, in a
large number of instances, never seen it otherwise ; but Kalten-
bach* records the occurrence of procidence without the bladder
following.
An excessively rare accident is procidentia of the bladder
through the urethiu. It is really an inversion of the organ].
I* ZHU-hrifl fikr (Mfuriskulfeuml fhjtmkoto^jie^^ T. Bani3, 1877, s. 462. Remarks
by J. Veit on the same subject will Iw found in the same volume^ s. ir»0].
I
LECTURE X.
MISPLACEMENTS OF THE UTEEUS.
VKftaioxs AVD Flrxions of the Uterus.
RetroreTHion of the Womb ; knowledge of its exintence in un impregnated statt
coin]>aratively recent Its cauAes^ and mode of its occuiTence. lllu9ti*atLv«
caaea.
AnteTersion often confounded with ante1iexion«
Flexions op Uterus— pTobahly more frequent thnn tnuplftOeiDantB of i^hioik
orgiin — iilwaya take place at one point, and why ; compar&tiTe frequency of
ante and retro flexion. Absence of disposition to apoiitAncoua cure ; existence
of ftdhesions and of atrophy of uterine wall. Iniluenco of fluxions on ntenia
in otiier respects, hjqwrtrophy of womb ; constriction of internal 08» kc.
Ohliqiiity from congenitfil malformation.
When speaking about prolapsus uteri, I expkiueJ to you how it
occurs that descent nf the womb is always a^sociatt^d with a dis-
position to retroversion of the organ ; or, in other words, to a
falling back of its fundus into the hollow of the sacrum. Such
minor degreevS of retroversion, however, are of comparatively trivial
importance, and whatever symptoms they may occasion are
entirely lost in the general consequences of the downward displace-
ment of the womb.
Cftses, however, especially of late years, have engaged the
attention of practitioners, in which, thougli the womb may be
somewhat lower tban natural, yet it is not only, nor even
principally, to this displacement that the patient's symptoms are
due, but rather to a falling of tlie fundus uteri downwards and
backwards into the hollow of the sacrum, accompanied with a
corresponding elevation of its cervix, whicli is directed upwards
and forwards against the symphysis. To Dr William Hunter we
owe, if not the first-mentioned, at least the first clear desrription,
of this rdrfwersimi of thr womb as an accident Uable to happen in
the early months of pregnancy ; and since his time no treatise on
midwifery has failed to mention its occurrence, and to delineate its
s>Tnptoms in colours even darker than are always needful*
180
RETROVERSION
But thougli it would seem natuml to anticipate that Ibis
accident should not always be limited to the prec^nant state, but
might also sometimes happen in any other circumstances wliich
rendered the womb heavier tlian natural, and its supports more
lax, yet it was long before this was I'ecognised as a general fact,
and the few instances of the displacement which were from time
to time recorded by Continental writers were regarded as mre and
exceptional occun-ences. The minute detail of four cases of this
misf»lacement of the un impregnated womb, by IVofessor Osiander
of Gottingen, in the year 1808, then in the zenith of his reputa-
tion, did much towards directing attention to the subject. It was
not, however, until some years later that the publication of the
essays of Professor Schweighauser* of Stnisbui'g, and of Professor
Schmitt of Vienna.'f fully establislied the frequency of the
accident, and furnished a description of its symptoms so minutely
accurate as to have left little room for the additions of subsequent
observers.
The researches of these German writers attracted but little
attention out of their own country ; and retr(>vcrsiou of the womb,
as well as the opposite condition of its auteversiou, were regarded
by medical wTiters.J both in France and England, as ailments
extmmely unusual in the unimpreguated condition of the org am
In the year 1848, however, a paper was published in the Dublin
JouTiml of Medical Sciences, by Professor Simpson of Edinburgh,
on retroversion and other misplacements of the unimpregnated
womb — accidents to which he had already drawn attention five
years before at a meeting of the Medico-Chirurgical Society of
Muihurgh ; and since tliat time the danger has been lest the im-
portance and frequency of these conditions should be overrated,
rather than lest they should be underestimated.^
* Scliweigliiiuser,-*4t*/ieto5fl5erCT»w^ Qeffenddndetier Geburtshulfi, 8vo, Ntirabeig,
1817, ^a|j. xxviii. p. 251 ; imd I)a.9 OeMren nach der beolnichkiejh Natur^ ^tnahv.Tg,
1S25, Svq, p. 234.
t Btinerkunfftn Ukr ^urikkhmffung dw Oeb&rfmUter iwi Niehttchwangtrcn, 8vo,
Wien, 1820.
J From lUis state me nt, lioweTer, it is only just to except the name of tl. Yelpeuu,
who vras letl by his own observation lon^ since to appreriatt? the frequency and
importance of flexions of the nteraa, and to deyiso meana for their cure* See p. 14
of ft small tract of hLs» Mahdifs de rUUriM, 8vo, Paris, 1851.
§ Opinions at vaHttnce with thoae of Dr Simpson wrrp, however, fxprfaaed by
several writera, aa, for instimcc, by Dr Bennett, Dr Oldham, and Dr Matthew?!
I
I
I
OF THE mriMPREGNATED UTERUa
181
One of the results of close attention being directed to the
situation of the womb in the pelvic cavity, has been to show that
the organ is liable in this respect to very great varieties ; that
not only may its fundus fall backwards into the hollow of the
aacrura, or forwards against the symphysis pubis, but that it
may also incline towards either side ; and tliat moreover its IxKly
is liable to be bent upon the cervix, constituting a new class of
misplacements called flexions. There seems also to be reason for
believing that the different varieties of flexions of the womb, as
its nrfrojlejtjiofi and an/^^t\riV>«, are of more fre(|uent oct^unenee
dian the corresponding alterations in position of the whole of the
organ which are known as reirm'ersion and anfeversionf if we
except that measure of retroversion which attends, as we have
8een, almost all cases of prolapsus uteri.
Fewer diihculties present the nisei ve.s in the way of under-
standing the mode of occurrenre of retrovcrdon than of the other
above-mentioned misplacemente of the womb. It has already
been seen that the tendency of the womb, wht^n at all enlai'ged,
IB not only to sink below its natural position in the pelvic cavity,
but at the same time to fall with its fundus backwards towards
the hollow of the sacrum, in consequence of the ut<^ro-sacral
ligaments conlininc^ it more ckjsely to the posterior part of the
pelvis than do the utero-vesical ligaments to the anterior pelvic
walL Moreover, enlargement of the womb, whether from the
presence of fibrous tumour, or dependent on simple congestion
and consequent hypeitrophy of the oi'gan. or resulting from ite
imperfect involution after delivery or miscarriage, is almost
always much more considerable at its posterior than at -ite
anterior walJ, and the womb in consequence naturally falls
toward that aide which is the heavier. The ordinary distension
of the bladder, too, necessarily tends to throw the uterus into the
posterior half of the pelvis ; and if the utero-vesical ligaments be
at all yielding, as they must be in cases where some degree of
prolaj^sus exists, the same cause must also dispose the fundus of
the oigan to fall backwards; while the inclination to the
Duncan, wUo, thoagli differing from each other in some re«pect«, yet nil formed
ft low e$tiniut4) of tht' importance of mere versions or flexiona of the uterus,
uid diaseutcil from the eniployment of mechanical means for tbeir ri'movoL
182 RETROVERSION OF THE UTERUS :
malposition will be increased b}' a loaded state of the bowels such
OS exists habitually in many peisoiis.
Wlien fLivuiiring causes, such as have been just referred to,
coincide, retroversion of the womb may take place either
gradually, or iis the result of some sudden accident which
viuleutly incretises the uterine misplacement, and throws the
fundus of the organ downwards and backwards into the hollow
of the sacrum^ It is thus suddenly that in the majijrity of
instances retroversion of the pregnant woml) takes place — an
accident, the comparative rarity of which is, I apprehend, to be
accounted for mjunly by the circumstance that not only does ita
physiological enlargement equally extend to the whole of the
organ, but also that the size and strength of its ligaments increiise
with the added weight which they have to bear. But wlule,
owing to tins wise provision,, the pregnant womb rises gi'adually
and .safely out of the pelvic cavity, the h^^:»ertrophied organ, or
that whose involution is imperfect, or in whose substance
tumours are developed, being destitute of such duly increased
supports, sinks down far lower than natural in the pelvis.
The sudden effort and consequent violent misplacement which
we generally find to constitute the history of retroversion of the
enlarged anil pregnant womb, are sometimes equally marked in
the case of the non-gravid uterus, showing that the mode of
occurrence of the accident is identical in both instances. Thus
a woman aged thirty, whose secuml and last labour had taken
place sixteen months before, while reaching over the fire to
remove a heavy tea-kettle, was suddenly seized bj violent pain
referred to the liack and the umbilicus, and liecanie for a time
unalde to pass her urine ; and though she aftenvarcls voided it,
yet it wa^ with pain and difficulty, and deftecation also was
attended by pain. On examinalion per vaginam the finger came
in contact witli a firm, but slightly elastic, globular tumour, which
felt alx)ut half tlie size of an orange, and occupied the posterior
half of the pelvis, having driven before it the posterior vaginal
wall, while the rectum could be traced passing behind it. The
situation of this timiour was not exactly in the mesial line, but it
occupied ratlier more of the right than of the left half of the
pelvis, while tlie oa uteri was situated high up, inmiediately
behind the symphysis pubLs, but a little to the left of the mesial
dal I
ITS CAUSES.
183
line. I may remark, in passing, that to this slight obliquity of
tlie retrovert-ed uterus it is due that the urethra and neck of the
hladder not iufrequentlj escape tliat pressure which wrmld otlier-
wiae be unavoidable; and thua it happens that difficulty of
micturition is, in many instances even of retroversion during
pregnancy, by no means so prominent a symptom as the state-
ments in most systematic treatises on the diseases of women
might lead one to expect. There wa^i, besides, in the left iliac
region, a firm sliglitly movable tumour, whose surface wa^ a Uttle
iiT^ular, as if nodulated, and pressure upon it was communicated
to the tumour in the pelvis, Inqiiiry ascertaining that the
patients bowels had long been in a constipated condition, it was
assumed that while the sudden exealion hud retro verted the
uterus, the accumulation of faeces in the sigmoid flexure of the
colon and in tlie uf^per part of the rectum had prevented its
spontaneous rephicement. Euemata and purgatives were employed,
and in the courae of seven days the womb, which was not much
larger than natural, had completely regained its proper position,
while a vague sense of some swelling in the posterior part of the
pelvic was ascertained to be due merely to the existence of very
great hypertrojiby of the walls of tlie rectum, a condition which Is
by no means uncomuiun in etises of long-standiug baliitual consti-
pation*
It is not thus suddenly, however, that retrovei^ion of the unim-
pregnated uterus usually occurs. In the majority of instances
the accident may be traced back to labour, menstruation, or mis-
carriage ; to some condition, iu short, which combines consider-
able enlargement of the womb with weakening of its supports, A
patient w^as received into St Baitholomew's Hospital, on account
of what was alleged to be a tumour in her womb, and suffering
from frequent bfuion Imge, from pain in the sacrum and hypogas-
trium, and from painful and ihtticult defsecation. All these
symptoms dated from a miscarriage at the third month, which
had occurred six weeks befoi-e. The uterus w^as completely
retr<ivert4jd, the os being directed forwards and somewhat up wai*ds,
w^hile an elastic, globular, slightly tender tumour occupied the
hollow of the sacrum. The uterine sound entered for 5} inches,
with its concavity directed backwards, and on turning the instru-
ment round, the tumour completely disappeared. Kest was
184
BETR0VEE3I0N, AND
followed by cessation of the iKeinorrhage, the use of the cold
douciic led to some diminution in the size of the uterus, though it
was still as much retroverted as ever, when the outbreak of small-
pox in the ward compelled the patient's discharge from the
hospital in less than three weeks after her admissiou.
Just two yeai^s later, the patient came once more under my
notice. She had in the interval been pregnant several times, but
had on each occasion miscarried early, wliile, wlien not pregnant,
she bad suflered much from menorrhagia. The uterus was no
longer so enlarged as before, though of greater size than natural,
but its misplacemeut was just as considerable ; still, however,
arlmittiiig of momentary removal by means of the sound, but
almost immediately falling back into its former position. If this
person had not been exposed to the risks of becoming pi^gnant,
there can be no doubt but that the involution of her womb would
have taken place much more completely ; though even then the
misplacement would almost certainly have continued unrelieved,
and accident might then have discovered a small and otherwise
healthy uterus completely retroverted with no other clue to the
cause of this occuiTence than would have been furnished by the
history of a m is caniagc, succeeded by long-continued ha^monhage,
some years before.
The state of the womb during menstruation is similar to its
condition after miscarriage, and favours in the same manner,
though of course in a less degree, the descent of the organ or its
retroversion, while in every form of misi)lacement of the uterus
the tendency of tlungs is to a deterioration rather than to
an improvement. The accumulation of urine in the bladder,
the distension of the rectum with faeces, have a disposition to
aggravate the misphicement ; while the stretched ligaments and
the lax vogina have no power of spontaneously recovering tlieir
tone and of thereby favouring the replacement of the womb.
With the return of each menstrual period, too, the uterus for the
time grows heavier, and subsides further and still further back
in the pelvis, till at length its retroversion becomes complete.
Nor must it be forgotten that in some at least of the instances
of this and of kindi'ed misplacements, any permanent improve-
ment is effectually prevented by the formation of adhesions
between the fundus of the uterus and the surface of the adjacent
L
akte\t:iision of the uterus.
185
intestines. Such attacks of circiinisoribed peritonitis as to
produce these consef[uences were first noticed by Madame
Boiviu* as a cause of atHDrtion, and she appears, indeed, to have
exaggerated both thuir frequency and their importance. They
are. neverthelesa, of considemijle niomeut, and none the less
for the circumstance that they are by no means constantly
accompanied by symptoms so severe as to force themselves on
the fiatieni*s attention. Their occurrence, and the con8equence43
which they leave behind, sufficiently account for the immobility
of the retroverted uterus in some instances, for its diflicult
replacement and immediate resumption of its malposition in
others.
Although I have spoken fii*st of retroversion of the womb, yet
the opposite state of anteversion of the unimpregnated organ
earlier attracted attention, and was descrilied by Levretf with
characteristic accuracy. In this condition the fundus is directed
forwards against the flymphysia of the pul»es, and its orifice
backwards into the hollow of the sacrum. How this accidpnt
oimea to happen, and to happen even with considemble fre-
quency, is certainly not easy to understand. The very form of
tli6 pelvis, as observed by tlie late I*ix»fessor Kiwisch^ while it
favours the production of retroversion, is opposed to any such
misi»Iacement as the antevei^ion of the womb, while the accu*
mulation of the urine in the bladder and of the faeces in the
tectum, the former taking phice from below upwards, the latter
from above downwards, alike tend to prevent and remove it.
There is, besides, no such pouch of peritoneum in front of the
uterus as exists behind it. allowing space for the de.scent of the
fundus uteri, and for its residence in this unnatural situation. In
spite, however, of these conditions, which would seem to oppose
the occurrence of anteversion of the uterus, it is yet met with in
many instances, though I beheve less often unassociated with
previous enlargement of the organ than the opposite state
of retroversion. Thus in fourteen out of twenty cases of
mmi^ Syo, Paris, 1822.
f *'Suruii depkcemeiit purttctili^ de l» matrioe, doot le« ©atetirs n'ont point
ptrle/* in Roux, Jowml rf« Mideeina, tU,, Sept 1778, vol xJ. J>. 2«9.
X Cjp. ciL vol. L p. 23&
186
VEBSIONS, AXD
anteversion or anteflexion of tlie womb tbere was marked
eiilarg<jment of tlie oi^^an, wliile the history of the patients
further warranted the behef that the mispiacement was in these
instances secondary to other much longer standing diseases.
8uch I heheve to have been tlie cause of the misplacement of
the womb in a patient whom 1 saw four yeai-g after her delivery,
wiiich had been succeeded by phlegmasia dolens, and symptoms
of uterine intkmmation so severe as to have confined her to her
bed for tliree months. Such possibly was the real history of a
woman who had lived three yeai-s in sterile marriage, and who
was attacked suddenly during menstruation, ten months before
I saw her, by severe pains in the abdomen, followed by
temporary cessation of the menses, by great pain in the
hypogastrium, diMculty and pain in micturition, and symptoms
like those of severe vaginitis, and who had ever after experienced
attacks of violent paroxysmal uterine pain. Her uterus was both
hard and enlarged, the fundus resting against the symphysis, ond
the OS in the hollow of the sacrum. Sometimes, moreover, one
meets with an increased degree of obUquity of the womb, though
short of actual anteversion, which appears to be tlie ahnost
meclianical residt of sexual intercourse. When in connexion
with this exaggerated obhquity of the womb tliere has also
existed some congestion of the organ, snch as is not nnnsual, par-
ticularly in sterile women, the misplacement is then often
associated with symptoms of uterine disorder, wliich probably are
due less to it than to the gorged state of the blood-vessels with
which it is associated.
Stili there arc instances, though of far less frequency than those
above referred to, in which there is no evidence of previously
existing disease, but where the anteversion of the w^omb was
apparently a primary occun'ence. It was so in the remarkable
case which lirst drew the attention of Levret* to this malposition.
In tliis instance, the fundus of the ante verted womb was taken for
a calculus in the bladder, and the patient died from the etlects of
lithotomy j)erformed under this eiToneous idea. In this instance
it is expressly stated that sUght engorgement of the anterior wall
of the nteros, and a somewhat unusual shortness of the round
ligaments, were the only appreciable causes of its nidposition. A
* Loc cU, J). 200,
FLEXIONS OF THE UTEBUa
187
woman»aged tliirty, the mother of four children, the last of whom
was born three yeai'S hetore she came under my observation, had
ever sinco experienced some, though inconsidei'at>le, abdominal
pain. A few days before I saw her, however, while turning a
mangle, she felt a sudden pain over the puhes, which extended
over tlie whole pelvic region, and on making an examini^tion, the
uterus was found remarkalily ant^nerted, the os being in contact
with the anterior wall of the sacrum, and the fundus resting
against the inner surface of the symphysis. It seems ditliciilt
here to avoid connecting the sympt^jms suddenly supervening
duiing exertion with the misplacement of the womk Still
harder does it appear to me to be to account for the mal-
{xisition of the organ in an unmarried lady, aged thirty-four,
whose menstruation had been habitually scanty, and who had
suffered fur eight mouths before she came under my care froui
hiemorrhoids, aecoruju^Lnied by profuse loss of blood. For four
months she had also experienced abiding aching pain in the
hypogasti'ium, witli frequent and jminful micturition. Her
uterus was lying Jilniost horizontally across the pelvis, its oritice
being directed backwards, and to the left, and this to so great a
degree a^s to render it almost impossible to touch the small
circular os, while the fundus was situated in the same manner
forwards and to the right-
Be the explanation of cases such as the ahove what it may —
and I confess myself unable satisfactorily to solve all the ditii-
cultie^s wiiich they present— there can be no doubt but thai,
in the greater nimilier of instances of alleged version of the
womb either forwards or backwards, the organ is really Hexed, or
bent upon itself; and further, that not infixniuently the two
conditions co-exist, the whole womb being thrown more forwards
or more backwards than natural, while, in addition, the body of
the organ is bent upon its cervix. As far as the symptoms are
concerned to which they give rise, these varieties of misplacement
present but little difference; but the distinction deserN^es t4> be
borne in mind, since it throws light on the manner in which the
accident is in many instances bmught about.
The point of Jlrxiini of the uterus^ whether it is bent forwards
or backwards, ajjpeai's always to be the same — namely, the point
of junction between the body and neck of the womb, or, in other
188
FLEXrOXS OF THE UTEEUS :
words, a spot corresponding to the internal os uteri ; so that the
organ assumes a shape closely resembling that of a chtimitral
retort Various reasons have been assigned for the constancy
T^dth which the organ m found to bend at this one situation ; and
various theories, such as an assumed atmphy of one part of the
uterine walls and engorgement of its fundus while tlie cendx
remains unaltered, and other suggestions less plausilile, have been
proposed in explanation of the fact. But these conditions are by
no means invanahly present even in cases of most marked
tlexionof the womb, and must therefore foe rejected as inadequate
to account for its taking place at the same situation in all cases.
The only explanation that I know, against which no such,
objection can be raised, is that proi^ounded by Professor Vii'cho^
of Berlin,' and which is based on the anatomical relations of the
organ. He points out the fact, that while the neck of ibe womb
is tirmly connected with the posti^rior and lower part of the
bladder, its body is perfectly movable ; the point to which the
peritoneum descends in the utero- vesical pouch coiTe^ponding ex-
actly to the situation of the internal os uteri, and consequently
to the spot where the fixed cervix passes over into the movable
body of the organ. The posterior surface of the cervix uteri,
though somewhat stirngtbened by the eelkilar tissue which sur-
rounds it, is by no means so firmly fastened as its anterior surface;
wliile tlie pouch of peritoneum da'^cends much lower do%vn behind
it, and is even on a lower level than the summit of the roof oi the
vagina. If, now, any cause interfere with tiie ready mol>ility of
the liody of the womb, while the attachments of its cervix retain
their lirmness and resistance, a bending of the one jiart on the
other must of necessity take place ; a bending which may occur
either forwards or backwards, and tluis constitute either antetlexion
or retroflexion. With reference to the production of the accitlent,
it is probably a matter of indifference whether its cause is one
that operates gradually and continuously, or suddenly and with
great force — a \iolent exertion may therefore prt:>duce it ; and just
as much may the slow action of adhesions tethering the fundus of
the womb either to the bladder or to the rectum, and compelling
the organ in the course of time to yield at its weakest point —
• Ueber r£i- Kviclttngen drr QtharmutUr ; m tlio Varhtmdlungtn der Q^ssUaehti^j
fur OtburO(hMf€, vol. iv. 1851, \\ SO,
THEIK MODE OF PRODUCTION.
189
namely, at that which corresponds to the junction of the body and
neck of the organ.
This explanation will account equally for the occurence of
anteflexion and of retroHexion. Of the two misplacements, the
former is idleged hy IJokitansky. and by other morbid anatomists,
to be the more frequent ; and observations during life confiiTu, on
the whole, the correctness of this statement. In my own notes,
indeed, I find the pailiciilars of forty-three cases of retroversion
or retroMexion, and of only twenty of auteversion or anteflexion ;
but these rasults are at variance with those of some most trust-
worthy observers, and I believe they are due to the circumstance,
that in the early period of my observations I often failed to mark
the slighter degi^ees of anteflexion, Valleix, in his vakiable
lectures on this subject * gives thirty-five deviations of the uterus
forwaixis and thirty*tbree backwards ; Dr Mayerf of Berlin met
with sixty-three cases of the former, and sixty*four of the latter ;
and ilM. Bernutz, Goupil, and Gosselin found a greater or leas
degree of flexion or vei'siou of the uterus forward, in lOG out of
lij'6 women who had never given birth to ebiltlren^. This latter
statement, however, represents the frequency of tliat physiological
cur\^ature of tlie womb which, while it exists in the child and in
the unmarried woman, ceases after childbirth, or is even replaced
by a disjKisition to version or flexion of the fundus backwards* A
condition met with in two women out of three can scarcely be
other than natural ■ and whOe I may have often overlooked it, I
believe that I do not err in regarding it as usu*dly of but small
importance.
The older opinions on this subject, indeed, are in conformity
with the conclusions which I have arrived at, and I believe them
to be correct, as far as any such degree of misplacement ib con-
cerned as would manifest itself by symptoms during life; whOe
the whole subject of uterine versions and flexions has been of late
much obscured by the confounding together of the natund and the
morlml degrees of these misplacements. There can be no doubt,
indeeil, but that slight degrees of anteflexion of the uterus are
* Den I)6tHtdi4m4 UUrines^ 8vo, P*ris, 1862, »ee p. 27.
f As flUted by Dr Rockwitz, in Verkandh der OegtlUchafi / (MtifCdL vol. v,
1652, ace p. 85.
Z Sim: notcB S vlxhX 4, At p. 465 of rot. ii. of BenitiU and Gonpil's CUnifm
MMieaU tuir Us Maladies tki Femmfs, 8vo, Piiris, 1862.
190
FLEXIONS OF THE UTERUS :
frequently overlooked during life, since not only does the finger
come less readily into contact with the parts in the anterior than
with those in the posterior half of the pelvis, hut further, unless
the bladder is completely empty, the tumour of the anteflexed
womb is scarcely perceptible, A slight tiexion of the wondj for-
warda is, however, a natural condition, as is exceedingly well
sho%vn in Kolilrausch's beautiful delineation of a section of the
pelvic viscera* " The uterine canal, " says he, " is not straight,
but shghtly canned like an italic /, and the whole organ has
in its natural position a slight ilexui'e, being curved at first
a little backwards, then bent more considerably fnrwarcls."
This curve, however, is no longer apporeut after child-bearing,
while, besides, any cause which produces enlnrgement of the womb
brings with it those influences that tend to favour retroversion or
retroflexion of the organ.
The explanation that has been proposed of the invariable occur-
rence of flexion of the uterus at the same point, suggests the
reason why the ailment lias no tendency, or scarcely any
tendency, to spontaneous cure, and explains why the misplaced
womb remains misplaced for years. Two conditions, moreover,
tend to give to the misjdaeement a permanent character, of which
one is the presence of adhesions binding down the fundus of the
uterus, either to the rectum posteriorly, or to the bladder in front ;
the other is the wasting of that wall of the uterus towards which
the flexion has taken place, and which must necessarily render
the organ incapable of retaining its natural position, even though
it were possible to replace it completely. Of these two eomlitions
the former is, I believe, the more frequent, and therefore the more
* Zur Anatomic^ de., dcr BrckmoTffftnr^ 4to, I.eipsig, 1854. In a paper read
before the Meilico-Chiniixifal Society, aTni afterwards pubUahcid in the Dublin
Medimi Jmtnml^ Angust I857» Dr Bennett gavo the resultn of Ilia own ittveottgE-
tionfl on the living subject, wliitdi led tn pre<:is<?ly the same conclnsions as tho&e
rtnived at by KohlrauHL-h. The observations of Boiinurd, containi'd in his thnsis,
which appeared in 1853, who believeil that a degree of antetkxion of the atera»,
fur exceeding nuy gentle i:ijrvt% was tbe really normal state of the uttnis, Imve
been shown by De|mul {Gti^elte din H6pitn^u:, No. 36, 1854) to be vitiated by the
circmtnatancen in whicb they were mude, luid that pnnrly cadaveric canses are
chiefly influential m prothicitig great flexions of the organ, and eHj>ectallj flexions
of the fuiidas forwanls. Boiillanrs statements, however, though they exjiggcratcd
tbe degree of the natumJ cun^attire, were correct as to the faet of its general
i^xistcnce, and describe the praisb whicli atUithcs to priority of obii«!rvfttion.
I
I
THEER MODE OF PKODUCTION.
191
important. Such adhesions are expressly mentioned in many of
the cases where, onexaminfition after death, flexiaiiB of the wanib
hftve l>een discovered ; and I can speak to the extreme frequency
of adhesions, false meoihranes, or other indications of bygone in-
flammation abont the womb or its appendages, since I n»et with
them in twenty-two ont of sixty-six cases in which I examined
the uteri of women who had died of some other than uterine
diseasa There appears to be some uncertainty as to the date of
the occurrence of atrophy of the nterine wall, and also as to the
degree in which it takes place. I found no trace of it in a case
where the uterus was greatly anteflected, and where the existence
of marked uterine symi»tonis for many yeara rendered it probable
that tlie condition was of long standing ; ami it is expressly
stated by Dr Eockmtz* not to have been present in the case of a
woman whose otenis had been comjiletely retroflected for a ye^ir
by the presence of an ovarian tumour. On the other hand,
Virchow describes the gradual wasting of the muscular substance
at the point of flexion till notluug is left but a small quantity of
flaccid, slightly hbrtjus, cellular tissue ; and in a very useful essay
on the subject, Dr Sommert relates some pimi-7Htyrkm examina-
tions in which this atrophy of the uterine wall was very
neniarkalile.
The efiect of such a change in the uterine wall is twofold. On
the one hand, it weakens the tissue at one point, and thus
incapacitates the organ for maintaining its proper position ; on
the others, it shortens the wall towards which the ilexion exists,
and thereby insures still more effectually the permanence of the
malposition ; and no one who is familiar with uterine ailments,
and has felt the bent uterus resume its malposition immediately
on the removal of the sound by which it had just been rectified.
but must l»elieve that such wasting of one uterine wall must exist
in a very large ninnber of instances.
A frequent, though by no means an invariable, result of
longstauLling flexion of the womb, and one whicii must be borne
in mind as explaining some of the symptoms to which it
occasionally gives rise, is a coutTaction of the internal orifice of
the womb. This constriction too, is, at any rate in Vii-chow's
• loe. dt. p, 82.
t Zur Lchro dcr lufractioiicn and Flcxionm der OebdrimUter, 8yo, Qiessea, 18&0,
192
"Flexions of the utebus :
opiniorii not a merely mechanical approximation uf the two sides
of the canal by the bending of the organ, but is in many
instances due to an organic mirrowing of the passage, produced
by the constant irritation of the raucous merabrane at this spot,
and its consequent tliiekeoing. Any positive obliteration of the
internal os, however, which Virchow has sometimes met with in
aged persons, is not merely a very rare occurrence, but is probably
due in large measure to the natural tendency to closure of the
internal os in old age, and wliieh the llexion of the uterus,
though it may have increased, has not originated.
One or two other cooseqiiencea of flexion of the womb deserve
mention, thoiigli I believe that the degree to which they exist
admits of very wide variation. The body and fundus of the
womb are very apt, as the result of tlieir altered position, to
become the seat of congestion ; a congestion tliat may be very
intense,* and with the existence of which it is reasonable to
associate the disposition to menorrlmgia that is so prominent a
featm^e in many aises of tliis kind. Moreover, a part that is the
freijuent seat of congestion teuds to enlarge, and hence the
misplaced body and fundus of the womb often become hypertro-
phied ; while the diniculty of escape of the secretions, when the
angle of flexion is very acute^ helps to increase the dimensions of
the uterine cavity, a result of the occurrence of which the uterine
sound informs us in a very large nuuiVier of instances.
The condition of the cervLx uteri is seldom natural, but there
is generally a profuse secretion from its glandulai^ apparatus,
wliile the edges of the os uteri are usually red, and their
epithelium is often abraded, a condition dependent doubtless on
the state of general irritation of the cervix* To the touch the
mai^ins of tlie os rarely present any marked de\iation from a
healthy condition, while the os itself (at letist in retroflexion,
concerning which my observations are more numerous than
concerning anteflexion) is often open so as to admit the tip of the
finger. The anterior hp, too, in cases of retroflexion, is usujilly
shorter than the posterior— an altemtion of the mituml relations
probably due, as Sommer suggests, to merely mechanical causes.
• As in the drawing of the witeflexed utenw at figs. 6 and 6 of plate iJL of Doivia
and Dug^^ AUat,
?n01f CONGEXITAL FORMATION.
193
aii<i to the drawing out of its place of the lip on that side which
correspooda to the convexity of the flexed womb.
In the oases to which reference has hitherto been made, the
uterine misplacement would seem k> be an acquired condition,
though one coming on at different periods of life, and under the
influence of causes which^ sometimes at least, are obscure. There
are other instances, however, in which ohliquity of the vieru»
forwards, backwards, or to either side, is the rmult nf con{ffnital
Tfurlfornvtiwri, aasociated with miirked difference in the length of
the womb and broad Uganients on the two sides, or depeud«_'nt on
mie(|uul development of the two halves of the womb itself* lu
one instance in which I found the womb, in an unmarried «^irl
aged eighteen* oblique in form, and inclined towards the right
side, the left ligamentum ovarii was 1'2 inch in length, while that
of the right side measured only (3 of an inch ; and in the body of
auotlier unmarried girl, aged nineteen, likewise free from all tmce
%}l uterine disease, the womb was unequal in si^e, its right corner
being *3 of an inch higher than the left, Profassor Tiedemann *
who was the first to call special attention to this condition, has
published in his treatise on the subject several drawings, which
rffpreaent very extreme degrees of uterine obliquity and malfor-
mation. There is nothing to surprise us in the occasional want of
symmetry of an organ formed, as the uterus is in great measure,
by the coalescence of two lateral lialves or cornua. At the same
time it seems very doubtful whether such inequality of the womb
gives rise to any symptom, or whether, in the event of pregnancy
and labour occurring, it produces any of those formidable results
which, Deventer and other practitioners of midwifery a hundred
and fifty years ago referred to obliquity of the uterus ; opinions
which, even at the present day, are not altogether exploded. I
refer to these conditions now chiedy for the ]>urpose of impre^ss-
ing on yuu the by no means needless caution, that since uterine
obliquity may depend on causes wholly beyond remedy, so
prudence dictates that when it gives rise to no s\Tnptoms we
should abstain from all endeavours at cure, which, to say the least,
arc needless, which very likely may be fruitless, which possibly
may prove very mischievous.
• Voii dtn Duvemeyiachffn, Driisen des Weihe^ uwi der iehitfen (kdedUnuj uml
Iavjc der Oebitn/wUgr, 4to, Heidellierg, 1840.
LECTURE XL
MISPLACEMENTS OF THE UTERUS,
Versions and Fi^xioxs of the UTEitus.
Symptoms. Conflicting opitiiona coneeromg them ; how they may to & certflin
extent be reconciled. Alleged Byiuptoms not always due to niisplacemeDta.
E ride nee of statistics j production of symptoms conncicted with other c&useH
acting on the womb. Enumeration of Bymptom&, imd separate e^camination of
each.
Diagnosis. Use of the aonnd.
Treatment. Historical sketch of opiniDn and practice on the subject The uterine
gupport<?r ; reasons for n^ feting mt'chani<;al contrivances, and for i»ref erring
palliative treatment. Plan of treatmtot described.
"We Iiave hitherto heeii occupied with the exaniiiuition of the nature
of the various verBions and flexions of the uterus, and liave had
occasion, in the course of this inquiry, to notice conflicting
opinions and opposing stat^meuts which it was very difficult, which
it was sometimes indeed quite impossible, to reconcile. Such
discrepancies become moj-e numerous and more frequently irrecon-
cilable as we pass to the study of the symptt^ms wbicli these mis-
placements produce, and to the consideration of the treatment
that they require. The symptoms are by some described as being
both numerous and characteristic, and the appropriate treatment
is by them alleged to be both simple, safe, and guccessful. Nor is
this all» but the existence of flexion of the womb is said to furnish
the clue to almost all forms of uterine aihnent — to be the chief
factor in their production. This opinion has even been pushed
to the extreme of being made the foundation of a so-called
mechanical system of uterine pathology, the natural corollary
from which is that a mechanical disorder must call for a
mechanical remedy ; though the author who states the postulate
demurs to the invariable adoption of the conclusion, and says
that *' it does not mean the use of a pessary in any and every case
I
I
I
ALLEGED RESULTS OF UTERINE FLEXIONS,
195
that presents itself."* On the other hand, it is denied by others
that the malpositions taken by themselves produce any syniptonis,
and asserted in opposition that the proposed treatment, while
attended by very considerable risk, is %vholly iimdeqnate to the
removal of the evil which it is intended to cure. Each of these
opinions, too» is maintained by men equal in the eminence of their
position, in their practical experieoce, and theiigood faitkf The
truth will perhaps be found, as not seldom is the case, between
the two extremes.
The alleged results of these uterine misplacements may be
briefly stated to consist in disorder of menstruation, which is
usually both excessive and painful, in leucoiThceal discharge, in
pain and difficulty both in deftccation and micturition, and in
pain in the pelvis general ly» though usually most severe in that
part of the pelvis towards which the fundus uteri is turned or
flexed, whQe sterUity is a further consequence stated to be
produced by flexions of the womb in a very large number of
instances. In these symptoms it is obWous that there is much
that of itself cannot be regarded as pathognomonic of one
uterine affection rather than of another, since they constitute just
that train of ailments which, in varying combinations and with
varying intensity, we meet with in almost every disorder of the
womb. To this, however, it would not be right to attach much
importance, since the uterine aliments that manifest themselves
by some one characteristic symptom, or by characteristic
oombinations of symptoms, are very few indeed. Just as sickness
may depend on sympathetic disturbance of the stomach daring
pregnancy, or on irritability of the organ consequent on some
exhausting disease, or on the presence of sarciuie in its cavity, or
on the development of cancer in its walls, so may the same
symptoms depend in one case on trivial disorder of the worah, in
another on its incurable disease, The symptoms aie like the
alarm-bell, wliich gives notice of a something wrong, and serves
to awaken attention ; it is not fair to expect that they should at
• Dr Omily Hiiwitt, The Medianiml StjHcm of Uterine Patkologff^ 4to, 1S78,
^ 3 ; and IH»sa»rs of Woimn^ 8fo, 3d ed. thap, viii.-xu
t The pobliabed repent of the ditcwsHion at I'iira on this sabje* t, contjiiutd m
Ukc Btdleiin dc I'Acad^UdeMitUdne for 1855-54, vol xix, pp. 778-976» is n most
raayylcAble illustratioii of the extent to which, in an unccrtaiii acience, difference
196
FLEXIONS OF THE UTEHUS :
once inform us not merely what part snffers, but what the exact
cause is on which those sufferings depend.
Another fact, however, has heen much insisted on as proof of
the unreality of the alleged symptoms of these misplacements—-
namely, that in many instances where accident has revealed the
existence of uterine misplacement, the functions of the womb
were performed in all respects naturally and painlessly. But
from this we must be careful not to draw too wide an inference,
for even the early sta^^es of uterine cancer pass not infrequently
unrevealed by any symptoms of disorder of the womb; and
fibrous tumours often attain a great development before their
existence is suspected, or a lull of their symptoms takes place so
complete and of such long continuance that careful examination
alone convinces ns of the persistence of tlie evil which had
produced them. There is a French phrase which exprt*sses
excellently well the character of those in whom both these
mispliicements and other uterine aliments are generally attended
by the most urgent symptoms ; they are persons q%ii s*iwuimi
vivre, — who watch themselves live; and the ailments of which
another would he barely conscious, are to them sources of
exquisite torture. The ailment may be a real one, and yet it may
be the wiser and more hopeful course to try to remedy the state
of coastitutioii whicli exaggerates the patient's sufferings, rather
than to meddle with the local affection that excites their present
manifestations*
But there are facts of a different kind which show that the
importance of these ailments has probably been overmted ; and
they are furnished by cases where the removal of the misplace-
ment, though no other uterine ailment was discoverable, has not
been followed by any mitigation of the patient's sufferings; as
well as by others in which the symptoms once present have
ceased, in spite of the persistence of the misplacement. A
woman, aged twenty -two, had been married four years, during
wliich period she miscarried four times ; on the last occasion, at ■
the sixth month, seven months before coming under my care,
** The more I oUserve," says M. Coui'ty, '*thc more lirroly aui 1 jwrrauaded thiit
in the immense majority of ca&tH (ifviiitions of the womb give rise to morbid symp-
toma only whi'ii they itrc extreme, iwid esp«)cijilly when they are accompaiiitfd by
flome other tiiorbid comlitioD of tbe uterus and its anpendoges.*'— ifrt/cuftc* de$
Femifu», 8vo, l\tris, 1808, p. 763,
I
I
I
I
I
THEra mrORTANCE OVEKHATED.
197
She icfoid from the date of her last miscarriage from pain^
leucorrhcea» and profuse nienstruatioD, accompanied hy discharge
ofcoagula; and on examinittion her utems was found retmilected,
the fundus being directed not only backwards, but also to the
left side. Twenty-seven months after her last abortion she
became pregnant, but the misphicement continued during the
early montbs of pregnancy, m was ascertained by examination.
She gave birth to a live chiM at the full period of uiero-gestation,
and expressed heiself as feeling afterwards perfectly well ;, but
her worn!) was still retrotlected, and I found it occupying its old
position fifteen months after her delivery, or four years and a
quarter after the miscarriage to which she originally referred all
her sufl'erings.
A woman, twenty-eight years old, had been married nine years,
had given birth to one child in the second year of her marriage,
and tive yeai's before I saw her had undergone some operation
for the removal, as she said, of an uterine tumour. Ever since
this operation she stated herself to have suBered from leucorrhceal
discharge, with pain of a burning character in the neighbourhood
of the uterus, much aggravated by defalcation or by sexual
intercourse, and being especially severe at the menstrual periods.
The perineum was somewhat torn, the uterus low down, its
orifice circular, with perfectly smooth edges, and its posterior Up
was connected firmly to the posterior vaginal wall, and cicatrices
ran from it for some distance to the left side of the vagina,* The
uterine soimd entered easily with its concavity directed back-
wards for 2^ inches ; on turning it round the tumour completely
disapiieared. Tor the first four or f\ve days after the replacement
of the uterus the patient expressed herself as feeling much
relieved; but her symptoms then returned, and have continued
just the same as before for four yeai-s and a half, during which
time I have had the opportunity of frequently examining the
condition of the uterus, and have always found it occupying its
natural position.
But be the value of cases such as these what it may, as proving
♦ It ia not witbout interest, as illuatnitive of the futility of many af the suggea-
tjona made for the earo of these aLiImeutji, to notice the existtmcfi in this case of
that Tery condition of adhesion between the cervix uteri and the va^nd wall, on
the {induction of which by mirgical interferenct M. Amussat has insiated as so
important a lueamt of cure.
198
FLEXIONS OF THE UTERUS 1
on the one hand that flexions of the womb do not of necessity
*jive rise to any sufieringj and on the other» that the removal of a
flexion of the organ may not be followed by the least relief to a
patient'a distress, the fact still remains, that misplacement of
the womb is in very many instances accompanied by various
uterine ailmenta, such as were not experienced before its occur-
rence. The qnestiou, however, suggests itself with reference to
these cases, as to whether their history presents any peculiarity
which would warrant our believing that the sjrmptoms are due
not simply to the misplacement, but to some other morbid condi-
tion with which the misplacement is associated, or to the two
causes together ? Now, there are circumstances which appear to
favoiu' the opinion, that in the majority of instances the symptoms
are due not to misplacement alone, but to misplacement accom-
panied by some other morbid state of the womb.
The fact, that of 131 instances of version or flexion of the
womb,* 115 occurred among married women, 16 only among those
who were single, tends to connect it with the performance of the
highest functions of the sexual system— with pregnancy, delivery,
and their consequences. This view is further confirmed by the
circumstance that the age at which the majority of women suffer
from its symptoms coincides with that period of hfe at which those
functions are in most active exercise, Valleix states that the
majority of his patients referred the commencement of their
ailments to between the ages of twenty and thirty years ; wliile
the fact that forty-nine out of the sixty-tliree patients of whose
cases I have preserved a record were under forty years old at the
time of their coming under my care, points in the same direction.
Moreover, in thirty-four out of fifty-seven cases of married women
referred to by M. Yalleix, and in twenty-one of my fifty-eight (or
twenty-one of forty- six, if for the moment twelve cases where
inarrii^e had proved sterile are omitted), the patients referred the
commencement of their ailments to delivery oi miscarriage ; to a
time, in short, wlien the womb was larger, heavier, and more
abundantly suppMed with blood than at other seasons, when its
recently stretched supports were less able than at other times to
keep it in its proper position, and when those attacks of circimi-
• The above oumbera are derived firom tlie 8iity-«iglit caaea of VaUeixt witli
iixty -three of my own.
I
I
THEIR CADSEa
199
scribed peritonitis, by which adhesions are produced between it
and the adjacent parts, are specially likely to occur. The case re-
lated in the last Lecture (p, 183) shows how in these conditions the
enlarged uterus may In?, retroverted, and shows further how, in
Bpite of its gradual redaction in size, the misplacemeni may stdl
continue : its symptoms aggravated after each fresh miscarriage,
which reproduced, though in a slighter degree, the same tiuin of
evils as attended the first occurrence of the accident. Of the
remaining thirty-saven patients, three had fibrous tumours in the
uterine walls, so that the misplacement of the womb might be
regainlod as in part due to their presence ; whUe in a fourth there
was a small tumour, probably ovarian, behind the uterus, which
not merely retrotlected it, but having become adherent both to the
womb and to the rectum, prevented the uterus from resuming its
proffer position even after the tumour, in which suppuration took
place, had dischai'ged its contents by the bowels ; and in a fifth
the misplacement was apparently consequent on the formation of
an abscess between the uterus and i-ectum, by which the organ had
been retroverted and finally bound down by adhesions in its
annatuml position. Four patients, one of whom wa-s unmarried,
referred their symptoms to a menstrual period, which had l>een
attended by an unusual amount of snflering, and one dated them
from intemperate sexual intercourse. Once the symptoms suc-
ceeded to an attack of vs^pnitis, which was most likely accom-
pftnied by peritoneal inflanmiation, since the anteflected womb was
bound down in its unnatural position ; and in one more, in whom
the enlarged and anteverted womb was similarly fixed in tlie
pelvis, there was a history of abdominal pain and temlerness
occurring causelessly five years before. Six times the accident
seemed to have succeeded to some sudden violent exertion, and in
one instance {that in which the symptoms persisted after the
removal of the misplacement) the patient dated her sutlering from
some operation performed live years previously, apparently for the
removal of a polypus. There still remain twenty patients, con-
cerning the cause of whose ailments no adequate explanation is
given* It is not without interest, however, to observe that in
almost all of these cases, the s^vTuptoms had come on very
gradually, and the misplaced uterus was in the great majority of
instances much enlarged The subsidence of the symptoms and
m
FLEXIONS OF THE UTERUS :
the diminution in size of tlie womb Uyok place simultaneously.
Sometimes as the organ grew smaller, it resumed its natnral
position of its own accord, while in other cases it remained mis-
placed, but there did not seem to be any invarial>le connexion
between the completeness of the patient's recovery and the return
of the womb to its proper situation.
It seems, then, that in by far the greater numljer of instances,
the development of all the symptoms uf flexion or version of the
uterus coincided witli the operation of some cause that increased
the size of the womb, or produced congestion of the pelvic viscera ;
and further, it may be added, that the almost immediate relief
which followed rest, local depletion, and the due re<2:nhition of the
bowels, seems to show that to these associated ailments, rather
than to the mere misplacement of the womb, the patient's sufler-
ings were to be attributed. Not infrequently, however, the relief,
though striking, was of short duration ; and the patient had not
long followed her usual avocations, or not long returned to her
husband's bed, before many of her former symptoms returned.
But this is by no means peculiar to misplacement of the womb ;
for we see illustrations of it in the increased suffering which, iu
almost every uterine ailment, attends upon the menstrual iieriod,
and in the aggravation of all previous uterine discomfort, which in
many women succeeds to marriage, and which is sometimes the
occasion of ailments being brought to light whovSe very existence
was previously unsuspected *
A woman, aged thirty-five, was adnutted into 8t Bartholomew's
Hospital, and gave the following history of herself: — She had
been married eleven months^ but had never been pregnant.
Previous to her marriage her health had been good, with the
• Thia eatimate of the ordinarily wnall importancQ of simple uterine flexiona
coincides very closely with tha c^jEcluttioris al which Scanzoni haa arrived, iind
which he holds so decidedly that he priuti tbem in large tyj^^ in the third eilition of
his book. *' Flexiona of the uterus are uerer of mui:h iuijjort^ince, never give rise
to serious evils, except whi^n eome other atfection of the uterine Rubstaiice ia asso-
ciAted vnth them.*'— CJp. aX p. 90. The conclusion, too, to which M. Bt^mntz
ia conducted by his and M. Goupirs ekborate inve^tigiition is^ that ** uterine
(Icviatioiis, vrith the exception of ch^.scent and prolapsus of tlie organ, givu rise,
when uucomplicatedi to no kind of funcriooal disorder/' — Op, cU. vol. it. p. 717.
It »y«ms alrarjst iiee<nija8 to multiply quotationB in BUpport of the views stat^ above^
hut a few worth of M. Courty are much to the point **One se^s," aays he,
** womea who have beeu coni|)elled to pasa years upon their couch, at length about
THETR STMFTOMS.
201
exception that menstruation, though regular, was always very
painful. Since her marriage, however, she had siifiered much from
constant aching pain round the loins, felt most in walking, and
constant desire to pass water, while her menstruation had hecorae
very frequent in its return. On making an examination, the os
uteri, which was small and circular, was found directed back-
wards ; while above the anterior wall of the vagina a tumour of a
rounded form was felt pressing forward against the liladder, and
could also be distiuguished by means of a sound introduced into
that organ* I imagined the body to be formed by the anteflected
uterus ; though, after careful and repeated examinations, in the
course of which I endeavoured unsuccessfully to introduce the
uterine sound, I changed this opinion, aud came to the conclusion
that it was a fibrous tumour growing from the anterior uterine
walL WTiichever view be correct, the case equally well iUus-
tmtes the hu^i that an uterine ailment may remain quiescent,
as far as the production of symptoms is concerned, for an indefinite
period, while yet it may be the cause of much auflTeriug, if any acci-
dent gives rise to an increased afflux of blood towards the womb.
Bearing in mind, then, their compound origin, we may next
inquire into the nafmr of tfw sjfmpt&nis that usually accompany
versions or Hex ions of the womU In the two instances where
the misplacement occurred suddenly as the result of over*
exertion or straiuing. much pain was at once experienced, and
was referred to the neigbboui'hooil of the uterus; while in
the case of retroversion there were considerable ditiiculty in
micttirition, and frequent desire to pass water. In other cases,
however, the supervention of the symptoms was gradual ;
discomfort about the pelvis, accompanied liy unusually profuse,
and often unusually painful, menstruation, being the symptoms
which first excited the patient's notice, and by their persistance
and their increase compelled her to seek for relief.
the time of thi; ceiisntion of the men^^, or even sooner, expfirienre a great improTe-
ment, Wonie able to get up, to walk, and gradiully to resume thctr onUniiry
^ccupfttioQs. Does thi« imnrovement depend perrhance od tha apontaneooji cuir
of thu misplacements. By no me-ons^ for on exauii nation one diAOOYCts tha.t the
position of the womb is nowiae alter<Ml Bat the uterus is no longer congested »
uor painful, th« a) mptorus of local peritonitia hiavft pwaed twiy, the mispkcemciit,
by little and little, haa become dniplo misijlaccment, and nothing more.**—
Ooarty, MaladUi <k ri/Umt, Sro, Pariit, 186d, p. 765.
202
FLEXIONS OF THE tTTERUS:
The followmg were the more prominent symptoms in the sixty-
tbree cases of version or flexion of the uterus of wliich, down to
the present time, I have preserved a recoi-d : —
lo the total
In twenty of them the uterua wai
wxty-thrtMi
ciiaes.
ajitererted or anteflexed.
JlfliiOTiui£|iii ■
* 20
.
3
jjjpnmsnaTtiiQBft
. 20
p
8 ^
L<*ucoriha*tt •
. 25
,
8
Ttiiii, or other discoaifort ( „,
. , . r
in micturitioiL
J.X
•
Fain ,
. 51
,
. 17
Bifflcult or paiuM
cation
def.. 1 ^^
.
3
1
Of the above sixty-three patients, fifty-eight were manied, of
whom twelve were sterile. The remaining forty-six, of whom all
but one were under forty years of age, bad given birth to
one hundred and twenty-four chQdren, and had had forty
miscarriages ; numbers which yield results ditfering but little
from those wliich we meet with among persons alHicied with
uterine disease in general ; and whose labours amount to 2'7,
tlieir miscarriages to 0*47 to a marriage, while one in 8^5 of the
total number proves sterile.
The above enumeration of symptoms, and of their comparative
frequency, which tallies in the main remarkably with the
statements of M Valleix on tlie subject, must be sufficient to
show that either the misplacement itself, or the state of the
uterus associated with it, is adequate to produce much positive
Buffering, and much functional disorder. The pain which was
experienced in all but twelve of my cases, and in sixty-four out
of sixty-five of those of M. Valleix, varied much in its intensity-
It was a constant sense of pain and aching in the back and
loins, and of pain shooting down the thighs ; often, though not
always, accompanied by a sense of bearing down, and by
sensations of the same kind as in general attend oi-dinary descent
of the womb, though more distressing in their character. In
yfiTj many sexual intercourse was attended by great pain, while
the sudering it produced had led in some instances to its
complete discontinuance. Those patients in whom the abiding
pain was the most considerable suffered also from occasional
THEIR SYMPTOMS*
203
attacks of paroxysmal pain, which was sometimes of extreme
intensity, and had tlie character of hystericd colic such as one
meets with occasionally in various uterine ailments, and such as
is especially associated with dysmeuorrhrea. I have not been
able to ascertain that there is any coEStant relation between the
direction in which the womb is flexed and the seat of the jiain in
the anterior or posterior pail of the pelvis, though difficoU. and
painful defiecation appears to be much more frequent in cases
whei-e the w^omb is retroflexed or retroverted than in those where
it is tiu-ned or bent forwards* I doubt, however, very much the
extent to which any of these symptoms can be referred to the mere
mechanical effects of the displacement of the womb, for in five out
of the fourteen cases in which difficult micturition attended
misplacement of the womb backwards, the organ was retroflexed
and not retroverted, and consequently the bladder was sub-
jected to no kind of pressure; while, moreover, in thirteen
cases of version or flexion of the womb forwards, the bladder was
relieved without either pain or difficulty. Pain and difficulty in
defsecatiou, too, are by no means such constant attendants upon
retroflexion as might be reasonably expected if they depended upon
a simply mechanical cause. The symptom was, indeed, for a long
time regartled as of purely mechanical origin, and the presence of
mucus in tlie evacuations was looked upon as ccmclusive evidence
of the irritation of the bowel by the misplaced womb. Further
observation has shown, however, that this symptom is by no means
constant in cases even of very marked retroflexion ; that further,
it is often absent in cases where the growth of fibrous tumours
from the posterior wall of the uterus exerts very considerable
pressure on the bowel ; while it is far from uncommon in various
uterine ailments attended with much irritation of the neighbour-
ing viscera, even though unaccompanied by any enlar^'ement or
misplacement of the womb. The same fact holds good still more
absolutely with reference to constipation, for the retroflected
fimdus is never found so to compress the rectum as to interfere
with the easy introduction of the finger into the bowel, and con-
seijuently cannot mechanically prevent the escape of its contents ;
while further, no accumulation of faeces is found to take place
above the fundus of the womb ; and lastly, constipation, even
more obstinate than that observed in these caaeSi attends upon a
204
FLEXIONS OF THE UTERUS :
large number of ailments, especially of an an^iemic or liyaterical
kind, in which there ia no local atl'ection of the uterus. The
leucorrhcea, the dysmenoirht^a, and the menorrhagia, though of
very frequent occurrence, are perhaps less characteristic than the
symptoms already eiinraerated, inasmuch as they are fi-equent
attendants upon so many uterine disorders. It is, however, worth
notice that the fiirty instances of disturbance of the menstrual
function occuri^ed in thirty-nine different persons ; but I am not
pi-epared to state that as a rule there was <Treater flexion of the
womb whem the meustrnation was most painful than in other
cases, or more marked enlargement or apparent congestion of the
organ where the menstruation was most profuse. It would not be
right, however, to pass over the subject of menstrual disorder in
connexion with extreme uterine flexioDs without noticing an
accident which on some few occasions I have seen attending an
exti-eme and long-standing retroflexion. Instead of the obstruc-
tion to the menstrual flux lessening it as well as rendering it more
painful, the blood poured out collects in the interior of the iMjdy
of the utenis, which it distends, and whence it is expelled in
gushes intermingled with coaguia just as haemorrhage takes place
in abortion. This collection of blood in the womb, and ita
expulsion under violent uterine eltbrts, w' hich yet fail to rectify
the malposition, may go on for many days together ; not merely
wearing the patient by the pain she endures, but enfeebhng her
constitutional powers by the large loss of blood which takes place
* at each protracted menstnml period. The large womb, the sharp
angle of retroflexion, the results of the introduction of the sound,
or even of pushing up the fundus if the sound cannot be readily
introduced ; a fresh gush of blood following the rectification of
the position of the womb, and corresponding with the disap-
pearance of the swelling which might otherwise readily be taken
for a uterine tibrt>id, — all show the real nature of the case, and
point it out as one where the mechanical aOment calls for a
mechanical cure.
Lastly, with reference to the influence o£ these conditious on
fecundity. Of the fifty-eight mamed women, one had become a
widow, and one had passed the child-lieiiring age, before any
symptoms of uterine ailment appeared, while in seven the symp*
toms were of less than a year's dui^ation, and consequently theiti
TJTEIR SYMPTOMS.
205
had not been time for the influence of the ailment in this respect
to Iwicome evident.
Of the remaimng fortj-nine, six gave birth to live chiUlren at
the full period, after the womb had been misplaced ; and one of
this number had five live children at the full term of ntero^gesta-
tion, in spite of the existence for fifteen years of all the signs of
retroflexion of the uterus.
In one of the above six, pregnancy was preceded by the replace-
ment of the organ ; but in the other five, not only was the womb
mtsplficed at the time of conception, but was ascertained to con-
tinue so after delivery.
Five having previously given birth to li\ing children, miscarried
after the development of ^TOiptoms of uterine misplacement ; and
in one of the number miscarriage had twice occurred, and in
another eleven times, while twenty-one, having prexdously given
birth to one or more li\ing chihlren, had passed more than a year
since the commencement of the symptoms without conceiving. In
eix of this number, however, though still within the child-bearing
age, conception had not taken place for from two to five years
previous to the commencement of the symptoms of misplacement
of the womb.
The above detail of symptoms sh^ws, I think, that while
versions and tlexions of the womb by no means invariably produce
either local sufiering or functional disturbance, their presence or
absence is yet far from being a matter of indifference, and we must
admit them as constitating a distinct class of by no means unim-
portant ailments of the womb. But even though they were them-
selves of liut little moment, it would nevertheless be very necessary
that we should learn to diMin/fuuili (hrm from other and moi'e
serious uterine ailments with which some of them are, on a super-
ficial examination, very likely to be confounded.
With ordinary care, indeed, any misplacement of the whole
uterus, assuming^ as it usually does, the form of retroversion, can
scarcely be overlooked or mistaken, for the fundus uteri thrown
backwards, and often downwartls, into the hollow of the sacrum ;
and the mouth of the womb directed forwards, and tilted upwards
against the symphysis of the pubes, are characteristic indications
of the change in its position. The sources of fallacy ai-e, however,
ffir more numerous in those caseij in which the organ is flexed and
206
FLEXIONS OF THE UTERUS :
its body is bent upon the cenix, producing a tumour which may
be mistaken for ovarian disease, or for a fibrous tumour of the
uterus, or for one of those extravasations of blood around the sub-
stance of the womb, to which, under the name of uterine haema-
tocele, attention has of late years been especially directetl In
cases where the uterus is bent forwaniSj the sources of error are
less numerous than incases of its retroflexion, and I am not aware
of anything except a fibrous tumour of the anterior uterine wmll
wliich ia likely to tlirow uncertainty upon our diagnosis, though I
have found the discrimination between flexion of the womb and
the presence of a fibrous tumour in its wall to be sometimes so
difficult as to be almost impossible. The tumoiu- formed by a
flexion of the womb usually begins immediately above its cervdx,
and the substance of the organ may be traced passing over into it.
At the same time no enlargement of the uterus can be felt by
the finger carried in front of the cemx in cases of retroflexion, or
beliind it in cases of anteflexion, while if the patient lies upon her
l>fick, and pressure is made with one hand over the pubes and the
other in the vagiua, the absence of any pelvic tumour may in
general be readily asceiiained. Moreover, in many instances,
pressure with the finger in the vagina upon the uterine tumour
impaits to it a degree of mobility w^ithout at all altering the
position of the cervix, such as would not be possible in the case
of a fibrous outgrowtJi from the organ* This, liowever, is not
always practicable ; for on the one hand, the tenderness of the
flexed womb not infrequently prevents any steady pressure upon
it being V>orne by the patient; and on the other, steady and
longKJontiniied pressure does not alwa)^ modify the position of
the organ, — ^and this even though no morbid adhesion connect its
fundus with adjacent parts. In a very lai^e number of the
doubtful cases we should remain in uncertainty for a very long
time, and come at length to a hesitating decision, if it were not
for the help afforded us by the uterine sound If this instrument
is introduced with its concavity directed either backwards or
forwards, according as the tumour is situated in front of the
cervix or behind it, and if it is then gently and carefully turned
round, w^e shall find that the tumour, pre\iously so distinct, will
comjTletely disappear, though often to be immediately reprnducetl
with the same character, and of precisely the same size as before.
THETR DUGNOSIS,
207
the moment that the instrwiueiit is withdrawD, The sound
affords at the same time the opportunity of ascertaining t!ie
j^K^rfect mobility of the uterus, and the absence of any such
increase of its weight as the existence of a tumour in ite walls
must of necessity occasion.
Valuable, however, as is this means of diagnosis, it is yet not
without g43me sources of fallacy, while its employment leads
occasionally to no satisfactory results. The instrument will
sometimes not pass beyond the internal os uteri; and thou^^h
pressure upwards against the tumour, so as to lessen the bend of
the cervical canal, not infrequently enables us to introduce it, yet
this is not always the case ; and I need not say that force is
never allowable in order t^ overcome the difficulty. But even io
these cases, the absence of any considemble sense of weight when
the oi^an is poised upon the instrument strengthL*ns the presump-
tion against the existence of any uterine tumour. Further, a
fibrous tumour projecting into the i-ecto- vaginal pouch may
present many of the charactei-s of the retroflect^^d womb, while
the fact tliat such a growth not infrequently flexes the organ, and
causes it sbghtly to deviate from its natural direction, increases
the probability of error. If, too, on turning round the sound
after its introduction, the handle of the instrument is much
depressed, its other end will of course be correspondingly raised,
and an uterine tumour being thus carried out of easy reach of
the Angel's, may apparently disappear, and the case be thus
mistaken for one of simple flexion of the womb. The safeguard
against this error is found in the precaution of not otherwise
altering the position of the sound, when the instrument is turned
round* The existence of adhesions, indeed, prevents any attempt
at replacing the flexed womb from being successful, and thus
deprives us of one means of diagnosis, though even in such cases
the direction in which the sound enters with facility, and the fact
that in no direction but that one will it enter at all, are not with-
out value. Ovarian tumours are almost always larger and more
spherical than the retrotlectcd fundus uteri, and the finger will
in general detect the Uydy of the uterus driven forwards by the
tumour, while with the finger of one hand in the vagina, and
the other hand over the jmbes, the practitioner will in geneml
be able to satisty himself as to the exact relations of the organ,
FLEXIONS OF THE UTERUS :
even though attempts to introduce the sound should not be
successfuL The sfitne statement also hohis good with reference
to uterine ha?matocele, and further, the tumour which it produces
does not usually present the same degree of resistance as the
retroHeeted uterus. One of the largest uterine hiematoceles,
liowjever, which has ever come under my notice had produced
complete retroversion of the oi^an, and thus rendered diagnosis
very difficult In such a case, and indeed in othei's where
tumours have flexed the womb, or have much altered its position,
the risks of error are very great indeed. I do not mean to claim
for the sound the advantage of always enabling us to come to a
correct conclusion, but only to express my conviction that it is a
very valuable Iielp to diagnosis, and that it restricts the doubtful
cases within very nanow Hmit-s, and enables us in the great
majority of instances to expi'ess ourselves at once and positively
with reference to questions wliich otherwise would often be very
obscure.
Lastly, we come to the consideration of the appropriate treat'
ment of these misplacements : a question which has received two
diflerent answers, according as practitioners have confined them-
selves to the endeavour to remove those ailments with which the
malposition was associated, and to winch the 8}Tnptoms appeared
to be directly due ; or, as they have aimed at something more, and
liave attempted to restore tlie uteriis to its right position, and to
maintain it there by mechanical contrivances. Of the Continen-
tal writers who first called special attention to these misplace-
ments of the womb, Schweighauser contented himself with the
employment of i^medies calculated to remove the constipation,
and to relieve the congestion of the pelvic viscera, and states that
having accomplished these objects he found that the uterus
returned invaiiably to its proper position ; and Schmitt also coin*
cided, in the main» in the same opinion. A view, in many
respects similar, has been ably advocated by Dr Oldham,* who
regards the misyjlacement of the womb as being invariably the
secondary consequence of its enlargement, and insists on the
special advant^es of the use of the bichloride of mercury in
removing this condition. Schmitt attempts in his essay to dis-
criminate between cases of primary misplacement of the womb
• (hiy*a Moifpital Btports, second mncs, vol vi.
THETR TREATMENT.
209
and those in wliich its altered position is Becondary to some
eiilar^'ement, or to some inflaramatory aflection of the organ. He
never employs any means for the purpose of replacing the womb
80 long as either constitutional disturbance or local tenderness of
the uterus is present, and recognises the frequency of its spon-
taneoua replacement after their removal; for accomplishing
which he trusts, like Schweighauser, chiefly to reM, and to the due
evacuation of the intestinal c^nal by the regular administration of
valine aperients. If the misplacement should still continue, or if
the case was already chronic in character at the time of its coming
under treatment^ he approves of careful attempts being made to
replace the womb. These attempts consist in pressure upon the
fundus with the finger in tlie vagina, or sometimes in the rectum,
and he throws out the suggestion that possibly in some instances
a eontrivauce employed by Ptofessor Richter of Moscow,* for
replacing the womb retroverted in pregnancy, may t>e of service.
As a subsidiary means tending to promote the replacement of the
organ, Schmitt further recommends that the patient sliould lie
uprm her side with the hips raised, on attitude to be changed only
for that on the abdomen, and that she should careftdly avoid Ij^ng
on the Ijack ; recommendations, all of which are much inaiated on
by many practitioners at the present day, who place their patients
on the prone couch in every case of i-etroversion or retroflexion of
the womb. Lastly, whenever the disposition to retroversion of
the womb continues in spite of ti-eatment, he em|doys one of
Levret's disk pessaries, made with an aperture sufficiently large to
admit of its embracing the neck of tlie w^omb ; following in this
I^vret's own directions ae laid down in his paper on anteversion
of the womb.f
Thifl essay of Schmitt's, to w^hich the particulars of nine casea
are appended, and which is even at the present day by far the
moet complete and most valuable contribution to our knowledge
of the subject, continued to be the guide of practice in Germany
until the publication of Sir J. Simpson's ingenious observations. Ho
• Sk^t? Richt^r'a Syiwpns /Vckcm Mtdiw-OhMetridWy ito, MoequiCp 1810, plmte ii,
p. 70, for A dejic-ription of thia instrameut^ which was compost of a curved atem
of wood, terminated by a kind of plug whicli was covered with a ciflaliion, and waa
ttit«nd^ U» iiD»wer the purpo^ of a long and strong finger in replacing the womb.
t Already rt:ferTvd to in JaumcU dc MAieeim, £^, see p, 2S0,
0
210
FLEXIONS OF THE UTERUS :
not only drew attention in tkiB countrj and in France to the
frequency of these misplacements, which had previously been
so much underrated, but he also insisted on their mechanical
rectification as the most important means of removing their symp-
toms, and suggested a novel contrivance both for replacing the
womb and for maintaining it in its position.
His first proposal, to replace the womb by means of the uterine
sound (an instrument wltich owes almost all its practical utility
to the altenitioiLS which he has made in its form), seems to have
been anticipated by Osiander in 1808 * who describes the intro-
duction of a slightly curved instrument into the retroverted womb,
by turning which round, the fundus uteri was at once restored to
its proper position. Ostander*8 suggestion, however, was disre-
garded, and hia facta were discredited and soon forgotten.
Velpeau claims-f the invention of a pessaiy with a somewhat
elastic stem projecting from the centre of a semicircular disk. The
disk being turned forwards in cases of retroversion, and backwards
in cases of the opposite kind of misplacement, the tendency of the
elastic stem would be gradually to restore the womb to its proper
position and gently to maintain it there. His trials, appear, how-
ever, by his own admission, to have been but few, and their results
were not encouraging.
Sir J. Simpson, believing that in the great majority of instances
the symptoms associated with misplacement of the womb, and
also the changes which the organ may present, ai'e mainly
dependent on its malposition, insists on tlie reposition of the
womb, and on the emplojrment of mechanictd means tf> secm*e its
continuing in its place. He proposes to accom|>lish the lirst oliject
by means of the uterine sound, and the second by means of a wire
stem introduced into the cavity of the womb, and maintained
there by 8uital:dc contrivances. This instrument underwent
several alterations in his hands, and although it has since been
mofUfied by the late Professor Kiwisch of Prague, yet Simpson's
uterine supporter, with the improvements devised by M. "^^alleix
of Paris, appears to me to be by far the safest, and the best
adapted for its purpose,
* Mtd. Vhir. ZHiung^ 1808> voL iv. p, 1?0, as (juoted in li note at p. 54 of
Sclimitt, op, at,
t Lib, cU, p. 102.
I
THEHS TKEATMENT BY IKTEA-LTERmK StrpPOKTS.
211
Sir J. Simpson's paper was not accompanied byany detafl of cases,
and contained scarcely any hint as to possible dangei-s or difficult
ties in the emplojTnent of his instniraent. The attention of prac-
titioners in this country had been called by him to an ailment, the
possible occurrence of which they had pre^donsly scarcely
recognised, while the simphcity and ini,^ennity of his prnpnsed
means of cure recommended it to almost universal adoption.
Some doubts, indeed, were expressed on theoretical grounds, as to
the probable result of maintaining a foreign body for weeks or
months together in the uterine cavity. Thase were, however,
silenced for a time by the detail of cases by different writers in
which the instrument was worn for a long period, not only
without injury, but with very obvious advantage. Still, l*y
degrees, unfavourable results began to be more generally heard of ;
much uterine pain, almost constant leucorrhtea, associated with a
distressing sense of pruritus; monorrhagia, and htemorrhage
between the menstrual periods, were found to be of no very rare
occurrence. The advocates of the mechanical ti-eatment of these
ailments, too, became in time impressed with the necessity for
greater caution. They not only removed the instrument at the
menstrual periods, which at first they were not accustomed to do,
but tried to habituate the womb by degrees to its presence, intro-
ducing it at first for an hour or an hour and a half at a time,
while some even recommended tliat it should on no occasion be
allowed to remain longer than three or four hours within the
womk Inconveniences such as Uiese, the incompleteness of the
patient's temporary recovery in some instances, the frequency of
her relapse in many more, the occurrence of serious inttamrnation
of the womb, or of dangerous peritonitis, and some instances of
death from the use of the instrument, have now led to its almost
universal discontiimanee.
It is probable that in a few years more the uterine supporter
and its uses will have become mere matter of history. It would
not, however, be right at present merely to condemn it witlu jut at
the same time assigning the reasons which appear to have led
most practitioners to abandon it.
l$t. The safe employment of the instrument requires that, as a
general rale, its use should be continued for only a very few hours
at a time,^ — a necessity which implies that evei-y woman who is
212
FLEXIONS OF THE UTEBUS :
submitted to this mode of treatment shall uudergo two vaginal
examinations eveiy day, — the one far the introduction of the
inBtriiment and the other for its withdrawal
2d, The quietude which its use imposes, and the restrictions to
which the patient is compelled to suTunit in order to avoid severe
sufl'ering and the risk of serious danf]jer, are at least as absolute in
their kind and as irksome to be borne as those which any other
mode of treatment inirolves, while it is necessary to continue them
for as lonii a time.
3d, In spite of all precautions the treatment is generally painful,
often dangerous, sometimes fatal; and the untoward accidents
have not been by any means constantly attributable to want of
prudence either on the part of the practitioner or of his patient
4:th, Cnn.\ even by the long continued employment of this
means for several months, ia uncertain, while relapses are very
frenuent after the medianical support is discontinued; besides
which the permanent cure of the misplacement is far from being
always followed by the cessation of the symptoms.*
* To nifpt assertions by mere coiiiitiT-statement ia invidiouSj iiiid carrief« no
(wmviction to thme whose opinions ditrer Trora our own. 1 win thercfoni Adduce
Tiere tlie testimony of two nion whose pnsition ajid character entitle their opinion
to especial weight
In the iliHctission before the Aead«tay of Medicine at Paris, M. Duboiq stated
that he hikfl himself treated more than twenty piiti*>nt9 by menna of the nterine
aupporter, which in some inatances wiis worn for several montha, but that tlie
roiaplaccraent reproduced itself within a very shwi time after the removal of the
instnuuent ; and that he bad made a similar observation in the case of many
patients who, having been thus treated by IL VaOeii and Sir J. Simp&on, had been
dtBinie^aed by those geiillemeii as cured.
Professor Bcanzoni, in « note appeniled to the fourth edition of Kiwiseh's work
on the DiseoKB of WoTnerif which he edited after tlie an thorns death, makes the
following statement :—
** The obserralion of (ifty-si^c cases of flexion of the nterns daring the past fonr
years compels me to expn^sji my decided conviction that th© meebanieal treatment
of this affection so elal>orately set forth by the author ia either oselees or |>08itively
mischit^voos/' After addiieiog some reasons for this opinion, he concludes : — ** I
will merely add, that since I have i|iiite discontinued leaving the sound in the
utt'rus, employinj^ the uterine »u[iporter, and so on, and have contented myself
with the use of cold vaginal irijeetions, with the antiphlogistic treatment of any
chronie uterine iuflamtnation, an<i the application of caustic to any ukerntton of
tbfl OS uteri, and with the endeavour to remove the ehlorotic symi*toins which arc
wldom ahj+ent, I have been mut h Ix'tter satisfied with the results of my treatment
than I was at thr time when 1 allo\iM-d myself to he seduced into the application
of a variety of m^cbanical coutrivaDces.'*— Ojj. ciL voL L pp, 135, 136.
THEOt TREATMENT.
213
On these accounts, though I liave tried the uterine supporter
in a few cases, I have now for some time quite given up ita
employment^ and content myself with a mode oi treatment which,
though it seems to ] promise leas, yet almost always atibrds great
relief, while in a large number of instances it quite removes thts
patient s aufleiings, and is not infrequently followed by the com-
plete rectitication of the position of the womb. I beUeve, too,
that even they who were the moat strenuous mlvocates of the
uterine supporter in this country have silently almost renounced
its use ; and M. Antn* states that M, Yalleix, who strove with so
much ability to introduce it in France, " had towards the close of
his life almost completely abandf med its employment, substitut-
ing for it the replac^emenfc of the womb with the uterine sound,
followed by the introduction of an air pessary either in front of
the womb or belund it, according to the direction in which the
flexion had taken place/*
The principle upon which I usually act in the management of
these caaes amounts pretty much to this : that to the best of my
power I take care of i\m general symptoms, and leave the
misplacement to take care of itself. In a very large number of
instances the misplacement succeetls to deliveiy or to miscarriage,
and the womb is, as might be anticipated, in a state of imperfect
involution. In these circumstances rest for a season in bed or on a
couch, occasional leechint^ if there is much tenderness of the
ergan, and the strictest attention to the condition of the bowels,
which should be kept freely open by moderate doses of saline
aperients, seldom fad speedily to relieve the congestion of the
womb and of the pelvic vessels, and to place the organ in the
most favourable condition for the aecomplishnieiit of those
prooeasea by which its bulk may be reduced With the approach
of each menstrual perio^l, precautioiis should be redoubled, for
m^istruation is very often excessive in quantity, and also
irregular and over-frequent in its return ; anticipating the proper
• Op, ciL p. 1015, The remarkA, too, of Or Fordycu Barker, at p. 14 of hi« annual
addrcM, already refrrreci to, deserve to bt^! laid to heart as a Tery tnoJeratA state-
ment oi the n)<»dical, ae oppo^d to the cran^ iiKH^hatiical, views of some writers on
gynvecol&gy. [It is also wt^ll known that for mniiy yearn liefore lib death Sir Jamva
Simpioti h(id, comparatively HjieakiDg, almost entirely gtven up the une of intrv
uterine i]iHtroiitet]1ji.J
214
FLEXIOKS OF THE UTEEUS :
time of its reappearance, and, moreover, after its apparent
ceasation coming on again causelessly or on the slightest
occasion* In proportion as this evil is chronic, may we nse more
decided means to check it The sulphuric acid and sulphate of
magnesia if the howels are at all constipated, the sulphate of aluui
if that condition dbes not exL^t, or the gallic acid or infusion of
matico, may be given internally, accompanied, if there is much
pain, with the tincture of henbane, or of Indian hemp, neither of
which hos the same tendency as opium to produce constipation.
Cold enemata twice a day may be employed after the second or
third day of the discharge, and in more obstinate cases, even
vaginal injections of matico or alum. I have not, however,
ventured upon those intra-uterine injections or cauterizations of
the inner surface of the womb which Kiwisch sometimes resorted
to, both during the presence of the catamenia and also in the
intervals between their flow.
In almost all cases of these ailments, a state of general debility,
often of very considemble anaemia, is present, and chalybeate
remedies are therefore nearly always of service. As a general
rule, there is none more suitable than the combination of iron
with an aperient salt, wldch I recommended to you when
speaking of the management of cases of menorrhagia * It is
obvious, however, that yonr prescriptions may here, as in other
cases, require to be varied according to the idiosyncrasies of your
patient or the peculiarities of her case.
After the general uterine tenderness has been diminished, if
necessary by previous leeching, recourse may be had with
advantage to the cold douche, which both restrains hmmorrhage
^ and leucorrfa«»a, lessens congestion, and tends to bring about
coutraction of the lax tissues of the enlarged womb. Sometimes,
however, the douche occasions pain ; and when this is the case,
the cold liip-bath, cold sponging of the loins, and cold vaginal
injections may be substituted for it, since, though less efficacious,
they exert a similar influence.
Pain» referred to one or other ovarian region, and varying in
severity much and causelessly, is a very frequent attendant on
these malpositions of the womb. It is generally much reheved
by counter-irritation, by means either of small blisters not kept
* S«« foirmula No. 1, p. 43.
I
TIIKIE TREATMENT,
on for a sufficiently long time to produce vesication, by the
emploj^inent of a croton oil liniment, whicb must he applied by
means of a piece of sponge, not rubbed into the part ; or by the
use, if the skin is very irritable, of the milder lijiiment of
aconite and belladonna.*
As in the coui-se of other uterine ailments, so in these there are
occasional attacks of violent paroxysmal pain, which though not
limited in their oceun-enoe to the menstrual perioda, are more
apt to come on at those times, and sometimes call fur immediate
relief. The local apphcation of chloroform often ^dves ease ; and
the mitigation of snfferiag which it procures irequentl}^ continues.
I have, however, in a few instances^ known the pJiJn to be
more severe and more lasting than the remedy .so applied could
remove; and when that is the case, its present intensity may be
relieved l>y inhalation of chloroform, and its return prevented or
mitigated by the occasional use of opiate enemata, or by the
administration of camphor and morphia, or camphor and
beUadonna, which last remedy, though somewhat uncertain, is
often of veiy gieat utility.
But you may inquire whether in these cases I reject not only
the use of permanent mechanical supports for the uterus, bat also
the employment of mechanial means for its replacement ? Now,
I believe that, with the exception of those rare instances in
which the misplacement is the result of some sudden shock or
violence, mechanical interference is rarely desirable; and that
the womb will of its own accord gradually revert to its proper
position, or, continuing misplaced, will cease, when its attendant
ailments have been removed, to give rise by its mere misplace-
ment to any inconvenience. While, therefore, 1 use the sound as
a means, and I believe a very valuable means, of diagnosis, I do
not resort to that frequent replacement of the organ by it which
has been adopted by some practitioners, who yet hesitate to
leave any kind of support permanently within the utenis. Ldo
not follow this plan, Itecause, while suffering occasionally remains
for a considerable time after the introduction of the instrument,
the womb almost invariably falls back again to its previous
unnatural position after its withdrawal
There has been much debate about the use of pessaries ia these
* Stse fontuihs No. 7, p. in.
216
"FLEXIONS OF THE UTERUS :
cases, since, while still employed by some practitioners, tliey are
decried as altogether uaservieoable by others^ and cliieJly by the
advoeates of the iiitm-uterine supporter. It must be confessed
that tliey are very imperfect means of suppchrt ; but, nevertheless,
I have seen much relief from their employment in cases of
retrotiexiuii and retroversion of the womb. They sevve to keep
the uterus comparatively fixed in the pelvis, and spare it from
many of the painful shoeks to which the organ is otherwise
almost unavoidably exposed when the patient begins to muve
about, and especially when she sita. They moreover diminish, in
many instances, the painful straining efforts at deftt'cation,— a
fact which shows how mucli more that ailment partakes of a
neuralgic character than of that of a disoKler due to mechanical
causes. The kind of pessary which has seemed to me usually
most serviceable is one of indian-rubber, of an oval form, inilateJ
with air, which, being introduced in the cid-fk-m^ Ijetween the
uterus and the i*ectum, serves to support and to keep steady the
fundus of the womb. This and the air pjessary inflated by
means of a syringe after it has been introduced ai^ indicated in
those casea already referred to, where profuse and painful
haemorrhages accompany retroficAion of tlie womk In them,
too, as indeed it is sciircely necessary to say, the reposition of the
w^omb by means of the sound is essential as the first step to the
cure. The large indiau-rubber ring pessaij, with a central
aperture large enough to allow of its embracing the cervix, is also
often very useful, as indeed is the lever or Hodge pessary wliich
I have already described. I have no experience of its use in
eases dilhcult to redress in association with an nnfixed tntra-
uterine stem. The combination haa the high authority of Dr
Barnes* in its favour, and there can be no doubt but that an
unfixed stem is free from many ol the gravest objections which
applied to fixed intra-uterine supports. When the perineum is
much torn, or the vagina extremely lax, we may tind a pessary i
invented by Dr Priestley extieniely useful. It may be described
as a sort of modified lever pessary, the lower end of which
occupies tlie cid-th-stw between the uterus itnd rectum, while the
stem is attached by four straps, the extremities of which are of
vulcanized rubber, to a band which goes round the abtlomen.
• CiiRkal History qf IHjxaaef of Wome^ Svo, 1873, {k 709,
THEIE TREATXrENT.
217
Baring the time when I had the large field for observation
which a hospital alTords, the relief of those cases of anteversion
and anteflexion, in which special clLscomfoii was produced by the
pressure of the fundus uteri against the bladder, was attended
with mucli difficulty. The maintaining any sujiport in front of
the uterus was practically almost impossible, and I have the
painful recollection of some cases passing from under my care
unrelieved. The ingenuity of Dr Graily Hewitt has since devised
an instrument which he terms the cradle pessary, and which
supplier this need very well. Still better, however, I think, and
easier of intrutluction, is Thomas's anteversion pessary, a Hodge
with a hui-tie shoe lever moving on elastic joints and attached to
its anterior aspect. When introihieeJ this horse shoe comes ta
be in front of the uterus, and pressing against it tends most
effectually to reduce any tilting or bending of the orgnn
forwards.
LECTURE XIL
M18PLACEM1KTS OF THE UTERUS.
Invsrsion op the Uterits, generally oceara daring labour ; eoraetimefl spon-
tuncomly ; symptoms uaually very fonnidalde. It* uhrcmie form ; tendency
of it to destroy life ; o<:casionnl oxL'«ptionH to this mlo ; alleged fipontaneous
replacement of iiterUH. Diagnosis, and management of accident when recent ;
state of womb modifies cliancea of replacemeiit, uliieli are very small, except
when attempted immediately.
Chronic Inversion, its management ; extiq>ation of iiteriiH ; causes modiiying
guct!ef»a of operation. Errors of diagnosis, how to avoid them ; further cautiODB
as t*) Ijeft modK of operating*
Inversion from TolypUi*. Practical cautions reapecting it.
Ascent op Uterub ; ita various caoaeu, and diagnoatic value.
Those forms of uterine misplacement to which our attention
has hitherto been directed, claimed our notice a,s much from the
frequency of their occurrence as from tlie importance of their
s}Tmptoms. We found them to he the occasion of discomfort of
vanous kinds, and not seldom the exciting cause of much
disturbance of the uterine functions ; but in scarcely any instance
were they of themselves dangeroua to life, while they moreover
always admitted of much palliation, often indeed of complete cure.
We have now, however, to turn to the study of a form of
uterine misplacement, which, though happily of very rare occur-
rence, is one of the most grievous accidents which can befall a
woman, inasmuch m its almost invariable tendency is to destroy
life, while the remedy to which alone we can resort in the greater
number of cases for its cure is an operation of a most hazardous
kind, one which mutilates the patient, and renders her for ever
incapable of performing the functions of her sex.
Inversion of the uterus, the turning of the organ inside out, is
an accident clearly impossible in the natural condition of the
nmnipregnated womb ; it being obviously essential for its occur-
i^nce that the organ should have attained a certain size, and that
I
INVERSION OF THE UTERUS.
219
its walls should be comparatively yielding* It is indeed only
at an advanced period of pregnancy that these conditions are
generally met with, and only during labour that an exciting cause
is likely to be superadded capable of producing the misplacement;
bnt at that time %iolent traction at the funis by some unskilled
practitioner, before the detachment of the placenta, may mechani-
cally invert the womb, or the organ may by its own coutractiona
invert itself, just as the intestine does in cases of intussusception.
The late Mr Crosse of Norwich, in his very elaborate K^isaif an
Inversii^n of the Utenis, which unhappily he did not live to com-
plete, states* that in 3o0 out of 400 cases of inverted uterus of
which he had found mention, the accident occurred as a con-
sequence of parturition ; and there can» I think, be no doubt but
that the i^eal proportion of cases in which it is traceable to this
cause is much higher than seven to one. Of the remaining fifty
cases, forty were said to have occurred in connexion with the
presence of a poljT>us in the interior of the womb, the accident
sometimes taking place spontaneously, in other iostances result-
ing from traction at the outgrowth in some attempt to accomplish
its removal
Almost all of those rare cases in wliidi the uterus is alleged to
have become inverted independently of either of the above causes,
are deficient in such details as are needed to substantiate their
oorrectness, and doubt may be reasonably entertained w4th refer-
ence either to the accuracy of the diagnosis, or else as to the
truthfulness of the history related by the patientf Enlargement
of the uterine ca\ity, however, associated with some cause capable
of exciting contraction of its fibres, may be looked on as the two
conditions essential tc> the inversion of the organ; and where
these two coexist, as in Dr Thatcher*s case of enlargement of tlie
womb from hydatids^ here the possibility of inversion taking
place must be conceded.
• Part iL p. 70.
t B«u(l*?loci:t^c's remarkable caae of alleged invertiou of the womb in a girl
fifteen years old, who sul^sred from menorrbagia, appears to me to be one in whidi
we iciay be allowed to eutertaip some donbt aa to the acouracj of the diagnciia ;
while nothing can be Toguer than the history of Liafranc'a patient {Clim^tm
Chinirgicale^ vol. iiL p. 380), whoae aymptoma are said to ha?e existtjd 0ve jean
U'fore ahe came under his observation.
♦ Aa narrated in Crosae'a JSswiy, part i. p. 67.
220
INVERSION OF THE IITEKUS ;
No instance has come under mj own obeervation of uterine
inversion in the recent state, and indeed the annals of the Dublin
Lying-in Hospital and tliose of the London Maternity Charity
sutHciently illustrate the mrity of tlie accident, since it was not
once met with in a total of more than 140,000 lal>ours * Its
s^m^ykrms, as detailed in works on midwifery, are so ajipalling and
80 characteristic that it would seem almost impossible either to
overlook or to misinterpret them. Sudden collapse, accompany-
ing abundant haemorrhage, associated with disappearance of the
tumour formed by the uterus in the abdomen, and the presence
of a large spherical body either just witliin tlie vagina or pr(>iect-
ing beyond the external parts, are the ordinary indications of the
womb having been iu verted ; and the occurrence even of some of
these accidents in the third stiige of labour, or just after the
detachment of the placenta, ought at once to excite the suspicions
of tlie attendant with reference to their almost invariable cause.
In spite of this, however^ in a very large proportion of instances
in which invei^ion of the uterus in the chronic state has come
under observation, the accident, though clearly traceable to delivery,
has been overlooked at the time of ita occurrence, and almost the
only opportunity of replacing the womb has thus been losL
Three cases of inversion of the uterus in the chronic state have
come under my own observation; but in none of them was the
condition discovered until some months after the patient's deli-
very. The history given of herself by one of these patients, who
fourteen months after her delivery was admitted under my care
into Ht Bartholomew's Hospital, was, that the detach uient of the
placenta, which she believed was eHected by the hand, was
accompanied by haemorrhage so profuse as to occasit>n syncope ;
and she was told by the nurse that the womb was brought down
and projected externally, but was apparently replaced by the
gentleman in attendance. Nothing further of any consequence
transpired for a week from this time, when on sitting up to have
a motion, the body again projected externally, but was once more
replaced by the nurse, since which time it had never again p*ro-
truded beyond the vulva. In the case of the seeond patient, the
placenta was removed by hand; and after a period of insensibility,
" Hardy nnd M'Clintock, Practical Obstrvatiom in Midwifery ^ p. 223 ; iwid
Rttniflbotimm, OhaUtric Medicine, 4c., 3d td. p. 719.
ITS CAUSES ANB 6\^MFrOMS.
221
which lasted for two days, iDflammatory s3Tiiptoms came on, but
no cireumstttiice awakened suspicion as to the existence of inver-
sion of the nteruft. In the third case the placenta came away
spontaneously ; the hfemDrrha.jL,fe does not ajipear to have been
very profnse ; and severe expulsive pain was the most prominent
symptom for the first two months aftt^r the patient's de!ive^>^ In
other instances there h^ive been even fewer sjTnptums to engage
attention, and nothing has been observed except some haemor-
riiage succeeding the spontaneous expulsion of the placenta, until
the return and the persistence of the bleeding have k^d to a
vaginal examination and to the discovery of the then almost
semediless displacement of the womb. In these cases there can
be no doubt but that the uterus has inverted itself, and that this
accident has been brought about, not by simple want of contrac*
tUity of the organ, but by the irregidar and unequal contraction
of its ditterent parts, a state of com|jarative relaxation of the 03
and cervix co-existing with violent action of it^ fundus * The
only circumstance, iudecd, which tends to prevent our receiving
this as the ordinary explanation of the occurrence of inversion of
the womb during labour, is its not happening in institutions such
as the Dublin Lying-in Hospital, in which the last stage of labour
is wisely conducted ; winle spontaneous inversion of the organ
would obviously be nearly as liable to happen among patients in
a lying-in hospital as elsewhere.
Profound shock to the nervous system and profuse haemorrhage
are, as has already been mentioned, the two characteristic symp-
toms of inversion of the uterus, Ur Radford has shown, however,
that except in cases where the pke^nta was still partially
adherent to the womb, the haemorrhage is by no means soformid-
• This mode of production of In version of the womb tlurijjg kbour, fiwt
recognised by Saxtorph, Ckmrnrndit Schriften^ 8vo, Kopcnhagen, 1804, p. 301, has
been fuLlj and ably set forth by Dr Radford, Dublin Journal for 1887| Noa. S4 «nd
S& ; and ia now gcinemlly received us a fn^qufut, if not the moat frequeot, inodt*
in which it ia brriught about. Sir J. Simpson, in expressing his adhesion to Dr
Badiord's views — see his Obsf^iric fForht^ voL i p. 817 — refers to two t-asi's in
which inversion of the uterus, with expulsion of the child^ took pkce after the
liioth(«r*s deatli. Both of the caaes aro very marvellouB. Bcemer'i patient,
indeed, had reached the full period of pregnancy ; but she whose history ia very
imperfectly reconied by Klaatsih, was only m the fourth month ; and the rnver-
ai(m of the womb is alleged to have occunvd in the second night after her death.
Ope ia at a loes as to the inferences to he drawn from historiea so wonderfd.
222
IKVERSrON OF THE UTERUS :
able as miglit beforehand be anticipated, and that the shock to
the system is independent to a great degree of the loss of blood.
If these immediate dangers are siu^mounted, the patient's subse-
quent history seems to be liable to considerable variation with
reference to the period at which formidable gymptoma reappear,
tbongh tlie symptoms themselvea are very uniform in their char-
acter. The state of the nterus, too, differs in a way which greatly
modifies our prognosis ; the organ remaining in some instances
comparatively soft and yielding, admitting of being indented by
the finger, and consequently allowing of attempts at its replace-
ment being made with a fair ]>rospect of success ; white in other
cases it becomes at once small and firmly contracted, and bids
defiance to every effort to rectify its position. I do not know
how to account for these differences in the state of the womb,
though their immediate cause must consist in the absence of» or
at least in the very imperfect involution of, the organ in one case,
and the rapid and complete accomphshment of it in another,
Tliose cases where the utenis remains soft and flaccid, and
capable of rephicement, are, however, exceptions to the general
rule, a^ might, indeed, be infeiTed from the rarity of the instances
in w'hich, after many days, or even after many hours, tbe accident
has admitted of remedy. In the majority of instances the con-
traction of the ut-erus occurs very speedily, and is so firm that the
inverted organ has sometimes been mistsiken for tbe head of a
second fa^tus, while the processes of involution usually go on as
completely as in the womb when in its natural position, Tliis
fact is attested by the numerous preparations of chronic in%^ersion
of the womb, in which, as in one in the ^luseum of 8t Bartholo-
mew's Hospital, the organ is so small that the opening of the
pouch which it forms would not admit anything larger than a
quill, while its dense tissue seems at first scarcely compatible with
the outpouring of so abundant a discharge of blood as that under
which the patient sank.
In many instances hiemorrhage bos continued to flow at short
but uncertain inttirvals from the moment of the occurrence of the
accident^ but to this there are occasional exceptions. In one of
the eases which came under my observation, a very slight
occasional dischai^e of blood was all that occurred for several
months after the patient's delivery ; she having suckled her child
I
ITS SYMPTOMS IN THE CHBONTC STATK
223
for thirteen months. At the eleventh month, however, the ovaries
resumed theii* functioD, and the menses were extremely profuse.
On their next return the bleeding was still more almndant, and
thirteen months after delivery the flooding was alsimiinrr from its
quantity, and was intermingled with large coagula, whieh were
diflcharged without any suffering. Even before the hiemorrhage
became profuse the patient suJIei'ed from ordinary leucorrhceal
discharges , which afterwards continued in the intervals of
menstruation. By degrees the intervals became shorter, the
htemon-hage more profuse, and the leuconlKeal discharge lost its
character of a mucous secretion, and became more serous. At
last, when well-nigh drained of all her blood, the red colour
almost completely disappeared from the discharges, and for the
last two or thme months of her life there was a constant flow of
serum, but the positive luemorrhage was very small. A sense of
bearing down, and the occasional appearance of the inverted womb
externally on walking or any exertion, so long as the patient was
able t*i fijUow her usual avocations, were her only other symptoms,
and, indeed, the only ones which are common in these cases.
There are, however, some instances in which the inverted womb,
from hanging externally, has been exposed to injury, and become
olcerated ; and others in wliich the violent constriction of the
inverted body of the womb by the os uteri has produced gangrene
of the organ,*
Such being the consequences that follow the inversion of the
litems during laboui*, it is ob\ious that they tend of necessity to a
fatal issue, and that tlue question is not so much how, as how soon,
a case will terminate. Mr Crosse.*f" whose industry has thrown
so much light on many subjects connected with this accident,
states, that in seventy-two out of one hundred and nine fatal
cases, death took place within a few hours, in eight within a week,
and in six more within four weeks. The immediate danger,
however, being surmounted, there follows during lactation an
interv^td of companiLive safety and of cessation of serious symp-
toms, which reappear when suckling is over. It api>ear3 that of
the remaining twenty-three patients only one died at the fifth
• Several references to tMs occurrence are given by Crosee, op. dL p*rt u.
p. Ill, Notes 104 and 105,
t r^. cU. p. 170.
TNTER5T0N OF THE UTERUS :
month, and then, as the Tesult of an opemtion which had an
unsuccessful issue, onB died at eight months, three at nine mouths,
and the others at various periods of from one year to twenty
yeara.
These latter cases of gi^eat prolongation of life, in spite of the
persistence of inversion of the womh, lead us lastly to notice those
mre instances in which life has not only continued for many
years, hut in which serious sjTnptouis have heen altogether absent.
Of these the most remarkable history is that recorded by Boivin
and DugijS* of a Wduian who was brought to one of the hospitals
at Paris six days after a hibour in which her womb had liecome
inverted. Repeated efforts were made by M. Dubois, as well as
by Madame Boivin herself, to replace the womb, but without
success, and no symptoms being at the time present, the patient
returned into the country by dili*:;ence on the eighteenth day after
her delivery. Nothing more was heard of her till five years after-
wards, when she presented herself to Madame Boivin, with her
uterus still inverted, though of smaller size than before. Some
fiense of dragging at the groins, a frequent desire to pass water
when she was up and exerting herself, and a discharge of a reddish
mucus recurring ever}^ fifteen or twenty days and lasting for a few
hoiurs, were t!ie only symptoms from wliich she suffered. She
was incommoded, however, by having grown enormously fat, and
expressed anxiety at the non-appearance of her menses. Two
cases are related by Lisfranc ;+ the one that of a woman who died
at the age of seventy years, of inflammation of the lungs ; and the
other that of a pei-son forty-eight years old, whose only uterine
symptoms were slight leucorrliopa, and dragging sensation at the
loins, and whose uterus, on her death from enteritis, was also
found completely inverted* In neither of these eaBes, indeed, was
there any satisfactory histor}^ of the manner in which the accident
took plnce ; but the existence of inversion at the examination
after death, and the absence of symptoms of it during the lifetime
of the patients, are both clearly substantia ted.J
Stranger still than the above are cases in which the uterus is
alleged to have spontaneously replaced itself. The possibility of
• Op, a'L vol i. p. 245.
t Op. cil, vol. it. pp. 379-383.
X Rererbuctfd to other dmiiax cases are givren by Mdjsanery op, cU, voL I i
ITS DIAGNOSIS.
225
the spontaneous replaoement of a partial inversion of the womb
during labour must be admitted, and can even be nnderstood ; ao
occurrence stated bj Saxtorph* to have taken place in a patient
whose ulems he endeavoured in ^vain to replace ; and being thus
compelled to leave the case to nature, the organ recovered in a
few days its natural position. But there are. other instances in
which spontaneous replacement of the completely inverted womb
is stated to have occurred many days, or even months or years,
after delivery. It is difficult to know what opinion to fonn
conceniinfT these cases; in some the accuracy of the diagnosis
appears veiy doubtful, and in others the details given are far too
meagre to warrant any conclusion with reference to their real
nature; while unquestionably no such exceptional occurrences
should be allowed to influence our treatment of any case which
may come under our care.+
Questions of obstetric practice do not fall within the scope of
these Lectures. I shall therefore say very little with reference to
the management of these misplacementa of the womb in their
recent state, but shall pass almost at once to the consideration of
the dia^fffwrns artd treuinient of the accident in its chronic foim.
In the recent state tl>e diagnosis of inversion can seldom be
obscure. There are instances, indeed, in which it has been over-
looked or mistaken, or in which the inverted uterus has even
lieen torn away under tlie supposition that it was the placenta ;
bat such errors imply a depth of ignorance and folly, upon which
all rule« and all experience would alike be wasted. There seem,
however, to be cases where, some short time after the detachment
of the placenta, the womb has become of its own accord partially
• 0€MiHfnelU SchriftcH, 8to, Kopenluigeti, 1304. |». 307.
t Th« most s&tiafactorj of Uieae ciMftis Dr Thfttcbcr's, referred to by Mr Crosse,
op, eit p. 170, note. But in ihh instance the ntenis bad resamed its proper pod-
tion at the oml of a month. The case related by D&illiez, Sur U BmverBfmaU de
la Jiairiot^ Bvo, Paris^ ISOB, p. 33, <:orrL>H[K)tidB mai&h more nearly with one of
poiypoB than of inversion ; and of Dr Meigs' two caaea the former is very defiuietit
in detail ; while with reference to both then^ is ti long period during whfeh the
pttfcieiitt were not under any one's observation — circmnatances that must diminish
their value. See Meigs' Tran-slation of Colouibatf Distiuieti of W&uunt dvo, Phila-
d«Iphia, 1845, p. 182. [For the more lan^uX disSusaion of thta sabject aeo Hennig,
Arehipf, Oyn. YH. Band b. 506; Matthewa Duncan, Mtehamsmo/ Natural and
Morind Partaritum, p. 304, where references will bo found to caaes and diBctuaioaa
by Scanioni and Spiegel berg. ]
226
CHKONIC INTTEKSION OF THE UTERUS:
inverted or depressed at ita fundus, and where, while much depres-
sion and s(ime hemorrhage have existed, there has neither heen a
tumour to he felt per vagiuam, nor disappearance of that whicli
the uterus should form in the abdomen. This partial inversion,
too, tends to increase, so that the depression of one day may
amount (to borrow Mr Crosse's terminology) to inlroversUm on
the next day, and to complete inversion on the tidrd, I do not
know that more is needed to preserve from this error tlian a
knowledge of the possibility of falling into it, and of the con-
sequent necessity of ascertaining in every instance where cause-
less depression and causeless bleeding follow the last stage of
labour, not only that tlie uterine tumour still remains in the
abdomen, but also that it retains its proper size and contour.
When the accident does occur liefore the detachment of the
placenta, the whole weight of evidence is, I think, in favour of
removing the placenta bet'oro endeavouring to return the womb ;
and the non-occurrence of serious bleeding in many instances of
recent inversion of the womb after the se|>aration of the placenta,
strongly corroborates the accuracy of the views as to the source
of hiemon'hage in labour, which, though so clearly exphiined by
the late Sir J, Simpson, have been much nnsunderstood and
misrepresented.
There is some discrepancy between the directions given by
different writers for the replacement of thu nkrH^ what iaverhd
during labour; for while some practitioners recommend the endea-
vour to indent the fundus of the oi^an with the fingers, and thus
to replace first that part which was first inverted, others advise
that the womb should be grasped between the fingei*s, and that
while thus compressed as much as possible, it should be carried
np through the os uteri or that part of the womb which represent.^
it, and sJiould be thus restored to its proper position. I imagine
that these different rules imply the exiisteiice in the one case of
the soft and flaccid condition of the womb ; in the other, of a
state of comparative firmness and contraction ; and that accord-
ing as the former or the latter state is present, the first or second
kind of manipulation may be advantageously employed. In the
great majority of instances where the uterus has been replaced
after the lapse of some considerable time, this lax state of the
uterus, which must greatly facilitate the endeavoui', appears
ITS TREATMENT,
227
to have still persisteii Thus in a case related by Dr Borggreve,
and referred to by Kiwisuh*, coutinued pressure by means of a
long ptjssary, fastened extenially with a T baEdage, reduced the
uterus in three days ; its employment having been commenced
on the fourth day after delivery, A similar contrivance was
succesaful in Dr Smart's case,"|" the uterus having already been
inverted three weeks when it was first employed. Dr White of
Buffalo, U.S.^t reduced the uterus on the seventh day, and Iir
Mendenhallg on the sixteenth day after delivery, by manipula-
tions assisted by the emph>yment of a large rectum bougie, the
patient in both instances being partially under the influence of
chloruform, l)r White's patient, however, died from the eflects
of the previous haemorrhage. In Dr Belcombe's case,]| the womb
was found twelve weeks after delivery a large spherical pouch ;
and in Dr Miller's patient,tJ at the end of three months, it likewise
admitted readily the introduction of two liugei-s into its cavity.
Such, too, must have been the state of the womb in the two cases** *
(if we adinit them as not too wonderful for credence) in which a
fall upon the nates at once replaced the womb, though inverted in
the one case for six montlis, and in the other for eight years.
Until very recently, the replacement of the uterus after long
invei-sion, and wlien it had already shrunk to small dimensions,
wa.s regarded almost as an imposaibility, and of the few instances
of its alleged accomplishment, some, at least, were of doubtful
authenticity. Dr White of Bulialo, however, emboldened by his
success in reducing the uterus on the seventh day after delivery,
as I have already mentioned, repeated the same manipulations
with an equally good result in another instance where the inversion
had existed for six months.tt ^^ Barrier! + succeeded in its
reduction at the end of fifteen months, and Dr White|l|| has
• Op* eiL vol. L p. 251, from Med, ZtUun^^ 18il, Ko. ixiiL
f Am^rioan Jpumal a/ Med. Science, 1S35, vol« xvi. p. SL
i Ibid, July 1868, p. 13. | CincimuUi Lancet^ July 1850, p. 3t>3.
H Mtdital QastUt, 1841, vol viL p. 783.
If m. Monthly Joiirml, Dec. 1851.
** Reported by DuUie^ OlmrvQli^n$^ 33 and 34, pp. 105 find 107. The sf-cond
and more remarkable of the two oisea was observed by Baudelocquc bimacll'.
tt Loc. cU. p. 17.
Xt Archives Qin, dt Mid^n^, May 1852, p. 100.
UH American Journal, Jan. 1859, p. 282,
22S
CHROMC DCTERSIOjr OF THE UTERUS:
published another case in which he replaced the uterus, at the end
of fifteen yeai's, though the patient died of peritonitis sixteen days
afterwards. In all of these instances the patients were put under
the influence of chloroform, but the efforts at replacing the womb
were made continuonsly by the hand, aided by the pressure of a
large boogie. For these somewhat violent proceedings, Dr Tyler
Smith substituted, with great ingenuity, a gentler method, which
in liis liands proved quite successful, he having by its means
replaced the inverted uterus after an interval of nearly twelve
yeai^.* He adopted the plan of keeping up constant pressure by
means of an air pessary in the vagina, while in addition twice a
day, for ten minutes at a time, eflbrts were made by tlie hand to *
restore the organ to its proper position. In the course of a few
days the os uteri, previously very small and rigid, seemed to be a
little more dilated, and a little yielding. No very great change,
however, seemed to have been brought about until the eighth or
ninth day, when, after a night of cousidenible uterine pain, it was
found on the ensuing nioniiDg that the invt^rsion had completely
disappeared. The organ showed no disposition to become again
misplaced, though as a matter of precaution an air pessary was
worn for some time. The previously profuse haemorrhages ceased,
menstruation became regular, and the patient some months after-
wards was in perfect health.
This ingenious plan was not long '^vithout its imitators. By its
means Mr P. TeaIeJun.,of Leeds, succeeded in the course of three
days in the replacement of an uterus which Iiad been inverted for
two years ami a half ;f I replaced the organ in four days after it
had been inverted tor nearly twelve months ;t and M. Bocken-
thal§ in seven days, after an inversion of six years' duration. IL
Bockenthal discarded all manipulations, and confined himself to
keeping up continuous pressure by means of the air pessary, a
course which had struck me, too, as likely to answer as well as
its combination with efforts at manual i^phicement, and whi^'h
opinion Mr Teale, in a letter with which he favoured me on the
subject, told me that he also shared.
* Thia ciise was relati'd by Dr Tyler Smith, nt ii meeting of the MfHlio^-Chinir-
gical Sociuty, on April Hth, 1868, iind ia ptibiiabed in vol. xU. of the Trajtaactwm,
p. 183.
t Mtdieal Ttrnw, August 20, 185&. ^ Ibid. October 29, 1859.
§ ZeOs^r. / fMurt^und€t toL xv, p. 313.
ITS TREATMENT.
229
It is disappointing, however, to know thftt this proceeding can
neither be counted on as invariably successful, nor even be
regarded as always free from danger^ M. Aran* tried and aban-
doned it, not only on account of tbe pessary becoming displaced
(an inconvenience that could be avoided by raouuting it, as I did,
on a stem, and cunnecting it with a liiiu baud which passed round
the abdomen), but also because the presence of the instrument in
the vagina produced abdominal pain, shivering, and febrile symp-*
toms. In the second case, ton, in which I attempted to replace
the uterus seven and a half months after delivery, although I
abstained from all manipulations with the hand, the pressure of
the instniiuent continued for twelve days, while it faileiUo replace
the womb gave rise to peritonitis, ol' which the patient died lour
days after the pessary had been removed. The instrument had
produced complete dilatation of the os uteri, but had had no
iotluence on its fundus, the uterine tissue at the point of inversion
being hard and puckered, so that the little finger could with
difficulty be pressed into the tul'dc'Sac formed by it Tlie hope,
therefore, which at first was entertained, of avoiding by this means
all recourse to hazardous operations in cases of ciironie inversion
of the uterus, does not seem likely to be fully realiseAf
The observation of cases in which now and theu women had
survived the tearing away of the uterus by some ignorant persons
during labour ; the occasional occurrence of instances where the
inverted uterus had slouglied away, and the patient had recovered
from the accident ; and the overbold surgery of the sixteenth and
seventeenth centuries, to which alike the facts and fables of
Roussett largely contributed, had familiarised practitionei^ with
tlie idea of extii-pating the uterus when iiTeducibly prolapsed or
inverted. It was not, however, until the end of the last century
«
♦ Op. eiL p. 917. The suceeaa of !£ Kci^eratli of New York, {ZeUsekr. /fir
(Murtik, vol. XX, p. 200) ill replacing the utemi tfter thirteen yous of iuversioo
bf dtaipalAtion with the hiuid ftlone, woolii •e«m to 1m» « l^uiber pnx^f t>f what
other obaervAtioiis it uder prohible, that the rorjring condition of the uU-nia itaelf
has At led^t m much to do with tiie succeas or the failure of atttruipts at its re-
phic«tDciit m the pecaliar mode of prti^revding reeortod to.
t I atu not nwiLTO whether Dr Btiruejt'B propoial to divide the oerrix in c«aie« of
tpparently irrediicible invtfmori of the uterus has met with imitaton. He practised
it onoe, 1>ut though his patient recovered and the inFeruioD wm ivdticed, the pro-
oeediBg wae Attended by much riak.
t Fmtm Fiviex MatnCwmra, Jtc, 8vo, BaoileiE, Un. S^dio Qmria,pp. 100-108.
230
CHKONIC mVEESION OP THE utehlts:
that tlie removal of the inverted uterus began to be admitted as
one of the legitimate operations of surgery, and that the questions
of its indications, and of the best mode of its performance, were
cai'efnlly considered.
In the majority of instances, the indications for the removal of
the inverted uterus have been furnislied by profuse haemorrhage
and discharge, exhausting the patient's strength and threatening
her life ; though in a few instances, as in that where Mr Chevalier*
removed the organ, the operation was not called for by actual
danj^er to the patient's lifci but by the extreme discomfort which
was produced by the tumour hanging between the patient's thighs,
and being thus exposed to all kinds of external injury. The uterus
has besides been remo%'ed in a few instances, either inimethately
on delivery, or within a few days afterwards; but with the
exception of one instance,! in which the organ had already passed
into a state of gangrene, the operation at this early period has been
due either to ignorance, or at least to erroi-s in diagnosis, and htus
been always dangerous, and usually fatal
If we confine our attention for tlie present to cases where the
inversion of the uterns succeeded to parturition, we shall find that
forty-two out of fifty-nine cases of extirpation of the womb had a
favourable result ; fifteen issued in the patient's death ; and in two,
though the patient survived, yet it was found necessary to
abandon the operation.^
* RcpoTted by Dr Mfimman, in hia .S^toyms of DiJkiiU PaHuriiion^ 4th ed.
Loruloiif 1826, 8vo, p. 306. I may ohstrve that thu last reported ca-ie of extirjm*
tion of the inverteil utrras of muny yeurft' atamJiug uiul pxtemally prolapsed, re-
ported liy Dr Gfddiiigs of Charleston, in America, at p. 211 of voL xxi* of Hank-
ing's Rdro^€tf warrants great doubt's aa to its having been an inverted (items at
alL The mass removed was iolid, and with no trace of a cavity. I have not in-
cluded it in the casea which I have referred to, 1 have, however, included Baxter's
case, J/«f. Fhtj^ieaUmmtal^ voh xxr, p. 210, though the objections which apply to
it nre nearly, if not r|uite, us cogent,
t Faivre, Jounml df, Midecitve, August 1786, p. 201.
X References to thirty-six of the above caaea arc given in Mr Gregory Forbes'a
excellent paper on Inversion of the Uterus in voL xxxv, of the McdieQ-CMrurffiml
Transom/ wnJS. The remainder are r —
Bern hard, Liteina, vol. i. p, 401.
Staub, Schic^izcr ZnL'<chr. / A^afur nndHeiXkundt, voL iii, No. L
Kuttler, OesteT. Jahrh.^ vol. xi No. 1»
Portal, n FUialrf Hthezio, Feb. 1841,
Michalowaky, Jourml eU la Soc. de Mid. de MonJ^lUer Itai 1S45.
ITS TREATMENT.
231
The following table shows the results obtained by the different
modes of perforniiixg the operation : —
trterns removed by ligature in
,1 „ knife <^r tcroAcur
\ knife or tcrajtrur J
" *' } mid ligature (
Recovered.
Died
0|)«ratioti
abandoned.
45
5
9
33
3
6
10
3
2
5d
42
15
2
The number of instances in which the ligature was employed is
so much greatei" than of those in wliich any otlier fiperative pro-
ceeding was had recourse to, as to preclude any fair comparison of
their results, and I am unable to contribute anything from my own
experience towards a solution of the question. It may, liowcver,
be worth notice that in one only of the &\'e cases of excision of
the utenis did any considerable bleeding occur ; in one of the
instances which terminated fatsilly, death was occasioned by peri-
Hoblier, Bulletin dc VJcadcttiu- (U Mtdf^dM, 1848, No. 41.
The above references to cases, all of whieli were successful, are given by Breslau,
in hisdiiisertation, Ik tUius ^Ueri exiii^wlion^, 4 to, Monacfiii^ 1852.
Besides this, there are snccestifal, iitid not nientione<l by Forbes or Brealau : —
Harrison, London Med. Gazette, April 1S40, p* 151,
Thatcher, related by CroHJje, op. cit. p. 57. The inversion took pUce in this
eaM after the exptilMon of a mtiBS of uterioe h jdatida.
Tcale, .Vcd Tifneaand OasrUe, 8ept. 1, 1865.
Oldham, Quys Hotp. Meports^ Sd Serien, vol. i. p. 171.
Two cuflesby Dr Putnam* and three by Dr Channing, mentioned by DrC. A. Lee,
in Aiiterican M'ld. Journal^ Oct. I860, p. 313*
Dr M*Clintoek, Clinkal Mtttunn mt Diswuet a/ fFrntu^Ht 8vo, Dublin, 1863, p. 85,
There are, besides, seven unsuccessful caaea in addition to thos« Ftit'errtsd to by
Mr Forbea, namely : —
Symonds, Medical GuzcUe^ Nov. 1830,
Met'ihoMt, in Salomon's dissertation, Ih lifort tiiMmoiUi 4c,, Dorpat, 1886,
referred to by lirealau, pw 40, No. 49 in hb table,
Ooatea, AMaoeialion Medical Jourtial, July 1855.
Covelier, iVe^w M^iaite, and Schmidt, JahrhUcher, July 1852, p. 182.
Dr Pntn«m, n?fcrred to by Dr C. Lee, Im, cU.
Dr Chunning, thid,
Amn, op. eit, p. 914.
Dr liiirne*, in Mni. Chit. Tmns. for 1869, and at p. 7114 of lils book, gives 58
laiaea, with 88 reco?«rie^, 18 duatliH, and 2 whert* the op^mtiuu was abandoned ;
the proportionate success of the different modea of prooeeding being exactly the
flame a^i j»tttk<d aljove*
CHUONIC INTERSION OF THE UTERUS:
tonitis alone; in the other, in spite of the etuployment of the
^crmeiir, abundant haemorrhage into tlie abdominal cavity was the
occasion of the peritonitis under which the patient sank. The
dread of haemorrhage which so long deterred practitioners from
excising iwlj-jsi, has been learnt by experience to be in great
measnrt; an exaggerated fear ; while the risk of inflammation of
the womb from the inclusion of some of its fibres within the liga-
ture has been found to be very real. It is deserving of considera-
tion whether, when the invei-sion is of long stunding, the uterus
small and hrmly contracted, and the diameter of the peritoneal pouch
conse<|uently scarcely larger than a crowquill, while the sensibilit}^
of the serous memlirane has been lessened by the long-C4>ntinued
change in its relations, the risk attending the excision w^ould not
be smaller than that associated with the ligature of the uterus.
The employment of the dcraseiir would probably be prefemble to
the application of the ligature, or it might be resorted to, a.^ in I>r
M'CUntock^a case, after the previous employment of the ligature.
The fact that the ^craseur is not an absolute safeguard against
haemorrhage doe,s not negative its employment, but merely
suggests the necessity for much care, and for w^orking the instru-
ment extremely slowly.
Tabic showrn// the pcrwd after delrvtri/ at whu-h the inverted
uterus W(ts e^tiTpatcd in fifty -Jive cases.
Patirats
Patieiita
Tot^I
Under 1 mouth . . , , .
recovijred-
di^d.
4
3
7
Between 1 und 2 nrioiiths
8
3
,. 2^ « n
3
'3
6
., 6-12 „
2
4
6
„ 12^18 „
10
2
12
„ 18—2 ymre
1
1
1. 2^» r,
6
5
*. 8-^4 „
2
2
,. 4-5 „
4
...
4
M 5-0 „
2
2
„ 6- 7 „
2
2
Aft«r 12 yeore , . .
1
1
„ U „ , . .
i
1 1
., IB M . . .
1
1
1
„ imny „ . . .
. .
2
S
41
14 1
65
ITS DIAGNOSIS, AND TREATMENT.
233
As might be anticipated, the result of the operation is to a very
eonsidemble extent modified by the period at which it is under-
taken. If performed soon after delivery, while the womb is still
comparatively large and vascular, and its Bensibilities acute, the
prospects of success are smaller than if the misplacement had be-
come a chronic evil before any kind of interference was resorted to.
It is perhaps deserving of mention, that in one of the cases
where the operation was successfully performed within a month
after the patient's delivery, the uterus was in a state of ;^rangreiie,
and tliafc in two uthers it lay beyond the external parts, a |>osition
which. I need not remind you, considerably lessens its sensibility.
The reniaiuing case was one in which the operation was perfarmed
by an ignorant miilwife with a razor, and is an illustration of the
wonderful power of repair, even of moat fearful injuries, which
nature exerts occasionally, rather than an example that can serve
for our guidance in practice.
In some of the fatal cases put on record, and probably also in
others which have not been published, inversion of the uterus has
been mistaken for puljT)us, and the error has only been discovered
after the supervention of formidable symptoms of peritoneal
inflammation, or after the death of the patient. It hence becomes
a matter of considerable importance to ascertain the nature of the
case before any operation is attempted, lest it should unexpectedly
appear that the ailment, iustead of being one the removal of which
is attended by but moderate risk, is in reality one whose cure is
unavoidably accompanied by most imminent hazard.
A want of caution on the part of the practitioner is obvious in
most instances of inverted uterus in which an eri'or of diagnosis
has been committed. l>ut still ilu^ dvif/nosis has now and tht'n
been rendered extremely diihcult by the firm contraction of the
OB uteri around the inverted body of the womb, which is thereby
compressed so as to resemble the pedicle of a gi^uwLh prc>ceeding
from within the uterine cavity, and thus closely to simulate a
polypus. The history of the patient in such a case, even if
accurately ascertained, is not absolutely conclusive, inasmuch as
uterine polypus may complicate preguancy, and may both give
rise to htemorrhage after delivery, and also to a tumour felt on
vaginal examination. The comparative sensiluUty of a polj^us
and of the inverted w^omb does not furnish any trustworthy
234
CHUOOTC INVERSION OF THE tJTEHUS:
criterion ; for the seDsibility of that organ is in many instances
very low, and was so in all the cases tliat came nnder my ohser-
vution ; while it may further be added, that there is no such
difference between the appearance of the tumonrs as can be relied
on in formiDg a decision.
Mr Arnott suggested to me some years ago a means of distin-
giiiahing between the two, which appears quite worthy of being
borne in nond. Let the tinger be introduced into the rectum, and
carried up as high as possible* On tnrning it round, if the uterus
is inverted, the linger will have been carried al love it, and will
easily ascertain the absence of the organ from its natural situation
in the pehds. If, on the other hand, the vaginal tumour is a
pol}"iJUs, the uterus will probably be found enhirged, and at any
rate occupying its pioper position.* The uterine sound furnishes
us with another valuable aid in doubtful cases. If a pol^^ius is
present, the uterine ca\4ty will be found enlai'ged, so tliat the
sound w^iU pass further than natural, and a sense of weight will
also, most likely, be experienced ; and by these two mtiuns of
examination combined^ 1 believe that in all cases of tuverted
uterus after labour, an erroneous diagnosis may be avoided.
It now remains for me to otter a few suggestions with reference
to the only means by which the almost inevitable results of
irreducible inversion of the womb can with cei-tainty be obviated ;
and these consist, as you know, in the e^irpation of the crryan,
either by the knife or the ligature. It is almost supertiuoiis to say
that, inasmuch as there are some few instances onrccoixi in which
iuveraion of tlie womb has not been followed by the serious results
to which it usually gives rise, so nothing but most obvious danger
to the patient*s life will justify the performance of an operation so
hazardous as the extirpation of the womb. But further, the
occurrence of severe liamioiThage, and the apprehension of its
increase at each return, will not suthce to render an operation
expedient within a few months after delivery, since the chances
of the patient/s recovery appear to inci'ease in proportion as the
accident is of long standinj^. Since also in scmie instances in
• [Varioau Tnodifications of thia almost self -evident procetlure have been carefuHy
proposed by Betachler and Hoist, by Rnsch and Moaer, by E, Von Siebold and by
Baroea. Se« ScanKoni'a Beiirdge, Batid L s. 27 and Hand 11. s* 6 ; Bosch and
Moaer^a Mandbuch der GchurUkunide^ 11, Band fi. 452 ; Croaao On Invermon, p. 152 ;
ObtUirieal Joumtd, vol L p- 3. J
ITS DUGNOSIS, AXD TBEAT>rENT.
235
whicli the function of the ovaries has been kept in abeyance by
lactation, but little lo^as of blood baa occurred for seveml niontha
after delivtiry, it would seem desirable that everj" woman auHering
from irreducible invei'sion of the uterus should be encouraged to
suckle her chUd, in order that time might be gained for the
occurrence of as complete an involution of the utenis as ]xissible
before its removal is attempted* When the freriuency of the
return of the haemorrhage, or the abundance of the losses of blood,
has shown the necessity of interference, it yet is not desirable to
select thu time wlien haemorrhage is going on for the operation,
inasmuch as such times usually correspond with a menstrual
period, and the uterine sensibility is generally greatest at those
aeasons. In spite of the general propriety of this rule* however,
it may be borne in mind that if bteraorrhage at any such period
should threaten life, and should not lie restrained by styptics or
by the plug, a ligature may be applied as a temporar}' expedient
with great probability of the loss of blood being thereby restrained,*
even though the ligature should be removed some hours after-
wards.
In the use of the ligature something seems to depend on the
kind of material employed. Both silk and whipcord appear to
irritate considerably ; and Dr Johnson of Dublin, who has had
greater success - in this operation than any one else, prefers a
ligature of well annealed silver wire and dentist's silk twisted
together, aa being more readily loosened if too tiglit, and as
causing less irritation than Ligatui-es of other kinds. It has some-
times been attempted to obviate the risk of inflammation by
applying the ligature at first so tightly around the inverted womb
as at once and completely to strangulate it. This proceeding.
however, whilst it causes intense suffering, does not appear to
have the desired eH'ect ; and a preferable plan seems to be that of
applying the ligature comparatively loosely, and of tightening it
gradually day by day as the patient is able to bear it. The great
prostration and severe pain which usually attend the first applica-
tion of the ligature would probably be obviated in great measure
by the administration of chloroform ; tiie subsequent superven-
* Thia nwult occurred in Dr JohMon'a Beoond caae, witli tb*; effect of clicckiDg
ttie hU'eiling, five weeks before the organ was icttuiUy extirpated Sec his paper
in YoL ill. of Dublin MoapikU Etporta.
236
INVERSIOX OF THE UTERUS:
tion of inflammatory symptoms seems to requii-e the immediate
slackening of the ligature, and may necessitate its complete
removal. After the ligature has about half eflected the division
of the part, there appears to be no sort of objection to the comple-
tion of the operation hy the kolfe or scissors ; but the double
operation of applying a tight ligature, and immediately excising
the womb, does not seem to be as safe a proceeding as either the
hgatm'e or the knife alone. I have already expressed my
opinion, however^ that the substitution of the icrascur for the
knife, and its employment after the pre\dous application of the
ligature, will be found, as Dr M*Clintock*s cases would lead one to
beUcvc, to be the safest mode of proceeding.
A few words must stiE be snid about those cases in which the
presence of a polypus in tfie mmiy of the wmnh has led to in-
version of the organ; an accident which» though probably not
rarer, has yet been less frequently noticed than inversion of
the womb after labour. The large siae of the outgrowth, the
presence of more tumours than one, together with the origin of
the polypus from the fundus of the womb, are the conditions
which have been met with in the majority of instances where tins
accident has happened. These, however, are by no means of
cojistaut occurrence; for a very small tumour has suthced to
invert the womb,* while the insertion of the pedicle of the polypus
into tlie fundus of the uterus is common to the greater number of
these grow til s ; and the large size of the tmnoiu*, or the presence
of several tumours, is by no means unusual, without any disposi-
tion to iuvei'sion of the womb. The accident seems to have taken
place with polypi of all descriptions ; ^*ith soft, malignant, or
pseudo-mtdignant tumours, as well as with those of a fibrous
texture, or which might be supposed to be actual outgrowths of
utt*rino tissue ; and I am not aware that in any instance the
observation has been made of any peculiar relation subsisting
between the substance of the womb and that of the tumour. In
most of the instances, I l^elieve, in which any definite history ha^
been given of the patient's previous condition, violent expulsive
* Of which a reuiflrkable illuatration is given by llr Crosse, up, cit, p, 47 and
plate viii., frota a preparation in the Maiicuui of the Royal CoU^e of Snrgcuns in
Dublin ; tbe tnraour which had produced complete iikveraion of the womb very
little exceeding a cbestmit m size.
JfBOit POLYPUS IN ITS CAVITY,
237
pains are stated to have preceded the inversion of the womb, I
need scar<?ely say, however, that violent expnlsive efforts are too
frequent a eoncomitant of the escape of a poly{>us into the vagina
to have much diagnostic value ; while m a reoiarkable case that
came nnder my own observation, the escape of the polypus and
the inversion of the woinb took place at a time when the
previously severe pain had almost completely subsided.
In other respects, the symptoms attendant upon inversion of
the litems complicating polypus present nothing at all peculiar —
leucorrhci^a, nieooiTbagia, and exhausting heenioirhages oecuiring
in case^ of ordinary fibrous tumour or polypus as frequently and
to as great extent, while the womb retains its propor position, as
when the organ is inverted
In a practical point of view, that which it behoves us to bear in
mind hyfimt, the possibility of this accident occurring in any case
of polypus growing from the cavity of the womb, and the especial
reason for suspecting it when any considerable or long-continued
expulsive efforts liave preceded the escRpe of the polypus into the
vagina; second, the expediency, before tying or excising any
polypus which either is very large, or the development of which
has been accompanied by such symptoms, of ascertaining by
means of the sound the exact dimensions of the nterine cavity,
that we may not unwittingly divide or tie the substance of the
womb instead of the pedicle of the tumour. If it is ascertained
tliat the womb is inverted, I should imagine the proper course
would he to excise the polypus sutliciently low down to avoid all
risk of seriously wounding the uterus, and then to endeavour to
replace the orgnn, — an ftttempt the impracticability of wliich
eeems to have not infrequently been assumed on insufficient
grounds, and which was accomplished in my own case with the
greatest facility:*
Lastly, it must be home in mind that the uterus may be
inverted by the tractions made at a polypus in the endeavour to
drag it down sufficiently low for ita excision. I do not think,
indeed, that there is much risk of this in the case of pol}7)i of
ordinary size ; but the cases related by M. Amussat, and one which
occurred still mure recently in the practice of Mr Johnson of
• [For oiker sacc^ssful cases, sue St BaTtholofmw*9 Hoejntal Beports^ 1878,
roL xiv.] ,
238
INVEKSION OF THE UTERUa
Norwicb,* show that wliea the tumour is of considerable size this
accident is very likely to occur.
[The theory of the production of inverted uterus has always
attracted much attention from obstetricians, and many adhere to
that whicli lias been defended at length in my work on the
7nechaniSfn of natural wml nwrbkl parturituyn. The difficulty of
accounting for the accident in nou-puerperal cases ia greater than
in the puerperal; but it is interestiug to find, in some recent re-
ports of such cases, confirmation of the theory referred to, which
reqiiires a laxity or paralysis of the upper part of the uterine
body. Schwartzt points out the remarkable thinning and weaken-
ing of the wall of the uterus where the myoma, which led to the
inversion in his case, was inserted ; and he cites Seaozoni as hold-
ing this state of the uterine wall to be a condition of such inver-
sions. In the same volume BruntzelJ refera, in like manner, to
the muscular atrophy of the seat of implantation of the myoma.
Although, in urgent cases, the removal of the uterus must be
resorted to when other means fail, yet there is still so much
danger from the operation, that gymecologists are everywhere
making sti^muous efibrts to perfect the methods of replacing the
organ. The gi^at danger of the operation for mmoval is not the
bleeding, which, iiowever, may cause alarm, but the reinversion
or replacement of the cervix after the removal of the body of the
utenis; and the operator should select that method which he
thinks best secures the avoidance of this accident* without bring-
ing contingent disadvantages. No doubt it is desirable, espticially
in women before the menopause, to rein vert or replace the organ*
This may l>e done forcibly and at once and without any
incisions. The cervix uteri offers little or no resistance : it is the
body of the organ that refuses to return. Besides Millot, Barnes,
and Simpson's proposal of incising the cervix to facilitate replace-
ment, 1 have practised incisions of the body with success in one
case, in which the residt is confirmed by the woman having since
the operation borne a child at the full time.§ But the medi-
eal journals, and such recent successes a^ those of Lawson Tait,
• See Crosse, oji. ciL p. 52.
t Archie fUr (^yndkoh^k^ Band XI 11. a. 479,
X IMd. 8. 869,
g Ed. M^. Journal, Much 1877.
JISCENT OF THE UTERUa
239
Aveling, and my own, excite the hope that cutting may be
eiiiii-ely dispeiised with, and that some apparatus, such m WTiite*s»
may be litted with a plan of proceeding caJcnlated to secure thf
replacement gnuJoally, that is, within one, two, or three days, and
without much pain or dan^^er. So many chronic cases have
been cured in thi.s gradual way, inaugurated by Tyler Smith, that
it is natural to regard them as not exceptional, except because the
proper detiiils of proceeding suitable for a majority of, if not the
whole of, the cases have not yet been discovered and established.]
A word or two, before concluding this Lecture, may be added
concerning a form of uterine misplacement of no practical
moment, except as sometimes helping to throw light on the nature
of a patient's ailments, otherwise perhaps obscure. The ancients
conceived, as pruhably yim know, that the peculiar sensation of
choking, the ffhfbti^ htfstericii.% from w^hich women often suifer, was
due to a positive ascetU of tJu ivombjrom its natural situation in
the pelvis. In oitier to expedite its return to its proper place,
they were accustomed, by a quaint combination of reward and
jiunishment, to employ aromatic fumigations to the vulva, while
foetid gums and other ill-savoured medicines were given by the
moutlL This practice, with many otlier absurdities of bygone
days, is exploded, but a vestige of the theory still remains behind,
for it is alleged by some Continental writers* that contmctions of
the uterine ligaments, or as some say of the peritoneum, raise tlie
womb from its proper situation, and thus supply a positive
mechanical cause for the unpleasant sensations about the pelvis,
of which hysterical patients frequently complain. For my own
part, I neither admit the explanation, nor do I believe the fact.
It is also said that the greater difficulty with which the oa uteri is
reached in the aged than during the yeai^ of sexual \igour, and
the narrowing vf the upper part of the vagina which is then
observed, are due to an actual elevation of the organ in advancing
jeai& ThiSj however, again appeara to me in the highest degree
problematical. We know that the uterus wastes ; that the pro-
jection of the cervix into the vagina also disappears from the same
cause ; that the vagina, too, becomes atrophied ; f and that if the
* Bosch, Oofhlechishben dea Weiht^, vol. iii. p. 473.
f [For an intcreating paper by Dr M'Clinlook, on Senile C^Dtraction of the
Vogmn, ave Dublin QtmrUrly Afcdical Jowmal for Auguat 1870.]
240
ASCENT OP THE UTERUS :
uterus, owing to the weakening of its supports, does not sink down,
and so distend the vagina, the calibre of that canal will become
much narrower than it was before. I am quite at a loss to under-
stand what causes operating in old age can tend really to raise the
nterus higher than it wa.«f before; nor, in fact, am I convinced
that such an elevation of the organ actually takes place.
But, though ascent of the womb does not call for notice as a
condition of itself producing any definite sjTmptoms, it is yet of
unportance to bear in mind the different circumstances in which
we are hkely to find the organ occupying a higher situation than
usual
Isf, It is a physiological attendant upon pregnancy, from about
the fourth to the eighth month, is especially marked in first preg-
nancies, is sometimes so considerable as to render it a matter of
extreme difficulty to reach the os uteri. With moderate attention,
however, to tlie patients history, and consideration of all the
circumstances of her case, the peculiarities presented by the
pregnant os uteri will seldom faO to keep the practitioner from
error.
2d, When any considerable degree of pelvic contraction exists,
the want of space often obliges both the uterus and bladiler to
remain above the pelvic brim, a circumstance to which much of
the difficulty of the operation of craniotomy is frequently due,
2d, In cases of inflammation of the pelvic ceDular tissue, or of
that between the folds of the bioad ligament, the uterus is often
found very high up, so that its oiificc is reached with difficult}\
This change in the position of the organ, too, is not necessarily due
to the formation of a tuuumr lower down in the pelvic cavity,
forcing it above its natural situation, though it may of courae be
pmduced in that way ; but it may depend on a positive riragging
of the womb upwards by the inflamed tissues.
4tk, In a large number of instances of ovarian dropsy, the cyst,
as it rises out of the pelvis, draws the uterus with it sometimes
even considerably above its natural position. In cases where a
tpiestion arises as to whether an accumulation of liuid in the
abdominal cavity is due to ascites or to ovarian dropsy, the
relations of the uterus often assist us in arriving at a correct con-
clusion, for the organ which is usually drawn upwards in ovarian
dropsy is generally depressed below its ordinary situation in cuses
ITS CAUSES AND IMPORT.
241
of ascites. More frequently it happens that doubt is entertained
as to the natiu'e of a iion -fluctuating tumour, coucerrjing which it
is uncertain whether it ia uterine or ovarian. Any considerable
elevation of the uterus ia much more frequently due to degenera-
tion of the ovary than to tumour of the womb.
5fh, and lastli/, In a few instances, fibrous tumours of the uterus
as they increase in size raise the organ more and more out of reach.
Nothing, indeed, is more common in cases where the uterua is the
seat of several fibrous tumoui-s, some of which have attained to a
considerahle size, than to find the organ so much deformed that
the 08 becomes situated high up behind one or other aide of the
ramus of the pubis. But besides those cases in which the firm
irregular outgrowths felt per vaginum leave no room for un-
certainty, there are a few exceptional instances in which a single
fibi-ous tumour in the uterine wall, without producing any
deformity of the organ appreciable per vagi nam, raises it in the
progi-ess of its development high out of the jjclvic cavity. In this
process, however, the greatly elongated cervix uteri scarcely partici-
pates in the growth of the body of the organ, but becomes
mechanir^illy stretched till it attains sometimes the length of
several inches,* As a result of this, the lips of the os uteri
become extremely thin, or disappear ahuost entirely, leaving the
o3 a funucl-shapcd entrance with almost membranous margins to
the elongated and narrow cervical canal When drawn upwards
by the enlarged ovary, the traction is exercised on the body, not
on the neck of the wumb, and hence no change is produced in the
character of tiie lips or os uteri.
With these hints, not without their use perhaps in the diagnosis
of uterine affections, we may take leave of the subject of malposi-
tions of the womb, and must at the next Lecture commence the
study of another and most important ckss of its diseasea
• As ia the Tory remarkable caae deacribed and delioeated by Professor Wnlter
of Dorpat, in which the cervLic was 2} inches long, and ncarc^ly any Indication of
the uterine lips wai» percoptiblc. See p. 10 of bis liaiay, Ueher Fihr^K K9rptr
dm OebdrinuUer, 4to. Dorjiat, 1862.
LECTURE XIIL
UTERmE TUMOURS AUTD OUTGROWTHS.
ThviT oPctiiTpncG connected with tendency of utenin to hypertrophy gencmlly.
Outgi'owths of the mucoua membrane, or Mrcoira Polyi'I ; their shnpluat form.
Fibro-Cellular Polypi, Glandulajv PiiLYPi from hyiHrtrophy of uterine
fullicles.
Cystic enlargement of follicles of certnx, or Mucous Cysts of the Uterus.
Symptoms of these alTectioDs : nature and souroe of the hmmorrlmgo they occiuion.
Diagnoais. Treatment.
FjBKiyotT.y Polypus, its natun* ; aiiHloj*y to other chronic tffusiona ©f blood,
Kote on some other alleged varieties of polyj>us.
In the course of the foregoing Lectures I have referred over and
over again, with an iteration that can scarcely have failed of being
wearisome, to the ready increase of the womh under the influence
of very various exciting causes. We have seeu that inflammation,
going on t€ the production of its ordinary consequences — sup-
puration, or the effusion of lymph— is of very rare occurrence.
Abscess of the womb is one of those accidents so uncommon, that
w^hen met with it seldom fails to he recorded among wliat the old
writers used txs term CumosA Medica ; and the effusion of lymph
into the tissue of the organ has been assumed in accordance with
certain physiological or pathological hypotheses rather than
actually demonstrated.
It is indeed scarcely ever, except after labour or miscarriage,
when the tissue of the womb passes physiologically through
changes such as those which inflammation tends to work, that the
diseased process manifests itself in its acute forms, or with
dangerous severity, while, even then, the serous investment of the
oigan, or the lining membrane of its veins, is generally the part
which shows marks of the most serious mischief. Often, too, the
signs of inflammation appearing at these tunes turn out to be
symptomatic less of aflection of the womb itself than of its
UTERIXE TUMOURS AND OUTGROWTHS.
243
appendages or of the cellulaT tissBe in its vicinity, or connecting
together the different pelvic viscera. At the same time, however,
we find that the causes which elsewhere might issue in intlamma-
tion produce in the case of the womb its overgrowth. It increases
from that frequent afflux of blood towards it w^iich produc^^s many
forms of menstrual disorder ; it remains permanently iQcreased
from defieieot involution after labour; it enlar^^^es, if ttexLjd or
misplaced ; and its prolapsus causes it in many instances to attain
to more than double its ordinary size.
But not only is hypertrophy of tlie womb more fi^quent than
the hypertrophy of any other organ, but each of its component
tissues is liable to a similar overgrowth^ — not i^egular, indeed, and
equable, but in pails here and there, constituting tumours and
outgrowths, which are met with in this oftener than in any other
part, and of which frequency the physiological peculiarities of the
womb furnish the only explanatiom The mucous membrane of
the uterine cavity undergoes, as we liave akeody seen, an
occasional hypertrophy in some menstrual disonlei-s, but becomes
eventually cast ofl^ in accordance witli the laws which regulate its
development in a state of health and under tlie ioflueuee of preg-
nancy. But the mucous membrane of the cervix also sometimes
becomes hypeilrophied, and such hypertrophies are not deciduous,
but assume the form either of a distinct fold at the orifice of the
womb,* or more frequently of distinct small p^ndidous out-
growths. Kow and theii, the admixture of a larger quantity of
eellular tissue than usual gives to these growths a more consider-
ftble size than they attain to when composed exclusively of
mucous membrane. Sometimes the same process of overgrowlli
allects the cellular structure of the neck of the womb, and then a
peculiar form of outgro\nh is produced, termed the glandular or
celhdar polypus of the cervix uteri. If one of these fullicles alone
iQcreasei? at the expense of the others, and without a corresfM^nd-
ing bj^pertrophy of the cellidar structure or mucous membrane,
there are then produced those cysts of the neck of the womb
whose nature and origin were once so little understood Lastly,
if the same process involves the uterine substimce itself, we then
meet with the so-called fibrous tumours of the womb, which,
• As wpU delitieat4?d by Dr Tyler Smith in pL ix. ofhii Eaaay in the M«d.'Ckir,
Traiufociions, vol, xxxv.
244
UTERINE OUTOHOWTHS :
identical with it ia their intimate structure, differ only in this,
tliafc they are not developed in accordance with the general con-
tour of the oTgdn in which they arise ; hut, springing from various
centres, grow with no symmetry towards its outer or its inner
surface, and produce symptoms which vary according to their
seat and the vigour of their growth.
With reference to these and other varieties of growths from the
womb, it is not altogether 'without importance to ohserve that the
time of their appearance is just that at which all the physiological
changes in the organ go on with the greatest activity, and that
they are rarely met with either in the season of decrepitude or of
early youth. The same fact, too, holds good to a great extent
witli reference to another gi^eat class of ailments of the uterus ;
those, namely, of a malignant character. These also occur chiefly
in the season of sexual activity, and seem to be connected, as
in the case of tlie female hreast, with the wide fluctuations in
growth and in actiWty which succeed each other in those parts
within very brief intervals.
Having thus thrown out a suggestion that may perhaps exphiin
in some degree the singular liability of the womb to various
tumoui^ and outgrowths, I propose to examine each kind in
succession, beginning with those of simplest character, namely,
outgrowths from the nterine mucous membrane ; the raucous
poh/pi of most writers on the diseases of women,*
These generally appear as small outgrowths from the fokls of
the so-called arhor v-Uw, varying from a third to half an inch in
length by about three lines in thickness ; the pedicle by which
they are connected with the nuicous memliraue being generally
exceedingly slender, though at the same time very short It
would seem as if they were originally uuplicatures of the mucous
membrane of equal thickness throughout, and as if the gradual
constriction of their pedicle were the process by which nature
gets rid of them, just by the same means as those by which the
loose cartilages in the knee-joint are by degrees detached from
* The jMipilhirit polypi of Hirsch, wliose Essay, Ueher dk HistoUgk und Format
drr Uferus-Poh/jieii, Svi>, GieaaeUi 1S55, is a vaJuftlile contribution to tliis depart-
ffiCDt of morbid anatomy, [See also Binrotb, Uehcr den Bau der Schlcimpolt/peit,
Berlin 1855. In this country several careful contributions to thia subject bave bt?eu
riitide by Hftrtlie and l/mlerbiil, and are to be found in tbe later volumes of tha
Edinburgh Mediml JoumaL]
MUCOUS AND FIBRO-CELLULAR POLYPI,
245
their connexion with the synovial membrane whence they origio-
ally sprang. They are usually of a bright rose tint, abundantly
supplied with a delicate net-work of vessels, and consist ex-
clusively of mucous tuembrane wnth a very small admixtures of
cellular tissue. The seat of these little bodies is nearly always
the cervical canal, from any part of which they may arise, though
they are usually neai\!r the external than the internal oa uteri,
and now and then I have found a single grawth of this kind in
the uterine cavity, but quite at its lower part* Though generally
pediculated, as just now described, they are now and then sessile,
of a Hatter form, and adherent along the whole of one of their
surfaces to the mucous membrane. Occasionally, too, they do not
assume the form of distinct outgrowths, but appear like hyper-
trophied folds of the arbor vitae, bearing the same relation to the
walls of the cervix as the attached camete columnse do to the
pariet^s of the heart.
Sometimes these growths are solitary, but it is at least as fre-
quent for two or three of them to be found in the same patient ;
they have a disposition also to be reproduced ; or at least suc-
cessive grawths form, so that it is not unusual f<»r a patient from
w^hom they have once been removed to require a repetition of
the operation after the lapse of a few^ montfis. I have known
them coexist with fibrous tumours of the uterus, but do not
imagine that this was the re.sult of more than a mere coincidence,
and have never seen reason for regarding them as the iirecursors
of malignant disease, though the late lir Montgomery of DubUu*
believed this to be not infrequently so in the aged
Those outgrowths, which are simple excrescences from the
mucous membrane, never exceed the very small dimensions which
I have just specified. Sometimes, however, a lai^er quantity of
rellular tissue enters into their composition, and they then acquire a
much lai'ger size, aud hang down beyond the os uteri into the vagina.
They are often the size of a small fig, of a flattened form, and ai-e
found to be made up of fbro'Ciiiular tissfir, having an investment
of mucous membrane, while they do not proceed exclusively from
the cervix, but have their origin also sometimes within the cavity
of the womb.
• la a very valuable pftjiffr on ** Polyp ua of llie Uterus^
of MedietU Scitne^ for August 1846.
' in the Dublin Jmmud
246
tJTERINE OUTGROWTHS :
Mom frequent than these are polypi of a more complex structure^
into the formation of wliich there enter not merely the mucous
membrane of tlie uterus, or its hypertrophied filvro-eellular tissue,
hut aim the large mucous follicles of the cervix. These polypi
assume different fonus, being sometimes pediculated, and the
pedicle is occasionally of consideralde length ; at other times
they appear as continuous outgrowths from the inner surface of
one or other uterine lip, most commonly, I think, of the anterior.
On dividing them, theh^ most strikiug pecnliimty is at once seen,
for they are found to contain a large quantity of tenacious, trans-
parent, ali>uminous matter, precisely similar to that which is
secreted by the Nabothian glands. Sometimes, when the growth
is still small, vesicles varying from the size of a pea to that of
kidney-bean, filled with this alhuniinous matter, compose the
greater hulk of the tumour, their walls still partially transparent,
hut readily distinguishahle beneath the delicate mncoins membrane
with which the whole is invested. In other instances, however,
and generally wlxenever the bigness of the growth exceeds the
size of the first joint of the thumh, the vesicles are not so distinct,
though the structure is equally characteristic- In the midst of
the succulent fibro-cellular tissue which entei-s into the composi-
tion of the tumour, there are numerous canals, whose walls are of
A denser structure, arranged longitudinally, side by side, some of
them coniuiunicatiiig with each other towards the pedicle, hut not
by any cross branches. These canals ai^ all directed towards the
surface of the tumour, where some of them terminate in blind
pouches. Others end in openings mostly of an oval form, and
invariably smaller than tlie calibre of the tube itself. Their
length is not quite uniform, and hence it results that the tumour
has a peculiar, uneven, almost lobulatud surface, closely resemlding
in this respect the appearance of a hypertrophied tonsil. They
are filled with tlie same albuminous matter as in the smaller out-
growths is contained in the vesicles I mentioned, [and are often
called, when the glairy cysts have burst, c^naliculated polypi],
Tlie origin bt>tli of them and of the smaller polypi appears to be
the same, namely, the mucous follicles of the neck of the womb.
The long pedicle with which these growths are sometimes furnished*
* 8«e Boivin et Dugts, Mal^ka cU VUttrus^ kc.^ Atliis, pi. i\ii fig, 2, and
pL lix fig, 2.
QLAKDULAK POLYPI, AND CERVICAL CYSTS.
does not contain any of the hypertrophied follicles, but is com-
posed entirely of fibro-cellular tissue. Usually, however, the
pedicle is very short, and the point of origin of the gmwLh low
down in the cervical canal, Tliough freely supplied with vessels,
these growths do not in general present any considerable vascu-
larity of tlie surface, which may be stated, on the authority of
Virchow * to he comjiosed of very dense cellular tissue, covered by
a thick layer of tesselated epithelium.
Lastly, in connexion with this class of ailments may be
mentioned the' occasional enlargemtJii of ike follicles of tiie armx
uteri, unconnected with any outgrowth of its proper tissue, or
any h}Tjertrophy of its mucous membrane, but assuming the
fonn of cysh whose development take^ place at the expense
of the uterine substance. Sometimes, too, though I bebeve not
in the majority of cases, these cysts or vesicles ai^ altogether
Tu:w formations ; and are not produced by the mere enlarge-
ment of occluded follicles. Such, at least, is the conclusion
which the examination of their structure by the microscope
leads us to adopt. In examining the uterus after death, it is
by no means unusual to observe several vesicles of the size of a
pea imbedded between the folds of the arbor vitaj, but scarcely,
if at all, projecting beyond the level of the mucous mem-
brane. This sixe, however, may be greatly exceeded* In
the uterus of a woman aged twenty-nine years, which pre-
sented no other appearance of disease, all the Nabothian glands
were much enhiiged, and the whole cer\"ical canal was filled
with tlieir secretion ; while at the upper part of the cervbc uteri
was one of these cysts as lai^^e as a kidney bean, distended with
albuminous matter, and having by its increase produced the
absorption of almost the whole of the uterine wall, which was
scarcely a line in tbickuess. The cyst had produced a degree of
bulging outwardly of the attenuated uterine wall, such tis must
have been obvious during life, and by which I behove that, on one
or two occasions, 1 have recognised this allection, %vhich might.
* In ihe Archiv fatr Pathol. AwatomUw^ Ph^fnologie, vol, viu 1654, p. 161, And
plate iL figs. 6 aud 6, A verj good descriptioa of the geueml dmr&ct^rs of this
kind of polyiiUB aad a iliagrani of its structurw were given by Dr Oldbaju in (/ify'i
Hagjnial BtporU, 2d scries, vol. iL ft Jias siso been well deacribed by Huguier ia
the Mimoira de la SocUU dc Chirunjie de FarU, vol i. 1847» {k 35.
248
UTERINE POLYPI ;
but for other symptoms, be taken for a solid turaour of the neck
of the womk*
Though I have met with many more cases in practice, yet I
have preBerved notes of only twenty-three instanca^ of these
varieties of uterine polj^pi, a circumstance readily explicable by
the speedy and complete removal of the ailment, by a very slight
and simple operatioii. Of the twenty-three cases, five occurred in
single, eighteen in married women, of whom twelve had given
birth to children iit the full period, one had aborted several times,
and live had never been pregnant The age of the youngest
patient was twenty-three, that of the oldest hfty-seven ; and the
average age of all was forty yetu-s. The si/mi)tonts which induced
the patients to seek for medical aid had existed for periods inary-
ing from tliree mouths to four years ; and were in every instance
very simdar in kind, though varying greatly in degree. Either
leucorrhiral discharge, or kemorrhage, or both, existed ; to which
bearing-down paius were sometimes, though by no means con-
stantly, superadded.
Once or twice I have accidentally discovered small polypi in
cases where they had produced no symptoms wdiatever. This,
however, is unusual, for ha;mon'hage is very generally present,
though its amount seems to be in great meiisure dependent on the
relation the polypi bear to the cerviail canal ; being usually much
more considerable if the growth is enclused within the lips of the
03 uU^ri than if it projects beyond them aud hangs down into the
vagina. This, indeed, is what might be expected beforehand, and
it serves to explain the history which patients occasionally relate
of themselves, that the hicmonhage which at *me time had been
pixjfuse has at length greatly diminished or even altogether cettsed.
The influence of these small poh7>i in produtiug uterine im tat ion
is sometimes exemplified by their giving rise to considerable
enlaigement of the neck of the womb, and a degree of hardness
consequent on engorgement of the pait from the considerable flux
of blood thither; a condition tliat may lead the practitioner,
unless on his guard, to overlook the real nature of the ailment,
• All extrf oi4?ly eliiborati? jMiper od this subject, with seviTal illustmtiTe drowuig^
lui been pnbliHljfti by M. Huguier, in tlio first volume of the Mimmrts de la SfmMi
lie CKirxirgkt pp. 241-295, and plates L-iii, The other portioua of thia Essay wiU
CaU for tiutkv hcretifttsr.
TIIEIK SYMTTOMS.
240
and to suppose that he has to do with hjri^ertrophy and induration*
the result of some bygone inflaDiniation of tlie neck of the woniL.
This same fact also explains why it is that a comparatively large
polypus hanging down into the vagina may be unaccompanied
with bleeding, while an extremely small outgrowth still included
within the neck of the womb may occa'^ion xery formidable
hfemorrha*^e.
These simple facts point, I believe, to the solution of a much
mooted que^ation as to the source of the hii^^morrhage in the^^ie and
other varieties of ut*?rine polypi and tumours. The growths are
themselves well supplied with vessels ; if wounded they bleed ; if
excised, the buemurrhage which takes place from thuir pedicle is
sometimes considerable, has even been known to pi-ove dangemus ;
but yet all eWdence goes to prove tlxat it is rather from the w*omb
itself than frf>ni the outgrowth that the principal bleeding flows,
and tliat the hiPoiorrhage is proportionate, less to the size of the
outgrowth than to the intimacy of the relation between it and the
womb. Of this I saw some years ago a ver}^ remarkable exempli-
iication. A woman came under my care who for three y^ars had
Buffered from very^ profuse haemorrhages, which had ceased without
known cause for three montlis before I saw her. The non-
appearance of the menses for the same period did not engage my
attention as it ought to have done ; and 1 accordingly excised a
fibrous polypus the size of a small ben's egi* which grew by a short
pedicle from the inside of the cer\ix uteri. Very profuse hleeding
fallowed the operation, but no other untoward symptom ; and
within six months more the patient was confined at the full term
of pregnancy. 1 do not relate the case now for the sake of the
moiid to lie *lrawn from it with reference to the absolute necessity
of care in your diagnosis, though in this respect it comments on
itself, but because it illustrates exceedingly w^ell the source
whence the moat abundant haimorrlMige flows. For three years
the polypus had irritated the womb, and blood hod been abun-
dantly poured out, Pregnaucy took place, there was increased
liow of blood towards the part ; the polypus must have gained
rather than lost in vascularity, but no bleeding occiirred. The
uterine cavity was now lined with decidua, find its cervical canal
w^as occupied by the mucous plug ponied out from the Nabothian
glands, and thus sheltered fmni irritation, the haemorrhage from
UTEBTKE POLYPI !
its Burface ceased, and leiieorrhcea alone caotinued the evidence
of the presence of the tumour.
The atructure of the polypus has, however, sometliiug to do with
the nature of the symptoms, with the occurrence, and still more
with the amount, of the hLcmoniiage. Those polypi which present
the compound structure due to enlargement of the Nabothian
glands, are always attended by profuse leucorrhcea, a circumstance
easily explicabte if we bear iu mind that the formation of the
outf^owth is associated with a state of h}'^>ertrophy aud over-
activdty of the whole secreting apparatus of the neck of tlie womb,
Tbeir vasculaiity heing less than that of the small mucous polypi,
they are also mom freipiently unaccompanied with bleeding, wbOe,
as might be expected, the haemorrhage is usually absent when
they assume the fonn of outgrowths from the inner surface of one
or other uterine lip, since in that case the cervical canal escapes
almost entirely from direct iiTitation.
I do not know whether these growths Iiave any special influence
unfavourable to conception, though there is no doubt hut that the
very nature of the sjauptoms to which they give rise is of a kind
to lessen the probabilities of a wonum becoming pregnant I once
excised a polypus, composed of enlarged Nabothian glands, of the
size of a sugared almond, from the anterior lip of the uterus of a
young woman who had lived for more than eighteen months
in sterile marriage, hut who became pregnant within a month
afterwards, and was delivered of a Uving child at the fuJl
period. Here, however, the relations of the tumour were such as
mechanically to narrow, and almost to occlude, the uterine
oriiice.
Tlie enlargement of one or more of the follicles of the cervix, so
ad to form distinct cysts in the uterine substance, is of rare
occurrence. In the few instances of it which have come under
my observation, a profuse albuminous discharge, unchecked by
treatment, or even by the free application of the nitrate of silver
witliin the cervical canal, has been invariably present. On one or
two occasions I have felt at the upper part of the cervix a small
nodule which might readily be taken for a small fibrous tumour,
but which may be known by its yielding slightly on iirm pressure,
and by its size not being invariably the same at different times. I
have not found these cysts associated with menorrhagia, though
THEIR DIAGNOSIS, A!TO TREATMENT,
231
that symptom was f)resenfc in some of the cases related in M,
Huguier s essay on tliis affection.
I do not know of any speciiil difficulty attending the diagnosis
of these outgrowths, nor of any particular rules which can he laid
down for the avoidance of error. The very small polypi are
sometimes scarcely perceptible hy the finger, and I ha\'e ah'eady
referred to the enlai*gemeut: of the cervix which they occ[tsionally
protioce, and which is hkely to mislead tlie unwary. The only
rule that can be given for practical guidance m, however, this :
that in no case of long-continued menorrhagia should we he
content with mere digital examination, but should invariably
employ the speculum ; and further, if no satisfactory' conclusion
is thereby arrived at, we should dilate the os uteri with sponge
tents in order that the cervical canal may be hronght. within reach
both of examination with the finger and with the speculum. If
these precautious are neglected, the patient whom we have failed
to relieve may place herself under some more careful practitioner,
who will at once detect the cause of her symptoms, and care her
by an extremely simple opemtion.
For the most piirt nothing is more easy than the rem&tal ofthme
mnall ontgroivfJLs, The smalh^t^t may he removed by laying hold
of them with a pair of long forcex>s, and twisting them oft', while
those which are somewhat larger, after being twisted to check the
risk of bleeding, may be cut off with a pair of scissors. The
bivalve specuhim should always be employed in doing this, and
both forceps and scissors are made for the purpose, so constructed
as to be readily worked within the speculum. To attempt their
removal by means of forceps or scissors simply guided by the
hand, is at best hut a bungling mode of jjroceediug, while besides,
the risk of htemorrhage is much greater than it would be if, after
the removal of the polypus, the part whence it sprang were
touched with the solid nitrate of silver, a precaution which I now
never omit
In the case of the larger growths made up either of fibro-
cellular tissue, or of hypertrophied uterine follicles, I ako employ
the speculum if practicable. If the outgrowth is too large to come
readily within the blades of the si>eculum, while its structure is
boo frail, or its pedicle too thin, to allow of its being seized and
drawn down by means of the Museux hooks, I employ a pair of
UTERINE polypi:
forceps similar to those used by surgeons for operations on tlie
tongue, with rackwork at the handles to ensure the firm closure of
the instrument. In all operations of this kind it is a great con-
venience to have the forceps or hooks made with a lock like tliat
of the midwifery forceps, by which means each hlarle niay lie
introduced separately, may he carried lugher up along tlie pedicle
of the growth, and made to seize it more firmly, than can he don^
if the blades are united, and have to be separated after theii
iutmduetion into the vagina. Tlie polypus being laid hold of by
this instrument, a pair of curved, blunt-pointed scissors may
easily be carrieil up to divide the pedicle, while any haemorrhage
that may follow will usually be checked with earn by the applica-
tion of oitKite of sdver through the speculum, and by the sub-
sequent introduction of a piece of cotton wool soaked in the
tincture of motion, and which may l^e easily udthdrawn after a few
hours by a thread previously fastened to it.
The question of the comparative merits of the Hgature and of
excision can scarcely he raised with reference to these small
polypi, aince the latter proceeding is so simple and easy, and with
due care is not attended by any serious risk of hfemorrhage. The
forcible avulsion of polypi is a rough and hazardous proceeding, a
i*elic of Ijarbarous surgery ; whde their strangulation by means of
peculiarly constructed forceps* appeai-s to me to be possessed of
no advantage over the use of tlie ligature.
Slight as in most cases the opemtion for the removal of these
outgi-owths is, it is yet a matter of prudence to keep our patient in
bed for one or two days after its performance. On the oidy
occasion in which I neglected this precaution, and allowed a
woman frL»m whom I had removed a small vascuhir polypus in the
out-patient room to return home, an attack of peritonitis came on
which necessitated her reception into the hospit^d, where, however,
the disease speedily yielded to appropriate remedies.
Since I became acquainted with the essay of M. Huguier, I have
not met with any of those euormons cystic enhirgements of the
uterine folheles whose natm'e was described a short time since. I
• A proceeding first suggt^stuii by Sir Charles BeU, in Ivifl lYincipk-a of Ojierativt
SurgcTjf, and renewed wiLh some modifications reecntly by M. UensonJ of Lyona,
in a pRnii>hlet tfiititlud A'^auveau proctdi pour o^drtr Us Pulype-n tie MeUrice, Lyons,
8vo, 1861.
mmmoxj^ polypi.
253
applied, in the few instances which had come under my notice, the
solid nitrate of silver abondantly within the cervical canal, but
with scarcely any benefit. At Hiiguier, however, has adopted »
and with marked success, the simple plan of scarifying the interior
of the neck of the womb previously to applying the caustic, by
which means the cysts are emptied of their albuminous contents,
and the cauistic comes to act immediately upon their secreting
membrane.
Allied to these outgrowths in many of the symptoms to which
they give rise, though diflering in their essential characters, are
those accumulations of blood within the uterine cavity where it
undergoes certain changes and a kind of imperfect organization,
which have Teceived th^ nmne oijibri/wtis poif/pi. The late Pro-
fessor Kiwisch,* who was, to the best of my knowledge, the first
person to give a complete description of this atleetion, admits tlie
comparative unsuitability of the epithet, which may, however, be
conveniently retained for the present. In certain conditions,
independent, as lie believes, of impregnation, — consequent, as
others think, upon previous abortion,— the walls of the uterus
may be so soft and yielding as to allow of the gradual accumula-
tion of effused blood in the cavity of the organ. In the coui-se of
time the clot may not only pass through changes that remove the
colouring matter from its exterior, — which assumes a dirty-white
or greyish aspect, while portions of a dark red hue are still to be
found within ; but may also be the seat of the same kind of im-
perfect organisation as has been observed in the case of htenior-
rh^es into the arachnoid, or of blood effused in other situations.f
Like cardiac fKilypi. so these become firmly adherent to the walls
of the cavity withtn which they form ; and the late Fmnz Kilian
of Mayence fouml one whose constituent fibrine was in various
• In tliti first edition of his Ktinisehe Forhrdge^ kc, published in 1849. vol. L
p. 420, § 222. Hli nifide no addition to the account there given in the subauqucnt
editions of hiii hook. Four years Ixjfore the appeamnce of his observntions u vtry
GhafioteriiitiG ewe of this occnrrcnce wm jiuhUshed by M. Lebert, under the iiAtne
of Tumeur Fihriiitusf dc I' Uterus^ ot p. 90 of vol ii af ]m Physiolofjie P(Uhotogi^%t^,
In thiB case tht; expulsion of the mass took pUoe ■UE weeks iifter a miscarriage ; and
for some time previooa both the pain and the hemorrhage which had accompanied
the miscarriage had altogether i^ueed,
t On which subject see Paget*s Leciura an Surffkal PtUholc^y, voh i. pp» 178 -
ITS.
254
tJTKEINE POLYPI :
stages of fibriliization, while its surface bad received a
iavestment of tesselated epithelium, %vhicli lie believed to
due to the advanced organization of the outer layer of fibrine.*
The very nature of the organ within which these collections
form la unfavourable to that more complete organization taking
place in them whicli may occur in similar elusions in otlier parts.
After the lapse of a few months at the latest, the uterus becomes
irritated by the presence of the clot, hemorrhage takes place, the
organ contmcts, and the mass is at length expelled witli symptoms
almost identical wiih those of an abortion.
The question, as I just now mentioned, has l>een raised as to
whether this fibrinous polypus forms independent of tlie previous
enlargement of the uterus by abortion or delivery at the full
period. Kiwisch believed that it does ; and alleged as character^!
istic of it that tlie chief accumulation of blood takes place not
within the body of the womb, but in the dilated cervical canaL
This statement, however, is controverted by his worthy successor.
Professor Scanzoni ;"f" and the fact that the patients in whom the
accident occurred were in every instance manied women, and
that in all the menses had been suppressed for a period of from
six weeks to three months previous to the outburst of the hn^mor*
rhage» favours the suspicion that conception had taken place, and
that the bleeding was at first but the e\ddence of abortion. In
this \iew, too, Yirchow} coincides, and states that on a post-mortem
examination he has invariably found the base of the swelling
formed either by actual remains of the fretal placenta or by the
adhesion of eoagula from the torn vessels to the uneven surface
of the maternal placenta, so that the fiuestion of the origin of
these polypi may bo considered as decided.
The external os uteri, indeed, closes so speedily after the occur-
rence of abortion in the early months of pregnancy, that there is
no difficulty iu understanding how blood may slowly collect with-
in the cavity of the organ, and, coagulating, remain there till by
its bulk it excites the contraction of the womb. The presence
• Henle and Pft'uffir*8 ZdtHchHft, toI. vil 1849, p. HP.
t Verhandlungm der Phys. Med. Qtsdhidiaft m Wwrssburg, vol. ii. p, 30 ; and
in Ms Lehrbueh der ErtrnkheUm der ewibliehm Seaoialorffane, 8vo, 3d ed. Wirn,
1863, p. 265.
t Bk Kraiikhaflert OtxkuHMe^ 8vo, B«rlin, 1868, vol, i. p, 119.
FTBRrS^OUS POLTPL
255
even of a very minute portion of the ovum greatly favours tliis
uecurrence, and I have known pain and hannorrhage eontinut? for
six weeks in one instance, for four months in another, after the
supposed completion of an abortion, till at length a portion of
decidua, or, at leasts of a substance resembling it, was expelled,
with the discharge of which the haBmorrhage and all the symp-
toms disappeared
Be the conditions under winch the hiemorrhage occurs wliat
they may, the object of all treatment would be the same —
namely, to empty the uteTus by exciting its action, and afterwards
to maintain the contracted state of the orjgan. For this pur|xjHe,
the removal of any coagidum that is within reach mf the fingers^
the administration of the ergot of rye. the local application of
cold, and the injection of the uterine cavity, are the melius U)
which we should obviously have recourse. Kiwisch was accuH-
t-omed always to employ cultl water; but in cases «>f this desrnji-
tion I have been accustomed to use it tepid, and have Umnd it
excite sufficiently enei^etic uterine c^rm tractions, without j^ruduo
ing that great shock which I have sometimes neen follow the
injection of perfectly cold water into the cavity of the unimpreg-
nated womb,*
* Tlien^ is a pe^^nlinr rorm of uUirine (x>ly[in«, of which Dp K. Lee glvtm % ib-
lin{>Ation Iti plate ix. fig. 1 othls t^cautiful, though unfortunatt*ly imrom)4ct«, i\v0>
ttcal Obs*riuitioiia on, IHaeaaeaof the UUriu, folio, 1849, fiart ii. He term» It lijthfo*
cy^ie itmiour ; but his account of ita structur« is too laoi^ro to i«fiAl)l« on* Ui
detennine its real DAtnre* Dr Oldham, in bin |wp«r alreiuly irfi^rnsl to^ givi«i a
tiketch of a simikr growth, and Bu^q^tt ib» tirobable nource in iiom« ijooitlimr atti^ra'
tion or hypertrophy of thi' ut«rine glands, a view which quits iceoids with thot
of Hirsch, who describes siJTersJ specimens of thia kind of oat|^owth, for whinh bi^
suggests {Ue, ci£. p. 61) ths Qsme of the DcciUasl'iiolyiius of the botly of Uis
uterus.
LECTURE XIV.
UTERINE TUMOURS AND OUTGROWTHS.
Fibrous TtTMoirits ; — tlieir general characters, varying ftcat, and identity of mforo^^
Bcopir stmctnre. Inliuenee of these growths upon the iitvn-us, and caus4.'M winch
modify it Their nnmber and size. Changes wliich they undergo, and na(:urt^*8
efforts to giet rid of them ; — their disLntegratioii) their ealcar^ous tiuiiflfonuii-
tion.
Fre(iu«ncy of these growths ;— influence of age on their produeiieo.
Symptoms : diiionleni of mRnatruation, hfemoirhage, pain, aterility* and miscar-
liigQ ; their compiimtive frLHiueney. Mode of aceesa of the symptomB,
Genend sketch of symptomfi of fibrotia tumours.
We are now about to enter on an examination of one of tlia i
imporUint ailments of the uterus j one which is frequent in its *
occuri-ence, serious in iUs results, and but little amenable to treat-
ment. It is, moreover, characterized by much uncertainty in its
rate of progresSj which, sometimes rapid, is at other times very
slow, while still more rarely tlie disease is almost or aUonetlier
cured by nature, who either eliminates the morbid structure fmm
the organ whence it sprang, or ef!'eet.% changes in it such as com-
pletely stop its growth, and render it quite harmless.
The JibrouB iummir of the uterus (for this name seems to me the
most appropriate among the many designations which it has
received) is a growth more or less intimately connected witli tlie
uterine walls, with which its structure is almost identical It is
seldom solitary, but several tumours are usually found to V>e
present at the same time, though one or two generally outstrip the
others in the rapidity of their development, the rate of which, as
well as the nature of the symptoms, are greatly influenced by the
situation that they occupy.
Whatever is the situtUion or size of one of these tumours, it is
characterized by a spherical form and a firm texture, though its
surface is sometimes nodulated, as if from the aggregation
FrBROUS TUMOIJKS OF THE UTERUS^
257
fcogether of several tumours ; and the firm texture is occasionally
intemipted by irregular spacea or cavities containing fluid, while
many miuor diilereiices exist in the degree of firmness^ elasticity,
or succulence of diiferent specimens. On a section being made of
any of these tumoure, they present great similarity to each other,
being composed of a dense greyish structure, intersected by
numerous dead white bands and lines which are almost invariably
arranged according to a definite type or plan. In some instances
these fibres have a concentric aixangement, while in others thoy
have a wavy distribution, or are disposed around several diilerent
oentres. Tumours of the firat kind are usually remarkable for their
hardness and tlieir small degree of vascularity ; they are also con-
tained within a remarkably distinct fibro-cellular investment, are
imbedded in the uterine substance, and seldom attain a size
exceeding that of a shelled walnut The other varieties are more
vascular, less firni, have a less complete capsule, may occupy all
parts of the exterior or interior of the womb, and may grow to a
very large size, so as to weigh twent};, forty, or even seventy
pounds. Moreover, it happens sometimes that in the course of
their development two or more tumours coalesce, at least
apparently, so as to form a large growth, though on a section it
will be aeon that the diHerent growths remain distinct fi-om each
other, separated by fibro-cellular septa, tlie remains of the more
complete investment by which, when smaller, each was surrounded.
Liistly, they sometimes assume the form of distinct outgrowths
from the uterine substance ; the fibres of the womb not merely
passing over the tumour at some parts, or even over the whole of
its surface, but actually growing into and being continuous with
it. This last form is, I believe, observed only in the case of some
fibrous tumours growing into the cavity of the womb, and con-
stituting polypi
None of these differences, however, are accompanied by impor-
tant modifications in the essential stntcture of these growths.
They are all made up of fibres resembling those of very dense
cellular tissue, or of tendinous substance, or of elastic tissue, pre-
senting various degrees of completeness of development, and
intermingled with cytoblasts and a granular sukstance, the
abundance of which is usually in inverse proportinn to the perfec-
tion of the fibrous element of the growth. In almost every
E
258
FlBROtTS TUMOURS :
inetance there are present also some of the broad unatriped
miiscolaT fibres of the uterine tissne, and these aometimes enter
very largely into the composition ol' the timiours ; while, w]>ere
this is not the case, the uterine tissue nevertheless is intermingled
with the pedicle of those growths which project into the cavity of
the womb, and furnishes them with a partial investment, often,
indeed, with a complete covering.* Wien to this we add, that
though the degree of vascularity of these tumonrs varies widely
in different instances, there is nothing at all peculiar in the
arrangement of their vessels, and further, that, like the tissne from
which they spring, they admit of being resolved into gelatine by
boiling, we have mentioned everything of moment concerning their
composition and their structure.
There are several different situations from any or all of which
these growths may proceed, and it is not veiy unusual to meet
with illustrations of all in the same uterus. Sometimes they are
developed immediately beneath the peritoneum wliich covers the
uteriLS, or the first half-inch or inch of the ovarian ligament or of
the Fallopian tubes. Such perfectly superficial gi'owths ari:*
generally limited to the fundus or upper part of the body of the
uterus, are more frequent on its posterior than on its anterior sur-
face, and for the most part remain of a very small size, scarcely
exceeding the bigness of a large pea or of a kidney bean, and
seldom project so far as to form more than the half of a much
flattened sphere. In other instances, they proceed from the
thickness of the uterine wall, and may then either grow outwards
towards the peritonenm, or inwiirds towards the cavity of the
womh, though the former is by far the more frequent occurrence,
and is so doubtless for the ohvious reason that in that direction
• The first careful microscopic examiDation of tbea© growtlis wa« made by
Valentm. See his lirpertf/riutHf 1843, p* 10. InWallnfs JMsseriation, already m-
ferred to^ utrt* the re^iults of the uiieroa€:opic dxamination of five different apeci*
Tnen8, by Professor Biddtjr^ § 20, pp. 37-41 ; auii lastly, the rc.sults of some other
exatninfltious aro given by Paget, oj}. HL vol. ii. pp. 135, 130. [The Uluv
giettasy and lymph (uigiectasy of ftbroiis tumours, to which Virchow, Leopold,
Eeiii {Ardiiv far Gyn(tk., IX. Baud 1876, a. 414), and others bftTO cilled
atteotkip, and of the fortiKT of which I have deacribed a specimen {Ediiibuirffh
Medical Jimnml, April 1868, p. 955), are rt^cent advances in the t>utholygy of these
growtbs, which promise to throw much light on their cavities and the discliargca of
watery fluid or of Uood from them, ]
THEIH STRUCTURE, AND RELATIONS TO THE UTREUS.
259
tlie tumour encounters tlie least resistance to its growth. Sucli
tumours sometimes attain the size of a goose's egg, of a large
pear, or even a greater bulk, and are connected with the uterus by
a thick pedicle into which uterine fibres enter, though, unlike
the tumours that grow towards the cavity of the womb, they do
not receive an investment from its substance. The tumours that
thus grow outwardly from the uterine walls are often present in
considerable number, as may be seen, for instance, in a prepara-
tion in the Museum of St Bartholomew's Hospital, where twelve
of these growths may be counted projecting from the surface of
the womb, though its interior is quite free from disease. Wien
they grow internally, they are sometimes positive outgi^owths of
the uterine tissue, while even when this is not the case, theii*
rehitions to the womb are generally very intimate. ♦ They receive
an investment of uterine tissue, and are often much more abun-
dantly supplied with blood than any other varieties of these
growths ; points, all of which are of very great practical moment,
modifyiriif the patient's symptoms, and intluencing also our con-
duct. Whatever be their point of origin, these growths usually
tend, as they increase in size, to become distinctly pediculated.
To this, however, there are occasional exceptionti. The tirm, very
slightly vascular tumour, with concentric aiTangement of its
fibres^ remains imbedded in the uterine substance, and covered by
its investment of cellular membrane, without any disposition to
project into the interior, or to protmde at the exterior of the
organ. In some cases, too, the more vascular variety of fibrous
tumour, with a very elastic and very succident tissue, becomes
developed in the thickness of one or other uterine wall, attaining
the 8i2e of the ftetal head, or even a greater bulk, and producing
very great enlargement of the uterus, but retaining its spherical
form, and continuing imbedded in the substance of the organ
rather than projecting from it in either direction^
The intluence which these growths exert upon the uterus varies
to a very remarkable extent, but is in proportion to the intimacy
* Tlie Muwnm of St Bartholcim«w'i Hospital containsi rvvo ^pecifneii^ iltuj$tmtmf(
exceedingly wdl tlw HikrmkOB bitWMn the outgrowth and the tumour, for which
pfurpOM they are dtagmnnuitbed by Sir J. Paget, op, eik voL il (>. 131, figs. 11
Mid 12.
t A condition admimbly repreaented in W«um1, Kmnkheilen dm Vierxu^ folio,
Mainz, 1516^ pktes yii, and riii,, x« and zi.
260
FIBROUS TUMOTTBS :
of the relation between the tiimom* and the womb, rather
than to the mere size to which the tumour itself attains. When
fiituated external to the womb, and growing into the peritoneal
cavity, the tumour oft-en acquires an enormous size, and the
womb is, as might be expected, much elongated and strangely de-
formed, but nevertheless is not in geneml much increased in
bulk. On tlie other hand, the development of a single tumour
within the substance of the womb brings about an increase of its
size, a thickening of its walls, and a development of its tissue very
similar to those which take place during pregnancy. Of this fact
a preparation in the Museum of St Bartholomew's Hospital
affords a very remarkable illustration. Imbedded in the anterior
wall of the uterus is a fibrous tumour, no larger than an uushelled
almond, and of so eh slight vascularity that the injection which
has deeply coloured the parietes of the womb has not entered the
vessels of the tumour. This small gi-owth^ Iiowever, has so
stimulated the uterus that it has grown to a length of five inches,
and that its walls are at least an inch and a quarter thick. In
like manner, the growths which project into the uterine cavity
bring with them a remarkable increase of the womb, and this not
due to the mere distension of the organ by the substance contained
within its cavity, but to the actual growth of it^ tissue and
unfolding of its mnscularity, such as takes place in pregnancy, and
even in those rare cases where the development of the ovnm goes
on external to the womb itself. In these cases, however, the
womb, after a certain period, contracts upon and expels the
tumour or polypus from its cavity, or the tumour passes out of it
quietly and imperceptibly, witli which occurrence the further
iucrea-^e of the organ not only comes to a standstill, but its size
diminishes, so that not infrequently a large polypus maybe found
connected with an uterus whose dimensions fall below the natural
standard* Hence it is that the instances in which the womb
acquires the largest size are not those in which the tumour hangs
down by a pedicle into its ca\^ty, but ihose in which its devel-
opment takes place into the substance of one or other uterine
wall ; and the organ thus increased in bulk sometimes attains
the size of a child's head; and its cavity, as measured by the
uterine sound, may be found to equal four, five, or six inches iu
length.
THEIR DTFFEKENT RELATIONS TO TEE DTEEU8. 261
It is a matter rather of idle curiosity than of practical utility to
determine the number of these growths that may exist in any one
litems, or the size to which they may attain-* They are seldom
solitary, sometimes they are very numerous ; and they are usually
present in the greatest number on the peritoneal surface of the
womb, while it is rare to find more than one projecting at the
same time into the cavity of the organ. This, however, is
probably due to the circumstance that there is not room for more
than one tumour at a time within the cavity of the womb, for it ia
not a very uncommon thing, some montlis after the removal of
one growth, to find another occupying the same situation, pro-
ducing the same symptoms, and calling once more for a recourse
to the same operation*
With reference to the size of these growths, we encounter wide
differences again in this respect, instances being on record of their
attaining to such dimensions as to weigh even eighty pounds; and
the weight of the growth in the remarkable case delineated by
Walter was seventy -four pounds.^ These u nquestionably are cju ite
exceptional instances, but they arc worth bearing in mind, as
showing that, in a diagnostic point of view, the mere size of the
tumour is not to be relied on in discriminating between growtlis
from the uterus and those proceeding from the ovary.
There are very few aUments in the course of which nature does
not make some efforts^ often, indeed, imperfect and unsuccessful
* Walters Diaaerkdim^ ahmiy qoDted, f| 11 lad 12, and pp. 27-^0 ; and
Meunner, op. ci£, voL ii. p. l<t-19, contain references to the most remArkable
cases of Lirge or numerous fibrous tnmoursi
t Op. eU. Though in this case the whole ttimoor was of solid te^ctnrev still ^
some instances the enormouB dimensions of these growths have l>een doe to cyst
formatioiL, and tha accumulation of alai^ga quantity of iuid in thi-ir interior This
lluid has sometimes amoiintjed to many pints, and the distinct Huctuation to which
it gave rise has led to the disease being taken for ovrtrian dropey, and to the
patieiit being tapped for its relief. No instance of it has come under my own
obwnratioii ; l^nt the impression left on my mind, by i«a4Mng the variooa recorded
(Utaes of it^ is, that the disease is essentially different from ordinary fibrous tnmonr,
since, in addition to one or two cysts of very great size, a nnmber of sriiaU cysts
•eem always to have been pfi^sent in their immediate vicinity, and enUtriug into
Ihe itrnctiire of the more solid portions of its growth. The cases^ in short, seem
to be instances oT Jibro-cystic dis<.'ase of the uterus^ and ba such call for special
investigation ; rather than ordinary fibrous tumours, in whoee sabstanoe cysts
liave aocidentsily formed. See, in addition to the references given by Pnget,
op. c^ vol ii. p. 133 ; Kiwisch, op, dL voL i p, 455 i and Chiori, op. ciL p. 404.
262 FIBROTJS TtJMOUES :
efforts, at cure. In the case of fibrous tumours, there are five
different modes iu which this attempt is made. Either the
pedicle undergoes a process of giwlual attenuation, and then gives
way, the tumour thus becoming detached from the uterus; or
more rarely, a portion of its investment becomes ulcerated or dies,
and the growth gradually shells out from the sheath of cellular
membmne which contained it; or a change takes place in its sub-
stance, tlie exact nature of which is not quite understood, it
becomes disintegrated, dies, and is got rid of piecemeal ; or a
different change occura, similar to what we see in other morbid
products, — the tumour undergoes the cretaceous transformation,
and though not eliminat^^d from the womb, it ceases to stand in
any vital relation to it, and the symptoms wliich it once produced
diminish, or altogether disappear.
Nothing can be simpler tban the jirocesses by which these
tumours, when gromng within the uterine cavity, may become
detached from their connexions and eventually expelled, though
my own experience does not lead me to believe that any of them
are of freijuent occurrence. It may happen, however, either that
the pedicle, by constant traction of the growth, becomes thinner
and thinner, till at length it gives way, or that the margins of
the OH uteri, tightly constricting, strangulate it, or that in its
violent expulsive efibrts the uterus snaps the slender stalk of the
outgrowtL* This detachment of the tumour, by the giving way
of its pedicle, is not limited to cavses in which it grows into the
cavity of the womb, but is also occasionally, though very i-arely,
observed in instances W'here the tumour has sprung from the pe-
ritoneal surface of the womb. In tlie only case of the kind which
bas come under my own notice, the tumour had arisen from the
posterior uterine wall, and had projected into the interspace
between the uterus and rectum, wdiich Continental wTiters com-
monly speak of as the space of Douglas. Tliough perfectly
detached fpom the uterus, however, the tumour, which was of the
size of a walnut, had not fallen loose into the peritoneal cavity,
but was held in its pasition by false membrane passing between
the uterus and rectum ; and I believe that in almost all recorded
• A very eUbomte paper on this subject, contaiuftig an enumeration of twenty-
four cmt% colleoted from diflerent soim-ea, was piablisbed by M. Marclml dc Calvi
in the Jnnalcs dc la Chimrgie^ August 1843.
4
WHICH THEY ARE LIABLE.
263
instances of the complete detachment of a fibrous tumour from
the outer surface of the womb, the outgrowth has been retaiued
in a similar manner close to the part whence it luiginally
fiprang.
Another mode by which fibrous tumours are sometimes got rid
of, is the disintej^mtion of their tissue, and their subsequent
expulsion* This process seems t^ lie one of death of the tumour ;
but the mode in which it is brought about is not by any means
clearly understood * It is not a process of intiammation, nor one
of its ordioary results. The fibrous tumour; when attacked by
inflammation, presents a virid rose-red colour, and ghows a
greatly increased vascularity; while local pain and the general
signs of inflammation attend the process during the putient's life*
The ilisinlegration of the tumour, on the contrary, takes place
imattended by symptoms wliieh could le^d to a suspicion of what
is going on ; and tlie outgrowth becomes soft, and breaks down
into a dirty putrilage. This change is not very unusual in the
lower part of fibrous polypi, when they project through the os
uteri into the vagina. The mucous membrane covering this part
becomes ulcerated, and being thus deprived of its most important
source of nutrition, the adjacent portion of the tumonr loses its
vitality ; the cellular tissue binding the bundles of its iibres
together, dies first; and such a growth may sometimes be found
firm and solid, and presenting all the ordinary characters of a
fibrous tumour at its upfier part, but lower down split up intci a
number of shreds or packets of fibres connected together by a
dirty decaying matter. By degrees, these firmer fibres themselves
soften, and the process of decay extending further and further,
the whole growth may come away imperceptibly ; or, on attempt-
ing to remove the polypus, we may be surprised to find that what
had once been a very firm mass is now so soft that the hooks by
which we endeavour to draw it down, tear out— that natui'e, in
short, has anticipated us, and that in a few more days or
weeks she will have completed her operation.
■ The rariotui modes by which the deatii of ii uterine fibmid takes place iiro
fully diaowaed by Giuserow in Billroth '« SmvUmch dtr Fmwnkmnkfi^ Umt lYUt
AUehmtt, Svo, Stuttgart, isrs, p, 28-32. [A paper by M*CUijtwk shouia aho be
<}oiisnJted. Iti« piititled '*Thi! SpontMieoiu EliminatioQ of Utmne Tomoura,"
and 18 to be found iu the Dublin Quarterly Journal pf Medkal Sckne* for Feb*
264
FIBROUS TUMOURS :
It is not, however, in these cases only that the death of a
fibrous tumour takes place. The same process may go on in the
tumour, while still completely within the cavity of the womb, and
while still of inconsiderable size. On examining the womb of a
woman sixty-three years old, and who was not known to have
sufiereil from any sjrmptoms of uterine disease, the oi'gan was
found deformed by eight fibrous tumours growing from its outer
surface, which altogether made up a mass three times the siiie of
the healthy womb. One of these tumours, as large as a pigeon's
egg, w^as connected w*ith the posterior uterine wall only by peri- .
toneum and a very slender pedicle of cellular tissue, and would
probably in a very short time have become completely sepm-ated,
while many other tumours w^ere undergoing the calcareous change,
and were thus in process of cure. On lajdng open the cavity of
the womb, it was found to be occupied by a growth of the size and
shape of a sugared almond, 1'25 inch long by '9 of an inch broad.
On its free surface it was covered by the uterine mucous mem-
brane ; but it was imbedded for about a fourth of its thickness in
the uterine wall, from which it was separated by a distinct
envelope of dense cellular tissue, such as surrounds fibrous tumours
in general It was of a dark almost melanotic colour through
the greater part, though not the whole of its substance, and
looked as if blood were infiltrated into the substance of a soften-
ing fibrous tumour; for enough of its tissue still remained to
show its real nature, even irrespective of the evidence aUbrded
by nimierous small fibrous tumours, varying in size from that
of a pea to that of a bean, which were imbedded in the uterine
walls.
Had this person lived a little longer, one of two things would
doubtless have occurred. — either the elements of the softened out-
growth w^ould have been absorbed, or its cellular investment would
at some point have given way, and a slight discharge, apparently
of coagulum, would have been the sole evidence of the ailment
from which the patient had suftered, and of the means by which
nature had wrought for its removal. Wniether without any such
change in its tissue, fibrous tumours are ever compiletely removed
by absorption, is a question that I am unable to answer from my
own observation, I should quite believe in the possibility of the
occurrence, though my impression is that softening and disinte-
CHANGES TO WHICH THEY ABE LIABLE.
gration usually precede the removal of the tumour, and that
almost invariably it is not ahsorljed, but is exjwlled in ita softened
state, and piecemeal, from the cavity of the womb.
Whether in health or in disease there is a general analogy
between nature's modes of proceeding even in cases apparently the
most diverse which it is Ixith interesting and instructive to study.
The tuberculous bronchial gland is softened, iut investment is
absorbed, a communication is opened with tlie air-tube, and the
diseased matter is expelled ; or when this cannot be accomplished,
another change in its elements takes place : the gland shrinks, its
substance grows harder and harder, chemical activities are set to
work, and a few masses of cfdcareous matter unexpectedly dis-
covei^ed close to the bronchi of some person who had died in a good
old age, tell, not infrequently, that in his youth he was the subject
of a disease which usually tends to destroy, and to destroy speedUy,
those whom it attat*ks»
Just the same kind of changes occurs in fibrous tumours of the
womb. We have already studied the process of softening, by
which their removal is sometimes brought about : a process of
hardening by calcareous deposit in their substance is still more
common. This deposit sometimes takes place mertdy in the peri-
phery of the tumour, w^liicb thus receives a calcareous investment
or shell, its interior remaining unaltered. This, however, is very
unusual, though it is less rare to find incipient calcification of the
interior of the tumour, w bile the change of its surface is complete.
The most common form is that in which irregular massea like
coral are defjoaited in various parts of the tumour, whence they
may be separated by maeemtion, or which make up in the case of
the smaller tumours ahnost the entire mass. Now and then, too,
this alteration goes on to the same extent even in the larger
growtlis, and they become converted into a substance of stony
hardness, which, as is the case with a tumour in the Museum of
the Middlesex Hospital, may receive as smooth a polish at the
hands of the lapidary as any geological specimen. The growths
which proc^eed from the outer surface of the womb, where nutrition
is Yisually the least active, are those isx which this change most
eommonly takes place. 8till the rule is by no me-ans without
exception, as a tumour projecting into the cavity of the womb
sometimes undergoes this alteration, and being at length expelled
!66
FIBHOUS TtJMOtTRS !
from the utenis, constitutes the so-called osseous concretions * the
origin and nature of %vhich were once a puzzle to observers. It is,
I imagine, almost superfluous to say that these tumours contain
none of the elements of true bone ; that the change which
takes place in them is unaccompanied by the fomiation of bone
cartilage ; that, in short, it is due to a chemical rather than to a
physiological process, and, like the so-called ossification of the
arteries, is an evidence of enfeebled vitality, not of active
nutrition.f
The only other question of importance concerning the pathology
of fibrous tumours of the uterus, is that of theii* relation to
malignant disease, and the possibility of their degeneration into
carcinomatous structures. Nothing but the imperfect means of
tjbservation possessed in former days woidcl have allowed this
question to remain so long undecided ; but while hard cancer was
believed to be a common form of uterine disease, and every
induration of the cervix was regarded as scirrhous, it is not
suifirising that hard tumours should have been believed to be at
least of kindred nature. It may, however, be now positively
asserted that such degeneration of a fibrous tumour scarcely ever
takes place; and further, that though fibrous tumours do not
exclude carcinoma, they yet are not associated together with any
special frequency. +
• Then! arc uonie good ilmwings iUnstrative of tlieaa t^liaiigfs in UKmus tuinoisrs
in Hooper's Morbid Analamy of Uu Human Ukru^, 4to, London, 1832, plat* vii
+ See on IMb subject the remarks of Professor Bidder at p. 42 of Waiter's Z>wi-
neriaiion^ who believes in the occasioniil presence of tme Iwne ; while Henle iilso»
Allqemtinc Aiwiomie, p. 809, states tlmt he hEis <llscovei"ed cartilage corpuscles in
them ; a stiit**meut whicb Vogel, in Wagner's Handbueh der Phi/aiologie, vol, i. p,
823, does not corn)borate.
+ Dr Lee, in his CHtticalEtporUof Uterine aiid Ovarian IHsmaesy relates one c«ae
nf the co-«3CistcDce of a calcareous fibrous tnmour iind malignmt ulceration of the
uterine cavity, p. 17(5, Case V.; and one case of the pres^ncfi of the two Imj* come
under my own notice. Chiari^s figures, indee<l, would It^arl to the belief t!mt fibrous
tumours of the womb are associated with a special liability to Tiialignant disease,
since in twenty-five exaDiinationa of patients suffering from thera^ two presented
also cancer of the womb^ one cancer of the mamma and lung, and aLx cancer of
other organs, &p. cit. p. 404. I know of no other data, however, which would lead
to the same conclusion. In M. Dcmar(:[uay*s elaborate lectures, op. cU. p. 163,
only one ease of the co-existence of fibrous tunioox and ut*^riue cancer is referred
to ; and Virehciw, KrankhafUn OtKhwUltU, vol. iii. p. 212, refori*, and with »omo
heaitatiou, to on isolated case of alleged carcinomatous degeneration of an uterin*i
fibroid*
THEIR FREQUENCT,
267
Fibrous tumours are generally regarded, and I believe with
truth, as the most frequent of all organic diseases of the womb,
though I cannot pretend to state the fact numerically, for the
reasons which have been already referred to as \itiutin^ the
statistics of hospital practice. Strange as it seems, too, the results
of posi'TJWrtem examinations are conflicting : on the one hand, we
have the statement, on Bayle's authority, that every fifth woman,
after the age of thirty-five, has fibrous tumours in her uterus ;
and on the other hand, the allegation of M. Pichard,* that they
were met with ordy seven times in 800 examinations made by
himself or by M. Lair.f Mr Pollock,! in a payjer read before the
MediccvChinirgical Society, states that of 583 uteri examined by
himself and his predecessor at St George s Hospital. 2Ho were
diseased, and in thirty-nine of them fibrous tumours were present,
while cancer existed in only thirty-eight. The value of these
statements is. however, not a little diminished by their referring
to females of all ages, from birth up to old age. Equally tmsatis*
factory are the data given by MM. Bniun and Chiari,§ according
to whom «jut of 2494 post-moriefni examinations of both sexes,
twenty- five instances were found of the presence of fibrous
tumours of the uterus. Of seventy instances in which I have
examined the uterus of women who died after puberty of other
than uterine diseases, seven presented fibrous tumour of the
uterus. From these data we arrive at nothing more definite than
the general conclusion that fibrous tumours of the uterus are very
frequent, probably more frequent than cancerous disease of that
organ.
The data of which we are possessed with reference t^ the ag€
of patients affected with tilmius tumours, though very scanty, are
yet more satisfactory, because more definite. Twenty-four pOAt-
moj'iem examinations of Braun and Chiari, and nine cases of my
own, yield tlie following result as to the age of the subjects in
whora the tumours were found : —
• Diet de» ScimceB MidicaUs^ Svo, Ptoi% 1818, article ** Corp* Fibreux de U
Matrice," p. 73.
t Iks Jbus <U la ComUHaatiai^ ^, damkiMalwiiude la Mairiee, 8to, Patu,
1S46, tabic ftt the imd.
t Lancet^ Feb. 7, 1852, p. 156.
I KiMk dcr GtbwrUkUlfi und GjfnOMo^, 2d put, ErlAiigiiii, 1S5S, p.
897.
268
FIBROUS TUMOURS :
2 age not stated
1 was aged 24 yeai^ ; and she died of puerperal
peritonitis.
3 were aged between 30 and 40 years.
33
In many of these cases, however, the tumours had doubtless
existed for many years, and we are therefore concerned rather
with the age at which patients fii-st complain of those symptoms
to wliich fibrous tumours give rise, though even then the disease
itself has probably existed in many instances for months, or even
years, befoi-e it attracted notice.
Braun and Chiari have stated the aga** of thirty-seven patients
who applied for relief at the great hospital at A-'ienna on ac-
count of fibrous tumours of the uterus, not including polypi ;
and if to these be added ninety-six cases which have come
under my own observation, we obtain a total of one hundred and
thirty-three, of which —
26 were between 20 and 30 years of age.
44
If
30 „ 40
47
1»
40 „ 60
15
»»
60 „ 60
1
99
72 years.
123
The above proportions differ in no important degree fram those
obtained by Malgaigne* on a comparison of fifty-one cases of
fibrous polypus of the uterus, from which, if twenty -two cases of
my own be added, we obtain the following result : —
♦ Dea Folffjm UUrina, f)Ust dc Coimurs, 4to, Pam, 1833, p. 12,
CAUSES IKFLUENCDfa THEIR OCCTJEBENCE.
yrom 26 to 30 years 4
30 to 40 , 24
40 to 50 „ 30
50 to 60 , . 7
60 to 70 , 3
70 to 74 , 5
169
Gusserow/ on a comparison of 953 cases from dillerent sources,
obtains the following results : —
Under 20 years of age 15
From 20 to 30 156
„ 30 to 40 .357
„ 40 to 50 338
„ 50 to 60 36
„ 60 to 70 12
Above 70 5
If, he
instead
patient
iking the age at which
applied at the hospital, we draw our conclusions, as we ought
rather t-o do, from the period at which the symptoms character-
istic of the disease tirst manifested themselves, it will lie seen that
fihrous tumours and fibrous polyjii are an affection incidental to
the season of sexaal vigour much oftener than to the period of its
declina
Age of patients.
Firtt came under
obaeiratioD.
Symptoms
comnieiicetL
Under 20 years .
• • •
3
Between 20 and 30 years
11
26
„ 30 „ 40 „
40
48
„ 40 „ 50 „
50
34
„ 50 ,. 60 ,,
15
5
Above 60 years .
1
1
117 117
It has been asserted on Bayle s authority that single women are
more liable to these tumours than those who are married, but my
own observation does not bear out the statement ; for of ninety-
six women affected with non-pedicnlated fibrous tumours eighty-
270
FIBROUS TUMOimS :
two were married ; or, including the casea of fibrous polypi, of one
Imndred and eighteen, ninetv-nine were married. The prepon-
derance of married women is so considerable as to show, I think
conclusively, in spite of the comparative smallness of the numbers,
that the nun-exercise of the sexual functions has no influence in
predisposing to the disease. This opinion, too, is fnrtber sup-
ported bj Gusserow's* statement that of 952 cases collected from
various sources, 672 were those of manied,287 of unmarried, wo men»
Taking leave, then, of that attempt to ascertain the cause of
this afi'ection, which in the case of all diseases we are so disposed
to make, and from which we so seldom arrive at any satisfactory
result, we may now pass to the very important inquiry concerning
the consequences that these tumoura produce, and the s^pnjjtoms
that they occasion.
First of all it may be premised that sometimes these tumours
are attended by no symptoms at all ; that they exist for many
years witliout producing any inconvenience whatever. Illustra-
tions of this fact are afforded ns by the discovery of fibrous
tiunoni's after death in the uteri of women wiiose sexual system
had never shown any sign of disturbance ; by our accidentally
ascertaining their presence when examining a patient for some
other purpose ; or by the sudden supervention of symptoms calling
our attention to the state of the womb, and revealing the existence
of a large fibrous timiour, whose growth must have been going on
for years. As might be expected, the constancy of tlie symptoms
is generally proportionate to the intimacy of the relation between
the tumour and the uterua The growtlis which proceed from the
outer surface of the womb often pr<>duce no symptoms except
such as are due to their mechanical pressure upon adjacent organs ;
whilst those which are imbedded in the uterine substance almost
always distm^b the functions of the oi*gan, even before tbey have
attained any considerable size ; and the polypi or growths which
occupy the cavity of the ivomb attract attention almost from the
first by the haemorrhage which they occasion. Some illation, too,
* Op. cU. p. 37* [The furtliir vigorous ctiscusaiona of tlit questions of age,
marriage, and thOd-beiiring, as iuHoencin^ t\w production of uUtib*? fibroids, sLow
that they are not tomjdetely or satisfactorily settled. Beocnt T<iJiblo coritribu-
tiona are to fn? found in the Edinburgh Afcdknl J&ufnalf toL xxHi, 1877, by
En^lmatm ; in Volkmann's Sammlung by Wiockel ; and in the great obstetric
LtArbuch of Splegi^lberg].
THEIR SYMPTOMS.
271
subsists between the general activity of the sexual system and the
exercise of its highest functions on the one hand, and the severity
of the symptoms of librous tumour on the other. It is thus that
in women advanced in life, and whose menstniation haa ceased,
the ed'ects of fihrous tumours are usually less serious than in
younger women. It is thus, too, that these growths may produce
80 little inconvenience as to be scarcely suspected so long as a
woman remains single, but may become the occasion of much
suffering as soon as she marries, and as sexual intercourse
occasions the frequently increased afflux of blood towards the
womb. The bearing of these facts upon our prognosis and treat-
ment must he sufficiently obvious even now, but will be still more
apparent after we have examined the symptoms of this affection
more in detail
Those tibrous tumours which hang by a pedicle into the uterine
cavity, and which are commonly called uterine pt>lypi» are
attended by one almost invarial>le and characteristic sjTuptom, —
viz,, haemorrhage. Since, then, their diagnosis is comparatively
easy, and since their treatment differs from that which isgeneiully
practicahle in the other forms of fibrous tumour, we will pa%tpone
their further consideration for the present ; and my remarks will
be understood to have reference to those varieties of fibrous
tumour which are either imbedded in the uterine substance, or
which prttject from its peritonejil surface. Menstrual disorder,
uterine haemorrhage, pain, dysuria, and more rarely difficult
deftecatioUj are the more important symptoms of fibmus tumours,
though* from being present in various degrees and in varying com-
binations, they often leave room for much doubt as to the nature
of the aflection to which they are due.
The following are the principal results deduced from a compari-
son of ninety-sLx cases of fibrous tumour of the uterus, of which I
have presei-ved a sufficient record : —
In eight of the ninety -six cases menstruation had already ceased
when the patients came under my observation, but in two of them
consideraljle hitmorrhage occurred from the uterus at irregular
intervals, in two such hfemorrhage occurred in but small quantity,
and in four it did not take place at all.
In thirty more cases the menstrual function w^as not disturbed
at all, and in twenty-four of them there was no intercurrent
272
ubig^s TOMoims:
uterine hemorrhage at other times ; but in six patients haemor-
rhage occasionally took place, which, however, had no relation in
the time of its occurrence to the menstrual function.
In the remaining fifty-eight cases menstruation was more or less
seriously disturbed, Iming
Excessive • » . . in 30 cases.
Painful
and painful
>, in-egnlar
and irregular
Irregidar
Scanty
58
It appears, tlien, that, in forty-five out of eighty*eight cases in
wliich menstruation bad not ceased, it was either excessive in
quantity, or over-frequent in recurrence, or both ; wliile in fifteen
instances the function was performed with excessive pain ; and
only in four instances did the quantity of blood lost at the period
fall below that to wlu'cb the patient was accustomed when in health.
In forty-four cases haemorrhage from the uterus occurred at
other times than those of mengtmation ; an accident which took
place after the cessation of the menses ....
coincided with menorrhagia or over-frecpient men-
struation. . . . ,
„ „ painful menstruation . , . . ,
„ f, „ and irregular menstruation
„ „ irregular menstruation
„ ,, nor disorder of menstruation ...
44
In sixty-five cases, pain was complained of at other periods than
those of menstruation. This pain varied greatly in its severity,
it% situation, and its continuance ; some patients describing it as
a burning sensation, others as a sense of bearing down, while
others, again, seemed to suffer from it in paroxysms of almost
intolerable anguish. This pain in thirteen of the sixty-five in-
stances coincided with painful menstruation ; but in four cases of
dysmenorrhoea pain was not experienced at other than the men-
in 4
cases,
„ 32
ft
M 2
t$
,. 1
i»
. 1
M
„ 4
ft
THEm STitPTOirs,
273
stnial e|>ochs* Meastruation had already ceased in six of tbe
cases in which pain was exijerienced, and in the remaining forty-
six was performed without suHeriug, and in nineteen of the
imml>er without disorder of any kind.
There were, moreover, thirty-five instances in which the patient
sul!ered from dysnria ; either from pain in voiding urine, or from
difficulty in its discharge, or from freqnent desire to pass it ; while
four times complaints were made of difficulty in defalcation : hnt
none of these sensations could be referred so distinctly to the seat
of the tumour or to its size as might beforehand have been ex-
pected.
The influence of librous tumours in modifying tlie rate of
fecundity 13 very remarkable, and shows itself both in diminishing
the number of conceptions, and also in increasing the proportion
of pregnancies which come to a premature termination.* Of the
ninety-six cases on which tiiese observations are founded, eighty-
two were those of married women ; of these twenty were sterile,
while the remaining sixty-two had given birlh t<i one hundred
and twenty- four children, and had miscarried forty-eight time^.
Thirty-one of the sixty-two bad had but one pregnancy, which in
the case of twenty-one had gone on to its full period ; in ten had
terminated prematurely by miscarriage. It is true that five
women had given birth to three children each, four to four, three
to five, one to eight, one to nine, and one to eleven, respectively ;
but in all but three of these instances, the tumour either grew
from the fundus, or was situated external to the post^^rior uterine
wall, and, as far as could be ascertained, did not involve the sub-
stance of the womb. We shall hereafter see that even wheu
proceeding from this situation, librous tumours of the uterus often
• Theliirger nnmlsen collected by Gosaerow, op. cit. p. 117-118, while they prove
the «zifltence of fibroid tumonrs of the utenw to he it marked cause of sterility, show
further thftt that iuHuenee comes into play lesa m Tendering womeo atwolutely
fttenle thuD in limitint? the numher of thtnr conceptionjj. From thi» it would Beem
18 though the condition of mftrriftge and the occuireoce of lonceptiou favoiired
the development of the growths rather than thu iion -exercise of the sexual funt^tion.
The pesiilt* of Winokpl and OusBerow art very remarkable :— Of 108 raarriixi women,
78 were sterile. Of the remainder, 37, or 41 'fi per cent, had 1 rhild ; 43, or 48 "3
per cent, from 2 to 5 ; 9, or l-S per cent, more than 5. In Saxony generally,
227 per cent, have 1 ; 55 '2 per cent* 2 to 5 ; 22*1 per cent, more than 6.
If larger nam bera confirm them remlU^ marriage and pregnancy would appcttx as
CBOSM tctoilly prediapoBJng to the occurrence of uterine fibroids.
S
274
FIBROUS TUMOURS :
render pregnancy, and labour, and the puerperal state, periods of
great hazard ; but it is easy to understand that when the growths
proceed from the exterior of the womb, they may not interfere
with the mere term of utero-gestation.
The symptoms of fibrous tumours for the most part come on
by degi^ees, so that the patient cannot narrowly define the com-
mencement of her illness, but speaks of a gradual increase in the
abundance of her menstruation, or of the discomforts which
attend it, or of some painful sensation at fii-st scarcely perceived,
becoming by little and little more and more importunate, until at
length, when driven to seek relief, she first becajjae aware of the
existence of the tumour. To this rule, however, exceptions are
by no means uncommon ; and in twenty-one of ninety-six coses
the symptoms came on suddenly, some grave accident at once
forcing itself on the attention of the patient, who had previously
imagined herself quite well. In eleven of these twenty -one cases,
it was haemorrhage ; in five inability to void the urine, such as to
CfiU for the use of the catheter, which first excited the patient's
ahirm; and five times it was intense abdominal pain; thougli it by
no means follows that the first symptoms should continue through-
out the most prominent. Lastly, I may add that in eleven in-
stances the accidentEil discovery of a tumour in the abdomen was
the first indication that the patient received of the existence of an
allection wOiich for years must have been in slow course of
development*
If now we endeavour to picture to ourselves the history of a
case of fibrous tumour of the uterus, we shall, I think, find our
sketch to be something of the following kind: — A person, pro*
bably a little past the prime of womanhood, hut at an age at
which the sexual functions are still actively performed, becomes
causelessly the subject of menorrhagia, which may or may not be
attended with pain. The hicmorrhage is at first readily sup-
pressed by rest and ordinary precautions, bnt it afterwards
returns on every sliglit exertion, and at length comes on without
any cause at all, or continues from one menstrual period to
another, so that the patient loses all count of the proper menstrual
ep«>chs. She does not experience that general constitutional dis-
turbance which almost always accompanies idiopathic menor-
rhagia, but sutlers merely from the loss of blood and its direct
THEIR SYMPTOMS.
m
results, while in the intervals between the attacks of bleeding she
is seldom troiililefl Ity leiicorrha'a, and never by any offensive dis-
charge. Coupled wiih the haemorrhage, sometimes from the very
first, generally within a few months from its onset, various
sensations of pain or discomfort are experienced in the lower part
of the abdomen and the neighbourhood of the womb. Among
these sensations of discomfort, that of a frequent desire to pass
water is one of the most frequent The abiding pain is seldom of
great intensity ; unlike the pain of chronic uterine inflammation,
it is not such as to render sudden changes of posture, tlie sitting
on a hard seat, or jolting on a rough road almost intolerable ; it
does not even preclude sexual intercourse. On the other hand,
it is not a sharp lancinating pain like that of carcinoma, but is a
dull aching, or burning, or throbbing, not in general very difficult to
bear, though now and then there are associated with it occasional
attacks of sufliering, evidently neuralgic in character, intense in
their severity, and sometimes accompanied by violent expulsive
eOorts.
Any symptoms of this kind should raise a suspicion in our
minds as to the probable existence of a fibrous tumour of the
utenis, while neither the comparative youth nor the advanced age
of the patient, neitlier the sudden supervention of the symptoms,
nor their very sh>w development, should be allowed to negative
this suspicion, or to bias our minds with reference to a question
which a careful examination can done decide. In any such case,
and indeed in ever)- instance where there is the least possibility of
the existence of a tumour of any kind, it is necessary to begin by
a careful exiiniination of the abdomen* The tumour formed by a
fibrous growth is generally very firm, nodulated, and uneven,
seldom mesial, but so often situated considerably to one side of
the abdomen, that its i^KJsition alone is not of much value as a
means of discriminating tetween it and tumour of the ovaries,
though it is not without importance that untU it has attained a
very large size it is usually confined to the lower part of the
abdomen. Mr Spencer Wells, moreover, observes* that it is far
less usual for the umliilical fossa to he diminished in depth, or for
the umbilicus to be actually prominent, in uterine than in ovarian
tumours, unless the former are complicated with ascites. Ovarian
• IHmtuetqfthe Ovaries 8ro, London, 1872, vol. tL jk 18C,
27G
HBROUS TUMOURS :
tumoura, may, however, generallj be distinguished by their smooth
surface and spherical contour, as well as by a certain degree of
elasticity* which m usually distinguishable in them, even though
they should yield no distinct sense of fluctuation. On making a
vaginal examination, the condition will be found to vary very
much, according to the position and relations of tlie tumonr» If
any tumour can be felt in the abdomen, the first point to ascertain
is the relation borne by it to that of the uterus, to determine
whether pressure on the one is immediately coniniunicat^d to the
otlier ; since thereby some clue may be obtained as to the proba-
bility of its connexion with the substance of the womb on the ouqH
hand, or with the uterine appeudaga^ on the other. The ovarian
tumour, when once it has risen out of the pelvis, almost always
draws the uterus up with it, while this change of position seldom
takes place when thegi'owth proceeds from the womb it-self. Tbe^
posterior uterine wall is the most common seat of fibrous tumours,"
inasmuch as they were present there in thirty-eight out of ninety-
six cases ;* and in twelve of the number could not be discovered
in any other part of the uterus that wa^ accessible to examination.
Hence we generally find a firm body, often, but not always,
uneven, occup^dng more or less of the posterior part of the pelvic
cavity, carrying the uteriia forwards towards the symphysiB pubis,
and frequently more or less completely retroverting tLe organ ; in
which case it is usually displaced from the mesial line, so that theJ
OS uteri is to be found near to the pubo-ilinc synostosis on one or
other side. The os uteri itself is generally small, circuhu^, and
healthy ; the tissue of the cervix smooth and healthy, or, at thm^
most, only somewhat turgid and hard, from the frequent afflux oi
blood towards the organ* If the tumour is very small, s}>ringing?
from just behind the cervix, the diagnosis between it and retro-
flexion of the uterus is a matter of much difficulty, and harder
still is it to make out the distinction between anteflexion of the
uterus and a fibrous tumour of its anterior wall, the possibOity of
which must not be lost sight of in the confessed rarity of its
* The Tf&uh thus obUined l>y examindtion during life tallica tolurably closely
Mitb that amv&d at by Mr Ltff, from a comparison of varioua pn-jmrations in the
Museumfl of the Metroi>olia ; who found that in twenty-two out of seventy-foar
caws the growth sprang from the po«t«rior wall of the hody or neck of thts utema.
flee Safford Lee Chi Tumours of the Uterus^ Svo, London, 1847, p. 2, tahk* i.
THEIE SYMPTOMS.
occtiiTence. If the tumour is within the uterine cavity, or
ini bedded in its walb,the reaultsof an examinatiou will of course
be ditfercnt ; the utems will be found larger, heavier, and less
movaljle than natural ; its lower segment may be distended by
the tumourj and in that case will not be unUke the form which is
assumed by the pregnant womb, though the lips of the uterus,
instead of presenting the development characteristic of the gravid
state, will be found mechanically thinned by the pressure of the
tumour The cervix uteri, too, in such cases not infrei[uently
disappears long before the grovrth has attained such a size tis by
its prominence in the abdomen to simulate the state of the womb
when gestation Is half completed. If, however, the tumour does
not thus project into the uterine cavity, its diagnosis will be much
more difficult, for a large, a somewhat hard, and a but partially
movable nteras, will be all that is at first apparent, ail perhaps
that even a repeated examination may discover. Still, even here,
the unaltered orifice of the womb, the absence of tenderness of its
cervix, and of any thickening about the roof of the vagina, will
suffice to show that neither has inflammation of its appendages
fixed the organ in its position, nor has inflammation of its sub-
stance or its cervix increased its size and weight The sound may
also show the easity of the uterus to be elongated ; and 1 believe
that an enlarged, and heavy, and somewhat hard uterus, [especially
if in any way unsymmetrical in shape], coupled with the causeless
occurrence and frequent return of uterine hit^morrhage, while the
OS and cervix uteri are healthy, are almost always characteristic of
fibrous deposit in the uterine substance. It is, I imagine, scarcely
necessary to say that not infrequently we come to this opiidon
rather by the exclusion of all other possible sources of similar
aymptoms than by the positive evidence aflbitJed by any single
sign pathognomonic of tins afiection.
It must remain, however, for our task at the next Lecture to
pass in review the various anomalies in the symptoms of fibrous
tumours of the uterus, and to study the difl'erent circumstances
which may render our diagnosis ditHcuIt or doubtful
LECTURE XV.
UTERINE TUMOURS AND OirTGROWTHa
FlBROtTB TuMOtms ;^-tht-ir diogaosis, and exceptional chamcter of thdr symp*
toma in some cafitfs. Oticaaional difiienlty of distinguishing between them
and ovarian tnmonm Menstnml if regularity and suhj»&|iieut smhleo haemor-
rhage have raised suspicion of niiscarriagi?. Sudden suppression of urine in
some cas«s ; its import. Ditliculty of distinguishing between flexions and
tumour of the uterus, Posaibility of mistaking for cancer. Cases charac-
terized by intense pain. Diagnosis hetwt^n pregnancy and lihroua tumour,
and difficulty of diaLOvering former when complicated with latter.
Progjjoaia ; progress generally slow ; illuatrative table. Influence of pregnancy
und labour ; dangers which attend them, and why.
We hav6 Litlierto looked at the symptoms of fibrous tuuioui'S of
the uterus only as they appear in the simplest cases, with nothing
to obscure or distort their characteristic features. In the study of
all diseases, however, our concern is at least as much mth the
exception as with the rule ; and if we would not fal! into gixDSS
errors, we must he as ready to undo the tangled web, and to find
in the midst of it the clue that may lead us right, as we should be
quick to follow the signs which point out the plainest path, and
render even a moment's doubt almost impossible.
Some of the rarer cases, then, must next engage ns ; and 1 must
try, even at the risk of wearin^^^ out your patience, to describe some
of the many circumstances which may cause us to hesitate in the
dwf/nosu of fibrous tumours of the uterus.
In enumerating the symptnins of this atiection, it has already
been mentioned that while haemorrhage very often attends it, the
occuiTcnce is by no means constant. It may. however, happen
that missing on some occasion this, which is one of the most char-
acteristic signs of the disease, we may begin to doubt its nature,
and to question whether the tumour which we discover is not
connected with the ovary rather than with the womb itself, I do
I
DIAGNOSIS OF FIBROUS TUMOURS.
279
not know any certaiD means of avoiding error in such cases, but
refer to them for the sake of impressing on you the fact, that the
mere absence of hiBmorrhage, or even a condition of scanty men-
struation, does not negative the possibility of the existence of
fibrous tumour ; just as, I may add, on the other hand, very pro-
fuse haemorrhage sometimes occurs in instances where the tumour
is unquestionably connected with the ovaries.
The kind of difficulty which presents itself in some instances in
distinguishing between tumours of the uterus and tumuurs of the
ovaries, and the considerations wliich guide us to a solution
(possibly, indeed, not always a correct one) of the question, will
perhaps be best understood by the foUowing sketch of the history
of a woman, aged tliirty*nine, who was admitted under my care
into St Bartholomew's Hospital in April 1851. She luid been
married twenty years, but for eighteen had been a widow, her only
cliild having been born a year after marriage, Her menstruation,
which commenced at fourteen, bad always been regular, and
unattended by any considerable inconvenience, while it had at one
time been excessiva She tirst noticed a swelling in the riglit side
of the abdomen between three and four inonths before she c^me
under my notice ; and this tumonr bad since gradually increased
in size. Since she first perceived the tumour, she had had two or
three attacks of pain in the back, followed by retention of urine ;
while her bowels were often constipated, and she frequently
required aperient Inedicine. Her general health, however, was
not seriously impaired.
The abdomen measured thirty-six inches and a half at the
umbilicus, forty -one inches and a half two inches lower down.
The abdominal integuments were loose, and contained a good deal
of fat. A solid movable tumour occupied the abdomen, extend-
ing from low down on the left side of the pelvis across the nif sial
line, reaching on the right side to an inch and a half above
the umbilicus, and to within three inches of the right crista ilii,
but not dipping down into the right side of the pelvis as it did on
the left This tumour was solid, non-fluctuating, and its surface
was somewhat nodulated. At its upper part, and at the right side
near the umbihcns, one portion of the tumour, a sort of otlshoot as
it seemed, was movable upon tlie other larger part of the growth.
On examining per vaginam, the ^nger at once came upon a firm
280
FIBROUS TUMOURS :
globular tumour oceupjiug the pelvic cavity, and dipping down
to within an inch of the outlet At the anterior and ri^ht part of
the tumour a depression could be felt, somewhat like the os uteri,
though the finger could not be made to enter it ; but in no other
situation could the least trace of an opening be discovered. A
grooved needle was introduced with some diificulty per vaginam
into the tumour, but no trace of any lluid was obtained.
In this case the circumstances which favoured the supposition
that the tumour was ovarian, were ita large size, the alleged
rapidity of its growth, the fact of its situation not being mesial,
and the absence of uterine hgemoiThage during its growth. On
the other hand, the mere size of the tumour is not conclusive,
since, as you know, a tibrous tumour of the uterus sometime.?
attains to enormous dimensions ; while further, the early stages of
its growth might all the more readily be overlooked owing tu the
lai-ge quantity of fat in the abdominal walls. Moreover, in spite
of the frequency of uterine hajmorrhage as a symptom of fibrous
tumours of the uterus, it is an accident by no means of constant
occurrence, and in some of the largest fibrous tumours that have
come under my notice, the only symptoms produced have been
purely mechanicah It is very unusual to find so large an ovarian
tumour without some sense of fluctuation ; the uneven nodulated
smf ace, and the mobility of one portion of the tumour upon the
other is, moreover, consonant with what one observes in tumours
of tlie uterus ratlier than in those of the ovary. The results of
vaginal examination, the solid tumour, the altered condition of the
lower segment of the uterus, the absence, or at least the impos-
sibihty of discovering the os uteri, unless it were represented, by
the small depression which I have mentioned, and lastly, the result
of puncture with the exploring needle, all seem to warrant the
conclusion that the tumour was uterine, and not ovarian.
In addition to these means of diagnosis, which will be found
more or less applicable in other cases, the position of the patient
during a vaginal examination is a matter of considerable import-
ance. If a woman assumes the usual attitude, the tumour
naturally falls towards the left side, carrying the uterus with it
To ascertain correctly the relations between the womb and the
tumour, the exananation shoidd be made with the patient lying
on her back, even though it should be necessarj% as very probably
THEIJI DIAGNOSia
281
It may be, for the sake of making a complete examination, to alter
her position, and to place her afterwards on her side,
I should perhaps add that tlie diagnosis between uterine and
ovarian tumours is sometimes still more obscured by the presence
of fluid in the abdominal ca\ity. Some degree of ascites is indeed
far fmrn unusual in cases of ovarian disease ; but its co-existence
with tiLirous tumour of the uterus is so rare that it may possibly
be forgotten. Twice, however, I have had occasion to tap the
abdomen in cases where a tumour was supposed to be ovarian, and
ii was only on a careful examinatiun, after the evacuation of the
fluid, that its real nature Ijecame apparent, and that the tumour
was ascertained to be connected with the uterus and not with the
ovary. Since, then, the two conditions may be present, it is wise
to abstain from forming a positive opinion as to the nature and
relations of any solid tnmour which may be felt in the abdomen
when much distended by fluid, and to wait till tapping has removed
the fluid, ami rendered the tumour accessible to a thorough
examiniition.
Another deviation from tlie ordinary chaincters of the disease
is seen when its symptoms set in with great suddenness, those
symptoms being generally either hti-morrhage, or retention of
urine. The sudden haemorrhage is sometimes assumed to be due
to miscarriage, and this upon groxmds as slender as a mere
impression upon the patient's mind that she was pregnant^ often
indeed a hope, rather than a belief, that this was the case, Tlae
great safeguard against this class of mistakes consists in never
taking a patient's statement as to the existence of pregnancy for
granted, but in always rjuestioning her cfcsely mth reference to
the date of her previous menstruation, and the evidence of her
alleged condition ; and if this is done, it will not infrequently
turn out that an assertion made most positively, is nevertheless
unsuppojied by a single tittle of prooL But further, the haemor-
rhage excited by a fibrous tumour is usually more profuse than that
of an early abortion — is often unattended by pain, while, when
pain is present, it is not of the same kind nor do the pain and the
bleeding cease at the same time as they do when miscarriage has
occun-ed. The causeless i-eturn of the bleeding in cases of librous
tumours generally removes the doubt which might have been felt;
while if an examination is made per vaginam, though in both
282
fOBOUS TUHOUHS :
cases the womb will be heavier than natural, yet the developed
lips of the OS, its patulous condition and soft texture, after a recent
miscarriage, difier much from the firm tissue of the neck of the
womb in the other case, its undeveloped lips, its small and scarcely
open orifice.
The other mode in which the symptoms sometimes suddenly
manifest themBclves is in the supervention of great difficulty in
voiding the urine, or in the occurrence of retention of urine such
as to necessitate the use of the catheter.
The occasional retention of urine is an occurrence by no means
infrequent, independent of organic disease, in women of a hysteri-
cal temperament, and cannot of itself be regarded as character-
istic of any one affection in particular. It is, however, weU to
bear it in mind, as being sometimes the first indication of the
eidstence of fibrous tumours of the uterus, while both it and
dysuria, and very frequent micturition, are less frequent atten-
dants upon ovarian tumours, except in those cases in which both
ovaries are aftected, and one occupies the pehis, while the other
fills the cavity of the abdomen. The reason for this difference
between ovarian and uterine tmnours is, I believe, to be found in
the tendency of the tumour of the ovary to rise out of the pelvic
ca\ity, while the fibrous tumour of the uterus still continues in its
original situation ; and, as it enlarges, either presses against the
neck of the bladder, or carries the uterus more and more fonvards
till it comes to press upon that organ, to irritate it, end even
mechanically to interfere with the discharge of its contents.*
This interference %vith the functions of the bladder is usually
most remarkable in those instances in which the tumour proceeds
from the anterior surface of the utenis ; and I relate the follomng
case Ixith in illustration of this fact, and also of another to which
reference has already been made, namely, the manner in which
some unwonted cause of uterine congestion may at once call into
painful distinctness a train of symptoms previously little felt, per-
haps even scarc;ely suspected
A woman, aged thirty-five^ married for eleven months, but who
had never been pregnant, was admitted under my care in Decem-
^ [An in toasting paper by Dr Hardie, Edinhurgh Medical Journal, JanTi&zy
1874» miiy he consulted on this point He attempts to aliow a t^oonuxion with, or
di^pendencti of retention of nrtne upon, the sweUing coincident with menstro&tiouj.
THEIK DIAG2f09]BL
283
ter 1852. Previous to her marriage, habitual dysmenorrhom liad
been the only form of ill health from which she had suflered, hut
since then she had been troubled with frequent desire to pass
water, and constant aching pain in the loinSi aggravated by
walking. The urine was either natural, or else threw down a
precipitate of the Hthates. The case seemed at first as thou^^h it
were simply one of uterine congestion after» marriage, and local
leeching 1>rought slight and temporary relief to the symptoms.
On examination per vt^'nam, however, the os uteri was found to
be directed nmch haekwai'ds, — it was very slightly open ; while
a tumour of a rounded form was distinctly felt in front of the
cervix, pressing immediately against the bladder, and the sound
introduced into the bladder encountered this same obstecle to its
introduction, wliich was overcome only after a little manipulation,
though no evidence was obtained at any time of the existence of
disease of that organ. The position of the os uteri, and the
circumstance of ita almost complete closure, while in cases of
fiexioB of the womb it is nearly always open, were two of the
reasons which led me to regard the cage as one of uterine tumour,
not of anteflexion of the uterus. In other instances of tumours of
the anterioT uterine wall, I have observed a nearly cxiual degree
of irritability of the bladder, hut coupled with biemorrhage and
other cliaracteristic symptoms of fibrous tumoui-s of the uterus
which in tliis case were absent
The discrimination between fibrous tumours of the posterior
uterine wall and retroflexion of the uterus, is often attended by at
least as much difficulty as that between the two opposite states
of anteflexion and tumour of the anterior walL These cases
iUustnite one remarkable fact, to which reference has already
been made when I was speaking of flexions of the uterus, namely,
the want of any constant rehition between the amount of mechani-
cal pressure on the rectum, and the degree of ditticulty in
deffecation. Sometimes, indeed, the presence of a tumour so
large as almost completely to fill the cavity of the jmlvis, will be
attended by scarcely any difficulty in the expulsion of the faeces,
while in another case, a growth of but small si^e will be accom-
panied by pain and difficulty in emptying the bowel, and the
presence of mucus in the evacuations will give unmistakeable
proof of the irritation to which it has given rise. The compara-
284
FIBEOHS TUMOURS ;
tively slow growth of a fibrous tumour, and the time consequently
given for the adaptation of parts to their new relations, no doubt
goes far to explain the general abBcnce of any serious difficulty
in defalcation; it occurred only in four of the ninety-six
instances on which my remarks are fonndci Nothing, how-
ever, is more variable than the amount of pain attendant upon
uterine ailments, and causes acting throngh the me<iium of
the general system, as well m others more local in their inHu-
ence, often excite intense suffering from some disease of the
womb which had existed for months or yeai"s before without
occasioning severe pain, perhaps even without producing serious
inconvenience.
Neither the amount of pain, nor the degree of difficulty in
defeecation, can be taken as afibrding any clue to the solution of
the question, whether we have to do with a retrotiected womb, or
witli a fibrous tumour of the posterior uterine wall The exact
relations of the tumour, the fact of the tissue of the cervix uteri
pasi^ing over into that of the tumour,— a characteristic of flexion
of the womb which the experienced touch will generally be able to
appreciate, — the state of the oa uteri, and the results of the intro-
dtiction of the uterine sound, which will remove the misplacement
and inform us of the weight of the uterus (supposing always that
we can intmduce it, thougli that is sometimes impracticable), ami
generally sufhcient to keep us from eiTor. In spite of all care,
however, we may sometimes meet with cases in wliich we shall
find it a most difficult matter to arrive at a certain diagnosis.
Need I say that the importance of a correct diagnosis consists* j
in these cases, not in its leading us to the adoption of any
special plan of treatment, but rather in its enabling us to re-
move much needless anxiety, to assure our patient that there
may be some misplacement of the womb, but that there is no
disease of the oi^an, nor any reason for anticipating an increase j
of suffering, still less for apprehending a painful and lingering j
illness.
The history alone of fibrous tumour may often raise the
suspicion that the patient is affected with cancer, for pain and
InemoiTliage may both be present, and the healtli may give way
under their continuance, while it needs but inattention to cleanli-
ness, and the allowing the coagula to remain in the vagina and
THETft DIAGNOSIS,
285
decay tbere, in order to produce the third symptom,— offensive
discharge, which is so often looked upon as almost pathognomonic
of malignant disease o( the womb. A vaginal examination, how-
ever, seldom fails to clear up all uncertainty ; so little is there in
common between the small os, the thin and undeveloped lips which
coexist with tihrous tumoiuv and the gaping orifice, with the
thickened, hard, irregular, and nodulated lips that characterise
cancer of the neck of the womb.
Error, however, is still possible, and Dr Montgomery, in his
valuable paper, to which reference has already been made,
mentions some instances where the pressure of a fibrous tumour
just about to project through the os uteri against the lower
segment of the womb, and the consequent alteratiun in the condi-
tion of the cervix, had led to the mistaken supposition that cancer
existed. Care ought to prevent you, I think, from falling into this
mistake. More difficult, however, is the diagnosis between cancer
of the body of the uterus and fibrous tumour of the oi-gan ; and
the risk is considerable, in spite of much watchfulness, of your
taking the more for the less serious disease. When speaking of
cancer of the womb, I shall shortly have occasion to refer again to
this subject. At present it may suffice to say that the more rapid
progress of the malignant disease, the persistence, though not of
necessity the greater abundance, of the haemorrhage, and the want
of mobility of the uterus, tliough its size be not such as to occupy
completely the pelvic cavity, are some of the more important
characters by which we may usually recognise that rare affection
^-cancer of the body of the womb.
Though not likely to induce any positive error of diagnosis,
there is yet another deviation from the ordinary sjmptoms of
fibrous tumours of the uterus which caUs for some notice. It
happens now and then that they are accompanied by attacks of
pain of such intense severity as to be almost unbearable, the pain
lieing evidently neuralgic in character, ceasing abruptly, returning
causelessly, and being Irnt little amenable to any kind of treat-
ment. These attacks do not seem to be dependent on the size of
the tumour, nor on its situation, and are certainly not connected
with any special pressure exerted by it on any organ, or on any
set of organs. In one case, in which it continued for years to
return occasionally, a sense of weight and burning referred to the
2S6
FIBEOUa TUMOURS :
womb being experienced in the intervala, the tumour was im-
bedded, as far as could be ascertained, in the posterior uterine
wall. Meeatmation was irregular but profuse ; its occurrence
had no influence either in increasing or in lessening the uterine
pain. The patient was at different times under mj care with
little benefit, and many trials were made of preparations of iodine
without her being able to continue the remedy. At length, after
the lapse of foui- yeai-s, she became able to take iodine without
the disturbance of health which it had previously occasioned, and
after about six weeks' continuance of it, both the abiding and the
paroxysmal pain were greatly lessened, though the condition of the
tumour remained unaltered.
The other case was one of a still more remarkable character. A
stout, tolerably healthy-looking woman, but whose somewhat
bloated face confirmed the suspicions which her calling as the wife
of a publican excited, presented herself one moniing at the out-
patient room of St Bartholomew's Hospital, At that time her
appearance and manner presented every sign of most intense
agony ; drops of perapkation stood on her forehead, her skin was
cold and clammy, and her pulse feeble. With these manifesta-
tions of extreme suffering, there were associated a disposition to
weep, and also a good deal of (fiobus hystericus. After being some
little time in bed, the intense pain subsided, and she then gave
the following account of herself : — She wm thirty-three years old,
had been married seventeen years, had given birth to one live
child at the eighth month, and had miscarried three times at early
periods ; twelve years having elapsed since her last miscarriage.
The catamenia had always been regular in their return, but for
the last two years the discharge had been more profuse than
before. For sixteen years she had had occasional attacks of pain
similarly those from which she suftered when she came under my
notice, but the attacks had always been mitigated by cupping and
leeching. For eight years, however, the pain had returned
regularly immediately after the cessation of menstruation, and
had continued for about a week after each period, the paroxysms
returning every two hours, and lasting from half an hour to an
houn Her health w^is generally best for a week before, and
sometimes during menstruation, though the pains had greatly
increased in their severity, and were sometimes brought on by
THEIE DIAGNOSIS.
287
exertion, or by sexual intercourse, while rest in the recumbent
posture always relieved them. The patient coroplaioed, besides,
uf a sort of cramping pain during micturition, and of difficult de-
ftiecation, as if fmm some substance contracting the paasage for the
faoes. When the pain came on she sat up in bed, swaying
herself from side to side, weeping loudly, complaining of pain like
the throes of labour, and also of a choking sensation, all of which
subsided by degrees in the course of about half an hour. The
abdomen was full ; its size, which was considerable, was partly
due to fat with which the integuments were loaded ; on laying
the hand upon it, spasm of the abdominal muscles was im-
mediately excited; and this for some minutes pi^vented the
attempt to determine whether any tumour was seated there
or not, though after a time this was settled in the negative.
The uterus was situated low down in the axis of the pelvic
outlet; its anterior lip was thi-ee- fourths of an inch longer
than the posterior ; the tissue of the cervix was healthy, the os
circular, and sliglitly open. Behind, and to the left of the
uterus, and extending also slightly in front, was a firm uneven
ncKlulated tumour, tender on pressure, connected, though appa-
rently not very intimately, with the utenis, but which w*as
ascertained by repeated examinations, and by evidence of the
uterine sound, which discovered the cavity of the organ to lie
four inches anrl a half
of the womb, and not
appendages.
At first quinine was gfiven in large doses and at short intervals,
but witli little eHect ; and I may state my general impression,
that t|uinine oftener fails to arrest uterine neumlgia than to
relieve pain seated in other systems of nerves. Afterw^ards the
pain was kept in check by opium, and the patient left the
hospital relieved, but not more than might be expected from
quiet, a regulated diet, and the anticipating each attack of sufTer-
ing by appropriate treatment.
The most frequent and the most important exceptional pecu*
liarities of these growths have now been passed in review ; but
reference ought perhaps to be made to the distinction Ijetween
fibrous tumours and pregnancy, and to the discrimination of preg-
nancy when it co-exists with tumours. Of the two, I believe
ng, to be in reality an outgrowth
tumour simply connected with ita
tmOIIS TUH0UB8 :
the latter to be far the more difficult ; and, indeed, when we find
the size of the womb obviously increased by fibrous outgrowths,
it is almost a pardonable eiTor to attribute to them the whole
increased bulk of the oi-gan, and to lose sight of the possibility of
a physiological cause having a share iu the production of the en-
largement. No direction can be laid down such os will always
keep from error ; the best safeguard is perhaps to be found in our
making it a rule for our guidance, iu every case of doubtful
tumour, to prove the non-existence of pregnancy before advaocing
a step further in forming a diagnosis. It is to be remembered,
sadly strange as it may seem, that there is scarcely any disease,
however formidable or however loathsome, in spite of which
sexual intercourse and conception may not take place. Vesico-
vaginal listnla, the most repulsive disease of tlie external organs,
cancers of the vagina or of the uterus, are far from proving the
bar to cohabitation that might be expected — a cohabitation often
on the woman's part sulmiitted to vtith pain of body and anguish
of mind ; for, indeed, it is in her sex, much less often than in our
own, that "the Centaur not fabulous" finds its aptest illustm-
tions.
Ueference has already been made to the different condition of
the womb in pregnancy from that which it presents when enlarged
by fibrous tumour ; and the dissimilar state of the lips and orifice
of the womb, and the diflerent consistence of its enlarged lower
segment, will generally suffice to keep the attentive observer from
error* It is, indeed, from relying on the evidence furnished by
some one or two 3}Tnptoms of pregnancy, and not taking into due
consideration the counterproof aQbrded by other symptoms, that
mistakes are almost always committed, Tlie uterus is found
enlarged, and its lower segment expanded ; movements supposed
to be ftetal are felt l>y the patient, and a sound resembling th€
uterine souffle is perhaps detected, and the existence of preg-
nancy is at once assumed ; no account being taken of the
occurrence of haemorrhage, of the non-development of the uterine
lips, and of those other phenomena which ought to have excited
suspicion; — which, duly weighed, might have at once proved
the case to be merely one of uterine tumour. It is well to
bear in mind that, in some cases of fibrous tumour a sound
is perceptible closely resembling the uterine souffle, and corre-
A
THEIH DIAGNOSIS.
38»
sponding witti it in situation, and in the extent of surface
over which it is heard.* The caution which this fact suggests
must not l>e lost sight of in any case of doubtful pregnancy,
and indeed it will be scarcely wise to allow our opinion to
be awayt^d in either direction by the presence or absence of
the sound.
The complication of fibrous tumour with pregnancy may inter-
fere very seriously with the detection of that condition, partly by
the misplacement of the womb which it frequently producer, the
conse<j;uenfc alteration in the form of the organ, and the difficulty
that it may give rise to in attempting to reach the os uteri ; and
partly by the impediment which the deposit itself may offer to
the occurrence of the physiological changes in the orifice, neck,
and lower segment of the womb.
Some time since a case was under my observation in the
hospital, in which I overlooked the existence of pregnancy ;
and I will relate to you some particulars of it as illustrating
the circumstances that may conspire to throw you off your
guard, and to obscure almost completely the usual symptoms of
pregnancy.
A woman, aged thirty-eight, who had been married twelve
months, but had never been pregnant, stated that she had had
tolerably good health, and had menstruated regularly until seven
weeks before she applied for admission, when the dischaigo
suddenly ceased after exposure to cold. Four months before I
saw her she first perceived a hard, painless swelling, about the
size of an egg, below and to the right of the umbilicus, and this
* In WolU'r's remarkable case, to which reference haa already been tniid<*. a
load soatQe contributed for a titnt* to ohscatQ the diagnosis. Soveral inatancea
of loud uterine soniBe co-existiug with uterine tumour, and independent of preg-
uancj, an related hy J. A. H, Depnnl, Traits (f AuKtUiatim Offdetricalt^ Svo, I*ariJ^
1847, pp. 209-222. My own observation, indeed^ would lead me to regard the
txiitCKuso of a sonflie in casea of fibrous tumour aa much nrer than it h alleged to
be by others. Dr J!*Cliutock, VHnical Not4$^ p, 130, refer* to it aa not uncommoug
though he N^lieves, and with much probability, that its occurrence i« limited to obm«
of interstitial fibroids. Winckel, quoted by Guaaorow, loc. dt. p» 66, itotes that be
discovered it in 54 per cent of all ca^e^, — an assertion which, if it ia intended to apply
to any sound in the least degree simulating the uterine isooflle, appears to me greatly
ezBggented. I have never heard tt in ornrian tnmoms, and Mr Rpencer Wella
•pwlu of it as extremely rare In them, tliough common in uterine outgrowtha^
/NMOMf of the Ovaries, vol ii. p. 188.
T
290
FIBROUS TiTMOmta ;
increased until it had attained half its suhseqiient size, without
any disturbance of her health. Since the cessation of her menses,
site liad suffered from pain in the back and loins, which, slight at
first, liad by degrees become very severe, and at length compelled
her to seek for medical advice. Leeching and rest bad relieved
her pain, but the tumour ^(radaally increjised in size. Three
weeks before her admission, a discharge, said to be menstrual,
again made its appearance, and continued for a week, when it
ceased for two days, but then returned, and was stdl going on
when the patient came under my care.
The abdomen was occupied by a tumour, which was not
symmetrical, but more prominent on the right than on the left
side of the umbilicus, reacbiug up to about its level, extending to
within about an inch and a half of the left crista of the ilium,
and completely occupying the right iliac region. It was hard,
unyielding, seemed about the size of an infant's head ; was tender
on pressure upon its most prominent part. On examining per
vaginam, the finger came at once upon a spherical body, occupy-
ing the pL>sterior half of the pelvis, and pressing the neck of tbt*
womb closely against the symphysis pubis. This tumour, which
was firm though somewhat elastic, began immediately beliind the
cervix uteri, which was about half an inch long, the hps soft,
and the oa open enough to admit the finger, while the cervica.1
canal was not closed, nor could any mucous plug be detected
in it.
After the patient's admission, there was very little hamion-hage
from the uteriLS, but she had frequent attacks of very violent pain
of an expulsive character. Opiates mitigated the severity of
these attacks and controlled their frequency, and at the end of a
month the psitient left the hospiUd much relieved, her abdomen
measuring thirty -three inches at the umbilicus, as on the day of
her admission,
A month after she left the hospital she was prematurely con-
fined of a still-born child at about the sixth month of utero-
gestation, and her recovery after her labour was retarded by an
attack of uterine intiammation, of which the patient spoke as
having been very severe* Nine weeks after her delivery, I again
saw her, and found her uterus low down and fixed in the pelvis,
the enlarged, elongated, and much tliickened cervix being closely
I
I
PROGNOSIS CONCERNING THEM,
291
in apposition with the anterior pelvic wall, while a lai^e tumour
connected with, and growing out of, the posterior uterine waU,
completely filled the pelvic cavity, and greatly contributed to the
immobility of the organ.
It were time wasted to dwell at length on the causes which
rendered the diagnosis of pregnancy so difficult in this case, or
which indeed prevented any suspicion of it being entertained.
Unsuspected by the patient herself, some of its symptoms were
doubtless unttoticed by her ; while the continuance of a discharge
like that of the menses^ its subsequent suppression for a short
period, its reappearance and persiatence for three weeks liefore
she was received into the hospital, all seemed moi-e like the
evidences of disease than any of the ordinary' results of pregnancy.
Examination* too, detected a tumour occupying the pelvic cavity,
and which was cleariy a fibrous outgrowth. This very tumour
prevented the ordinary changes in the lower segment of the
uterus from taking place, and thus led to the behef that uterine
disciise, and disease alone, existed You know, however, thai
a correct diagnosis implies, not simply the discovery of the
patient's disease, but the formation of a right judgment concern-
ing that patient in all respects. The public feel as little res|x^ct
for an incomplete diagnosis as for one that is altogether
wr<jng.
It is not possible with reference to any disease whose pr<»gress
ia 80 variable and course so nneeilain as that of uterine fibrous
tumour, to make any general statement concerning the pro^^nvsis
that we sliould form» for the contingencies are very numerous by
which the patient's condition may l»e modified. Thus rnueh,
however, may be stated : that apart from the risks attendant on
pregnancy and labour, fibrous tumours do not tend generally, nor
ever rapidly to tlie destiiiction of life, though they undenuine a
person^s health, and must often make lier an easy prey to any
intercurrent disease. In only one out of the ninety-six cases on
which these observations are based did the patient die of hiemor-
rhage, and the fatal event in this instance occurred nine years
after the appearance of the first symptoms of the disease ; while
in the other two fatal case^ death was due to uterine and
peritoneal inflanmiation aft«r delivery. The subjoined table, which
shows the duration of the symptoms at the time when the
292
FIBROUS TUMOUBfl :
patients first came under my observation, illustrates the com-
paratively slow coarse of the affection.
The sjinptoms had lasted less than . . 1 year in 23
„ „ between 1 and 2 years in 8
for
In 1
who died after delivery^ the existence of the tumour —
waa not saspccted tUl labour took place. Total, 96
Unlike, then, any form of malif^iiant disease, uterine fibrous
tumour shows no constant tendency to advance or to increase ;
and if we are compelled to allow that medicine furnishes no
certain means by which to arrest its ^owth, and that snidery can
but seldom be called to onr aid, it is yet a consolation to be able
truthfully to assure our patient that the much dreaded ailment is
yet less formidable than it was supposed to be, much less bo than
it has often been represented.
I purposely, however, excepted one contingency when mention-
ing the comparatively small risk to life from fibrous tumour of the
uterus, and spoke of the disease apart from the dangers that
attend upon it when associated with pregnancy, labour, and the
puerperal state. We have already seen that the existence of
fibrous tumours in the uterus lessens the chances of conception,
and it is fortunate that it does so, for the increased afflux of blood
towards the womb which pregnancy occasions is almost sure to ac-
celerate the growth of any tumour connected with it. Pregnancy,
indeed, when it does take place, often has a premature termination ;
PROGNOSIS WHZN ASSOaATRB Wmi PREGNANCY*
for the presence of a tumour in the wall of the uterus interfereg
with the regular development of the organ, and thus in many in-
stances ahndges the term of gestation. Kot long since a patient
was under my care, in whom the existence of a tumour, imhetlded
in the left wall of the uterus, was ascertained soon after the occur-
rence of an apparently causeless raiscarriaga Four other miscar-
riages have since successively occurred, and no other reason can be
assigned for them than that which the uterine tumoiu' suggests,
[In many cases, including probably all the subserous, no change
is produced by pregnancy except such physical changes as in
position and shape. But, in the imbedded or intramural kind,
the tumours frequently partake in the hypertrophy of the
womb, — increasing in bulk during pregnancy, and becoming
atrophied after miscarriage or delivery at term ; and the hyper*
trophy and atrophy have been ascertained by the miscroscope to
be exactly as in the prfjper uterine structure. The increase of
size is accompanied by such softness and juiciness as permits a
feeling as if of fluid, or a spurious fluctuation. In a case of this
kind whose whole course I was able to follow, the increase of size
was to at least three times the original linear dimensions, and so
was the subsequent atrophy. When at its greatest dimensions, it
felt so like a cyst and caused so much distress that a fellow
practitioner desired to puncture it. In this case the tumour did
not disappear entirely after delivery, but cases are recorflerl in
which this result is described as liaving fortunately ix^ciirred.]
But there are greater evils than either sterility or the premature
tennination of pregnancy, to which patiente aflected with fibrous
tuTnours of the uterus are liable. The annab of medicine are
full of cases illustrating the dangerous character of this complica-
tion, which may expose the patient to one or all of three different
perils. The tumour may mechanically prevent the passage of the
child through the pelvis, and may thus even necessitate the per-
formance of the Coesarean section. It may interfere with the
efficient contraction of the uterus after the expulsion of the
placenta, and thus expose the patient to lucmorrbage which it
will be very difficult to control. Or lastly, it may interfere with
the processes of involution of the womb after deliver)^ and may
either itself undergo a morbid softening and disintegration, or may
be the occasion, either in connexion with inflammation of its own
iu
FrBROUS TUMOURS.
substance and of that of the womb, or independently of it, oi
peritonitis, always dangerous, too often fatal
While I beheve the risk of any of these untoward occurrences
complicating labour to be very real and very serious, it is never-
theless my impression that the danger has been overstated by
some writers of very deaer%"ed reputation. There can be no doubt
but that the peril depends in great measure on the intimacy of
the relatione between the tumour and the uterine substance ; and
that those pediculated outgrowths which spring from the peri-
toneal surface of the utems are of no great moment except in so
far as by their size and position they encroach on the pelvic
cavity, and interfere with the passage of the child. I know four
women, one of whom has given birth to one child, the others to
several, from the fundus of whose uterus there springs a tumour
ha\ing all the characters of a fibrous outgrov^th ; and yet, mth
the exception of some disposition to haemorrhage in two of the
cases (and that, indeed, by no means difficult to restrain), labour
and its consequences have been uninterrupted by any imtoward
occurrence. Even in other instances, the exceptions to an un-
favourable issue are far too numerous to warrant us in admitting
the disposition to disintegi'ation and softening or suppuration of
the tumour to be as invai-iable an attendant on advanced preg-
nancy as some writers suppose. My own experience, too, leads
me to connect the fatal issue, when it does take place, more with
peritoneal inflammation than with any constant change in the
substance of the tumour ; while, lastly, it is not to be forgotten
that the softening and diaintegration of fibrous tumours, when
they occur in the unimprcgnated condition, are not attended by
any formidable symptoms.*
The bearing of these facts on the question of the induction of
premature labour in pregnancy, compUcated with fibrous tumours
of the uterus, must be reserved till after I have said what little
there may be to tell you with reference to the general treatment
of tlie disease,
* With rt.'fereii(?e to thia subject and the practical question* connected with it,
the reader may conaah Puebelt, Dc tamoribuit inpelvi partum impedietUibw, Svo,
Heidelbeft^, 1840, cap. I ii. v. [►p. 68, 66, 104 ; Anhwcll, Guy's HospUal Bep&rts^
vol i. p. 300 ; LeFer, ihid, vol vii. pp. 98-103 ; and some rerimrksbjf Sir J. Siinpaoii
which firat appeared in the Edinburgh Monthly Journal ^ Atigmt 1847, and are re-
published at p. 833 of vol I of hii collected Obstaric Works, 8vo, Edinburgh, 1855.
I
I
I
I
I
LECTURE XVL
UTERmE TITMOURS AKD OUTGROWTHS.
Fibrous Tfhours. Treatment. Precautionary measure.^ to retard their growtli ;
m&tiiig^emeut of meDBtni«l j^ricMls, nod palliative treatmfnt, Alli'getl gpfcifica:
iojine, bromine, the waters of Krenxnach. Sargieai proceedings; great hazard
attending them ; lessened by recent improTements in abdominal »iirgery, Bourcea
of danger^ and management of pregnancy and labour complicratcxl with fibrous
tamoUTs. Rare varieties of tumour, occassional exceptional sources of hortnorrhage ;
and how to treat it Occaaioual ways in which tumoor proves fataL
Wb now come, last of all, to the consideratioD of the treatnuni
of fibrous tumours of the uterus. The treatment, indeed, of an
irremediahle disease may seem to require but brief notice, and to
present but slender interest to the student of medicine. But in
fact it is not so. There are as large opportunities for skill in
palliating the irremediable ill, as in curing the sickness which
gives the widest scope for the healing art to show itself most
sovereif^n ; and there are occasions, too, far more nuinei*ou3, for
the exercise of all those sweet charities of life which render our
profession in its right exercise so unalloyed a blesaing to man-
kind. Hereafti^r I shall have to plead the same reasons for be|T-
ging your most heedful attention to the management of cancer, and
of other aOmeutjs more hopeless, more constantly, more quickly
fatal than that vvdiich we are now studying. I urge tliem on you
now, liowever, because there is a not unnatural disposition on the
part of the student and the young practitioner to fix their atten-
tion on the great diseases which admit of great remedies, and to
pasB almost unnoticed the slow, wearing ailments, in which each
day's suffering is hke that of the day before ; with no prospect,
indeed, of return to health, but with a decline so tardy, marked by
80 few events, that the shadow on the diid seems scarcely to go
down at all.
Fortunately, in the present cade, the disease often has pauses
k
296
FIBROUS TUMOTJBS :
in its course, which, though uncertain alike in their occurrence
and their daration, are yet frequent enough to lend a little
brightness to the patient*8 prospects. These, too, are still further
cheered hy the rare accident of a perfect recovery being now and
then brought about by nature's hands ; while concerning it we
can foretell so little, that every patient may with almost equal
reason hope that she herself will prove the happy exception to
the general rule.
We have already seen enough of the conditions that favour the
development and growth of fibrous tumours to be able to infer
the nature of those precautions by which their increase may be
retarded. We find their gro%vth to be moj-e rapid, and their
symptoms generally to be more formidable, during the years of
sexual activity than after the time when those fimctions have
ceased ; wldle pregnancy and its consequences are not only
attended by certain positive dangers, but appear to be accom*
panied by a greatly accelerated mte of increase of the disoasa
Hence it may be regarded as a fortunate circumstauce \v!ien the
symptoms of this aflection come on comparatively late in life, and
we then venture to hold out to our patient the expectation of
amendment taking place when menstruation ceases. Hence, too,
a more encouraging prognosis may usually be expressed in the
case of an unmarried woman or of a widow, than of one who is
still cohabiting with her husband. Apart, indeed, from the
occurrence of pregnancy, there can be no doubt but that mere
sexual intercoui*se is injurious to patients with fibrous tumour,
and that tlie congestion of the uterus and pelvic viscem, and the
increa.sed vitality of the sexual organs which the act induces,
favour its increase. If, then, your patient is a married woman, it
is your duty to acquaint her with this fact ; it is not generally
your duty to do more ; for often there are complicated questions,
both moral and physical, involved, which you Tinist not ignore,
but into which, unasked, you have no right to intrude.
But while you most to a great extent leave this matter to be
settled by your patient, there are some other points concerning
which your advice cannot be out of place. Independent of the
risks of haemorrhage which attend it, the menstrual period is
always unfavourable to this claas of patients, and the moi-e quietly
you can succeed in conducting them through it the better*
THEIH TREATirENT.
297
Absolute rest through the whole of eiich period is of great
importance ; while, if much ha^niorrhafre or severe pain accom-
panies it, the patient should remain in her bed for the tirst forty-
eight hotii-s, and should not move further than to her sofa during
the whole of its continuance. If it sets in with severe pain,
associated, as m usually the case, with abdominal tenderness, a
few leeches over the hypogastrium, or over the tender part of the
tumour as felt through the abdomen, will often be of service, but
the caution which I have already given as to the inexpediency of
leeching the uterus just before the commencement of a menstrual
period, holds good in this case. Both the pain and the haemor-
rhage are often much lessened, not only by keeping the bowels
acting with regularity at all times, but also by giving an aperient
just before the discharge commences. If menstruation should be
very excessive, the case must be treated just like any other case
of menorrhagia, and in anticipation of profuse loss of blood,
astringents may be employed from the very first day of the dis-
charge appearing. Not infrequently there is a disposition to
intercurrent hEcraorrhage between the periods, which may in
many instances be warded off by complete rest at the time, by
the avoidance of all stimulants, by salines and sedatives, such as
the citratii of ix>tiisli with tincture of henbane, and by the applica-
tion of a few leeches to tbe abdomen, if the threatenings of loss
of blood ai-e accompanied with much pain, I do not think thot
in cases of fibrous tumour of the uterus veiy much is gained by
the application of the leeches directly to the womb itself, though
in simple hypertrophy of the organ that constitutes our most
efficient mode of treatment. Sometimes, however, when men-
struation is sc4inty, and, as is then generally the case, painful ; or
when there is considemble uterine tenderness and a puffy or
indurated condition of tlie cervix, much is obtained by this
measure. I believe, however, that then it is the gene ml state of
the utems, rather than the tumour of the organ, which is bene-
fited. Much standing, much exertion, and especially much walk-
ing, are all objectionable, for all tend to produce and to keep up
a congested state of the pelvic viscera. If these, however, are
mteidicted, and the patient is thereby condemned to a sedentary
life, it is obvious that to maintain her health she must adopt a
mild, unstimulaiiiig diet, that she must live more simply, even
398
FIBEOirs TtTMOTTRS :
more abstemiously, than before. On the degree to which you can
command your patient's confidence, and can induce her to adopt
this somewhat self-denying kind of life, and on the extent to
which she has fortitude to persevere in it, month after month,
even year after year, will depend the measure of her health, her
comfort, and her powers of usefulnCvSs,
It would profit hut little t<3 repeat all that has been said before
when treating of dysmenorrhcea and of excessive menstruation ;
for the rules then given and the remedies then suggested apply
equally to the mitigation of pain or the suppression of bleeding
when dependent on fibrous tumour. It may not, however, be
superfluous to add, that the steady observance of the hygienic
rules which I have laid down is of more importance tban the
mere use of medicines for the permanent mitigation of either of
these symptoms.
But it may be asked whether there is no remedy that exerts a
specific influence on the growth of these tumours — none by which
we can obtain their absorption, or at least feel sure of putting a
stop to their growth ? I very much fear that no such remedy
exists, or at least has been at present discovered. Mercurial pre-
parations most certainly have no such influence ; and the alleged
powers of iodine seem to have been very much overrated, for in a
very large proportion of the instances in which it has been per-
severingly employed, no effect whatever has appeared to follow
its administration. The disintegration of the tumours, and their
expulsion, have never, in my experience, succeeded the continued
use of preparations of iodine, but have taken place unexpectedly,
and independent of any assignable cause. Still it is possible that
the rapid increase of these growths may be sometimes restrained
by this agent^ and I therefore employ it as our best, though but
an uncertain remedy, and with a yearly lessening faith in its
efficacy. To gain anything by it, indeed, it is essential that its
use should be continued for many months ; and, in order to this,
the patient must be brought very gnidually under its infiuence,
since large or frequently repeated doses often disorder the diges-
tion^ occasion sleeplessness, or produce a febrile condition, which
compels the discontinuance of the medicine. I seldom give more
than one grain of the iodide of potass, with twenty minims of the
syrup of iodide of iron, twice a day ; and though in addition I
THETtt TREATirENT.
299
^generally recommend the inunction af an iodine ointment over
the tumour, yet this is rather as an additional means of impi*eg-
uating the system with iodine than oo account of any marked
local influence which its employment in this manner has seemed
to me tu exert. The introduction into the vagina of halls of
iodine ointment, for the sake of the supposed local action of the
remedy on the tumour, does not appear to me to have evidence
in its favour suthcient to counterbalance the obvious disadvan-
tages attendant on constant local medicution of the womb, and the
didJy introduction of irritanL'3 into the vagina. The simie kind of
objection, with the additional drawl lacks attendant on the proved
inefficac}^ of mercurials, attaches to the local use of the unguentum
hydrargyria and its injection, as has been recoumiended, into the
cavity of the womb.
The bromide of potassium has been spoken of as of superior
eflicaey to the salts of iodine^ I cannot say whether it deserves
this character or not ; but it certainly has the advantage of being
Iwiitter tiilerated, and for a longer time, by the [»atient. It must
also be remembered that the waters of Ki'euznach* in Germany,
which have acquired considerable reputation for the special in-
fluence which they are supposed to exert over enlargements and
fibmus tumours of the uterus, contain salts of bromine in much
larger quantity than those of iodine. I am much at a loss, how-
ever, aa to how far the alleged influence of these waters on fibriDUS
tumours is a real one, and must confess that in no instance have
^ Dr Satro, in his work od the Owmem Min$ral Waien, 2d o(L LondoiL, 1S65,
girvs at pagie 17S the foUowing reiitlt of an inalyiis by Profeasor Lowig of Zuricb,
of tli« contonU of tdxtoen oti&ces of the water : —
72 'SS cMoride of aoditun
1S*3S IP calcium
4 07 ,, magnefliani
0 62 „ potaaamm
O-fll ,, lithiuta
0 i^T broiuidc of magnestum
0-03 iodide ,,
1 '39 c«xbonat« of limia
GDI „ baryta
O'lO magnoaia
0-16 oxide of iroti
0*02 phoaphate of alumina
0'12tfilica
04 02
too
HBHOUS TUMOTJKS :
I seen any marked diminution of a tumour result from their use,
still lesa have I known a tumour become absorbed or disappear.
The waters are no doubt possessed of great potency, and in many
scrofulous and secondary syphilitic affections prove of much
service. The mode of their employment, too, is very energetic, so
that failure cannot be attributed, as when the watei^ are used in
this country, to the imperfection or insufficiency of their applica-
tion. For six or seven vreeks the patient spends three-quarters of
an hour daily in a bath, the sti-ength of which hi\B been increased
by the gradual addition of from twenty-four to thirty pint® of the
mot hi' r h/c,ov liquor which remains after evaporation of the water,
to four hundred pints of the water. Besides this, twice a day for
an hour togetlier, warm fomentations of the mother lye are applied
to the abdomen, and these fomentations are increased in strength
until they produce a burning sensation, and an eruption of pimples
on the surface. The patient, in addition, takes the waters
internally, and employs an enema of two ounces of the water, with
twenty to thirty minims of the mother lye, every day after the
bowels have acted. This treatment is continued until constitu-
tional symptoms, indicative of what is regarded m saturation of
the system with the remedy, are produced ; and then, after a
pause of three or four weeks, a second similar course of four or six
weeks is undergone, and this plan is repeated in many instances
for two or three successive summers.*
If to this energetic treatment there be superadded the obser-
vance of all those subsidiary measures, often too hard to enforce
in other circumstances, but which seldom fail to be attended to
when a patient leaves lier home and places herself for some
months under the care, not of an ordinar}^ practitioner, but of one
who seems to preside as a sort of genius of the place over the
wonder-working spring, we certainly have all those conditions
assembled from which most striking results might be anticipated.
My own conclusions, however, are fully borne out by the greater
experience of Scanzoni,t who says that he " does not believe that
by these means any important diminution of a real fibroid tumour
• For this account of the plfto puraiied at Kn^uznach I ara indebted to a letter
from Dr Eiigelmann, who has practised there for many yeara, and has writt<»n a
little hook on the use of the waters in seoondAiy syphilitic Atlectmna^—Th^; Bath4
of Krtuznaek, 8vo, Frankfort, 1852.
t O^h at, p. 287.
THKR TREATMENT,
301
has ever been effected.'* It seems, too, from the statement of Dr
Primer hiniself, a gentlemaa who first brought the waters of
Kreuznach into notice, and who for many years practised there
with well-merited reputation, that by far the greater proportion of
cures occurred in liis experience in ca.'^es of simple hypertrophy of
tlie uterus, and not of fibrous tumours of the organ.
My own observation confirms Dr Prieger's statement. I have
aeen simple enlargements of the uterus consequent on chronic in-
flammation of the organ, or a deficient involution after delivery or
miscarriage, much reduced in bulk; and I have also seen the
womb in whose substance fibrous tumours were imbedded grow
smaller, not fi'om reduction of the tumour, but from lessening of
the hypertrophy of its tissue, to which the tumour had given rise.
With this improvement, too, in the local condition, there has been
a lessening of the discomforts from wliich the patient previously
suffered. I do not know, however, that 1 have seen this relief, in
cases of fibrous tumours, persist for long after the patients return
home, or her attempt to resume her previous mode of life ; nor
have I found it U^ be more complete or more lasting than I have
seen follow in other instances from obedience to simple rules
deduced from general principles of treatment Still, when our
remedies are so few, we cannot well afford to dLspense with any,
even though their viitues may be questionable; and I often
aaaction, or even suggest, a visit to Kreuznach, though accom-
panying it with a hint that relief of discomfort, rather than
absolute cure, ie all that I can promise from the experiment
I should also say that of late years the Kreuznach salt and the
motlier lye have been imported into this country ; and patients
anxious to make trial of their virtues can obtain them from most
of the principal chemists in London. They are employed either
in hip'baths, or in the form of epithems worn over the lower part
of the abdomen, and I have known patients ol*tain relief from
both of these proceedings. I doubt, however, whether the latter
does more than act as a moderate counter-irritant, and whether
tlie comfort afforded by the former is not due as much to the
soothing influence of the warm water as to the medicinal action of
the salt which it contains.* One other alleged remedy, the
• One pint of the mother lye and one pound of common s< in an ordinary
lup^batli at 8<S* is a suftiGiently close imitation of tbo baths of the mineral spring
302
FIBROUS TUMOITRS :
chloride of calcium, calls for mention. It is an old remedy mucli
used by Professor Hamilton of Edinburgh, and was reintroduced
into practice by Dr Rigby, and at one time was employed rather ex-
tensively by Mr Spencer Wells, on the assumption that it promotes
the calcification of fibrous tiunoura if continued for one or two
years. Since, however, there seems reason t^i believe that it also
promotes calcareous deposit in the coats of the arteries, it scarcely
comes within the saving clause of anceps remedluTib meiius quam
nuUujju If medicine, however, is so slow, and confessedly so uncer-
tain in its action upon these growths, are they, you may inquire,
equally beyond the reach of surgical interference ? There seems
to be no doubt but that as far as one of the sympt4>ms, the
haemorrbage, is coucerned, surgical and even mere manual inter-
ference is sometimes of much use. Interstitial fibroids when
situated low down in the uterus produce haemorrhage, just as
pediculated tumours also do by their pressure against the lower
segment of the uterus. In such cases incisions into the cervix,
which need not be very deep, nor carried up to the internal os
uteri, have a remarkable influence in stopping the bleeding, and
Dr Barnes* says that on many occasions he has found the
lia_^moiThage equally arrested by simple dilatation of the cervical
canal This too allows the local application of some stj^tic to
the surface of t!ie tumour, or even, if need be, of the injection
of the perchloride of iron int^^ the cavity of the uterus* But
surgery did not williugly in its function limit us to dealing
with a single symptom, and the observation of cases in which the
death of part of the investing membrane of a fibrous tumour was
followed by its disintegration, aud at length by its complete
enucleation and expulsion, led to the endeavour to imitute by art
this occasional eflbrt of nature. With this view three different
proceedings have been resorted to ; the detaching from the surface
of the tumour a portion of its investing membrane, the gouging
out a portion of its substance, and the destruction of a portion of
it by the hot iron. Of these tliree proceedings, the first is not
itaeir, diffpring from it chiefly in being stronger than tbe baths are at Kreuznach,
io will eh the whole botly is imTfierst'd.
• Op. cit. p. 773. |F(ir a fuU discuasioti of this subject, with illuatratiFe caaes,
see two papers by Dr Matlbi^ws Duncan, *'0n Hiemorrhiige from Fibrous Tumours
of the UteniB : Its Nature, Source and Surgical Treatment," in Edinburgh Medical
Journal for Janoary and February 1367.]
THEIK SUBGICAL TREATMENT.
808
always easy of accompliBhment, while it is very rarely of avail ; the
second set8 up disintegration in many cases, bnt sets up not in-
frequently niiaoluef which extends to the uterus and proves fatal ;
and there are not instances enough on record to enaV»Ie one to
estimate whether the risk of setting up this process hy means of
the hot iron Is less than that of exciting it hy the gouge.*
Besides these indirect methods, as they may he termed, a more
direct mode of proceeding was introduced into practice hy Jbf.
Amuisat, and has had since numerous imitators, with various
snooesB. His oiieratiou consists in the enucleation of tihrous
tumours of the uterine walla by an incision made throngh the os
uteri, or the lower segment of the womb. No one can have
noticed the exti-emely loose connexion between the uterus and
fibrous tumours imbedded in its substance,, without the feasibility
of an ojieration for their removal occurring to bis mind, and it
was suggested on theoretic^il grounds, by M. Velpeau, some years
bef(>re the idea was put in practice in 1840 by M, Amussat. The
results of it, however, are by no means encouraging, so long as we
limit our inquirj^ t4:j cases of enucleation of interstitial tibrous
tumour of the body of the uterus, for twenty-eight operations
yield fourteen deaths to fourteen recoveries, while in four of the
latter the operation was incomplete, and a portion of the tumour
was left behind.t If now to the published mortality we make
some addition — and I fear it ought to be a very large one — for
suppressed, or at least for non-reported cases, we anive at a
residt which compels us to class the opemtion among the most
hazardous in surgery. Tliese risks, too, be it observed, are in-
curred not in the case of a disease surely and rapidly destroying
* See Dr Gi«enha]gh'8 |Mip«r in vol. lix. of Medioa-Chimrgical TrommdiamM,
t The following reJferenoes include all the caies with which I im MtpAinttd
that fitrieUy belong to this citegoiy : —
8CrcC£S«FUL CASES.
Amuuttt 2 caae», reported in full in ^aminaisuT Midicah^ Yth. 184S.
Malflonnetive 2 „ BulUtm de tAtxid, de Mid., xiv. 722 ; and OuaoiU <j«i
MdpUauaii, Dec. 6. 184^,
GtimidalQ 1 ,, Liverpool Medko-ChirurgiealJoumal, Jan. 185?, p. 54.
Tetle 1 „ Medieid Timeg, Maith 22, 1856, p. 28S,
Atlw 7 , , TranmOums qf American Mmiieal A$90ci4Uum, voL vi p. 569.
Bavij 1 „ Trtmudsiffiu of the OhUirieal Soskiy, toI ii. 1861, p. 17.
Hi
FIBROUS TUMOURS :
life, bat of one that runs a slow course, that often comes to a
standstill of its own accord, and that almost always aftbrda a pro-
spect of months or years of valetudinarianisui indeed^ but still of
life, which the operation may cut short in a few days. Success^
on the other hand, by no means necessarily frees the patient from
licr ills, for fibrous tumours are but seldom soUtary, and the re-
moval of one may but serve to bring to hght the existence of
another beyond the reach of surgical interfei^nce.
In the performance of the operation itself, the main difficulties
seem to arise from the size of the tumour, the inadequate space
afforded by the opening of the os uteri, which it has generally
been necessary to incise or to dilate forcibly, and from a thinness
of the uterine parieteg, so extreme as to necessitate the most
cautious manipulation, lest the peritoneal cavity should be opened
in the endeavour to extract the tumour. It must, indeed, be im-
possible for any one to read the particulars of opemtions such as
those of Amussat and Boyer, where the patient was more than
two hours under the hands of the surgeon; or of that of
I
Boyer
B«rard
Maisoaiieiava I
Cliiftri
BaktjT Brown
Atba
SiiDpsoii 1
Self
FATAL OASES.
1 case, Hhme MSdieate, March 1845 ; death in 6 diys.
2 ,, Bull de la SociiU Avmlotniquet 1842, p. 82 ; death in 5 weeks;
in Ms otk«r case, mentioned by Jarjava)'^ death took place
in 2 daja,
Bulktin de la BocUtS de Ckirurgie, toI. I pp. 458, 474. M,
ituisonneuire doea tiot himself mention the death of the
patient, but the fact in nirntioDed by JurjaYay, who atates
that ilmth took place at the end of a njoDtk See the
translation of hia thesis, "D*^3 Operations aux Corpa
Ftbrenx da TUtenis/' in toL rii* of the AnaUkttn ffkr
Fraumkrankhmtcii, p. 426.
1 ,, Clmil- der OehurUhillfc, &c., p. 408 ; dietl in 36 days.
2 ,, Medical Times, Jnly 25, 1867 j death of oni^ in 80 boura, of
the other in 1 3 dftys*
5 », Loc. cU. The date of death was 1 month, 11 days, 5 days,
7 weeks, and 20 days nefipectively, after the firEt operation
was Qttemptud.
£d. MimlAlp Jimmal, if arch 1848, and repnbliabed in
ObaUtric MefwHrM, p. 118 ; died in 6 days.
I
14 cases.
The temptation to sappresn due meutioti of ciaet h^Ting an unfortnnate issue
He«tns altnost insurmountable, while it vitiates all the concluHions which wi* may
Attempt to draw from the statistics of thche ndveuturous operationa. Thus, in the
J
THEIE atmOICAL TREATMENT.
305
Maisonnetive, in which the hasmorrhage that immediately followed
it wa« veiy alamaing, without feeling much hesitation m to the
propriety of exposing a pei-sou to so gi-eat a risk for advantages so
tmceitain. It is not, however, the loss of blood, for that ia not in
general considerable, nor the immediate effect of the shoek, which
is most to be apprehended ; for no patient appeai-s to liave died
from hfemotrhage, and only two from the direct shock, and one of
tjiese patients had already been exhausted by frequent operations.
Peritonitis, phlebitis, and pyaemia, the consequences of violence
done to the uterus of women exhausted by large and frequently
repeated floodings, are danger from which but few have alto-
gether escaped ; under which I fear that correct statistics would
show that most have poccumbed.
The amount of difficulty in the performance of the operation,
and the degree of risk which it will entail on the patient, can
scarcely be estimated beforehand ; and of tliis it would not be
easy to give an apter illustration than is furnished by my own
unsuccessful case of attempted enucleation of a fibrous tumour.
di«cnaaioti tlmt ai-oae at the 8odete i!e Cliimrgie, on Doc. &, lS4d, with reference
to M. Maisonninive's third and fatal ca»t<, that geDtleman him!M.4f mentioned
htTin^r seen a *'good number'' of tmsnccessftd attciupta at enucleation of fibrous
tumoiLra, all of which had a fatal i&saq; while M. Huguier relates an inj^tunco
whrrt* death took plaet- two daya after another umuccesBful operation at which bo
himself assisted. Our tables, however, bear no record of these failures and lieatha
any morw than of two other fatal cases of 8ir J. Siiiipaon'«, tnaking tbn^ deaths oat
of four operations, which are njferred to by Dr Araeth of Vienna, in hia "Imprea*
siona of a Journey/* published in the Witner ZeU^hrift^ Tiii. 3, 1852, and Sthmidt^
voL Ijcxv. p, 323. It is to be regrt^tted that Sir J, Simpson's Obaktrie Mrfnoirs have
liad to little of hia 8up?rvision as to conUun no account of many of those failures in
this or in other ca»e«^ which no&kiil can prevent, wliich are knottTi to have mo<lified
his own practice, and which might alTord leesona so well worth leaniin^ to others.
Hinee these lines were written, GuRserow, loe, cU, p. 82, has puljlisbed ikr
more extended statistics^ from which it api>ears that 103 out of 154 cases of
enncleation of fibroufi tumours hav«» b*icn auecessFol ; or, in other words, that the
mortality hasb^en reduced fnmi 50 iu 33'1 percent. Id some of those ea^es the of*eni-
tion waa performed in liifferent stances, extending even over a f>eriod of six months.
He observes that the reaulU ohtained from the oj>eratioti in the last few years are
fftr more favourable than fonaerty, in part from the^mscr selection of casea^ and also
from the improvements in the modes of r>|>eniting ; but partly alswi, he says, "hecanse
people do not consider it necessary to publish their unsuccessfol cases/' The old
•tovy of tho want of honesty which vitiates th« results of all our statistics. [Besides
tiM p»per of Ottiaerow, attention is demanded by thoaa of Whitcford, Edttiimrgik
Midiaal Journal, February 1870 ; Martin^ Ztitschrifi fUr O^h, ti%ui Frauenhr^^BiuiX'
gart, 1876, s. 143 ; Maentiel, Pratjer FitrUffahrschr, ^ 1874, Bd- iL; and by othera-1
V
306
FIBeOUS TUMOURS ;
TLe patient was thirty-nine years old, the mother of three
ehndiea. The first sj^mptom of her disease had appeared a year
beforei when she had a sudden attack of most profuse hiemor-
rhage, which, returning thrice at intervals of a fortnight, reduced
her to a state of extreme exhaustion. The enlai-ged uterus was
only with difiiculty felt by the liand over the pubes ; its enlarge-
ment was due to the presence of a tumour as large as an orange,
imbedded in the anterior uterine wallj which had distended the OS
uteri to about the size of the top of a wine-glass, but did not pro-
ject beyond its margins ; the surface of the tumour being adherent
to the anterior uterine lip* The uterine sound appeared to circum-
scribe more than half of Llie growtli. The moderate size of the
tumour, the open state of the os uteri, and the circnmstance that
so large a portion of the tumour was unattached, seemed both to
Sir J. Paget and myself to render the case one in which, if hajmur-
rhage returned dangerously, enucleation might be attempted. For
a few months no considerable bleeding took place ; but then the
hsemorrhages returned ; and ten months after the patient first
canie under niy notice, tlie operation was attempted, the tumour
apparently retaining very nearly its original size and relations, A
pair of hooks were firmly fixed in the tumour, and by their means
the uterus was drawn down near to the vulva. The anterior
uterine lip was then dissected off from it, and as far as the finger
could reach the shelling of the tumour out of its investing mem-
brane was easily accompUshd, The band was partly introduced
into the cavity of the womb, and the detaclmicnt of the tumour
poateritirly wjis accomplished ; but no ellbrt succeeded in reaching
high enough in front to complete its separation. Attempts were
made to separate the growth by traction, or to invert the uteruB
so as to bring it within reach of the finger, but in vain ; and the
operation was left incomplete after the enucleation of al>out four-
fifths of t!ie tumour had been accomplished. Before abantloning
the attempt, however, incisions were nmde in various directions
into the substance of the growth, in the hoi>e that its vitality
might be destroyed, and that eventually it might be got rid of in
a state of disintegration,
Th^ operation lasted about one hour, very little blood was lost
in its performance, but the patient sufi'ered much, and was left in
a state of great depression, which seemed to require the hberal
I
I
I
I
TnEm stmoicAL treatment,
Wt
employment of stimulants. As this condition subsided, the com-
plaints of abdominal pain became greater, imd the tenderness more
exquisite, on which account two dozen leeches were applied on
the third day after the operation, and mercurials were given which
produced salivation in five days, marked relief of all the symp-
toms taking place about the same time. A profuse, fa^tid, and
very atrid disL'harge came on soon after the ofK^ration, and con-
tinued for more than a month, causing the patient much distress
by exc-oriating the \idva and nates ; but though the whole of the
tumour disappeared, it was but once that a very small portion of
it was discovered in the matter which flowed from the vagina.
The operation was performed on December 21st ; by January
5th the patient seemed to be in a state of safety ; and before the
end of the month she was able to walk about the ward. On
February 11th she complained of some increase of pain in the
left iliac region, which subsided on the application of half a dozen
leeches ; and which seemed the lass to call for any serious
anxiety, since the patient a few days before had menstruated
scantily, though naturally, In the afternoon of Februarj^ 14th,
however, the patient, who had been up and walking about in the
morning, was seized with a violent rigor and a return of pain,
which once more subsided completely on the application of a few
leeches, and the administration of an opiate. On the 20th she
was so well that she was about to leave the hospital the next
day ; but at two o'clock in the morning w^as attacked by
violent shivering, intense abdominal pain, and those indications
of collapse w*bich accompany peritonitis from intestinal perfora-
tion, and died at four o'clock in the afternoon of the same day.
After death, all the evidences of recent acute peritonitis were
discovered, with a considerable quantity of a sero-purulent fluid ;
which in the pelvic cavity was found Uj consist almost entirely of
pus. This pus seemed to proceed from the cellular tissue between
the !iterus and rectum, though the aljscess there did not appear to
have Ijeen large, Tlie matter hatl escaped into the peritoneal
cavity through several small openings formed by sloughing of the
serous membrane in that situation. The uterus was healthy ; the
upper part of its cavity retained its ordinary appearance, but a
little above the os there existed a cavity formed at the expense of
the uterine wall, which was here less thick than elsewhere. This
308
FTBEOUS TtJitOtTRS :
cavity, which was evidently the bed whence the tumour had been
t^moved, me^iaiired 1| inch in ita lateral diameter, half an inch in
depth, and the same in its antero-posterior diameter. It was
lined by soft, pale granalationa, and no trace of the tumour was
t€ be seen in it
But for the biu-sting of this abscess into the peritoneum this
case would have been numbered among the successes. The fatal
accident, it ia true, was one of very mre occurrence, unlikely to
happen again on another occasion, but it ia this ver}' liability to
rare accidents which foresiglit cannot anticipate nor skill prevent,
that serves to distinguish these exceptional proceedings from those
operations whose indications can be clearly defined and their
dangei-s accurately estimated, and which fall within the more
legitimate domain of surgery.
It seems to nie worthy of consideration how far the mere incis-
ing fibrous tumours, so as to destroy, or, at any rate, greatly to
impair their vitality, might be substituted for the more hazardous
attempt at their entire enucleation, In the case just narrated,
this might have been done without the infliction of any such
violence on the uterus as was inseparable from the attempt at the
complete removal of the tumour ; and some instance's have since
been recorded, in which the gouging out a portion from the centre
of a fibrous tumour of the uterus has proved successfuh* The great
hazard attending this as well as all other operations on the sexual
oi'gans of women is that of the supervention of pyferaia; and it
must not be foi-gotten that the previous exhaustion of the patient
by frequent hajmorrhages renders her specially hable to this
accident.
But while the hazard attendant on operations for the enuclea*
tion of iuterstitial fibrous tumours of the uterua, when still im-
bedded in the walls of the organ, is so extreme as to render them
generally inadmissilile, and to remove them to that class of ex-
ceptional proceedings which the special condition of the patient,
and the unusual dexterity of the surgeon alone justify, there is a
class of cases in wldch the attempt at the removal of these
growths may be admissible. Such are those instances, some of
which are recorded by Lis£ranc,t where a small tumour was im-
* Baker Brown, Obt^, Tranmcl, vol iii. p. 67,
t Cliniqiu! Chimr^icoJe^ &c., vol ii. pp, 172, 173, 178, 179.
I
I
I
THEIK SUBGICiLL TREATMENT.
309
bedded in the substance of tlie uterine lip, and its removal could
consequBiitly be affected without any violence to the cavity of
the womb. A case of this kind was once under my care in St
Bartholomew's Hospital. Tlie lomour, which weighed 2 j ounces,
fuid which presented all the ordinary characters of a fibrous
tumour, was iml>edded in the posterior lip of the uterus of a
patient aged forty-seven. An incision was made by Sir J. Paget
tUong the whole posterior surface of the uterine lip, and was
carried forwards to the margin of the 03» The growth was then
shelled out by the finger with the greatest ease, except at one
small point at ita front and upper part, where it adhered firmly
to the uterine tissue, but was detached by a few strokes of the
bistonri No heemorrhage of importance, nor any bad symptoms^
followed tlie operation, and the patient left the hospital quite well
in a fortnight
The operation, too, is comparatively free fnim danger in those
cases where the tumour has approached the pedunculated form,
and has consequently been easily reached through the widely open
or easily divided os uteri, or perhaps has admitted of still readier
removal, owing to its having passed beyond the orifice of the womb»
and come to lie almost completely within the vagina. The opera-
tion here would seem to stand on much the same footing with
operations on pedunculated tumours or polj^i ; and the details
of cases such as those of Dr Pancoast * Mr Teale,t Dr Gilbert,J
* Sodm iM. /awmal, Oct 9, 1844.
t M<d, TimM, Aag. 20, 185S ; and (bid. Mirch 2% 1S5«.
t BoH^m M«tk Journal^ voL xxxi, p, 2&0, For thin last reference, tokd also for
cnliiug mf attention to JJr AlW^s c«m«, I &m indebted to some very interesting
pspen by Mr Uutohinaon, in tb« MediaU TUna^ July 25 to Aagust 15, 1857. Four
of the GMeSi lunverer, wbich he includes in hi.i table being thoa« of opermtions on
two p«tieiiti with rMUirent fibroid tumour of the uterus, appeared to me to be out
of pkee them ; and for the reaaon aaajgned in the text, the seven oases jxut refemHl
to asiiiisd to require to be ranged in a different category fcDin that to which
operation* on interstitial tibrous ttmioan belong. Thi« diviaion appearf to mc to
convey a jnster tntprcsdion of the sources of danger from the oficration than one
bisad on the mode of ita performance. In many, enucleation by the induction of
piQgreiie was attempted, only because [primary cnndeation hj«d been attempted
iiid failed. The very uncertainty in cases of interstitisl (ibroua tumour as to
which operation will be practicable, or whether both may not alike prove impossible^
00B«titQte« to my mind the great oljactioii to these proceedings. The real qnesUou
is olwcured, if stated so as to seem one concerning the eomparatiTe meritd of two
kinds of operations.
310
FIBROUS TtTMOUKS:
and M. Latigenbeck * appear to bear out the correctness
of a sapposition which has all theoretical probabilities in its
favoui^ Absolute safety, however, cannot be claimed even for
this simple operation. I performed it once on a patient who had
long suffered from a fibroug tumour, which, growing somew4iat in
a polypoid form, had on three previous occasions been partially
removed. At length spontaneous inversion of the ntenis took
place, and the timiour with the inverted womb was now easily
draw^n by a pair of midwifery forceps beyond the vulva. The
mass, weighing six ounces, was readOy shelled out of the uteidne
tissue by the hand, and scarcely any blood was lost in accom-
plishing this; the inverted womb being afterwards reatiily re-
placed. Seventeen days afterwards the patient died of pyaemia ;
a largo coagiilum, in which pus cells were abundantly present,
tilled the inferior vena cava, and there were purulent deposits In
the lungs, spleen, and left kidney, though the large uterus, its
appendages, and its veins were perfectly healthy.
The triumphs of surgery in cases of ovarian disease, for wliich
we are mainly indebted to Mr Spencer Wells, have of late years
emboldened medical men to attempt operations which were once
regarded as altogetlier inadmissible. The few cases which some
fifteen years ago were on record of the removal of uterine fibroids
by opening the abdomen, either with or without extirpation of the
uterus, were then looked on rather as warnings to avoid, than as
examples to imitate. I do not know that they teach us a very
diflerent lesson now ; but as I have no personal experience on the
subject, it is hut right that I should give you the most recent
statistics, those of Gusserow, whose work appeared last year.f
He says that of 17 cases of removal of a fibrous tumour alone
* DcutMhf Klink, 1859, p. 1. Three casea are related, odp of wliich does not
belong here, since the operation wag performed aa a matter of necessity during
labour, when the ftfitient was alrtiady much exhausted, and death was attributable
to the delay rather than to the operation. The other two coseSj which had a
successful issue, iUustrate th© indiciitions for the perfomiance of the operation,
which iL Langenbeck dehnea as being ' ' The y«uth of th« jiatient, the d&ngcraua
nature of the hsmorrhage, and the seat of the tumour in the liubbtauce of either
lip, flr of either waU of the cervix uteri, so that it am be ix^ached by the knife,
without forrlbly drawing down the womb.'* Two other additional cases by M,
Santesaon and M. Janger» both of which had a favonrabk tissue^ or© related in
SdimUlCt Jahrbu^hcr, 1858, vol, 100, p. 4L
t Op. cU. p. 89-&L
I
I
I
MASAGEMENT WHKK COMPUCATING LABOCB.
311
12 died, or 70*5 per cent Koeberie, however, who published 20
cases, some of which were tilTro-cystic, not true fibroids, had 8
recoveries and 12 deaths, or a mortality of 60 per cent.
The results of extirpation of the uterus, together with the
ttimoors, seem very con tlicting. Koeberle colleeted 42 cases with
a mortality of 34, tir 81 jFcr cent ; Boinel 42, with 32 deaths, or
73 per cent. ; while pL*an professes to have had 17 recoveries out
of 25, which represents a mortality of only 32 per cent.
What I said alx>ut the risks of enucleation, ami the reasons
against it, save in very exceptional cases, seems to me to hold
good even more emphatically with reference to thase two opera-
tions. [Dr Tliomas Keith,* however, has three times excised uteri
with tibro -cystic tumours, and all the crises have been successful.]
In conclusion, and before taking leave of the subject of fibrous
tumours, a few remarks miLst be made on the numagement of cases
in which they occur as complications of pregnancy or labour. It
happens occasionally, as in a case which some years since came
under my own observation, that the pelvic aivity is fotmd at the
commencement of labour occupied by a large and firm tumour,
the existence of which had not been betrayed previously by any
symptoms whatever of iiterine disease. In some of these cades
the Cfesarean section has been performed; but I am not acquainted
with any instance where a favourable result has followed the
operation when rendered necessary by uterine tumour The
presence of the growth both interferes with the due contraction of
the womb, and thus exposes tlie patient to great risk of haemor-
rhage, and also, if this danger should be surmounted, seems to
ensure the supervention of inflammation of the uterus and peri-
toneum of a kind so perdous, that in every recoixied instance it
has hitherto proved ftital. Unfortunately the cases are but very
few in which extirpation of the tumour is possible, for, in com*
parison with any operation l>y which the fwritooeal cavity is laid
open, that would seem to be far less haaiardous. The succe^ful
removal of pjlypi during labour, and the extirpation of large
fibrous tumours of the pelvic walls^f encou ntge to such a proceed-
ing ; but the only instances with which I am acquainted of the
• LanfH, May 15, 1875.
t As in the remarkable case related by the !ate Profeaaor Burns of Glasgow, in
his Midwifery ^ eighth edition, 8vo, Loadou, IS 32, p. 3!$.
HBHOUS TUMOURS !
actual enucleation of a fibroiis tiimoiir from the utems itself
during lal>our, are related by M. Dtinyau,* M, Langenbeck,t I>r
Keating, t and Dr Braxton Hicka.§ M* Danyiiua patient was
thirty years old, had given birth to three children, after easy
labours, and had reached the end of her fourth pregnancy, though
slight hajuiorrhage had been goin^ti on for three weeks. Forty
hours after the escape of the liquor amnii, a foot of the child was
felt presenting, while the pelvic cavity wag almost completely
filled by a tumour which seemed to be formed by the thickened
posterior lip of the uterus, and which did not leave a space of
above tliree-([uarter3 of an inch to an inch and a quarter between
itself and the .sympbysis pubis. The child having been ascertained
to be dead, and no question therefore arising as to the performance
of the Ca^sarean section, M. Danyan, having consulted with Pro-
fessor Dubois, carried a Ijistonri on two fingers <jf bis left hand
through the os uteri, which was open to the size of the top of a
small wine-glass, made a longitudiualincision through the anterior
and upper part of the tumour, and then succeeded with two
fiugei-s of the right hand in shelling it out of the uterus, and
removing it from the pelvis. The tumour weighed twenty ounces
aeven drachms ; its longest diameter was five iuches and three*
quartei-s; its shape conical, with the apex downwarda The
extraction of the child was easily accomplished after the removal
of the tumour, and the patient recovered without any bad symp-
toms, though a considerable quantity of venous blood escaped at
the commencement oE the operation, when the tumour was first
cut into. The patients of M. I^ingenbeck and of I)r Keating were
less furtunate. The former, exhausted by the previous long dura-
tion of labour pains, died within twenty-fouj houj^, while the
• Oas. df» Hdjrt'MuXj No. xM. 1851 ; and Sohjnidt*8 Jahrbikher, roL Ijtxl.
Augmit 1851, p, 190.
t Loc. eit. p. 3.
% Awcrirmi Journaiof Med. Stititcfs, May 1858 ; and Scbmidt, voL IDO, p* 40i
I purposely do not j^ into the co aside roti on of thoee cfisea, of which several are on
recoct, with varying Peawlta, of the extirpation of polypi or of non-petlicnliitcd
tumoiirti uoon itfter delivery, for I have no personal ex]JorienLe on the sultjpct. My
leaning, however, wonhl ba to noD-luterfeece with them in the puerpi'ral state,
nuk'KS Ryiupton)8 urgtrntly called for an opposite course, Bince I should fear that
the greater fiwrllity of their removal would be more than outwit ighed by the greater
lisk of pundent abgorption aftcrwarda.
§ Larwd^ July 80, 1870.
1
I
■
I
THEIR MAKAGE^firNT WHEN COMPLICATING LABOUB.
313
latter was attacked by puerperal phlebitis, which proved fatal on
the eighth day. In Dr Hicka* case the tuBiour. whicli filled the
whole posterior part of the vagina and prevented the descent of
the fcetal head, waa enucleated with considerable ease. The child
was li%ing, and the mother recovered without a bad symptouL
In all case3» however, where it is practicftLile, operations on the
parturient uterus are to be avoided • and the first thing to ascertain
with refei'ence to any tumour is whether it admits of beini:;
moved out of the pelvic cavity, since if that can be done, it is
obviooj^ly attended with the least possible hazard. In my own
case it was readily accomplished ; and there can be little doubt
but that the same proceeding would have been successful in the
(tase well described and delineated by Dr Etlinger.f in which
Professor Kilian of Bonn performed the Csesarean section on a
patient whose pelvis was occupied by a fibrous tumour that grew
by a rather broad peduncle from the posterior surface of the
womb. This pei"soo died forty-eight hours after the operation,
fnmi the effects of the haimorrhage which attimded it. My
patient survived till the sixth day, and I cannot but attribute her
death to an attempt which was made (injudiciously on my part)
to puncture the tumour before trying to cany it above the pelvic
brpi. Tliere was no general peritonitis, but the wound in the
tumour was guping widely ; tlie tissue about it was of a black
colour, and discoloration extendeil thence inwards towards the
centre of the tumour. The dark portion of the tumour was
softened, but the rest of it waa of a vivid red colour, and neither
it nor the other tumour, which was abi)nt the same size, namely,
that of the head of a fu'tus at seven months, presented auy trace
of that general softening and disintegration which have been
alleged U) occur in these growths after delivery. The intestines
* Mao J yean tince I went ftilly iuto thia subject on the occtision of a case of
OMMmn Miction which I described in the Mtd.-Chir, Transadiofuf for 1851, vi>K
xxxiv. pv dl, [The operation, known generally by the name of Porro of H ilon, con-
sisting of ampDtution of the uterus and ovaries after CtMMreftii necticm, has now
been many tiiuei perfonned and with some suc<:esa. (See Wasseigei Buli. de VAead.
Mffifok d« MideciTui de Bdgique, tome xii. 1878 ; aUo Spaeth, Dr WitUUh^tTB
Wimher MaL ITocAevucAr. No. 4, 1978. ) It bmi been done twice for fibroaa tumontr
of the Qteroa, onoe nnittieoeufally by Btorvr, and at least once sacce«tfiilly by Fono
{IhUa ampuUiziime uUro &parieOf kc, MOi&nov 1876),]
t EtUngur, Ob$«fvaHimeit Obstetrician, 4to* Bonnie, 1864, aee pp, 50-55, andplatea
i and u.
314
FIBROUS TIBfOmWS
in the left iliac fossa were matted together hy recent lymph, and
about four inches of them, just where they lay in contact with
the punctured tumour, were much congested, quita rotten, and
their posterior part was converted into a large greenish- black
slough. This slough corresponded to a large slough on tlie outer
and upper part of the punctured tumour. The other tumour was
of a rose tint ; the nteros, which presented some half-dozen small
tumours al>oiifc the size of peas on its surface, was, in other
respects, perfectly healthy. It seemed, in short, as if the puncturtj
of the tumour luid been the point of departixre whence all the
subsequent mischief proceeded.*
In aU instances, then, the endeavour to carry the tumour out
of reach should precede any attempt at reducing its bulk by
puucture. In the event, however, of the former failing, the
apparent solidity of the growth must not be taken as warrant
sufficient for dispensing with the trocar ; for a cyst, if very tense,
either from the accumulation of fluid within, or fmm any very
great pressure upon it from without, will often yield, even to the
well-practised tinger, scarcely any sensation by wliich the nature
of its contents can he suspect-ed.
Lastly, I am disposed to think that in almost all of these cases
it will be preferable to turn the child ratlier than to make any
attempt at extracting it with the forceps ; and even if the want
uf space is very great indeed, craniotomy, followed by turning
and the use of the c^phalotribe to break up tlie base of the skuU,
wUI, I doubt not, enable us to carry to a safe conclusion a case
wliich at first appeared to offer no alternative but the performance
of the Cesarean section.!
At the close of the last Lecture, I stated my dissent from the
opinion that there is a constant, or at least a general tendency on
tbe part of these tumours to pass into a state of softening, or
disintegration during pregnancy, I do not therefore conceive that
the induction of premature labour, and still more of abortion.
I
* A second case, almost identical in it« feat^irea with the roregoiug, and, like it,
bnriDg u fatal tertnitiation, came under my notice ia 1862, and has been reported
hj Dr Uadgei in the fourth volume of th« Obddriatl Transactions,
+ D«taarqnaj, op. cH. p. 214, quoting the theab of M* r^ainhurt, ^ves the result
of 14 Oaisarian sections in casea of uterine fibroids, as yieldiug 7 children deliirercd
alive, and 1 muteniid recovery to 18 deaths.
ITNUSUAL VARHrriES,
315
simply because a fibmus tumour ia connected with the uterus, is
either necessary or justifiable. The presence of a fibrous tumour
so encroaching on the pelvic ca\ity as to render labour difficult
or dangerous, ia of course an indication for the operation ; so also
may perhaps be the experience of a previous delivery which had
been followed by symptoms of uterine inflammation. The mis-
chief, however, dates, I believe, in all instances, not from any
particular epoch of pregnancy, but from the expulsion of the
ovum whenever that occura; and the greater hazard attendant
upon labours at the full periwi, is due to the greater violence
undeigona by the uterus and the tumour during the passage of
the foetus in advanced than in early pregnancy. Each case, then,
must be considered and treated on ilii own merits ; the mere fact
of a pregnant woman having a fibrous tumour of her uterus
cannot be taken as a sufficient indication for the induction of
abortion or of jiremature labour.
[Before passing altogether from the subject of uterine fibroids, it
is well to mention some rarities and novelties which yet are not
mere curiosities. I fw)ssess a unique specimen of diU'use fibrous
hy[»ertrophy of the uterus derived from a case which I have
partially described,* and which I attended for a long series of years.
After enucleating a small fibrous tumour, the health improved
greatly for some years ; but serous and often bloody discharge was
incessant. She then began to sufier from malignant disease of
the peritoneum, a cancerous tumour was quickly formed in
Douglas' space, and death ensued amid much sutTering from
obstruction of the rectum. The uterus, which for many years had
undergone no perceptible change in size, had a healthy cervix,
which at its upper part began to partake in the difi'use fibrous
hypertrophy wliich afiected uniformly the whole body of the
organ. It was 6 inches in length ; and its fundus, which was
tliiekest, measured about 3 inches. The mucous membrane was
atrophied.
Examples of petliculated peritoneal fibroids are not very rare.
They may become detached from the uterus and be found loose
in the peritoneal cavity ; and if calcified, get the name of calculi.
Or they may be detached from tlie uterus but adherent to some
other peritoneal surface. I possess a pretty specimen of a fibroid
♦ Edinburgh Medical Journal, toL xiL Feb. 1867, p, 125.
816
FTBHOUS TUMOURS !
of the size of a small hen*s egg, wliicli is loosely pediculated an3
attached to a Fallupian tube. Id such a case the diagnosis from
ovarian enlai'gement would t>e protmbly impossible during life.
But, besides being occ^asionally polypoid and rarely detached, we
have curious histories of such adherent tunioors retaining con-
nexion with the uterus, but leading to tensile elongation of the
cervix^ extreme atrophy of it, or even its complete diviBion, A
similar series of events is described as affecting the ovary alone,
or the ovary and corresponding Fallopian tube together* Uti^rine
oases are spoken of by Eokitansky * and one interesting example
IS described by Times.t
The most important foiTu of spontaneous enucleation of a fib-
roid, that in which it passes through the mucous membrane, haa
been fully described. Other liirections of tlie enucleating procesa
do however occur, as into the peritoneum, through the anterior
abdominal wall, and into the bladderj.
Examples of descent of pol3^ii from the interior of the uterus
into the vagina, generally during menstruation, or at least during
bleeding, and subsequent ascent, are not very rare. The uterine
contractions sometimes produce the same phenomena in the case
of a fibroid undergoing spontaneous enucleation,§ and of this I
have seen examples.
I have been directly or indirectly connected with several cases
of death from hft^morrhage in fibrous tumour of the uterus. Tliis
termination may happen during the bleeding, and of this I had,
a few years ago, a terrible example. A lady was sent to me by
Dr Adarnson of St Andrews, because, in her two last menstrua-
tions, she was so faint and ill that he sat at her ttedside, using
appropriate remedies, yet momentarily expecting her death, I
resolved to attempt the enucleation of a large fibroid, imbedded
and occupying the lower part of the wall of the body of the
uterus. A\l)ile canying on preliminary proceedings, and encoun-
tering social obstacles to surgical proceedings, I arrested the
hiemorrhages by injecting into the uterine cavity, on repeated
I
I
I
* Maniuil of PatMoffietU Anaimn^, Sydeuhiim edition, vol. ii p. 297.
t Obslifricai TrcMtaetiomj vol. iL p. 34.
t For sRtveral referenooi, iee SoKrocdcr, in ZiemMen's Handbuch der KrankheUm
der ymblkhen Otse^hektmrgane^ II. Aoa, &. 2^1.
§ Edinburgh Medkal Jmtrtud^ Februftiy 1S67, p. 721,
UKUSUAL VAElETlBa
SI?
occasions, a drachm of solution of perchloride of iron through a
hollow uterine probe made for the purpose. Under this treatment
and assiduous care she so gi'eatly improved in health that she
believed herself cured, and, against the entreaties of her rchitives,
left Eiliiiburgh for her home in the country. Some bleeding was
induced by the fatigues of the journey in railway car and carriage.
The next bleeding or menstruation proved rapidly fatal Such
bleedings no doubt come from open uterine sinuses which ore
sometimes easily found on the surface of enucleated fibroids, as
in the one alreitdy referred to when speaking of descent and
ascent of the tumour.* Such open sinuses are also occasionally
found on the mucous surface investing the tumour. But great
bleedings in such cases are not to be wondered at, when we con-
sider the irritation often caused by such tumours, the mechanical
impediments they may throw in tlie way of the i^tum of venous
blood from the surfaces liable to pour out blood, the often very
great extent of such surfaces above what is natural, and the
liability to venous obstmction from the spasms or uterine contrac-
tions so apt to come on in connexion with tibroids*
Occasionally the amemia produced by the ba?niorrhage becomes
permcious,as it is now called, or progresses to a fatal termination; and
this may come long after the haemoirhages have been completel}'
an^ested A case of this kind was under my care in the Eoyal In-
timiary of Edinburgh some years ago. She was considered to be in
so great danger that desperate attempts were made to reach the
small intramural tumour, of the size of a mandarin orange; but they
failed in consequence of the great length of the cervix, the eleva-
tion of the uterus, and the impossibility of depressing it arising
from the fatness of the abdominal widL While under my care she
was twice supposed to be dying from hydrothorax, hydropericar-
dium, ascites, and anasarca. Consultations were lield ; and the
fatal screen for seclusion and peace, well known in the ward, was
placed around her bed But she recovered and was removed to a
medical ward under Dr Haldane's care. Here she remained for
several mouths, daily improving, till she was carried otT rapidly by
a sudden return of her former dropsies. The post-moHcm showed
* For an (*xiimple and a rererenoe to CniV6llJuer« aoe EdinJbiurf/K Medkal
Jmmal^ January 1867, p. 682.
318 FIBROUS TUMOURS
no notable disease except amemia. Theuterioe tumour could have
been easily disimbedcled, if it had been reached. It was round,
softp and fattiiy degenerated.
To prevent haemorrhage, intrauterine injections have been
much resorted to. But their use involves difficulties and dan-
gere such as to render them appropriate only in the severest
cases ; and even in them their employment is confessedly
not a thorougbly settled matter. I have used solution of per-
chloride of iron frequently in cases of uterine fibroid for this
purpose. Several times I have seen pain follow the injection, and
last for some hours. Once, besides pain, tliere was an attack of
phlegmasia dolens. But hitterly, much has been made of the
induction of uterine contmction by ergot, not such contractions or
spasms as we have already spoken of in describing the production
of hfeniorrhage, but uniform and persistent ei*gotic contraction of
the whole organ. I have repeatedly seen tlie use of ergot
apparently produce or accelerate the descent or enucleation of a
fibroid ; but this also is not what is desii'ed as the result of the
ti'eatment referred to, which is generally connected with the name
of Hildebrandt of Konigsberg. In some cases the good effects of
the ergot treatment are very decided, as in one which I have
deacrilied* and which I know still maintains its improved condition.
The diminution of the tumour and of the hu-morrhage are the
objects to be gained, and they are attainable only in the imbedded
or intramural cases,! Other plans have tH3eu followed by several
practitioners, as by Atthill,t who describes improvements in the
details of treatment The plan may be carried out by hypodermic fl
injection of ergotine or ordinar}^ ergotic doses by the mouth dtdly, ^
or every second day, and continued even for months, or not longer
than is rei|uired to produce the desired effects. U
Fibrous tumour of the ut^^rus may prove fatal in various extra-
ordinary ways. Of the following I have seen examples. One of
the rarest is obstruction of the rectum by pressure, and of this I
have seen only one distinct instance.§ Of death caused by
♦ Mtdiral Estamintr, March 28, 187S.
t HUdebmtidt'B onginiil \m\itt appeared in the 3d Tolumc of tbe Berlin B^Uyy
sur GeburUfhUl/e UTui Oynakologie,
X BHH^k MediealJimrmi^ Sept 2, 1876, p. 299.
§ See Queuiot, referred to in the Obddrkal Jourjud, vol. i, p. 8S9.
I
bh
UNUSUAL VABIETIES.
319
obatructive pressure on tlie ureters and oousequent unetnia, one
example,* €)f death from gangrene of a peritoneal ixjlypoid
tumour, the result of torsion of the pedicle, one example, attended
in consultation with Dr Cappie*t Cases of acute peritonitis, of
chronic peritonitis, and of peritoneal cancer, all apparently caused
by the tumoui^, are known. One case of fatal suppurative peri-
tonitis I have seen from spontaneous traumatic origin. In it the
fibrous tumour was subperitoneal and calcilied en mqui\ Tlie
shrinking of the fibrous contents of the calcareous brittle shell led
to the cracking and spurring out of its superficial layers, and thus
to several lacerations of the thin atrophied covering peritoneum,
and consequent peritonitis.]
• Mrdiml Ernmintr, March 28, 1878.
t Mditthurfih Metlieal Journal, May 1S74. p. 1040, nod July 1874, l>. 10.
LECTURE XVIL
CTERINE TUMOURS AND OUTGROWTHS.
FiBKOUB Polypi ; their structuret, vascular supply, and uonrce of hflemorrha^
wliioh attends them. Their syraptoraa. Ojwrations for their removal ; other
luodea superseded by the use of the wire icra^tur. Mtmagemeot of labour
cornplicateil with polypus.
Fibho-Ctstic TuMotTRB ; their Btnictun? ; probably due to degeneratiou of Shroid
tumount ; difficulty of diagnosis from ovarian tumours, Pmctiral conclnmoDS
concerning them*
Sarcoma or Recurrent Fierouj TLraiouR or Uterus ; imperfectjon of know-
ledge concerning it* I Dnat native coses.
Fattt Tcmours op UrERirs. Structure ; relation to malignant disease, rarity.
Other Unuscal VAiiiETfEa of Uteri>je Tcmour. Fibrous polypus in course of
enueltfltion. Mollnscura j ita jieculiar characters. Adenoma ; evidence of its
mcilignam-y. Hydatids.
Tfberoular Degeneration of Utkeus. Its characters, seat of the disease, and
connexion with general tuberculosis.
It still remains for iis to consider that variety of uterine fibrous
timiourwbicli grows from tlie inner surface of the womb, or which,
less frequently springing from either lip, haDgs down by a stalk or
pedicle into the cavity of the uterus, or into the canal of the
vagina. The impropriety of the term Polypus as applied to these
solid growths, need not occupy us now ; it is sufficient that jt has
been uuiversally adopted, and is so well understood, that no one
will be misled by the incorrect terminology.
In general etmctui-e these tumours are aloiost identical with
those w^e have hitherto been stiid}ing ; the only important differ-
ence, perhaps, beirtg, that whereas tlie growth in all the former
cases was distinct from the uterine tissue, even though imbedded
in it, or prnjecting from it, tuouie polypi are positive outgrowths of
uterine tissue, their texture and that of the w^omb itself being in-
extricably interwoven* Even in these instances, however, the
• Afl in a prepamtion in the Museum of St Bartholomew's Hospital, sket
and referred to by Figet, op. dt. vd. ii» p. 131, fig. 11.
I
I
I
IXBB0U8 l*OLYPI,
321
substance of the growth is usually finner, denser, and less vas-
cular than that of the adjacent uterine wall ; wliile on the other
hand, the pediculated fibrous tumour is generally, when gi-owing
from the interior of the womh, more aucculeiit and better supplied
with blood than similar tumours whose position and relations are
dilferent The pedicle of these tumours is composed of uterine
substance mingled with more or less dense cellular tissue, and
though generally single,, is sometimes fonned by the coalescence
of two or three bundles of fibres springing from diflerent, though
nearly adjacent, parts of the womb. A layer of uterine substance
is continued from the pedicle for a varying distance along the
tumour, sometimes investing it completely, at other times only in
part, as the cup surrounds the acorn, or the calyx the petals of a
flower. Besides this, the polypus is always covered by the
mucous membrane of the uterus, wliich becomes firmer and denser
than natural^ both it and also the muscular fibres of the womb
itself undergoing development somewhat in proportion to that of
the tumour. The tumour can often be shelled out of its cover-
ings just in the same manner as an ordinary fibrous tumour may
be enucleated from its investment of dense cellular tissue ; but
this is not invariably the case, and the connexion between the
substance of the poljrpus and the membrane tliat surrounds it is
now and then very intimate. The vascular supply, as already
stated, is more abundant than that of other fibrous tumours,
though it may generally be observed that neither the arterial
trunks entering the tumour nor the veins leaving it are propor-
tionate in siz« to what might be anticipated from the quantity of
blood in its substance. Some part of its supply of blood also
comes to the polypus through the mucous membrane by which it
is invested, though even in this no considerable vessels are in
general perceptible. This comparatively small appai'ent supply
of blood to these tumours, coupled with the fact that they always
give rise to very profuse haemorrhage, while such hBemorrhage is
always arrested by a ligature applied round their pedicle, have con-
tributed to form a problem in uterine pathology, which, till within
a recent date, received very conflicting and very unsatisfactory
solutions. The profuse bleeding which is excited alike by non-
pediculated fibrous tumours, and also by the ver}' minute vas-
cular polypi of the organ, seems to show that it is rather
I
322
FIBEOUS POLYH:
from the irritated mucous membrane of the uterus than from the
surface of the tumour itself that the bleeding flaws. The same
fact, too, 13 further illustrated by facts such as the following. A
woman, aged forty-six, was admitted under my care into St
Bartholomew's Hospital She was a single woman, and, with
the exception of a sense of weight at the lower part of the
abdomen, since the cessation oi her menses at the age of forty*
tliree, had had good health till three weeks before she came under
my notice. She was then suddenly attacked liy profuse haimor-
rhage, and at the same time a tumour had partially forced its way
through her vulva- The loss of blood had continued more or leae
since, and the patient, at her admission, seemed very much
exhausted by it. This tumour, winch at its lower part was
already in a state of superficial slough, was a fibrous tumour which
measured seven inches in length by four in diameter at its widest
part, and weighed one pound one ounce and a half. It was
connected by a small and short pedicle with the posterior lip of
the uterus ; an arterial trunk about tJie size of one of the digital
arteries seemed to be the source whence its supply of blood was
derived ; though it presented an unusual degree of vascularity,
and its lower part, which bad projected beyond the %Tilva, and had
been subjected to pressure, was so intensely congested as to have
an almost ai>oplectic appeanince. Now this large and vascular
growth had gone on, doubtless, for years, increasing in size, and
yet producing no symptoms, giving rise to no haemorrhage, until
having partially escaped beyond the \Tilva, it began to drag upon
the womb, to pull it downwards, and to initate it, and then all at
once, from the womb itself, for there was no appearance of bleed-
ing from any part of the surface of the tumour, sudden and most
formidable hiemoiThage broke forth. The suspension of bleeding
by the application of a hgature around the pedicle of a polypus
does not of necessity imply that the source whence the hiemor-
rhage proceeded is thus mechanically shut ofl; but is also
intelligible on the supposition that t!ie ligature intei-rapts the vital
relations between the tunumr and the w<»mb, and thus renders the
poljrpus a far leas powerful excitant of the uterine mucous
membrane than it was before. No stronger proof can be aflbrded
ol the difference between a vital and a mere mechanical stimulant
of the uterus than is given by the compttrati\'e impunity with
I
I
I
I
THEIR KELATIOXS TO TEB trTERUa
323
whichp in many instances, the metallic stem of the uterine
supporter is borae within the cavity of the womb, as contrasted
with the almost irrestminable hiemorrhages that are often excited
by even the smallest vascular poly];ti.
Fibrous polypi are susceptible of the same kinds of changes as
may take place in fibrous tumours elsewhere situated. I am not
aware, however, of their undergoing that atrophy which occasion-
ally occurs in other fibrous tumours of the uterus, while
calcareous deposits in their sul>stance are excessively rare. On the
other hand, both a*Jema of their substance, and the extravasation
of blood into their tissue, are far from being of unusual occurrence ;
and when they have passed through the os uteri into the vagina,
the membrane covering tlieir lower surface not infrequently
becomes ulcerated, or passes even into a sloughing condition,
which may extend to the adjacent substance of the growth*
They do not, however, so far as 1 know, ever shell out com-
pletely from their investment as some other fibrous tumours
now and then do; and when spontaneously detached and ex-
pelled, their natural cure is brought about by tlieir pedicle giving
way.
Formed, as these polypi usually are, within the cavity of the
uterus, their influence upon that organ seems to depend somewhat
on the situation whence they spring. Thus if it arise low down
in the cervical canal, the tumour soon grows beyond these limits,
and hanging down into tlie vagina, may acquire a considerable
size without exerting nuich influence on the womb itself, neither
disturbing its functions nor producing any considerable hyper-
tKiphy of its tissue. On the other hand, those pol^-yii w^hich are
developed from some point high up in the womb, naturally remain
within its cavity till they have acquired a considerable size, and
thus give rise to enlargement of the organ, a!ul to thickening of
its walls. There seem, however, to be considerable diversities
between the relations Vhieh the polypus continues to bear in
diffiBFent cases to the c»rgan within which it is developed. In the
great majority of instances, before it has acquired the size of a
small apple, the os uteri, against which the lower part of the
polypus lies, gradually dilates to allow its passage, and the
growth is then found hanging down into the vagina, its pedicle
embraced, though but seldom tightly constringed, by the orifice of
M4
FIBHOUS polypi;
tlie womb. Sometimes, however, I know not why, this process Ls
effected much less quickly j the margins of the os uteri do not
yield so aa to allow of the easy exit of the polypus, but violent
uterine action is set up, aod under efforts like those of labour, and
which recur in paroxyams, and then subside, and again recur
after the lapse, perhaps, of many days, the polypus is literally
bom. It is usually under these violent throes that the womb, as
was explained in a former Lecture,^ sometimes becomes literally
inverted, or turned inside out; an accident which is brought alx)ut
less by the mere mechaoical action of the weight of the tumour
than by the efforts which it excites in the miLScular tissue of the
w^omb.
When once in the vfi^^na, the growth of the polypus still goes
on, and probably even more rapidly than before, since it is no
longer subjected to the same degree of pressui-e as while it was
within the uterag. For the most part, however, the symptoms to
which it haa given rise have been so serious as to lead to its early
detection, and it is removed before it has acquired any very
formidable diniensions.f If it is allowed to sojourn for any time
in the vagina, that part of the tumour to which the air has access
seldom fails to become ulcerated, while it is further by no means
unusual for the adjacent surface of vagina to become likewise
inflamed and ulcerated, and for atlhesion then to take place
between the two. A similar occurrence happens occasionally,
though much less often, between the tumour and the lining
membrane of the uterus itself ; and either of these accidents may
make the diagnosis obscure, and must render all forms of
operative interference unusually difficult.
The two grand m^m2}toms of polypus uteri are ha;morrhage and
leucorrhcea, symptoms which go on increasing in severity and
continuance until, if their cause be undiscovered or nnremoved,
they will at length exhaust and destroy the patient. At first the
seasons of menstruation are those when the haemorrhage takes
place, the periods lasting longer, returning sooner, and being
* See Lecture Xtl. on Inversion of the Utenia^ |>, 236*
f I have already mentioned one case wbere the polypus weighed 1 Ih. IJ oa. An
instance is related by Hey f elder, Studien ini Gtbkic dcr Meilwmenschaji, Svo,
Stuttgart, 1838» vol. i. p. '2M^ of a polypus which weighed 1 lb. 3 oz. 7 dr. ; and
Bunieroii* referencea are given by Meisaner, op. cU. vol. L p. 838, to cases of jwlyin of
«aormouA dimen^ons.
I
I
I
THEIR SYMPTOMS, AN1> DIAGNOSIS,
325
mccompanied with a more proJiise loss than was their wont, while
abundant leucorrlia^a persists in their intervals. Then the
periodicity of the hiKinorrhage ceases, for its presence becomes
gener&l, or constant, and it is at length found impossible to keep
any account of when menstruation last took place, or when it
may next be expecttd*
A constant sense of Jjearing down may be experienced, or some
mechanical inconvenience or other, from the preasure of the poly-
pus, if large, upon adjacent parts ; or expulsive efforts may some-
times occur, but thoy are by no means constant ; and the last-
meutii>ned symptom in particular is met with only in a small
minority of Ciises, It has been said that the escape of coagula of
an annular shape, due to their being formed around the pedicle of
the polypus, is characteristic of this affection. This, however, ia
one of those plausibiUties which savour more of the study than of
the bed-side, and experience does not continn the statement
The only nile, indeed, which I can give you as to the diagnosis of
polypi is, that whenever hiemorrhage^ having taken place cause-
lessly at one menstruid period, recurs equally without cause at
the succeeding one, you should on no account omit making a
vaginal examination. The tumour projecting through the 08
uteri, encircled by its lips, and passing up into its cavity, perhaps
beyond the point to which your finger can reach, can scarcely be
mifltaken for anything else, except, perhaps, for the inverted
uterus, the distinctive characters of which 1 have almady endea-
voured to point out.* Neither, indeed, can the nature of those
pol>T)oid growths which proceed from one or other lip of the
uterus be doubtful, since the os uteri will be perceptible either in
front of the growth or behind it
In cases where the pol^^jius has not yet passed through the os
uteri, the diaf/nosis may be very ditHcult, for luvmorrhage and
leucorrhtjeal discharge ai-e common to many uterine ailments,
while the growth itself may not be sufficiently large to produce
any marked increase in the size of the womb, still less to expand
ita lower segment. In doubtful cases the uterine sound is often
of much service, since as, by means of it, we ascertain either that
the uterine cavity exceeds its natural dimensions, or is limited to
them^ so the presumption in favour of the presence of some
• See pt 238,
326
FIBROUS POLYPI:
i
tumour in the womb is either greatly strengthened, or altogether
refuted. .Sometimes, however, the introduction of the sound is
very difficult, or, from its extremity impinging on the body of the
tumour, is altogether impossible; while even at the liest^
though the sound may raise our presumption of the existence
of a polypus almost to a certainty, we are not thereby at
all assisted towards its removal. The ingenuity of Sir J.
Simpson,* however, has furnished ns, in the sponge tent, or the
huuinaria, or seatangle tent introduced by l)r Shian of Ayr, and
now generally used, with a means by which we can readily dilate
the OS uteri sufficiently to make a careful examination of the
interior of the womb, aad to perform any operation which the
tumour may call for, almost as easily as if it had already de-
scended into the vagina.
This brings me, in conclusion, to consider the best means of
remorim/ these fibrous polypi of the utenis, for I will not waste
your time in rejieating again all tlie measures by which yon must
try for the moment t^i stanch tlie profuse haemorrhage to which
these growths sometimes give rise. Now there were two different
prt^cLHulings, eoch of which was strenuously advocated by some
persons, and eqiuxlly strongly reprobated by others.i- One of
these consisted in strangulating the growth by means of a Ugature,
the oth(!r in its excision with the scissors or some other cutting
instrument. The apprehension of dangerous bleeding from the
it?ninval of polypi, to which mistaken anatomical views in a
measure contributed, led to the adoption of the ligature in the
first instance ; but its use has now, with propriety, been almost
un i versally aliandoned.
I used formerly to be compelled to occupy some time in estimat-
ing the compai-ative merits of the ligature and of excision. Within
tlie iRst few yeai-s, however, a means has been devised for the
removal of fibrous pol}^i, which combines the safety from bivmor-
rhage which the ligature aflorded, with the avoidance of the risk
of purulent absorption and consequent 8eptic<Bmia which was
almost inseparable from that mode of operating, while at the same
^ On the DtUHion ,d'C,,o/ TfUra-uUrine Poljjpi in Ed. Monihiy Jmimal, Jon. IS50,
ami OkUdrk Memmrs, vol i. p. 122.
t S«« a paper hy Dr Simpson, Obsktric MtmotrM, vol, i. p. 160, strongly con-
deuinatory of the u*e of the ligatuw.
I
I
THEIR 8UBGIGAL TREATMEXT,
327
time it is almost as rapid and quite as easy aa excision with
apiaaora or any other sharp instrument The wire rope errasair is
less painful than the ordinary mode of excising these growths, for
by nieans of it we can dispense with the necessity for drawing
down the uterus so as tn bring the pedicle of the tumour within
reach of the scissors — a proceeding always painful, and not always
devoid of risk. The passing the wire round the neck of the poly-
pus is also a far easier proceeding than was the application of the
ligature by means of the double canuhi, while if any difficulties
should arise owing to the contracted state of the oa uteri in any
case where the polypus is still retained within the cavity of the
womb, it can be easily dilated by a sponge tent, followed by on©
of Barnes's bags* It is of course always desiral)le to apply the
instrument as high as possible upon the pedicle of the polj^pus,
but it should not be forgotten that if pain is experienced on
tightening the wire this indicates that some portion of the uterine
fibres, which, as I said, sometimes descend on the stem of the out-
growth, have been included within its grasp. In that case it
must be loosened and reapplied lower down. It now and then
has happened that after it has been separated a polypus is not
easil}^ removed from the vagina Sometimes it can be extracted
by hooks, sometimes even the midwifery forceps have been
required, and in a few rare instances it has lieen necessary while
the polypus was firmly held to di\ide and remove it piecemeal.*
By whatever means a polypus is separated from the uterus
(polyj»i of a malignant character oV course excepted), the pedicle
withers, and the growth is not reproduced. This fact, which was
once reganled as sugge-sting a problem of tlifficidt solution, is not
hard to undei'stand, if we bear in mind tliat the pedicle is formed
of uterine tissue. On the removal of the growth, the stimulus to
hypertrophy of the uterus is withdrawn, the whole organ returns
* Dr G Siraon, who has don* so much for the iraprov«»in?nt of oiwrative surgery
in the diBeoscB uf women, Bugge«U a very iiigv-tiiouA ihoiIl' of obtaitiing acccsa to
tli« pi'dicle of very vohiniitious polypi. This proce4?dmg couswte in making a
deep tnmvrerso uicisioti as high as posaiblo iDto the body of the polypnn, and thon
diflsactiz^ off its c&pstik from hwM the drciimfereuce of the growth. If now the
polyptu h seized with hooks, and stesdy traction ma^le upon it, its fibres will
elongnte to such an extent as to aUow ready Access to the pedicle, though before,
while the mass retained a more globuUr form, it might have been altogether out
of reach. {MonatsxhriJlJ. OtbutUkunde, voh xx^ p. 467.)
^928
FIBROUS POLYPI t THEIE INFLUEKCE ON LABOXTK.
by that process of involution of which we see so many illus-
trations to its natural dimensions, wliUe the pedicle of the poly-
pus, having no longer any office to perform, is completely
removed.
Some reference ought, perhaps, to be made to the occasional
compHcation of pregnancy or labour with polypus of the utenis
before we take a tinal leave of this subject.* There seeras to be
good reason for believing that polv'pi participate in the general
development of the uterus during pregnancy, and that a growth
preWously vety small may attain to a very considerable size
during gestation. They do not, however, in general produce
marked symptoms during pregnancy, nor do they tend to interfere
with its natural progress. After the couimencement of labour
their injurious ettects become manifest, since they sometimes
present a mechanical obstacle to the passage of the child, and at
other timas give rise to untoward consequences after its expulsion.
Of these, one of the most frequent is haemorrhage ; the polypus
within the uterine cavity interfering with the due eonti-action of
the organ, just as the portion of adherent placenta does in cases
of its disruption. The other risk is that of violent and uncontrol-
lable uterine action being excited, and exhausting the patient by
its severity and continuance, as, for instance, in the remarkable
case related by Dr Gooch,*t" in wliich, after delivery, a polypus
weighing three pounds fifteen ounces was expelled beyond the
external part-s, and the patient died while her medical attendants
were still iincertain as to what her ailment was, and what should
be done for her cure.
In spite of these contingencies, however, the general rule, and
one concerning the wisdom of wliich there can be no doubt, is not
to meddle with an uterine polypus either in labour or after
delivery, unless the symptoms are so serious as to leave us na
alternative. The ground for this rule is furnished by the risk of
hicmoiTlmge if the polypus is excised, and of plilebitis from the
absorption of decaying animal matter if the growth is removeil by
ligature ; while the vascularity of the polypus, aud probably its
size, will rapidly diminish as the involution of the uterus goes on,
• Arery able esaay on thin subject, wHinh will wcU repoy peruaal, wfta pnblishccl
by Dr Old hum in tlie Gup*3 Ifoiqntnl KepffHs, 2tid scHifa, vol. ii.
t On Diseases of JFomcn, &c., p, 28 1, case vii.
I
I
I
i L
FrBRO-CYSTIC TUMOURS.
S29
and the whole organ growa le«s and less susceptible as the date of
delivery becomes more distant.
It is thei*efoTe better during labour to extract the child, and
afterwards to check hiemorrhage, and by opiates to still any violent
uterine efforts, if possible, rather than by attempting the im-
mediate removal of the polypus, to expose the patient to hazards
80 serious and so difficult to obviate. If, however, interference
became urgently necessary, the wire icTa$€ur would here, as in
other circumstances, furnish the readiest and safest means of
operating.
There still remain a few varieties of uterine disease, concern-
ing which something should be said, before we pass to the study
of those malignant atiections of the womb that constitute
the most /painfully important of all the ailments of the female
sexual system. To a brief notice of these I propose devoting the
remainder of this Lecture : and first, I must refer to a variety of
uterine fibroid which seems to claim a special notice both on
account of the peculiarities of its structure, as well as on account
of the grave questions involved in its diagnosis — the fifrro-mfsHc
tumours of the u terns. From time to time the observation has
been made of growths proceeding from the peritoneal surface of
the uterus, or imbedded in its walls, but never, as far as I know,
projecting into its cavity, of which not only was the substance
softer than that of ordinary fibrous tumours, but which also con-
tained within their interstices irregidar cavities, often intercom-
municating, containing a transparent yellowish, slightly blood-
stained highly coagulahle fluid. Sometimes^ also, the quantity of
fluid contained in theee cavities was so considerable as to cause
the swellings to yield a distinct sense of fluctuation and to occasion
them to be mistaken for ovarian cysts, and tlius to lead to their
removal, or attempted removal, under that err«>neous impres-
sion.^
In spite, however, of the large size to which these tumours some-
times attain, and in spite of their having received a distinct name,
it may still be doubted whether they are anytliing else than
uterine fibroids, which under conditions of which at present we
are ignorant, undergo a peculiar form of degeneration, Virchow*8^
• Spell cpr WVUs, two eosea. Op, eU, vot L p, 3J64H5*
i (^ ciL Tol iiL p. 19».
830
EIBRO-CYSTIC TUMOURS.
opinion inclines to this view, which is further supported by the
invariable or almost invariable absence of any cyst wall.
Practically there are one or two important conclusions to be
drawn from these cases. First, that the mere existence of distinct
fluctnatio]! does not absolutely prove a tumour to be ovarian ;
second, th^t there is no one certain means of diagnosis between
ovarian and fibro-cystic uterine tumours ; since the latter, owing
to their mode of growth, neither disturb menstruation in general,
nor modify invarialjlj either the contour or the position of the
uterus ; third, that there seems reason to believe that an explora-
tory tapping, which otherwise might he resorted to, is attended
with much fjeril in these coses ; so that the greater or less
intimacy of the relations of the tumour to the uterus become after
all one of the chief grounds on which to base a diagnosis ; while
frmrthly, the results of gastrotomy and the removal of the tumour,
even when performed as the result of an erroneous diag^uosis, are
less unfavourable than might have been expected, yielding, accord-
ing to Gnssemw * 22 successes out of 41 opemtions, or 53*6 per
cent, of recoveries. It is evident, however, that our knowledge of
this variety of fibroid tumour is still very fragmentary in every
respect^f
One other very rare form of disease which seems to constitute a
sort of transition between non-malignant and cancerous afrection,
is that which has been termed Sarcoma, or Eeemrrni Fibroid of
the uterus ; the latter term expressive of its tendency to return
again and again as malignant disease is wont to do after frequent
removal
In the eighth volume of the Tmnmdioiis of tlir Pathological
Socicti/X there are recorded by Mr Hutchinson the particulars of a
cane in which a tumour formed within the uterine cavity of a
middle-aged unmamed woman, and gave rise to flnodings large in
amount and frequent in their retuni. At the end of twenty-three
* Op. cU. p. 114.
t [It is not to he forgotteTi that, m the cose of an imbedded soft fibroid, nterine
roTitractio% felt sometimes by the patient, may be induced by the niatiipiitation
of the rhyBician and perceived by him. Although theAo hardenings of a tumour
afford good evidence of ita nature they are raiuly bo distinct as to be reliable in n
difficulty ; and still more rarely so, as might b« expected^ in a case of librgcyatic
tumour],
:t Page 287
I
I
SARCOMA. OR RECURKEKT FIBROID TUMOUR.
331
months an attempt was made to remove the tumour, which sprang
ffora within the uterus by a pedicle as thick as the wrist, whence
a mass as large as three fiats projected into the vagina, while the
uterus itself was felt as largt? as a child's head above the pubes.
The soft texture of the tumour prevented it from l>eing firmly
grasped, and the operation was discontinued after only a compar-
atively small portion of the maas had been detached. The bulk
of the tumour, however, subsequently sloughed away, and at
the end of a mouth no trace of it could be discovered, nor any
enlargement of the womb detected. Fpr the next three months
the patient continued so to improve that it was ho|>ed a perfect
cure hml been etlected ; but at the end of six months tlie growth
was reproduced, though it had not quite regained its former size*
A second operation was now performed, and the hand intmduced
into the uterine cavity broke down the tissue of the tumour,
wideh it was found possible only very imperfectly to i-emove.
Temporary improvement again followed, but in three months more
the tumour had grown again, and was attended by its old symp-
toms. Attempts to destroy its tissue by caustic injections caused
much suffering and did little good, and death took place two
years and ten months after the commencement of the patient's
illness.
The uterus was about the size of two fiats, and contained a
white soft growth, attached by a very broad l>ase to the fundus
and posterior surface, its free extremity hanging down in a poly-
poid shape close to the os. The mucous lining of the cervix,
though congested, was healthy. The uterine waOs were mneh
thickened in those parts t^3 which the tumour had no attachment,
but were thinned, evidently by its mliltration, at the base of the
growth.
On a microscopic examination the tumour was found to be
composed of a fibroid tissue, and of a softer material made up of
round nuclear bodies, of transparent molecules, and of some
fusiform cells- Both its microscopic character as well as the
history of the disease seem to remove the tumour from the class
of ordinary malignant growths/ though the disease presents two
• [It may be doubted, howcTer, whether Mr Hutchinson a case wa« not rather one
of adentnna of thi5 mucous membrane. 1 1 Ls like one deijcriljctl by Dr Sla\'jiuuikj uid
Dr MfttthewB ptmcan in Edir^urgh Medical Journal, August 1873.]
332
SARCOMA,
unmistakable cliaracters of malignancy, that namely of return
after removal , and of its tendency to attack different and distant
organs.
In his paper on the enncleiition of fibrous tumours, Mr Hutch-
inson refers to a case of Dr Atlee's, as probably belonging to the
same category with the one just related. The account given by
Dr Atlee * however, is too vague to enable one to form any very
accurate judgment of the structure of the growth, though its rapid
reproduction after removal renders his opinion in the highest
degree probable. A case has also come under my own observation.
that })elongs to the same class, and the details of which, as will be
seen, harmonize very closely with the hist^iry of Mr Hutchinson's
patient
A young unmarried woman, aged twenty-three, who had always
had good healthy and since her fourteenth year had menstruated
acautily, but without pain, every three weeks, was kicked on the
lower part of her back during a menstrual period in July 1852.
This kick was followed by frequent abundant discharges of blood
from the vagina, and towards the end of September by pain
referred to the loins and hypogastrium, and by a sense of bearing
down, which, however, was not aggnwated by moderate exertion,
nor relieved by the recurubent posture.
The discharges, which had reduced her to a state of great weak-
ness, were described at the time of her admission into the hospital
on October 1st, 1852, as being habitually oilensive, consisting
sometimes of fliud blood, often intermixed with large coagula, but
being at other times greenish and watery.
On examination the os uteri was found widely open, and a
polypus, apparently of the size of a pigeon's egg, protruded through
it, but the tinger coidd not be passed high enough up to reach the
point of its insertion. The hooked forceps introduced to di-aw it
down, tore out from its substance, which was found to be remark-
ably soft ; but a portion as big as an egg having been removed, a
large mass was still left behind in the uterus. No haemorrhage
followed this first operation, which waa attempted on October
4th ; on the 10th, the ergot of rye having been given in the
interv^al in the hope of forcing the tumour lower down, the sound
passed four and a half inches, and the finger detected a rough
* Traftmaiom of Ammcan Medical Asaoeiaiicn, irol vi p, 579, case iiu
I
I
OR KECURRENT FIBROIB TrMOUB.
333
mass, not unlike placenta or very old clot, finnly adherent
to the walls of the uterus, which was perfectly movable in the
pelvis.
On November 11th a second attempt "was made to remove the
tumour, the patient having in the interval Buffered nmeh from
haemorrhage, and haWng also experienced considerable paku The
attempt, however, isaued in the removal of but a veiy small
portion of the tumour, whose texture again broke down, while its
attachment to the posterior and lowei- part of the uterus was too
broad to allow of a ligatui'e being placed around it On Decem-
ber 20th a tliird operation was attempted ; a fourth on January
5th ; a fifth on February 2l8t ; and a sixth on March 8th ; the
growth being partly torn away by the fingerSj in part scraj»ed from
the interior of the utei-us by a blunt knife, whose blade was fixed
at right angles to its handle. After each operation masses of the
tnmouT came away, and it was estimated that altogether the
quantity removed in and after the several operations amounted to
about six ounces. On April llth^ the sound still entered three
and a half inches, showing that though the si-ze of the uterus was
diminished, it yet had not returned to its natural dimensions ;
while, though the os was closed^ so that the exact state of things
could not be ascerttiined, I yet feared the reproduction of the
tumour, for I had been struck by the circumstance that in spite
of its laceration and of the forcible avulsion of portions of it at
each operation, it yet, on every repetition of the proceeding, pre-
sented the same smooth surface.
Microscopic examination of the portions of the tumour showed
its texture to be made up of imperfectly formed fibres, and of an
aggregation of cells resembling those of inflammatory lymph, or
granulation cells.
lo April the patient left the hospital, but at the end of June
she had a most alarming haemorrhage, during which large portions
of the tumour were discharged, intermixed with coa^^la. At the
beginning of August she w^as readmitted, and the enlarged uterus
was now felt distinctly over the pubes, while on a vagiual
examination its lower segment was found much distended. The os
uteri was diJated with sponge tents, and as nmch of the tumoiir
as could be removed in fmgmenta was extracted, though the
quantity did not much exceed six drachma. The muriated
334
SARCOMA,
tincture of iron was now injected into the broken-do\ni tissue, in
the hopes of thos expediting its destruction, and this was repeated
thrice between that time and the 17th of October. The patient,
however, dreaded these injections very much on account of the
severe ptiin which they occasioned ; wlule chloroform produced
80 much and such abiding sickness and depression, that it wafi
not possible to have i-ecourse to its use.
In December 1853, an attack of haemorrhage wtis accompanied
by the expulsion of six ounces of the tumour ; and on the 15th of
that mouth a lai^^e portion was removed ; and on February 20tb«
1864, a ninth and last operation was performed* The suffering
caused by each operation, not so much at the moment of its
performance as subsequently, when much abdominal tenderness
was always experienced, and a great degree of constitutional
disturbance was produced, coupled with the necessarily incomplete
character of each operation, and the extreme rapidity with which
the growth was reproduced, led me from this time to abstain from
all interference. It would be tedious to relate minutely the
subsequent bistor)* of the patient, who, in the autumn of 1857,
was still able to follow a sedentary occupation, and to walk half a
mile in order to show herself to me at the hospital. She had had
many attacks of profuse haemorrhage, one of which, in May 1856,
very nearly proved fatal, and was followed for weeks by alarming
depression with severe abdominal pain, which was kept under only
by large doses of morphia ; and by profuse, extremely offensive
watery flischarge. The outline of the abdominal tumour, too,
could l>e felt above the umbilicus, the abdomen measuring at that
point tbirty-two and a half inches ; while per vaginam a
lobulated soft growth extended through the widely-dilated mouth
of the womb. In spite of the decided increase of the abdominal
tumour, however, the patient*s condition steadily improved, after
her recovery from the hicmorrhage in May 18 56 , since which time
no considerable loss of blood occmTed, though the abdomen
i-emained extremely tender ; and the patient, in spite of added
strength, remained pale as a marble statue.
On December 20th, 1857, she re-entered the hospital for the last
time, not suffering indeed from any return of her uterine
symptoms, but from pain, which she conceived to be rheumatic,
in her neck, and from cough brought on by exposure to cold a
OB BECURRENT FIBROID TUMOUR,
335
week before. Some swelling was perceptible on the right aide of
the cemciil vertebrae, and light was throwTi on its probable
nature in the course of a few days by the occurreoce of numbness
of the right arai and le^^ and difficulty in moving them. Next»
power over the left arm and leg became similarly impaired j and
the urine was voided involutitarily as well as uoconscioualy.
The respiratiuu, too, was laboured to an extent wliich auscultation
did not account for; and the strength daily decUned, though
without suffering, and death took place quietly on the 3rd of
January 1858 ; neai*ly six and a quarter ye^irs from tlie com-
mencement of the patient's illness.
The following account of the appearances after death is from
the not€3 of m}^ friend and colleague, Mr Callender, The rarity
of the case furnishes my excuse for relating it in such detail : —
On opening the sac of the peritoneum, a large oval tumour, in
front of which lay several coils of smuU intestine, was seen
occupying the left iliac fossa, and extending upwards to about
the level of the middle of the left kidney* It was invested by a
tliin transparent membrane, which dipped in between the con-
volutions that divided the tumour into lobes of unequal size.
Tlie tumour was of a white or pale straw colour, slightly vas-
cular, a few large blood-vessels ramifying over its surface. It
grew from the posterior wall of the uterus, to which it was con-
nected by means of a broad base, two inches and a lialf thick, by
one and a half in length. The tumour itself measured live and a
half inches in breadth. The uterus occupied the entiixi jielvis,
and rose to some height above the level of its brim. Its walk
were only a quarter of an inch in thickness, and the os uteri was
80 dQated by a tumour which projected through it, that it was
im|>ossible to determine exactly where the utems ceased and the
vagina began. The uterus thus atteimated was stretched over a
large tumour which occupied its interior, Tliis tumour was
attached by a broad base to the posterior uterine wall, where it
was continuous with tlie gi'owth which projected into the iliac
fossaf while anteriorly and at the sides it was perfectly free.
Independently of this, a few isolated nodules were connected
with the right side of the uterus, and projected upon its inner
aspect, involving the mucous and submucous coat The lobed
surface of the tumour was free from any irregularities such as
336
SABCOMA :
might have heen expected from the previous opemtiona. The
lobes were more marked and more irregular on the anterior and
lower portion of the tnmour than elsewhere. It measured seven
and a half inches in length, bj five inches in breadth. These
tumours presented throughout the ordinaiy charactera of recurrent
fibroid growths, being composed of narrow, elongated, caudate,
and oat-shaped nucleated cells with some detached nuclei, and
granular matter.
The lumbar glands were the seat of a simDar deposit ; and
nodules of a similar kind were imbedded in the lungs, and con-
nected with the parietal layer of the pericardium. A mass of
the same kind was seen projecting from the body of the sixth
cervical vertebra, and the same deposit, being infiltrated into the
substance of the bone, had expanded it, both anteriorly and
posteriorly, compressing the anterior columns of the spinal coid,
and producing the symptoms which at length proved fatal*
I have related this case at length on account of its rarity, and
because its duration of more than six years brings into stronger
prominence^ than did the history of Mr Hutchinson's patient, the
differences between this kind of growth and those of a truly
malignant character* No cancer cells were detected in the
uterine tumour either during the patient^a life, or wh^n the parts
were removed after her death ; and though the nodules in the
hin^
were thought by some who examined their stmcture to
contain cells resembling those of ordinary scirrhus, yet Mr
Callender did not discover any, while every one agreed as to the
abundance of tibroid materiaL
I have seen no other cases resembling this. Our experience is
at present too small to warrant our arriving at very positive con-
clusiona respecting the disease which they ilhistrate. Virchow'sf
observations on its structure indeed tend to give it a place among
quasi-maUgnant growths. He describes it as abounding in soft
round cells like those of medullary cancer, but at the same time
as being here and there so firm as to bo easily mistaken for true
* Tliifl case in described at length by Mr Calleiider, in to], uc of the TransaetionB
o/ihe Palh^logiad S&cidy, p. 327.
t Op. cU. vol ii. p. 350- [An ekborat* pii|w}r oa the mibject, with historical
details, ib ti) be found in Ed. Med, Journal^ Jan. 1876, II is entitled ** SarconiA
Uteri,'' and b from the i>eii of Professor Simpson.]
I
I
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I
ITS RELATION TO CAKCER. FATTV TUMOUR,
337
fibroiJ, A poiQt still uadetermined about it is whether it
is due to the degeneration of a previously existing fibroid or
whotlier the characters which eventually distinguish it exist, ag is
indeed most probable, from the veiy commencement The whole
medical literature, however, contains at present reports of but 62
cases ;• so that is not surprising tiiat there should be many
questions concerning it which we are still unable to solve. We di
not know what conditions favour its occurrence beyond the fact
that from forty to fifty years is the age of its greatest frequency,
and that unlike carcinoma, in which disease there is a history of
more than average fecundity, 25 out of 53 married women who
werie the subjects of sarcoma or recurrent fibroid were sterile.
Practically all that just now we can say with certainty is that
there is a disease of rare occurrence in which a tumour forms
usually inside but sometimes in the walls or even on the outer
surface of the uterus, having many of the characters and producing
many of the symptoms of fibrous growths, but difteriug essentially
from them, and having altinities rather with maligntint disease,
though slower in its course ami involving the whole system les«
invariably and less rapidly. With reference to its treatment, a
question which I cannot undertake to answer is whether it bright
to interfere, or whether it may not be wiser to let it alone, since,
while its complete removal seems almost impossible, its partial
extirpation appears to be followed by an increased rapidity in it.*^
reproduction.
Two instances of Fatty Tmmurs of the uterus are reported in
the German medical journals ; and though notliing of the kind
has ever come under my notice, it might seem an omission if I
failed to refer to them.
The patients in whom this growth was observed were of the
r«3Spective ages of fifty and fifty- three.f The former of these
women, after sufiering for eleven years from leucorrhcpa, expelled
from the vagina a tumour the size of the fist, which was ascer-
tained to be made up of fat, closely resembling cliolesterine^
thovigh not quite identical with it. In the other case the tumour,
which was of the size of a child's head, projected beyond the
* Q^merowt op. eit, p, 150.
+ The C41QI we reUtod bj Dr W. Busih, in AfiVhr'/i Atrhiv^ 1851, p. 858 ; and Dr
in fTBHemk 2Ssiitokr,^ vaL r. 1852, uad Scktuidia/a^r6,, D«c 1852, p. 3SS.
I
S38
BAEE VAEIETIES
external parts but was connected by a pedicle three fingers broad
with tlie whole mai^n of tlie os uteri. It was removed by lig^
ture, aDd the patient, wlio had been subject t^> menorrhagia for a
year previously, recovered. The tumour, which w^eighed three
pounds and a half, ia said to have been an ordinary fatty tumour,
having an investment of dense cellular tissue, septa of which
clipped down into its substance. The patient in the first case
Cimtinued after tlie expulsion of the tumour Iklile to periodical
discharges of verj- ofllensive slimy, waterj^ fluid, in which w^ere
now and then small flat masses similar to the larger substance.
The state of the cervbc was quite natural, and I suppose that in
this case tlie deposit of fat had taken place upon the free surface ^
of the diseased mucous membrane of the womb, and bad by ^
degrees accumulated in the cavity of the organ until it stimu-
lated its muscular fibres to contract upon and expel it,
[Between the tumours proper of the uterus and the malignaut
growths, mention may be made of some conditions not frequently
met with. It is not veiy uncommon t^) find a fibroid, with all the
appearance and symptoms of a true fibrous polypus, but really a
false one, that is, having no muscular or mucous capsule, being
denuded of these and in the process of enucleation and expulsion.
The practitioner, seizing such a tumour, finds it sometimes easily
detached by the pulling intended merely to put the pedicle on
the stretch ; for the pedicle here consists merely of the limited
and still persistent tibrous connections of the tumour with its
capsule,
A tumour more or less polypoid, soft and connected with the
mucous membmne of the body of the uterus, is occasionally
found occupying the uterine cavity ; appearing sometimes as if it
bad grown to fill up a vacant space. Some such si>ecimens have
Ijeen examined for me by Di^ Hardie and Underhiil, and may be
called examples of mdluscum ; for they have not the shape of
true polypi ; they are single and not diffused, as in tlie fungous or
polypous endometritis, and liave not the history or structure of the
adenoma to be presently described. Microscopically examined
they are found to consist of loose cellular or connective tissue,
^dth a cylindrical epithelial iuvestmeut. X have found them in
uteri otherwise apparently healthy, and in cases of uteri ue fibroid,
projecLing into the uterine cavity, and appearing as if formed to
I
I
I
OF UTKSm TUMOlTBSb
339
fill tip vacant spaces produced in the uterine cavity by peculiarities
in growth of one or several fibrous tuuiours. They seeoi to l^e in
some cases the source of bleeding, for I have known the hias
diminished greatly after their removal. They vary in size from
that of a pea to that of the largest Brazil not. I Iiave seen one
in a post-mortem examination as large as half an orange.
Ihe malignant polypous adeiwma is a rare disease. It consiats
of an outgrowth of the mucous membrane of the liody of the
uterus, with all ite glandular structai^s hyfjcrtrophied, and by
this it is easily distinguished from the mulliiscum. The same
characters give it resemblance to the growths of p^jlypous or
fungous endometritis ; but from tliLs it is easily differentiated by
its rapidity and enormous extent of gi'owth, its rapid course and
other clinical characters of malignancy* It^ microscopical
characters are given in a case put on record by Slavjan.^ky and
myself.* and in anotlier by Rreisky.f In my case (and 1 have
anotlier cloaely resembUng ii under my care at present) Slavjansky
found no microscopical evidence of malignancy ; but I bad no
doubt of it, and its history after Sluvjansky's examination proved
it. After the growth, springing from the fundus, was removed, it
rapidly grew again, distended the uterus, opened up its cervix, grew
into and filled the vagina and protrutled through the vaginal
orifice before death, which took place five months after my first
examination. Latterly, the discharges were fetid, but there was
never much hiBmorrhage. The patient died in the country, and
the autopsy was made under unfavourable circumstances. It was
said to verify in every respect the opinion formed of the case
before death.
Tumours in the pebds are sometimes formed by true hydatids,
and Graily Hewitt has described a case in which they were
expelled from the uterus. I have never seen an example, and it
will be enough to refer to the paper of Frt»und and Cbadwicki
where all literary references are duly given,]
In conclusion, I will add a few words conreming iuhrrmhr
(ItposU in the uterus, though it ought not, perhaps, in strict
* Elinburgih Mtdiiml Jofwmal^ Attgust 1873.
t Priujer Med. W<i^maekr. iL 1877, and Daseerow^ Xaihihfungeii du Vtn'uf,
8ti?ttgart 187S. *l 225.
, t American jQinrmU </ ObtUirkif Fcbftmry 1875.
340
TUBERCLE OF THE UTEBrs
propriety, to be noticed here, but sliould rather be referred to t
separate cato^^'ory. Coavenience, however, may be allowed to
ovenTile strictly scientifiG arrangement. It happens occasionalJy
that on examining the uteruB, although ite exterior may appear
quite healthy, and the canal of tht^ cervix also be free from
disease, the whole of its cavity is found occupied by a matter of a
dirty yellow colour, closely resembling both in its aspect anj its
consistence the subgtance of a tubercular bronchial gland when
just beginning to soften. This deposit is generally about an
eighth of an inch in thickness, is easily scraped away with the
back of the scalpel ; but on its removal it is found that all trace
of the lining of the uterus has disappeared too, or if anywhere a
portion of it remains, tliat u seen to be opaque, more vascular
than natural, and to present beneath it smaU yellow spots looldiig
like distinct tubercular deposits, which, in fact, they have been
ascertained ttj be by careful microscoxjic examination. In cases
where the disease is only b^iginniug, the separate yellow deposits
in the mucous membrane are alone apparent; while when the
disease is far advance<l (and it was so in the two cases which came
under my own observation), not only is the mucous membrane
completely destroyed, l}Ut the deposit encroaches on the suljstance
of the woiiil), its cavity is enlarged by the abundance of the
morbid substance, and its walls are thickened ; changes that m
some instances have been known to occur to a very considerable
extent
In the great majority of cases the tubercular deposit does not
extend beyond the cavity of the uterus, though sometimes a
similar matter is fonml distending the Falloidan tubes, and tuber-
cular degeneration of the ovaries now and then co-exists with the
disease of the interior of the iivomb. Either of these occurrences
is, however, more f reqiient than the extension of the disease to the
cervical canal; and Kokitaasky* states that it scarcely ever
appears there as a primary deposit. Occasionally one sees in the
living subject, on the surface of one or both lips of the uterus,
deposits of a yellow colour, of the mm of a split pea, or smaller,
having altogether the appearance of small deposits of yellow
tubercle, and which on being pricked give issue to a small quantity
of matter of the consistence of pus, or rather firmer, and ha\ ing a
^ Paihok Analomu^ Sd od. 1861, rul. ill. i\ 49d.
ITS CHARACTERS. AND <
841
graiuilar appearance under the microscope. These deposits have
1 leeo ftUeged to Im tu1>erciilous ; and the hiph authority of the late*
l*rofessor Kiwisch* may lie adduced in support of that opinion,
I am familiar with the apf^eamnce, but am not altogether con-
vinced of itH tuberi'ulous character, and am rather inclined to con-
sider it as due to liypertrophy of some of the Nabothijin follicles,
with obliteration of their oriOces and altemtion of their cx>ntent8.
At any rate, though small slightly excavated ulcei's are now and
then left behind, I have never been able to trace any connection
between this appearance and any form of destnictive ulceration
of the cervix.
The disease seems to be always Eecondary to tubercular deposit
elsewhere, and even then to be of rare occur ence, though perhaps
less so than it was lielieved to be by L(:ans,'|- who did not estimate
its frequency liigher than one and a half per cent, of all cases of
tuljercle in geneml M, KiwischJ states, that at Prague it was
met with once in every forty cases, or, in other words, with a
frecjuency of two and a half per cent. ; ard I know of no other
statistics bearing on llie subject.
The following table deduced from data furnished by Kiwisch and
a recent very painstaking v^Titeron the subject^ Dr Geil,§ furnishes
some information not without its value : —
Tubercular deposit in the uterus was met with —
In 6 subjects between 10 and 20 years.
20
—
30
30
—
40
40
—
50
50
—
60
60
70
70
—
80
Total, 68
^ Ofh eiL Toi. I p, 558.
t Richefrkes mtr la I'MJUHe, 2d eel., Pani 1634, p. 142*
: Ojs. eU. p, 559.
I In Ml inAaguml diBaertation, published at Erkngen in 1651, wid of which to
abatriict is giTen in Schmidt'^ JahrhiiehtTt Manh 1852, p. 324. Some udditionAl
Ottet, whidi, hfiwetrvr, throw no frp^^h light on thn Hnhjcct, wiU \m found in the
ttbBtrw^t of a paper by U, Crocq in Archtvegdt Af«f., l^dO, toI. ii. p. ^\h \ ind in
another h^ Al. TaaUen, in Schniidt'd Jahrh^heTf 1853^ toL 60, p. %t%
342
.IfUBSBCLE OP THE UTEHUS
In forty-five of the cases collected by Ur Geil, tlie seat of th^
afifection is distinguished —
Uterus alone affected
, ^ , f with affectiun of peritonemu .
„ and tubes- ,. .
{ without ,, „
Utenis,tiibes,and J in form of an aphthous process
vagiua . . ( ,, true tuljerculuiis ulcers 1 case
Tubes alone affected • . 8 casea
Eight tube alone ,,...,,.... 2
Total, 45
Auienorrhcea or dysmcnorrhci/a, often associated with leiieor-
Tbteal discharges, are the sf/itiptoins which are ordinarily obseneil
in coimection with uterine tuberculosis. Pain appeai-s to be an
exceptional occurrence, and when present, neither to be an early
symptom, nor commonly to attain to any great severity, though
now and tlien — as in the interesting case which eauie under my
own notice, and which was described by Mr Tomlinson of Burton-
on-Trent, at a meeting of the Obstetrical Society — pain may beeonxe
very severe. In many instances no symptonjs have attended the
affection during life, wliile those which have just l>een enum-
erated present, as I scarcely need to say, nothing pathogno-
monic of this peculiar disease. Indeed, if we bear in mind that
tuhevculoua aO'ections of the womb* appear to be almost always
* Twice I luire met with sjicptoiiis of iliaeafi« of tbi^ womb which I regarded 18
tiibercylous, Imt bad no opportunity of verifying my diognofliB by a post-mortcin
cxAmiiiatioi). The patiootii in these cusi-a were Jigtd 35 mtd 6S years reapectively.
The youngvr hnd given birth to childroti ; the dder hiui not mniTied ontO kte in
life, aticl had neviT l»een pregnant The younger patient was in ft state of advanctd
IththisiB, with cavities in the langa ; the elder had had Hyniiitnms of confiumptive
disease in early life, and jHTcussion was dnU and respiration feeble in the left
infra-clavicular region. In both patients leucorrh<ra had pn-eedid any other local
symptom ; in lioth this diacharge came from the inlt^rior of tbv nt^^nia, wa« thick,
tenacious, yellowish in one caae, greeniab in the othiT ; bud a p^enliar faint smell,
but not tJie offensive odonr of cancer. In neither waB there any haenumiuge ;
and incntitruation, which «till continued in the younger {mtient, bad in hef bocome
mtsnmAy aomity. Pain had come on gradually^ bod increaied tIowly» but
siiUHiQted at lost, after the lapse of a year, to intolerable ceaseleM oiigaiah. There
was Bonie t^^'udemesa about ili« u tenia, which woft some what enlarged ; but there
wiia no hardness about the cervix— no unhealtby condition, cither to the touch or
eye, about the mouth of the womk The symptoms were not those of cancer of the
I
*
i
ITS SYMPTOMS. 343
secondary to extensive deposit of tubercle in other organs, we are
led to the practical inference that, in cases where phthisical
symptoms are present, there is every reason for interfering as little
as possible for the removal of amenorrhoea, or other irregularities
of the menstrual function, and especially for abstaining from much
local treatment of any other uterine ailment that may occur.
body of the uterus, but they resembled not a little those described by Mr Tom-
linson. I do not know how long either of these patients lived, but I know that it
was more than two years. A very exhaustive note on the literature of tubercle of
the generative organs, added by M. Mauriac in the French translation of these
lectures, p. 394-397, yet leaves the practical point much as stated in the text
LECTURE XVIIL
MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS.
volvetl
H4>pelii8ane98 of the subject, but importdnee of questions
erroneouft opiniooa foraierly held coiicemiiig it.
Definition of Cai;c£Il ; ita varii^tiea. Scirrhiis extremoly rmre ; its anatomicft]
chamet4?ra.
ilwiullary Cancer ; its nature, mode of occurrence of ulcemtion, its rapid progras ;
abortive nttenipts ut cure, ami advance of the di&e«jse. Hypertrophy ofutertiii
in ita course ; tlisngei* in its walls ; its interior j on it» aurfnce. Extenmon of
diseiUNJ to vwgimi and bludder. Exceptional eows ; caneer of body of ntems ;
canceroua polypi . AJ veolar ean ccr.
Epithelial Cancer ; its genciid characters, ita relation to xnedullaiy cmncer ; eveiitiftl
identity with Cauliflowex Excrescence.
Ulcer of the os ut«rt ; the scNcalled Tuberculous Ulcer ; Corroding Ulcer.
Frequency of aocondary afiections in cum of uterine cancer.
I ami
In the study of the diseaaes which have hitherto engaged our
attention, we have never entirely lost ft sense of hopefulnesa.
Either medicine ini^lit cure the ailment^ or surgery might remove
it ; or at the very worst, so much might be done to retard its
progress, and to alleviate the sufferings which it occasioned, thut
life w^as in many iostannes but little, if at all shortened; was
sonietimea even scarcely embittered by its presence.
In passing now. however, to the investigation of the malignant
diseases of the womb, of mnccr faid its allied die onj el's, we shall
find but few of those mitigjating circumstances which lessen the
darkness of the picture in the case of many other incurable affec-
tions. Tiiin, often exceeding in intensity all that can be imagined
asmostintolemblc, attended by accidents which render the suflei^r
most loathsome to herself and to those whom strong aflection still
gatliers ixmnd her bed; the general health broken down by the
action of the same poison as produces the local sutrering, and all
tending anrely, swiftly, to a fatal issue, which skill cannot avert,
from which it can scarcely take away its bitterest anguish j such
I
I
r.\XCER OF THE UTEBDS.
345
are the features in the picture which T must now call on you to
CDDtenipIate, and that not hurriedly, nor for a moment, but most
carefully and deliberately, and in all its various aspects* There
are, indeed, many reasons which prevent our passing over the
subject of uterine cancer (as we might be glad to do) with but a
L passing notice* The frci|uency of the disease forbids it, for scarcely
f***'^any age is free from its attack, while it ia doubtful whether any
otlier form of organic affection of the womb is met with so often,
^ and it is certain that there is no otlier so fatal The dread most
natundly felt, lest this symptom or that symptom should portend
the outset or imply the existence of cancer, forliids it ; for we are
called on over and over again to remove the appi-ehensions of
women whose fears have lieen excited by some uterine ailment
perhaps of no great moment, but out of which they have shaped
to their atlrighted fancies all the hideous features of an incurable,
an almost unbearable disease. Need I say, then, how much it
imjKjrts that we should be aide to remove such apprehensions
when causeless, not by holding out vague hopes or uuceitain
expectations, hut by positive assurances founded on large and
accurate experience, and, as far as may be, on certain know-
ledge ?
To those practitioners and wi-iters, both English and foreign,
who have taken the most active part in the study of the intlaui-
matory aflbctions of the nec^k of the womb, and whose investiga-
tions have led them (as some Imlieve, and I confess myself to be
of that number) to an exaggerated estimate both of their
frequency and of their importance, we yet owe a debt of gratitude
for the light which they have thrown on this disease, which
outweighs many overstatements and cancels many errors. Cancer
of the uterus used before their time to be described as a disease
slow in progress, continuing in its first quiescent stage of scirrhus
not only for months, but for years, and then, excited by one knows
not wdiat cause to activity, passing into the state of ulcerated
carcinoma, and thus at its close quickly destroyiug the patient
It 8u*ticed,theu, for the neck of the womb to l>e hard and painful,
and somewhat enlarged, for the suspicion of malignant disease to
be entertained, and for years of causeless anxiety to be entailed
upon the patient. Such and suchlike were the results which
followed from confounding the consequences of inflammation and
346
CANCER OF THE UTERUS t
of kindred processes, with the changes which the deposit of
elements of cancer brings about in the aliected part.
It is scarcely necessary to dejifie cancer ^ but if some defiuitioo
must be adopted, I know of none better than Miiller's :* " Those
growths may be te lined cancerous which destroy the natural
structure of all tissues, wluch are constitutional from their vetj'
commeucenient, or become so in the natural process of their
development, and which when once they have infected the
constitution, if extirpated, invariably return, and conduct the
person who is affected by them to inevitable destruction/' Takiug
this definition, however, as, on the whole, the Ijest that can be
given, we must still bear in mind that morbid anatomy and
chemical research have both, within the forty years that have
passed since it was framed, tended to show great diversities
between the different forms of carcinoma, atid to show also that
many of those which affect the womb are local in their oriji[in» and
continue so through much of their progress; and that probahly if
we could always discover the existence of the disease early, we
often need not despair of its cm-e.
No form of carcinoma seems to be peculiar to the xitems,
though they do not all occur with anything like the same
frequency. Fungoid or medullary carcinoma is by far the most
common ; next in frequency may be classed the epithelial varieties
of the disease, if, indeed, it be not more con'ect, as some men of
high authority believe, to refer them to a separate category distinct
from genuine cancer. Next to them, but divided by an inten^al
wiiich widens in exact proportion as fresh evidence is brought to
bear on the sul^ject, may be classed scirrhiis, or hard cancer,
while almost as rare, or, perhaps even more uncommon, stands
the colloid, or alveolar variety of the disease.
The only attempt with winch I am acquainted at a numerical
estimate of the comparative frequency of sciitUvs, or hard mncer
and other varieties of niahgnant disease of the womb, is the
statement by the late Professor Kiwisch,f that about three of
every ten cases of cancer of the womb are scirrhous. This
estimate, however, in all pnjbability nuich overrates the frequency
of scirrhus ; and I cannot but tliink that many insUmees of firm
• (H Cancer ^ kc,, Englith Traraktiou, 8vo, London, 1840, \k 28.
iOp^ciL vol i. p. 518.
ITS VARIETIES,
S47
Hiullary cancer have been regarded as acirrhus, and this not
otklj by le^s competent observers, but even by Kiwisch himself*
He goes on to say " that with the commencement of the softeninj^
of fibrous carcinoma, the peculiar characters of the growth
progressively disappear ; it grows like medullary cancer, becomes
more vascular, and is easily broken down ; contains a puhaccous,
brain-hke substance, and the ulcer which forms upon it presents
precisely the same external appearance, and the same charactera
as those %vhich result from the breaking down of medullary
cancer.
The great authority of Eokitansky* may furtlier be adduced in
support of the opinion that ** tibrous cancer is of extieme rarity ; '*
while, on the other hiind, *' medullary carcinoma occurs with the
greatest freipiency," To say after this that I have not met on a
post-mortem examination with any example of genuine scirrhus
of the utenis, considering how few compamtively are my oppor-
tunities for observation after death, may seem almost an idle im-
pertinence. It is more to the purpose, however, to add that Sir
James Paget informed me that he had not met with any instance
of it, wldle any one who carefully examines the preparations in
our anatomical museums will find that this disease, once said to
be so common, is in reality but seldom met witli. It is perhaps
not irrelevant to mention, that of one hundred and seventy eases
of uterine cancer of which I have a record, tlie disease appeared
from an examination during the patient's hfe to be of the medul-
lary kind in a hundred and thirty-seven, epithelial in twenty-
eight, epithelial and fungoid combined in two, and colloid in two,
while in only one instance did I recognise the characters ci
ficirrhus, though I have seen some cases of alleged scirrhus in
wiiich the history of the patient, and the result of long-contiiiued
observation, plainly showed the name ttj have been misapplierl,
and the enlargement and induration to lie due to causes of a
perfectly innocent kind.f
In spite of differences on other points, all observers are agreed
• Patkolotfi»cIte Anatnmif, vol. iji. p, 550,
t I &ai wt^n aware that this sii|}«rficial kiiul of exaDiiuation wMeh alone ia pTftC-
ticublc* during life h alnioHt valueless towardii tho deciBioti of a question concerning
wliiuli nuii'li difFt^ronoe of opinion exists, even nmong the best morbid anatonil^tB,
such as Virt'Low and Rukitaiiaky, The rarity of true scirrhus is the one point
concerning which aU are agreed.
348
CANCER OF THE UTKRITS :
that the neck of the womb, or rather that part of it vrhMi
projects into the vajTina^the portio vaginalis Js the point at whicJi
cancer generally commenfes, and to which, for a reason, it is
confinerl Its mode of coranif^ncement differs, according iv6 the
disease belongs to the cpiihcimi or to the meduildry form. In tlie
lirsfc case, the papilhe of the 03 uteri seem to be the point of i
departure of the evil, and a large, granular, sprouting outgrowtJi
not infrequently projects into the vagina, while still the subjacent ^
tissue is but little involved- In the second case, the morbid
deposit takes place in the substance of the part, enlai^ng, but
thickening far more than lengthening it, increasing the size of the
lips of the uterus, rendering them hard and tense, though still
not without a certain elasticity, and at the same time irregular
and nodukLed ; wliile as they enlai^e they usually gape, and
leave the mouth of the womb and the lower part of its cervical
canal more widely open than in a state of health.
On making an incision into tlie pait.s wliich have tlius lost
their ordinary chamcters, tlie place of the natural structui^ of tlie
nterus is found to be more or less occupied by a white, firm,
semi-transparent deposit, which in some parts seems infiltrated
into the pri>per tissue of the womb, in others has entirely taken
its place. Tltis deposit is always more abundant near the mucous
surface of the organ than towards its outer wall j and a thin
layer of muscular substance may often be detected beneath the
peritoneal investment of the uterus, even wlien the conversion of
its tissues into cancerous structure has been most complete.
It is very seldom that after death one finds nothing more than
this substitution of cancerous deposit for the proper tissue of the
womb. In the great majority of c^ses softening tukes pktce, even
while the pait involved is but a comparatively small portion of
the womb; softening is soon followed by death of the mucoua
membrane of the os uteri ; an ulcer foims, a ragged, uneven som,
witli raised, irregular, hardened edges ; and a dirty putrilage
covering its uneven surface takes the place of the smooth but
enlarged lips of the organ. Or, if the disease goes on still further,
tlie lips of the womb and its cervix are altcigether destroyed, and
a soft, dirty-wliite floccnlent substance covers the uneven, granu-
lar, and hardened tissue, which alone marks their former
situation.
I
I
ITS PATHOLOQICAL CHAILiCTERS.
349
These ulcerations, wlien once formed, increase with great
rapidity, a fact of wliich I have more than once seen remarkable
illnstratiuns* A patient, aged forty-nine years, was admitted
under my care into St Bartholomew's Hospital, whose sjrmptoms
c^niisted of kemordmge, at first profuse, afterwards occurring
frequently and withont cause, tliougli in Iei§s abundance, and with
it some pain in the back had of late been associated. The uterus
was low down, quite movable in the pelvis, and not much en-
larged. The posterior lip was thin, and seemed healthy, the
anterior was thick, liard, and nodulated, though the mucous mem-
brane covering the surface of both appeared healthy under the
speculum. Twelve days afterwards the examination was repeated,
and the advance of disease withiu this short time was very re-
markable. The posterior lip was now no longer thin and natural,
but thickened, puckered, and uneven, and tlie inner surface of the
anterior lip was irregntar, as if from ulceration, while the intro-
duction of the speculum showed the surface to be uneven, ragged,
black, and bleeding.
I have seen other similar cases, but none in which the occur-
rence of ulceration was so sudden, or its subsequent progress so
rapid, as in this instance. It is not easy to account for the occur-
rence of ulceration in all instances. Commonly it is preceded by
softening of the morbid deposit, but this is by no means constant,
for in the very instance which I have related, and in others too,
in which it has been possible to fix the date of the ulceration, and
to trace its subsequent progress, the cancerous substance round the
ulcer has been, and has still continued firm. Mere rapidity of
grawtli, too, does not of itself produce ulceration ; for some instances
of rapidly growing medullary cancer of the womb excite our sus-
picion, and yet obscure our diagnosis by tlie absence of ulceration
even up to a late period. All that we can venture to assert with
reference to the subject is, that in all forms of cancer of the womb
(with the exception, perhaps, of that of its body), ulceration and
the formation of an open sore take place souner or later ; and
further, that this ulceration may occur in one of two ways,* either
proceeding from within outwards, in which case it is preceded by
softening of the cancerous tissues, or from without inwards ; tlie
vitality of the investing membrane of the uterine lips being
* See, witli reference to tliU aubjuct, Vaget, op. cU* vol ii. \\ 331.
USD
CANCER OF THE UTERUS :
desteojred first, Just in the same way as the vitality of the skin is j
sometimes destroyed over a cancerous tumour of the breasts
A few days often suffice to give to the ulceratiau the dimensions 1
and even the depth which it may be found to retain for months I
suhsequently. The jmtient, indeed, grows worse, the discharged *
continue, composed of pus fnjm the ulcerated surface, fcetid from
the admixture with it of dead and decaying materials, tinged with
blood from the giving way of some of the vessels distriVmted to
the granulations, while every now and then abundant hi^mor-
rhages break forlh profuse enough, perhaps, to excite apprehensians
even for the patient's present safety. If we examine, we find
sprouting granulations or positive fungous outgrowth from the
surface, and, then, after a time, the fungus disappears, the aurfacae
feels less uneven, the edges less unhealthy, and we can almost j
persuade ourselves that here and there a process of cicatrisation
has begun. And yet healing does not take place. " The canc-er
sore does not heal, because its base, the cancer substance, is not
cicatrix tissue, and consequently can form no scar, and the
apparent scats which now and then form are never lasting. It
does not heal, because the outgrowth is constantly going on ; it
does not lieal, because no skinning takes place upon its surface,
and, lastly, it does not heal, because the new-fonned tissue
speedily dies again;"* New formation and death of the nswly-
formed tissues go on in constant succession ; a series of abortive
attempts at cure, such as prevent the rapid extension of the ulccr^
Buch as cheer the patient with delusive hopes of recovery, such as
sometimes mislead the unwary, even among members of our own
profession ; and such as, I blush to say it, furnish the wretched
charlatan with a fair pretext for tlie most despicable of all false-
hoods ; for those with which, for bis own behoof, the doctor dares
to impose on the credulity of his patient.
Slowly, however, though the disease may sometimes seem to
* Bnich, IfeberdwDiagnoBe der bSmriiffen OesehwUlste^ 8yo» MaiBz, 1847, p* 461.
The few isolated itistntifes of spontaneous cure of canetr IimitM to the portin
tfo^ncUis do not invaHilati* the gcsneral tnith of this Htateinont. Such a cure take*
|ilace, act ordinfj to U<»kitanaky, Palhol.Anatimiitf 3d ed. vol. iii. p. 495, by aprotseas
of shiitghinji; ulceration ; the consequent los« of substance IcAVtug a funneNhaped
acar, with iu apex dirtxtod njiwrinis towai\is the internal orifice of the utema. 8<*e
Acaae of Scanzoni'B, op, aX p. 282 r and some remfirks of Wngner, Ikr OtbSif^
muUerkrehs, 8vo, Leipjsig, 1858, p. 27.
I
I
I
ITS MANNER OF INCREASE.
331
advance, ib yet does advance, cancerous deposits extending from
the cervix into the substance of the body of the uterus ; the new-
formed tissues dying, itud dying on the whole to a greater extent
than tliey are reproduced, nntil at length the lips of the os are
qnit^B destroyed, the portio vaginalis of the cervix is destroyed too,
and a widely gaping opening, with tb ick, hard, and irregular edges
is all that is left to mark tlie point where the womb begins, and
the canal leading to it erxAs. Often, though not invariably, a step
preliminary to this occurrence is the forma tion of adhesions
between the lips of the nterus and the contiguous surfaces of the
vagina. Sometimes these adhesions are limited to one lip, often
they involve both, and to them is in a great measure due that ap-
parent shortening of the vagina which is very marked in many
cases of uterine cancer, and which does not at all imply the
previous occurrence of any descent of the womb. In the softer
kind of medullary cancer, in which this condition is met with
most frequently and in the greatest degree, the surface of the
portio vaginalis and the walla of the vagina become sometimes so
completely fused togctlier that a mere tliickened ring is all that
indicates the situation of the mouth of the womb. Even this, at
length, becomes indistinct, owing to the extension of the cancerous
disease along the vaginal walls, and the linger at last discovers no
distinction between the uterus and vagina, but finds only that the
uneven walls of the canal end in a cavity filled with a dirty
putrilage.
Sometimes, indeed, this fusion between the two surfaces does
not take place, but nevertheless the vagina becomes almost always
implicated in the advance of the disease. Cancerous deposit takes
place in its cellular tissue, confined at first pretty much to the
roof of the vagina, where it produces that thickening, hardness,
and ri3siHtance, wliich render the cancerous womb less movable
than natuml. With the lapse of time the deposit both becomes
more considerable at its original seat, and also extends further and
further along the canal, shortening as well as thickening it, while
general hypertrophy of the tissues tends to the same result. Nor
is the disease confined to the substance of the vagina, but it
affects the mucous lining in almost ever^^ instance, and this, as
might be expected, most remarkaUy in the iumiediate vicinity of
.the womb. The whole mucous membrane, indeed, is often red and
352 . CANCER OF THE UTEKUS :
inflamed, bat as the neck of the uterus is approached It is also
found softened and thickened. Small spots of whitish cancerous
deposit, from the size of a pin's head to that of a barley-corn, not
infrequently beset the upper part of the canal, and unhealthy,
superficial ulcerations, usually irregular in form, and having a
transverse direction, are often present. These ulcerations are said
by M. Leberfc* seldom to have a cancerous base, and are probably
due in great measure to the acrid nature of the discharge in which
the upper part of the canal is almost constantly bathed. What
renders this opinion the more probable is, that in cases of
epithelial canoer in which this discharge is often absent, the
ulcerations are also commonly wanting.
It is almost needless to say, that. while disease advances at the
lower part of the uterus, the rest of the organ is not left in a
healthy state. If life is sufficiently prolonged, the deposit by
degrees extends farther and further upwards, till even as high as
the ligaments of the ovaries, or sometimes higher still, the walls
of the organ are thickened by infiltration of canceroas matter, or
are completely converted into it. This, however, is not the only
cause of that enlargement of the whole uterus which is met with
in almost every case of carcinoma. In other organs of the body,
the advance of canceroas deposit, and the wasting and disappear-
ance of the proper tissue of the part, go on simultaneously and in
equal proportions. In the case of the uterus, however, that
disposition to growth and development of which we have seen so
many illustrations, shows itself even during the progress of
malignant disease. The walls thicken in parts which the cancer
has not yet reached, for the increased afflux of blood brings with
it an increased activity of growth, and even in those situations
where the malignant deposit is abundant, there remains up to
a late period a layer of muscular fibre bounding it externally ; the
product, as I imagine, of new formation, not simply the residue of
the original parietes of the organ.
But though the cancerous disease, either for the reason which
I have assigned, or on some other account as yet inexplicable,
seldom reaches to and involves the external surface of the womb,
its mucous lining has no such immunity from disease. Its con-
dition, however, is very variable. Sometimes nothing more is
♦ Op, eU, p. 280.
ITS MANNER OF IXCREASE.
appai-ent than a general and intense redness of the interior of the
womb; but much more frequeutly the uterine lining meuiljrane
is covered by a dark offensive secretion, and is beset liere and
there by smBill white deposits of cancer. If disease is more
advanced, the mucous membrane is absent, at any rate from the
lower part of the uterine cavity, and the surface is uneven and
granular from the infiltration of cancerous deposit into the uterine
tiasua On one occasion, too, I found the whole interior of the
womb lined by a white membraniform layer of cancerous deposit,
beneath which its substance was irregular and granular, as if
ulcerated.
This partial destruction of its mucous lining, and this granular
state of its interior, occasion that roughness which the finger so
constantly perceives when introduced within tlie orifice of the
cancerous womb. There is however, besides, in many instances
of uterine carcinoma, a distinct polypoid cancerous outgrowth,
which springs from low down in the cavity of the womb, or from
tlie upper part of its cervix, seldom attaining any considerable
size, but varying from month to month, and UHually disappearing
altogether as ulceration advances, and as the uterine structure is
with its advance more and more extensively destroyed. Besides
these, which are usually but temporary pbeuomena, there are dis-
tinct malignant polypi, concerning which I must say more pre-
sently, but about which it may suffice now to mention that they
may be formed independently of disease of the 03 or cervix uteri,
though those parts, too, became almost invariably involved in tlie
progress of the cancerous growth.
If now from the substance of the womb and its interior we pass
to the study of the alterations which cancerous disease brings
about on its external surface, we shall find occasion to notice many
itnportant changes, though none perhaps so striking as those
which we have already observed. Many circumstances concur to
produce that firm fixing of the uterus in the pelvic cavity which
is observable in almost every instance of carcinoma of the
medullary kind, except in its very earliest stages. It is partly
brought about by a chronic form of peritonitis, which is generally,
though not constantly limited to the parts in the immediate
vicinity of the pelvis, and widch glues the womb to the
rectum and bladder. This, however, is not its only cause, but
854
CANCER OP THE UTERUS :
infiltration of cancerous mutter between the uterus and adjacent
parts, and between the folds of the broad ligament, lands to tix it
in the pelvis, and to form it and the parts connected with it intu
one immovable mass. These deposits usually take place on tht
visceral surface of the peritoneum, and are sometimes so extensive
as to be the apparent occasion of a degree of wasting of the womb
itself, which I have once or twice found in the midst of abundant
medullary deposit, small and sbrunken, and its outer surface
rougli, as if partially eroded or destroyed by the morbid structure.
While these deposits are but inconsiderable, they may still be
seen in smnll patches beneath the peritoneum ; but with tbeir
increase the peritoneiim too becomes involved, and at length is
nndistinguisliable in the midst of the large mass of cancerous
disease which conceals the uterus and it^ ajipendages from view.
In cases where these deposits are most abundant,, it is by no means
unusual to find softened cancerous matter in the pelvic cavity, or
between the folds of the In-oad ligaments ; while sometimes the
intestines are glued together above the pelvic brim, so as to
form the upper wall of an in-egular ca\nty lined with cancerous
matter, and now and then a real ftecal abscess is produced by the
extension of the disease to the intestines, and their consequent
J *erf oration.
More fi-equent than the actual destruction of the peritoneum by
deposits of cancer beneath it, is the occurrence of numerous small
masses of the same substance on its outer surface. These are
sometimes fiat and sessile, like small tubercles distributed over it ;
at other times they are connected with the serous membrane by a
small and slender membranous pedicle, similar to that by whicli
small fibrous outgrowths are not infrequently attached to the
fundus and adjacent parts of the womb. (In two occasions I have
also found, in the midst of the ciincerous substance which
enveloped the uterus, serous cysts of the size of a filbert, contain-
ing a rather deep straw-coloured, transparent senmi, their avails
thin, their outer surface free, their inner connected w ith the uterus
itself by the interftosition of a layer of cancerous substance of
uncertain thickness. In one instance, five cysts w*ere present, and
the material which aurroimded them, and which also had matted
together the uterine appendages, was intermingled fat and e^inccr
substance. In the other case, there was only one cyst, but it also
I
ITS MAXNER OF INCREASE.
S55
wag surrounded by a very abundant deposit of cancer. These
cysts showed no sign of endogenous growth in tlieir interior, "l>nt
appeared to be simple serous cysts, such as sometimes form on the
exterior of the uterus, independent of any other disease. I am
therefore uncerfcain in what rehitiou they stood to the cancerous
deposits, whether in that of mere accidental complication, or
whether the connexiou between the two was more intimate.*
Reference has already been made to the formation of adhesions
between the uterine lips and the vaginal walls, and it is obvious
enough that when this takes place, the extension of disease to the
substance of the vagina is almost sure to follow* It is matter ot
observation, however, that the anterior vaginal w^all and the
bladder are much more fre^Lnently involved by the advance of
uterine cancer than are its posterior wall and the rectum. It has
been attempted to explain this occurrence by the assumption that
cancer oftener attacks the anterior than the posterior lip of the
uterus ; but facts do not bear out this assertion, and my own
experience, indeed, would lead me rather to the coQclusion that
cancer is oftener limited to the posterior, and that certainly the
disease of the posterior lip is often further advanced than that of
the anterior. The intimate connection between the oeck of the
womb and the bladder, parts which are separated only by the
intervention of a fold of the pelvic fascia, while posteriorly the
peritoneum dt^scends even below the level of the commencement
of the portio vaginalis, accounts much more satisfactorily for the
more speedy infiltration of cancerous matter into parts contiguous
with the front than w^ith the back of the oi^n.f
• In aU the caaes of serons cysts of the nteros described by Hogiiicr in his Tery
TAliiuble Essay in vol i* of the Mimmreg de FAmdimu de. Chirargu^ cliap. iL
pp. 295-325, ami plates iv. and v., the cyats are irab-peritoneal. Those which I
observed in the two c&aea above described were simihir to the cysts d*5lineated by
Boiviii tt!jd Duf^esj in plates xiv. and xxxiii. fig. 1 of their AUaSt bnt of which thc-y
give no particular dewjrifTtioti.
t Wjiguer, 0/1. eit pp, 49 and 60, gives the proportions as 38 per ceot. of the
former to H per cent of the latter. Hia data, however, bring out a facit far
which 1 wa^ not prepured — natnely, the much greater ffei[iiency of recto- vaginal
thun of yesico-TagiudJ ftsttiU as the result of cjinceroua diaea^e. It appears that
while there were but twenty-eight eases of vesico- vaginal fistula in eighty-three
instances of cane^ronn disease of the bladdt?r \ fistulous communication with the
▼a^na exists in twenty-four out of thirty -three cases in which cancer had
implicated the rechitn.
3S6
CANCEK OP THE UTERU3 :
Though, perhaps, not strictly in place, it will yet be convenient
to add a fev^^ words morB about the aifection of the bladder in
cases of uterine cancer. It is by no means unusual, independent
of any trace of cancerous deposit in the organ, to find the inucotis
membrane of the bladder intensely congested and of a deep red
colour, sometimes inllamed, even ulcerated, pus covering its rugn^
and all the coats of the organ thickened, ahowtng, what indeed
the dysuria during the patient's life but too constantly announces^
how close tlie sympathy is bet%veen the bladder and the wooiK
The mode in which the first anatomical evidence of positive
disaas^i of tlie bladder appears is not constant. Sometimes the
mischief seems entirely to proceed from without inwards, and
then at one spot, where the bladder and vagina ai^ closely united,
the mucous membrane of the former viscus may present a slightly
lIuCGulent appearance. If touched, it will be found to be softened;
if pressed on with a probe, it will give way ; the cancerous deposit
has gradually destroyed all the intervening tissues, and a few days
more would have sufficed for the production of a fistulous open-
ing. In other instances, disease attacks the bladder, secondarily
indeed, but independently of mere extension to it by continuity
of tissue. Deposits of cancer, in the form of small flat whitish
tubercles, take place beneath its mucous membrane ; not Uniited
to that part where the uterus or the vagina and bladder are in
immediate contact, though genemlly much more al)imdant there
than elsewhere. These tubercles enlarge somewhat, though
they do not coalesce nor attain any considerable size, but they
destroy the mucous membrane above them, while that of the rest
of the organ is generally inflamed, thickened, and sometimes even
ulcerated. When the fistulous opening has once formed, the
bladder undergoes all those changes that attend a vesieo- vaginal
fistula, however produced, only aggravated by the constant advances
of the disease by which the fistula was occasioned.
But to return to tliat more special study of cancer of the womb
itself which is our present business, I may observe, that though
the description of the disease already given holds good to a great
extent of all forms of uterine cancer, there are some varidiea of
the dlmase in which deviations occur from its most common
course. It has been stated as a general rule, that cancer begins
in the U5ck of the womb, and this statement is open to almost as
I
I
ITS C0MPUCATI0N8, AKD VARIETIES,
86T
few exceptions as the directly opposite one with reference to the
exclusive seat of fibrous tumours in the l>ody of the oFgan. In
three, however, out of one hundred and seventy cases of xiterine
cancer, the disease occupied the body of the tmjan, and ran its
course to a fatal issue without the occurrence of ulceration of the
03 uteri, or of any change in its condition, such as during life could
lead to the suspicion of its being the seat of malignant disease,
though its tissue was found after death infdtrated with cancerous
deposit^ In all of these cases the enlargement of the uterus was
verj^ considerable ; in one it measured five inches in length, in a
second six inches, and in the third was nearly as large as the
adult head. This increase of size w^as dae in two of the cases to
the extreme thickening of the uterine w^alls by infiltration of
cancerous deposit, which in one had converted the whole organ
into a tulerably uniform mass of soft, indistinctly fibrous tissue,
of a dirty greyish-w^dte colour, soaked in a dirty serum, very
soft, but tearing most readily in a longitudinal direction, w^hile no
trace of mucous membrane was discoverable, nor any remains of
uterine cavity beyond half an inch frum the orifice of the womb,
which Wiis small and circular, and outwardly presented noevidcucc
of disease. In the other case, the walls of the uterus were simi-
larly thickened, though in a less degree, and the uterine cavity was
not obliterated, but a mass of soft medullary cancer, of the size of
a walnut, projected into it, springing from a little above the situa-
tion of the internal os uteri. Externally, the lips of the os uteii
were healthy, tlieir sui'face perfectly smtXTtb, and of a vivid red
colour. This character continued to just within the cervix, but
there the mucous membrane at once t^ecame rough ened^ of a red
colour, with dead white spots of cancerous deposit showing through
it every where.t A similarly healthy state of the os existed in the
tliird instance, in which tlie uterus measured five inches in lengtli.
The organ in that case was surrounded by a maas of softening
carcinomatous matter, but its w^alls were not infiltrated with
* [A cAae of tMa kind, remarkable for its great size and for the appearance of
healttimejiB of t!ip cervix, Ijiit atUl more for ita mobility till death, in described in
the (Mmtrlrkal Ttfitnmclims for 1878, p, 27,]
t A brit'f but interesting deBcriijtion of several cades of this kind m ^v«?n by Dr
Simpnon in liia Obdt^iric Memoirs^ &c., voL L p. 193, and a more or Itss detailed
account of many others collected frotu dilferent sources wiU be found in Wngncr,
ajK cU, px). 122-13S, ^
358
CANCER OF THE UTEliUS !
iiialignant deposit The iBcreaaed size of the wouib, indeed, wai
due to expansion of its cavity; not at all to tliickeiiing of its walls;
but their inner surface presented a very remai'kahle appearance,
being everywhere teset by small warty growths, or irregularities,
among which were one or two rather hirger than the i^st, but even
these did not exceed the size of a pea. These granulations were
quite sessile, and the surface altogether looked more like that of a
chronically ulcerated bladder than of a part the seat of morbid
deposit. In the substance of these gmnulations no distinct cancer
cells were found, but at the fundus of the uterus, whei"e the walls
were generally veiy thin, there was an aperture of comnaunica^
tion lai'ge enough to allow the finger to pass between the cavity
of the womb and the mass oE carcinoma which surrounded it.
Here, too, the uterine wall was softened and disintegrated, aixd
seemed infdtrat^jd with the same kind of matter*
Besides thess cases, two others out of the total one hundred and
seventy presented a great preponderance of disease in the interior
of the womb, though the lips were not in a healthy condition. It
was clear, however, in both instances, that the mischief had prci-
ceeded from within outwards, not in its usual course ; and 1 am
disposed to think that the commencement of cancerous disease in
the interior of the wnmb, instead of about its orifice or in the sub-
stance of its neck, is not of that extreme rarity which is generally
supposed.
Lastly, in connection with those cases in wbicli the os uteri
escapes the cancerous deposit, or becomes affected only secondarily,
some mention must he made of those rare instances in wtiidi
poff/pi of wali^nttnt strudurt' grow from the interior of the uterus,
independent of previous disease of its orifice. Eeference has
already been made to the frequent formation of polypoid
raitgrowths of malignant structure during the course of general
uterine cancer, but these outgrowths are for the most pai-t of
inconsiderable size, constitute but a small part of the general mass
of disease, and disappear witli the advance of the carcinoma. Now
and then, however, at a time wlien tlie lips of the os are still un-
afi'ected, an outgrowth of cancerous tissue, generally of the
medullary kind, springs from the interior of the womb, and
descends into the vagina. The point of origin of such malignant
polypi is usually low down in the ca\ity of the womb, or actually
L^
CANCEEOUS POLYPI, AND ALVEOLAE, AND EPITHELIAL CANCER. 359
within the canal of the cervix, but QCMjasionally they spring from
its fundus. Of this a remarkable illustration is given by Boiviii
and Duges, and an instance of it came under my own obsen-ation
some yeara since at the Middlesex Hospital, into which institution
a woman came to die, apparently of ascites. An abundant and
very offensive vaginal discharge attracted attention to the state of
her womb, when a polypus considerably larger than the fist was
discovered in the vagina* After her deaths in addition to ext-en-
sive cancerous deposits in various abdominal viscera, the walls of
the uterus were found thickened by medullary deposit, and its
cavity distended by the polypus, which sprang by a pedicle half
the size of the wrist from the fundus of the womb. The polypus
was of a very soft texture, and possessed of considerable vixscu-
larity. One other case of cancerous polypus has come under my
observation. The outgrowth was of much smaller size, and, as
well as could be ascertained, sprang from low down in the body of
the womb. It projected but a short distance into the vagina, and
the lips of the os uteri looked healthy, thougli there was some
degree of thickening and indumtion of the posterior lip, 1 believe,
indeed, that Uiough the formation of the malignant polypus may
precede other disease in the womb, yet the c^incer before long
extends to the uterine walls, and I am not aware of malignant
outgrowths having ever been found in an othenvise healthy
uterus,
I beheve that I have twice met with aireohtr cmurr of the woml>,
but in one instance only have I had the oppoitunity of corro-
lx>rating my opinion by an examination after death. In that
case the lips of the os uteri were nearly destroyed, and a layer of
dense medullar}* carcinoma formed the base from which pmjected
numerous semi-ti-ansptireut warty granulations, occupying the
whole interior of the ut'Crus and filled with a rather firm semi-
transparent gelatinous matter, such as Lebeit,* who appears to
have met with this condition several times, speaks of as its char-
acteristic
The epithdial cancer of the uterus presents itself under two
forms ; either assuming the character of a granular outgrowth
I {mm the lips of the uterus, or else of an intractable ulceration of
t surface. In its most characteristic form, the first variety is
I
I
I
860 CANCER OF THE UTERUS
the caidiJUmer ejocrescejict of Dr John and Sir Charles Clarke ; bn
of far more common occurrence are cases wliiuh, though essentially
the same, present points of ditlereoce approxiuiatiiig them to ordi-
nary medullary cancer. fl
In its very early stages, epithelial cancer* of the womb has only
twice come under my observation ; for the comparatively trifling
aymptoms to which it at first gives rise seldom force themselves
npon the attention of our patients. In one of the instances in
which I had t!ie opportunity of seeing the disease of the uterus at
its commencement, it was secondary to the same affection in the
vagina, but in the other the vagina was perfectly healthy. In
the first case them was a patch of the size of a shilling on the
surface of the posterior uterine lip, somewhat raised al)ove the
.^nirronnding surface, of a wid red colour, bleeding readily, ami
with a papillary structure so fine that it closely resembled the
pile of red velvet. In the second case the disease occupied the
anterior part of the anterior uterine lip, the outer edge of which
lelt sharp-cut and everted, and the speculum discovered on it a
small patch of abrasion, soft and velvety to the touch, and seen
under the apeculimi to be beset with fine sessile gmnulations. In
all otlier instances that have come under my notice, the disease
has bt^en much more advanced, the cervix of the womb has been
already somewliat increased in size, the os uteri not open, but ita
lips flattened and exj>auded, so that their edge, which felt a little
ragged, pmjected a hue or two beyond the circumference of the
cervix, while their surface was rough and granular to the touch* H
* I have retaineil th^- tenn cancer as apiilied to tlie*e vaiietifs of maligiuLiit
disease of the uteras, becuuiifl^their mutual rehitiouH Kcem to lue to be still uudi--
ternuQed, while the geneml tendency of cpitbvllal and oani-roid di&eajies of the
womb is to become luttociateil during their i»rvgre«s with OHjdullary caurer ; oflirni
indeed, they lose their own distinctive fealurra coiiipletely, merging theiu in tboais
of ordinnry uteriufi eareinomo. From th*: point of view of the microscopic pfttho*
logiit, there c^n, indeed^ ho no doubt but that pupillary DUtgrowtfas take pl«ee
horn tiie 08 uteri, though very nirely, which are jK^rfertly innocent in chiiracter^ and
approximuie in their iTitimnte t^tructure rather to tibroid growthii than to those
mnlignant excrescences to which they yet bear a certain Rn|)ertieia1 resemblance.
1 do uot think, however, that we nef;d be »ueh purist* oi to do away with tlie name
of cauliflower excrescence, which expresses 80 distinctly the character of a diseaae^
exceptioDally, perhapa, non -malignant, and in otlier intitancea not presenting in its
earliest stage under tht* microscope the diittiuct peculiarities of carcinoma, thougli
tending to aaauine by degrees, and often rapidly, the charactera of cancerous^ or, if
the distinction h» thought important, of cancroid dij^caac.
I
EPITHELIAL CANCER,
361
On ititroducing the speculum, tliis irregularity was seen to be
produced by the aggregation of numerous small, somewhat tiattened
papillae or grauulations, of a reddish colour, semi-transparent ap-
pearance, and often bleeding very readily. Sometimes these
granulations continue for many months, scarcely at all increasing
in size or altering in character ; and then on one or other lip an
ulcer forms, with irregular, excavated edges, and the case, if then
seen for the first time, would scarcely be suspected to have been
other than one of ordinary uterine cancer. Often, however, the
smaU sessile papilhe increase in size, and form a distinct outgrowth
from the whole circumference of the os uteri, of the size of an egg,
an apple, or even of a greater magnitude. These growths are
split up by deep fissures into lobules of various sizes, all of which,
however, seem to be connected together at their base, though the
fissures are so deep, and their directions so variomi, that it is seldom
|K>f}sihle, when the growth Ls of any size, to distinguish betw^een
them and the as uteri itself. The dimensions of these growths
are not in general the same throughout, but they spring from the
surface of the os uteri by a short thick pedicle or stem, the elong-
ated and hypertrophied cervix, and then expand below into that
I>ectiliar caulitlow^er-hke shape from which their name has been
derived. Even the most careful examination generally breaks
down some of the tissue of the growth, and produces hiuniojThage ;
but if, in spite of this, the finger is carried doiMi to its base, the
substance will be found to become much firmer, and at the stinie
time, to be possessed of a [degree of sensibihty which, though but
low, is much greater than that of the more depending part of the
tumour. Sometimes the outgrowth is confined, at any rate at its
commencement, to one lip, and may attain a considerable size
before the other is involved in the disease,* This is more likely
to occur if the posterior than if the anterior lip is aflected, and
lor the obvious mechanical reason which accounts for every large
polypoid outgrowth being flattened on its anterior surface,
spheroidal on its posterior. The hollow of the sacrum allows
more room for the development of any outgrowth than is aObrded
by the comparatively fiattened anterior half of the pelvic cavity
bounded by the rami of the pubes.
* or which there is a very cliaractifjiBtic drawing in Boivin and Dag^* AUtm
plate xxiy, tig. 1,
362
CANCEE OP THE UTERUS
Tlioiigli the Tagilia does not by any means escape from a paiti'*
cipation in the disease, and a gi-anular or papillaiy structure may
be felt sumetiineB extending over its rut>i> and for some dLstauci*
along one or other wall, yet this is by no means constant ; and
so long as the disease retains its original characters well marked.
tlie disposition to involve adjacent parts is far less than in ordinary
uterine cancer. The tendency, however, to pass into ordinary
medullary cancer, or to become associated with it, is very strong;
while we find that the tumour itself undergoes the same procesaea
of alternate partial death and partial reproduction, as we have
noticed in otiier forms of malignant disease. Usually the outgrowth
in the coin*se of time disappeai-s in part, and the irregular, sharp-
cut edge of the os, whence it grew, is at first felt granular and
uneven within, but afterwards grows thicker and nodulated,
assuming by degrees all the diameters of a part which has from
the first been the seat of medullary cancer, whUe the walls of the
organ and its interior likewise undei-go just the same changes.
Between this disease and genuine cauliflower excrescence the
ditlerences appear to be of degree rather tlian of kind. In the
Litter, indeed, the epithelial cells which compose it are of the
cylindrical form, liut its more obvious peculiarities consist in the
larger size of its vessels, in the greater dehcacy of their walls, and
in their being covered by a thin investment, not bound together
into a comparatively sohd mass by connecting tissue, but " hang-
ing in fringes almost like a mass of uterine hydatids ; *'♦ w^hile
the base of cancer substance, which in the more solid growths
is deposited very early, in tlie delicate and vascular cauliflower
excrescence is not formed till a much later period, or even not
at all. Their intimate structure* however, and their microscopic
elements are just the same, and both consist of hypertrophied
papilla?, composed of epithelial cells richly supplied in their
interior with large and delicate vessels, and covered with a
• This not inapt co]ii|itin»on ia tniide by Virchow in hh dfrscripdon of the cniett^
scopic stmrture of tliiNse growths, in the Vtrhnmil, der Phyjt. Med, Q€»€lUchoft m
tVilrzimrrf^ vol. i. p. 110, vtlndi !uuinouizi» with mid coniplotes previous obaanrn-
tions. Very good repn'aeutatioaH of tht^ genera] ii§]>ect of thc»e gro^vths arc given
by Sir C. Ckrke in vol ii. pi. i. of hiH work on Disfosea of IFomat ; by Sir J.
Siruiiflon, at pp. I«i5 and ItJtJ of his OhsiHric IVork'A ; and by Dr Mayer, in vol. lY, of
tli« VerhandL dtf Gi*, /. Gttmrtsh. in Berlin, wbitih also couttiiu^ a dmwing of the
Appeumneea presented under h low magnifying imwtT,
EPITHELIAL CANCER, AND CAKCROID ULCERATIONS.
363
tliickenecl layer of epithelium. The enormous looped capiUaiiea
uf the caulitlower excrescence explain the abnndant h^Finorrhagea
and the profuse serous discharges tliat attend it, while the almence
of that solid structure wliich is found in other forms of epithelial
caiieer accounts for the peculiarly favourable results tluxt have
followed its extirpation, and also for the fact that after its
removal a few slireds are all that remain of what had seemed to
be a large and firm tumour,
I Jifterence of opinionexists as to the exact nature of those ijitrad-
ahU ukemiions of the os and cervix uteri, which, in accordance,
as I believe, with the prepondemnce of authority on the subject,
I have referred to epithelial carcinama, but which are alleged by
some very competent observers to be tuberculous. When speak-
ing of uterine tubercle, I made mention of numerous small
deposits of a yellowish colour sometimes met with on the surface
of the 08 uteri, and which, if punctured, or if their contents
escape spontaneously, sometimes leave behind small slightly
excavated ulcers. Their tuberculous character did not, how^ever,
appear to me to be clearly substantiated, since I had never
observed any general fusion of the deposits, and consequent
breaking down of the tissue of the cervLx, M. Lisfranc, however,*
has described a condition >vhieh has never come under my own
notice, but which has been seen and described by M. l{ol»ert,'f JI.
I*ichard,J and others, who relate cases illustrative of its character,
and who refer it to the breaking down of tubercular deposits in
the substance of the cervix.
"These tubercular ulcerations of the cervix uteri," says M.
l£obert,§ *' may be recognised by their excavated base, their
greyisli appearance, and the presence of a caseous matter in the
midst of the rauco-puruleut discharges which come fi'um the
interior of the cervix. They may also l>e known by the pre^sence
in the cervix of tumours of uncertain size, of a rounded form, at
first firm and with no change of colour, afterw^ards soft,
whitish, yielding to the pressure of the fingers, and giving an
indistinct sense of fluctuation. These tumours are formed by
* Climqw CMntrgicale, &c., voL iii. fp, 548-6&3.
f Det Affections, <tc:, du Col de V Uterus, Svo, Paris, 1848.
t Dea Aims tU la CauUriaaUonf *ii:,, darts les Maladies dc la Matrice, 8to, Pari%
16ie. pp. 124-132. I Op, ciL p. 48.
CANCER OF THE UTERUS :
the tubercular matter atill in a crude stote, or in course of
softening,
" It is, moreover, to be observed tbat these scrofulous ulcera- ^
tionaare g-lmoat always accompanied by considerable engorgenieot fl
of the cervix uteri, a condition whicli is due either to the presence
of masses of tul^erck^, still unsoftened, or to some tubercular in-
tOtration still remaining, or lastly, to that intlammatory process
which accompanies the softeuin*^ and elimination of this kind of
morbid product. Tliis last circomstance may obscure the diagnosis
of the case, and lead to the belief that the engorgements or Uie
ulcerations are of a malignant chamcter, an error which Lisfranc
confesses that he fell into several tinies."
These appearancas, however,, receive a different interpi-etation
when the microscope is called in to aid our researches. The
softened matter is found uofc to consist of the elements of
tubercle, but of epitlielial cells similar to those of the uterine
mucous membrane, while the indurated callous structure which
forms the base of the ulcer is formed of a mixture of fibro-plastic
and epidermoid materials. In short, as M. Eobin* says, this kind
of ulcer is to the uterus what lupus or cancroid ulcers are to the
face, the cliief difleiences between tliem depending on the constant
exposure of the latter to the air; and the constant contact of the
former with the mucous and otlier secretions of the vagnia.
One afteetion still remains to notice, which, though less strictly
deserving to be ranked with cancer than were those varieties of
malignant disease which we have just now been studying, yet%vill
find here perhaps its fittest place. The late Dr John Clarke waa
the hrst writer who described, under the name of corwdhtff uteer^
a poculiar form of destructive ulceration of the os and cenix uteris
beginning at the mucous membrane wluch covers it» involving the
whole circumference of the us, and utterly destroying it and the
subjacent parts, but differing from carcinoma in the absence of
any thickening, hardness, or deposit of new matter in its vicinity.
Not to dwell on certain diflerences between its symptoms, arid
• The coiuoint testimony of Kobin, Archives ik Mtdtcine^ Atigiint 1848, [tp, 407—
411 I of Lcbert, Ma Indies Canci reuses, p, 218 ; and of Hannover, Das EpUhelioma^
8vo, Liipwig, 1852, \k 126, niiiy be taken as deciadvt? on Ihia jjobt. It ia, 1 think,
t'XtremtUj doubtful wbwther Dr Oibhft* ctae of alleged extensive tubc^rculoua u]o«r-
rttiori ut' tlie uterna and blit«1der» deBcribed at \k 2tJ9 of vol. \i. of Tranrndion* of
the PiUhiil(*^(uU Society^ otiglit not mthur Ui h*i rvfi^rrtd to tbltf cutegory.
fuequency of affection of other orgaxs.
S65
tlioso of ulcerated carcinoma, the fact that the corroding ulcer may-
con tinue for several yeara without causing any very formidahle
symptoms, while death takes place speedily as well as inevitably
in ulcerated cancer, points to some essential difference between
the two diseases.
Its real nature hag given rise to much difference of opinion,
and the rarity of the affection has been a great obstacle to its
thorouj^h un^lerstanding. There can be no doubt, however, but
that it ought to be classed with rodent ulcers, as indeed it has
been by all recent microscopic observers, for, like them, its aspect,
rate, and mode of progress are unlike those of cancer, while neitlier
cancer cells nor epithehum formations are present in the adjacent
tissues.*
One point only connected with the morbid anatoniy of uterine
cancer still remains for notice, and that concerns the freqiitncif
vnlh which othr org^ms become affh-ted in the course of the tiisease.
I apprehend the number of cases to be very few indeed in which
cancer lias not extended before the death of the patient by
continuity of tissue from the uterus itself to some of the parts
immediately adjacent Thus, for instance, it is certainly very
unusual for a patient to die of uterine cancer, in whom there does
not exist some degree of cincerous infiltration into the upper part
of the vagina ; and, as we shall see hereafter, the frequency of
this occurrence, even at a comparatively early period of medullary
cancer, is one of the circumstances wluch most of alt interferes
witli the success of operative proceedings fnr its cure, and which
oftenest contra-indicates any attempt at their performance* There
does, however, seem to be reason for believing that carcinoma of
the uterus is oftener at its commencement confined to one part,
and that it continues ao for a longer period than does cancer when
situated in any other organ of the body, though iu neither of these
respects does it present the striking difterences from cancers of
other parts which was formerly supposed, and in whicli one would
gladly still believe. M. Lebert-f- states that the evidence of general
infection of the system, as manifested by secondary deposits in
otlier organs, existed in only a third out of forty-five cases of
uterine cancer, but in twenty-four out of thirty-four, or in five-
sevenths of the number of cases of cancer of the breast These
• naanover, a^. ciL p* 128. t QpcU. pp. 239, 310, 39i,
366
CANCER OF THE UTEHUSt
re^nltSi liowever, are more favourable than those which the IsXe
Professor Kiwisch deduced from seventy-three post-mortem
exam! nations of uteri oe cancer made ia the hospital at Pra^e.
He found cancer of the bladder in 42 per cent, of liis eases;
Lebert* only in 13 per cent ; of tlie ovaries in 19 ; and of the
lun;^9 in 7"5 per cent. ; while Tiel^ert met with each of them only
in the proportion of 4*4 per cent. These discrepancies, which I
am not able from personal observation to explain, are yet probably
due to the ditlercnt forma of cancer having occurred in different
proportions at Pam and at Prague ; possibly t^ the greater
frequeney of epithelial cancer in the former city, and of medullary
caucer in the latter. In any future statistical table showing the
frequency of cancerous infection of the system, it will obviously
Ite necessary t^j refer the cases to different categories according to
the character of the primitive disease. In the meantime, the
knowledge of the fact that such infection of the system occurs
perhaps less invariably, probably less early in cancer of the womb
than in other formf^ of the disease, may serve to throw a feeble
ray of hopefulness over the gkajmy prospect which we have now
to contemplate from other points of view.-f
* Op. cit, voh L p. 511,
t From ft compariatm of uterine canrer with can cor of tltt^ stomach, Wagnffr,
op. eiL \>. 100, comes to tlie conclusion, and T very much fear the correct cuuclll-
uion, tbat in respect of the extenMiou of the discaiw fmni its ongiiuil sc^t, and of
the occnrrenoc of iecontlary dcptinit.^, utcrint* cancer lim'S Dot ocrnpy tlmt cxc*j>-
tional jtositioin which waa otn c sQp[>os*»dj but tluit it pre^senU » n^marlcablt! nimi-
Iftrity to mucer of other liollow orgnns, chiefly composed of organic tnuscu|*f
fibre, 08 the cesopliBgas, stooiacli, and intettiiics. The stAtktics collected i>y
Gusserow, Op, eiL p. 183, l««ire the q^uestlon jtitt where !t waa.
1
LECTURE XIX.
I
MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS.
Their frequency ; causes influencmg the ocaarrence of can<:cr, — aa a^e^ state of the
memtnial function, its mode of establialiment, cHld-bearing ; influijace of
child -iK'ftring acrountt'd for ; hereditary tendency,
Symptoins of ennoer ; mode of onaet, and first Hyinptom. Pain, its clmracli»r and
caosee^ Hsetnorrliage, its import ; frequent as m iirst uymptom, and why. Dis-
cbarges ; cause of their otfenaive character, and of variationa m thia refipect
Cancerous cachexia ; its characterH.
Two exceptional furma of cancer, th« latent and the acute.
Influence of onnccr U[ion labour.
Diagnosis of uterine cancer.
Duration of the Disease.
One of the reasons wliicb at the conimenceineTit of the last
Lecture I assigned for occupying much of your time with the
study of carcinoma of the uterus was the ficquejwi/ of its
occurrence, and a starthng fact which impresses the importance of
the disease still more on our attention is the general increase or
frequency of cancer in alt its forms throughout the couutrj^^ of late
years. Our tables of mortaUty, indeed, do not at present enable
us to learn with complete accuracy how often it is met with, but
they furnish data from which it is not diilicult to make a tolerable
approximation to the truth. It appeal^ from the Thirty-Eighth
Pieimrt of the Kegistrar-General * that the mortality from cancer
tliToughout England in the year 1875 amounted to 3640 males,
7766 females. The whole of tliis excess of female mortality from
cancer may be confidently attributed either to cancer of the breast
or of the womb. According to Tanchou's tables,"|" however,
* Thirty-eighth Report of Registmr-Genenil, 1877, p. 231. It has increased
within the hut 25 years from 302 per million in the firet 5 to 443 per million in
be last 6 years ; and rose aa high as 480 per mil I ion in the year 1875,
f RtchfTchasur Ic TtailnietU Midicnh dfs Tumcara Canc^evses duSein 8vo, 1844,
p* 258.
CAXCER OF THE UTEKUS \
1
1
deduced from tlie mortuary registers uf Paris, cancer of the warn
was more frequent tlian cancer of t!ie female breast, in the pro- ^
portion of 2996 to 1147i or as 2*6 to 1. Neither thia statement, H
however, nor the assertion which he also makes, that uterine
eancer was the cause of 1'6 per cent, of all female deaths duiin;;
the decennial period to which his calculations refer, can be
received as absolutely correct, though it is my impression thnt
neither the one nor the other deviates much from the truth. The
absolute freL^uency of uterine cancer, thougli not tlie exact propor-
tion which it bears to other fatal diseases of the female sex,
receives another illustration from the fact that out of 5122 post*
mortem exauiinations of both sexes in the hospitals of Prague,
Vienna, and Leipzig, there were 441 of cancer, of which 113 were
of cancer of the womb * Picot'sf tables, deduced from poet-
niorleni examinations in the hospitals of Paris, yield a total of
1971 cases of cancer, of which 559 occurred in the male, 1412
in the female subject. Of the latter 242 were cases of cancer of
the breast. 765 of the uterus or other of the sexual organB.
I have already referred more than once to the circuuistances
which render the statistics of a large hospital inconclusive as
evidence of the comparative fret|ueecy of different diseases. The
sutferings that generally attend cancer in some of its stages, and
the costly nature of the remedies by which these sufferings are
best assuaged, induce a very large number of patients aHlicted
with thtit disease to seek relief at a wealthy institution Uke St
BarLholomew*s Hospital, and I have no doubt but that my own
experience there would, without allowing for these causes, lead
me to suppose cancer of the womb to be even more common than
is actually the case.J But though this be so, the disease still
remains, of all organic affections of the womb, alike the most
frequent and the most terrible.
• Wftguer, ojh cit, p. 2.
t Lwgrandi proeofus morlndtgt 8vO| FariSi 1878^ roL ti p. IISS.
t Dt I^ver* on DmoMtt of the (Il/^ms, Svo, Loud cm » 1843, p, 165, ttntes
among tht out-piitieRUi of Guy'ft Hos|Htal, the pn)i>ortioa of cases ol uterine
canc«r to other uterino diseases waa nearly iw ] in 7, or 13 '5 [ler ct*nL At BartUo-
lomew'a I found the proportion to be 1 in 18 2, or 5 '4 per cent) numbers whicli 1
in(?ntion TUfrcly a» ahowing how unaaf^ tt wouM be to draw jL»y inferouc^a as to
the CTmparative fn?queucy of that, or, indeed^ of any other diaeAae, from ancH data
as are afforded by the out-patient hoolui of an H'tapitaL
ITS FHEQTIENCT, AND CAUSES.
369
We light at once upon surer ground if, from tlie attempt to
determine its exact frequency, we pass to the inquiry into the
circumstances that favour its development ; the inHuence of age,
of marriage, child -hearing, &c., upon its production.
Dr Walshe * whose erudite work on Cancer will always con-
tinue to be, with reference to many points, the best authority on
the subject of which it treats, w^aa the first to show that there is a
progressive increase in the frer|uency of cancer with the advance
of age. I hardly need observe that the frequency of any disease
at different ages can be rightly estimated only by a comparison
of the number of cases in which it occurs, with the total popula-
tion at the same age ; though, from neglecting this obvious con-
dition, erroneous conclusions have sometimes been drawu with
reference to this and other similar questions*
Taking the population of England, however, at decennial periods,
it seems, and Sir J, Paget's researt^hes lead to the same result,
that with every ten yeai's of additional age after the age of twenty,
the liability to cancer steadily increases. A fact this of great
interest, showing how a cUsease of constitutional degeneracy grow*s
more and more common with the enfeebling of the powders of nu-
trition, and attains its gmatest frequency wheu nature's alchemy
has well nigh reached its end, and the power to transmute the
rough material into the highly organized and wonderfully com-
])lex tissues of the body is almost gone. But it is scarcely less
interesting to find that wdien a part has outlived its uses it
tyften begins to die, and that the greatest frequency of cancer
of the breast and of the womb is not governed by the same
law as prevails with reference to the disease in other parts,
but occurs long before the ordinar)^ period of human life has been
attained.
"The age of most frequent occurrence of scirrhous cancer of the
breast," says Sir J. Paget,"f " is between forty-five and fifty years.
Nearly all records, I think, agree in this. The disease has been
seen before puberty, but it is extremely rare at any age under
twenty-five ; after this age it increases till between forty -five and
fifty, and then decreases in frequency; but at no later agebecomea
so infrequent as it is before twenty:"
Op. cU. p. 140.
t Op, cil. vol it. p. 324.
2a
S70
CANCER OF THE UTERUS :
This statement, too, he illustrates, not simply hy the absolbte
numl^ers of cases which he has collected, but likewise by com-
parison with the popiilatioo at different ages*
Mnch the same fact holds good with reference to uterine canoer^fl
as IB shown by the suhjoiped table of the ages of the patients in
595 cases * collected from various sources.
Actiuil Number*
Between 25 and 30
years,
39
. 30 „ 40
«
166
„ 40 , 50
n
242
„ 50 „ 60
n
95
. 60 „ 70
it
48
Above 70
U
J
595
A comparigon of 2263 cases collected by Gusserow+ frmnn
different sources yields indeed a different percentflf^e at the dif-
ferent ages; hut tallies exactly in the grand result of an iiicreaspd
frequency of uterine cancer from womanhood up to the agp of 50,
and then a rapid decline as old age advances.
Though the period of a w^oman's life exerts ao great an in-
fluence in predisposing to cancer of the womb, it yet doea not
appear that the actual cessation of the menses has any importaat
share in callin;^ that predisposition into activity. In six out of
eighteen of Lebert's cases,^ in which menstruation had already
ceased, the commencement of the disease was stated to coincide
"With the cessation of the menses. The same coincidence, how-
ever, was observed only in three out of thirty-nine of my patients
in whom menstruation had already ceased. In two even of these
the symptoms were said to have existed for eight and ten years
respectively, so that all which can be reasonably alleged concern-
• Of thmi^ cases 170 are from my own notes ; Ihp retnainder are collected froin
Lcbert, KiwisL'li, and hh editor Sainxoiii, from Cliiftri, and from Mr Sibley's
** Report on tlie SUtlftiCH of Cant^er in the Middlesox Hospitftl/' in vol. xHL of
Medieo-Chirurgicai Tranmctioita, I jvurpoaely do uot include the ofTcnHptott'd table
given by MadAtne Boiviii {op. cU. vol. ii p. t>), becnuye it was dmwn up at A time
when other discaseji were Dot mfre<|t]entlv confounded with cancer, and tlmt Ker
fiicta are vitiated by this error h abundnntly evident
+ Op, ciL p. 186. t Op. cU, p. 275.
rnEvious state of the seximl FUNcnoNa 371
Ing thoni is that indications of uterine disease had persisted ever
since the luenstniol crisis, and that at length cancerous disease
had become developed. In one case the first symptom of cancer
appeared within five months, in another within eight months, in
three in a year, in two in threef years, and in the remaining thirty
at periods varying from tliree and a half to twenty-nine years
from the cessation of the menses.
The antecedent condition of the patients uterine functions, as
far as the presence or ahsence of menstrual disorder, or of pre\ious
disease of the womh is concerned, is not without interest from
the negative result which it yields, and from the evidence thus
afforded, if further proof of the fact were wanting, that no relation
whatever subsists between inflammatory affections of the womb
and the subsequent occurrence of cancer of the organ.
In 157 out of the 170 cases, the manner in which the men-
strual function was usually performed was made the subject
of special inquiry. In 131 cases it was performed in all re-
spects naturally, from the time of its comi)lete establishment
until the commencement of the disease. In 26 cases it was
either habitually or frequently unnatural in some respect or
other, viz* ; —
In 1 scanty,
„ 10 painful,
„ 2 profuse,
„ 4 profuse and painful,
,. 4 postponing,
„ 4 irregular,
„ 1 anticipating.
If the inquirj^ be made with reference to the first establishment
of menstruation, we shall as little find anything indicative of a
special connexion between the difficult establishment of the men-
strual function and the subsequent development of cancer. In
117 out of 146 cases, menstruation was established without any
untoward symptom, while in 29 instances its first occurrence was
attended by more or less local or constitutional sufferings These
numbers yield the proportion of almost exactly 20 per cent, of
unfavourable cases, while the average which I obtained from all
372 UTERINE CANCER
Ijatients who came to me at St Bartholomew's Hospital on account
of uterine ailmeiits "was 25*7 per cent of iinfavourable cases ; and
Ml' Wliitehead, of Manchester, arrives at 22'30 j^ier cent, as the
proportion of unfavoiimhle cases among 4000 wumen not sufiTering
from any special disorder of their sexual system.
But though it should appear that in these cases neither the first
establishment of meustruation nor the manner of its ordinary per-
formance has presented any striking deviation from health, it may
yet be supposed that we shall find indications of previous uterint-i
disorder (as some suppose of uterine intiammation), out of wlii<
the cancerous disease has been subsequently developed. Evidetii
liowever, seems to be directly opposed to this supposition, for
the history of only 5 out of the whole 170 cases is there any
mention of serious uterine ailment previous to the commencement
of the cancer. One patient had had a polypus removed ten years
before, two stated that they had suHered ever since their last
confinement, ten years before in the one instance, and tlireein
the other, from symptoms of uterine affection ; in one the symp-
toms gradually developed themselves out of those of uterine
inriammation, and in the fifth out of those of pehic abscess in^
the course of two years.
Though ample proof to the contrary has been long since adduced,
we still find it asserted sometimes that single women and those
who have had no cliildren are most liable to be attacked by cancer,
Tlie truth appears to Ije the direct reverse of this statement ; for
out of 168 cases of uterine cancer, there were but 3 in which they
were single women, and only 13 in which they were sterile. In
other words, there was but 1 sterile marriage in every 13 of tha^
cancer patients, while the general average among my patients at St fl
Bartholomew's Hospital was 1 sterile marriage iu every 8*5, and
among those with uterine fibroids 1 in every 4"1. Xor is this all ;
but the further we carry this inquiry the more strikingly does it
appear, not that sterility, but rather that over fecundity, pi^edispoaes
to uterine cancer. As already stated, only 13 out of 165 married fl
women affected with cancer were sterile, 2 are said to have had V
children, but their number is not stated, wbUe the remaining 105
liad been pregnant 1046 times, 189 of the pregnancies terminating
])rematurely, 857 at the full period Or, to state the same fact
somewhat differently, there was an average of 6'S pregnancies ta
1
I
L^
4
BflLtTENCE OF FECUNDITT AS A CAUSE.
373
each fruitful marriage, or 5'6 children at the full period, and 1*2
abortions, while the Bumber of children per maniage in this
coimtry generally is estimated at 4'2.*
Some of these points will perhaps be still better illustrated by
t!ie subjoined table : —
Number
PregnaDcies
Number
Children
Number Abortionp |
of women.
to each.
of womem.
loeAdi.
of women, 1
to each.
18 .
. 1
15 .
. 1
32 . .
1
16 .
• . 2
16 .
. 2
22 . ,
2
11 . .
. S
18 .
. 3
11 , .
3 ,
7 . .
. 4
11 ,
. 4
6 . .
4
11 . .
. 6
17 .
. 6
6 * .
5
ir .
. 6
14 .
. 6
1 . .
7
14 .
. 7
16 .
, 7
1 . .
3
10 .
. 8
11 .
. 8
1 . .
11
10 ,
. d
9 .
. 9
• •'
9 .
. 10
8 .
. 10
..♦
*.,
11 .
. 11
3 .
. 11
..*
...
6 .
. 12
3 .
. 12
...
...
7 .
. 18
2 .
. 13
».,
..*
2 . .
. 14
2 .
. 14
^.,
...
2 .
. 16
1 .
. 17
.,.
1 .
. 17
1 .
. 18
...
...
1 .
. 18
*,.
<••
•«.
,,,
1 . ,
. 19
>«<
1.*
.*•
t..
I . .
. 20
...
».*
1 .
. 24
-
*.,
150
148
80
The table explains itself sufficiently to render comment super-
fluous. One fact only seems worth remarking on — nanielj, thut
there were but 2 out of the whole 150 women whose pregnancy
hod issued merely in abortion.
In 18 of the 150 cases, the particulars of which are given in
the annexed table, the termination of the patient's pregnancy
occurred within a sufficiently short period from the commencement
vi the symptoms of cancer to warrant the suspicion that, in some
of them at least, the changes of the puerperal state had a share in
calling the disease into activity.
♦ It is almost auperfliious to addace further evidence of thin fact, Tims Mr
Sibky'fl Report tm Uie Sttdhtica of Cancer givej* an average of 11 jier cent sterile
mmaget, and E>'2 children to each fmilFul mumage. Scamoni's figures, op, dL
JK 284, yield the sin^pilar resalt of 7 children to each fraitful niarriflge, bnt at the
same time 36 sterile mairiages out of 108.
k
374
CAKCEB OF THE UTEKCS :
Kutnberof
Kumber of
Number of
iHsiie of last
Dmte of dymptoms
Pregnnncy.
Children.
Aboi'tlons.
Pr^gnatiuy. i
of Castovr.
3
8
Lire Child.
10 moDtlii^
7
6
I
t *
6 t.
12
12
.*.
It
« ,,
10
5
1 5
1*
* „
4
8
1
»i
Iinm«di«t«ly*
10
7
S
VI
t*
9
9
...
tl
t*
2
1
I 1
tl
t*
6
2
4
Jl
If
7
5
2
, ,
S
2
1
Abortion at
4 lUOQthB,
1 month. 1
11
10
1
IMttoat
5 til Tiif>ijth.
IminediAtely.
7
G
1
Ditto at
2| iBOtithd.
»f
7
4
3
Ditto at
3 iiiontli§«
t«
6
4
2
Ditto at
4 tnoiithj).
»♦
13
9
4
Ditto ftt
4 month*.
'*
10
7
3
Ditto, Period
not stated.
M
17
IS
4
Ditto, ditto.
t*
1
I
All of these patients were seen by me within fifteen months;
most of them within six months from tlie occurrence of aborticm
or lalxiur. When the symptoms are stoted, as in thirteen instances
they are, to have come on immediately, it is meant that there
was no inten^al of health hetween the patient's delivery or miscar*
riage and the occurrence of liannonhage, or of some well-marked
syniptorn of cancer, such m had continued in each case t^ charac-
terise it subsequently, and which in most instances was present at
the time of the patient coming under my care, A few moments*
consideration will, I thinks do away with any feeling of surprise at
the result which these tables show. With old age comes
imperfect and perverted nutrition, and witlx it cancer in the Ijody
geneially increases in frequency. Such old age, such imperfect
nutrition, befall the womb earlier than they do other organs^ and
cancer becomes developed there proportionately early. With each
successive pregnancy the development of the womb is less and
leM perfectly accomplished, and the feeble uterine action of the
multipara, the greater comparative frequency of haemorrhage after
[
k
d
ITS PREDISPOSING CAUSES.
-375
4lelivery» and even of rapture of the uterus in women who have
given birth to several children, than in those who are in hihoor
for the first time, are but no many different illustratiuns of the
same fact. It is not therefore the woman who has never conceived,
but she whose uterus has oftenest undergone all the changes which
the puerperal state brings with it — the fatty degenemtion of its
fibres, the wasting of its tissue, the most profound disturbance of
its nutrition — in whom this disease of perverted, imperfect nutri-
tion is most frequent Nor is the fact without its significance as
illustrative of tlie same law, that in 18 out of 110 women living
in fruitful marriage, in w^hora cancer of the womb came on before
the fiftieth year, or, in other words, before the period of sexual
vigour w^as passed, the very moment at which the important
changes of the puerperal state were going on, the very time when
the nutrition of the womb was most disordered, should have been
that at which, one might almost say out of which, this disease, so
insidious and so fatal, was developed.
One point still remains for notice with reference to the produc-
tion of cancer — namely, the influence of heredit^iry predisposition
in favouring its development In the case of cancer generally,
the influence of constitutional taint has been ascertained to be
very real ; nor does it aj^pear to be less so iu the case of cancer of
the womb, though the number of observations bearing on the
subject is perhaps too small to warrant a positive opinion. Of
160 cases of cancer of all parts, coDccted by Paget,* 26, or 1 in 6*1,
presented the history of hereditary cancerous taint ; and the same
fact was ascertained with reference to 14 in 102, or 1 iu 7 "2 of the
cases referred to liy Lebertf Lebert found evidence of hereditary
tendency to cancer in 2 out of 13 cases of cancer of the wTimb ;l
and it existed in 8 out of 49 cases, or in 1 out of G'l, in wldch I
made this point the subject of inL|uiry. In one of the 8 cases the
patient's father had died of cancer of the throat; in 2 the
mother J and in 4 the sister had died of cancer of the womb, and
in 1 the sister had died of cancer of the breast K'o one, however,
who has had even a small amount of practical experience but
must be aware of the extreme difficulty of obtaining reliable
answers to questions concerning the family history of our
Qp. cU. vol. iL p. 538.
t Op. ciL p. 131.
t Ibid, p. 2/3,
376
CANCER OF THE UTERUS ;
patients. The results are vitiated in hospital practice by tl
ignorance of those with whom we have to do; while in the
wealthier classes of society, the woman is reluctant to aflbrd whjil
may seem to her to be, fresh evidence of the existence of the ill
which she so much dreads. It would seem, indeed, as far as we
have the means of judging, that the influence of liereditaiy
tendency in the case of uterine cancer, is certainly not greater, is
probably soiuewhat less, than in the case of other forms of the
disea.se. Such at least is the conclusion to which Gusserow's* in-
defatigable industry would lead us, for he found that 1028 cases
of uterine cancer, reported as occuring in the better classes of
society, yielded a history of hereditary tendency in 7*6 per cenL,
while the proportion was 13 per cent, in 978 cases of cancerous
disease in general.
There are three symptoms of cancer of the womb so almost
invariable in their occurrence that the merest tyro would not fail
to mention them, and the nmii of greatest experience would still
enumerate them as its grand chamcteristics. Pain, and hfemor-
rliagi^, and vaginal discharge often co-exist in the advanced stagea
of the disease, and one or other of them is present from ita com-
niencement, or furnishes us at least with the first evidence of its
existence. The once common error, howev^er, which confounded
under the name of scirrhug a variety of uterine ailments that had
no real relation whatever to malignant Llisease, led to e^iaally
serious misapprehension of the import of these symptoms.
Haemorrhage was supposed to be the invariable evidence of
ulceration having occurred, wiiile patn and constitutional disorder
and sundry forms of functional disturbance, both of the womb
and of adjacent viscera, were imagined to characteriise the first
or so called scirrhous stage of the disease.
In 166 cases the first symptom of cancer was stated by the
patient to have been —
In 30 instances, or 18*0 per cent, pain of various kinds, and of
various degrees of intensity*
„ 77 „ 46'3 „ haemorrhage, generally profuse,
without pain.
„ 13'8 „ hicmorrhage, accomp:micd by
paim
* €p,eU,^ 188.
I
I
23
i
ITS SYMPTOMS : FAIN.
377
In 15 instances, or 9'0 per cent, pain and leucorrlia^a, or watery
discharge, sometimes offen-
sive.
,, 21 „ 12*6 „ leocorriiofa, or other discharge
without pain.
Each of these symptoms deserves a more carefnl examination,
and, first, with reference to the pain. Botli at the commencement
and thi-oiigh the wliole course of the disease, this varies greatly
in situation, in character, and in intensity ; and there is no one
kind of pain which can be regarded as peculiar to uterine caucer
in any stage of its progress. Under the term pain, too, must be
inclnded various uneasy sensations experienced during the act of
defsecation or micturition, the result sometimes doubtless of the
disease having at an early period affected the bladder or the
IkjwcI, but oftener the consequence of the congested state of the
pelvic vessels, or of that sympathy betweeu the womb and other
l>elvic organs, of which, in the course of all uterine ailments, one
meets with so many illustrations. As a general rule, the pain of
the early stage of cancer is not severe ; it is by no means con-
stantly referred to the uterus, but is more often spoken of as
backache, or pain in the loins, wearying by its constancy rather
than by its severity. Witli this is associated in some instances
pain in the hypogastrium, usually of the same dull character ; but
hypogastric paiu alone, and unaccompanied liy backache, is
decidedly unusual Lancinating pain, decidedly referred to the
uterus, is not Cfmimon at an early stage of cancer, neither is the
organ in general tender to the touch, and in not a few instances
even sexual intercourse does not appear to be attended by any
special suffering. As in other forms of uterine disease, pain is
occasionally referred to one or other iliac region, and, Uke ovarian
pain in general, is marked liy a tendency to exacerbation in par-
ijxysms* In those cases in which the disease sets in with menor-
rbagia, the excessive loss of lilood is often accompanied with much
pain J but, as appears from the table, the majority of cases of
haemorrhage at the outset of cancer are ch^ractyrized by the
absence of pain ; while the cessation of the previously profuse
bl&eding is often associated with the setting in of pain^ from
which the patient was previously free.
With the advjuice of the cancerous disease, pain in general in-
378
CANCER OF TITE UTERITS :
creases much in severity though there is no invariable rule wfaicb
determines either the amount or the seat of the chief suffering ;
while, in by far tlve greater number of cases, the severest pain is
experienced long before the patient's death, and the last monthsof
existence, when all the evidences of the cancerous cachexia are
most marked, and the strength is daily dechning, are happily not in
general agonised by intensity of sufleriug such ashadbeen previously
endured. The causes, however, which contribute up to a certain
point to increase the patient's sufferings as her disease advances
are many, while all the old sources of distress continue. Pain
referreii to the uterus is now often supenidded to the former piiin
in the back and the abdomen ; and this pain, though comitanl,
has its exacerbations, in which it becomes utterly intolerable, i»
sometimes described as a burning pain, sometimes as a stabbing
paiu ; while, when most intense, it is a horrible f^ony, which can
be likened to no other Buffering, of which words seem unable to
convey any idea. Every night generally brings w*ith it increase of
suffering ; but the fits of the sharpest pain are uncertain in their
occurrence, and ap]>ear to come on without any exciting causa
Sometimes the severer pain precedes an outburst of haemorrhage,
and then the bleeding gives relief for a time; but in many in*
stances this is not the wise. Besides the old hypogastric paiu, from
which the patient often suffei'S in the earlier stages of this diBease,
there are now frequent attacks of circumscribed abdominal jiain
and tendeneas. indicative of the peritoneum covering the pelvid
organs having been attacked by inflammation, and such inilauima*
tion comes and goes several times in the course of the disease. The
advance of the disease from the uterus itself along the walls of the
vagina, adds much to the patient*s sufferings, and doe^ eo
especially when the anterior vaginal wall is thus affected. In
this case the infiltration of cancer into the tissues at the upper
part of the vagina interferes with the return of blood from parts
quite uninvolved in the disease. Hence the great swelling of the
urethra, which may often be felt of the size of two thumbs all
the way from the symphysis |nibis to the bladder, and hence in a
measure the frequent desire to pass water, the difficulty in void-
ing it» and the occasional inability to retain it, which so greatly
harass patients with cancer in the womb, lint other cattees
•besides tend to aggravate this symptom. It is, as we saw wheu
I
k
ITSI
PAiy,
'379
studying the morbid anatomy of cancer of the womb, by no
meiins unusual for the Hudder, iiKlepeodeiit of the extension to it
of mcili^^fnant disease, to be the seat of intense congestion, or of
intiammation going on to the deposit of lymph on its rug?e, or to
actual nlceration of its mucous membrane. Moreover, the exten-
sion of cancer from the u terns or vagina into the bladder is
usnally accompanied by much severer suffering than is experi-
enced in primary malignant disease of that organ, while, when
once utero or vagiiio* vesical fistula has been formed, sufterings
from a new source are entaned upon the patient In some in-
stances, too, when there m much deposit of cancerous matter
about the bladder, one or other ureter is obstructed, though not in
general absolutely closed, and it becomes much dikitud, running
a tortuous instead of a straight course, while its walls are greatly
thickened ; and the kidney itself, owing to the difhcuJty in the
pciformance of its functions, and in the escape of its contents,
wastes, its glandular structure almost completely disappearing, its
caHces being dUated into a number of sacculi, distended by a
urinous tiuid.* In a minor degree, this occurrence is by no
means unusual, and to it mnst, I think, be attributed a measure
of the backache and of the dysuria from which patients with
uterine cancer sutler.
And now, liefore passing to the examination of another symp-
tom, something ought to be said with reference to those few
exceptional cases in which cancer of the womb runs its course
entirely, or almost entirely, without pain. It cannot be too
constantly borne in mind, that in many instances the three grand
symptoms of cancer — pain, and ha*nioiThage, and offensive dis-
charge— are not present at the same time. The tUsease often sets
in with htcmorrhage, and often while the bleeding lasts no pain is
experienced, nor is any fetid discha^ge perceptible. At a lattT
stage the bleeding ceases, the pain then becomes severe, and the
discharge oBbnsive, and continues so to the end, though the pain
frequently subsides, sometimes altogether ceases long before the
patient dies» Most of the errors in the diagnosis of uterine
cancer which have come to my knowledge have arisen from
• Sec, for remarks on tkis comiition of the kidnpj, Cruveilhier, Anahtrm
Pntfrnio^iqu^, vol. ii, p, 370 and Athis Uvniison utvii., pi ii. fig. 2 ; and •Lbo
Wigner, op. ct^. p. 111. ^
380
CAKCm OF THE UTERUS :
forgetfiilnesfs of this fact ; and the absence of pain or of fetor of
the discLai'ge has been assumed to negative the possibility of
cancer in spite of the clearest evidence afforded by vaginal
examination of its existence. It is, however, a very rare occur-
rence indeed for pain to be absent through the whole course of
cancer, though by no means unusual for the disease to have made
great progress before any suffering is experienced. Though not
invariably, yet in the majority of cases, it is the epithelial v^arietr
of cancer wluch is distinguished by this absence of pain. Stilly
ia some of the soft varieties of medullary cancer, I have observed
the same thing. One patient^ a young woman, aged thirty, was not
aware of the existence of any serious disease until a profuse dis-
charge of blood took place on one occasion during sexual inter-
course ; and I knew another who imagined herself to be suffering
merely from menorrhagia.to have had intercourse with her husband,
and not to have supposed her ailment to be serious tiil abortion
at the sixth week of her pi*egnancy destroyed her by the haemor-
rhage which accompanied it. In both of these cases tlie disease
was of the medullary kind. The most remarkable ca^e, however,
which I have met with, and indeed the only instance in which no
pain at all was experienced, was that of a woman aged thirty,
who had menstruated irregukrly for three years, though without
any symptom of local ailment, and had recovered but imperfectly
from her sixth labour fourteen months before she came under my
notice. Eleven months before I saw her, she had sudden and
very profuse haemorrhage, which continued for eight weeks, and
was then succeeded by abundant transparent non-offensive
ihscharge* From that time until her reception into the hospital,
the haemorrhage or the watery discharge had been constantly
present, and the patient was admitted, in a state of extin^m©
exhaustion, on the 15th of July, fost and astringents checked
both the bleeding and the discharge, and foud and wine restored
her strength so far, that on the 30th she went iiome to arrange
fiunre domestic mattei-s, but on my representation of the serious
nature of her disease, she returned on tlie 5th of August.
Hiemorrhage recurred the next day, and continued for ten day%
but on the 2 1st she was so far recovered, and had i^egained so
much strength, that all my persuasions to induce her to remain
were inelTectuaL She went home; on the 1st of September
I
ITS SYMPTOMS : HAEMORRHAGE.
381
hfEmorrliage returned, and of this she died on the 5th, having
throughout hud no other sense of discomfort than some difficulty
in micturition, from which she had euflered for two years, and
which was not at all increased in severity by the supervention of
the cancerous disease.
Next on the list of symptoms stands haemorrhage ; and contrary
to what is still laid down in some books, hkeding, so far from
being a proof that the disease lias reached the stage of ulceration,
is often tlie earliest sign of its existence, since it is mentis med in
forty-six per cent, of the cases as preceding any other ailment A
similar err^r, as you scarcely need to be reminded, was once gene-
rally current with reference to hEemorrlmge from the linigs in
phtliisis* The htemoptysis, wliich we know to be in many
instances due to congestion of the lung, and to be the herald of
coming mischief, was supposed to be the proof of irremediable in-
jury already inflicted, of the giving way of a vessel in conseritience
of its being involved in the spread of the ulceration. The same
explanatitfU as accounts for the bleeding in the one case may be
admitted as interpreting it in the other ; and the practical infer-
ence to be drawn from this fact, concerns the extreme importance
to be attached to causeless haemorrhage from the womb, the urgent
need for making a vaginal examination by which we may detect
some forms at least of malignant disease, at or near their outset,
at a time when remedies can retard their progress, when surgery
may perhaps altogether remove them.
Hospital practice gives so httle opportunity for tracing cases of
chronic disease from their commencement to their close, that I can
give no definite sUitement as to the general relations borne by
haemorrhage to the other symptoms of cancer throughont its whole
coui-se. The form in which the bleeding lirst shows itself is very
various. Somi'times it is a draining of blood, not profuse, but
continuous, resembling the discharge at an ordinary menstrual
period, except that it may not have come on at the right epoch,
and that it generally continues for a longer time, until it excites
anxiety l*y its persistence, or in other instances by the fre(|uency
of its return. It sometimes assumes these characters in the aged,
in whom all the sexual functions have long ceased, but who at
tirst regard the reappearance of a sanguineous discharge with
a sort of half complacency, as though it w^ere an e\idence of their
382
CANCER OF THE UTERUS :
rejuvenescence; but it is not in the aged aloue that this form of
htemorrhage takes place. It is, however, more common for
htemorrhage to take place either at a menstrual periodp or a day
or two after its cessation ; but though ao ill-marked periodicity is
j^enerally observable in all hiT^morrhages from the womb, whatever
he their cause, and whatever the age of the patient in whom they
occur, it is certainly unusual for menstruation in cases of cancer
to continue regular in its return. Sometimes menstruation anti-
cipates, at other times there is a fortnightly luemorrhage, the dis-
charge at each period presenting an equal claim to be regarded aa
menstrual ; but it is not often that the proper period continues to
be recoguisalile after two or three, returns of bleeding. A few
cases occur of a single profuse outhm^st of blood, not followed by
any return of hseniorrhage, or merely by the occasional admixture
of sangnineons tluid with the discharge which takes place at other
times. Profuse lochial discharges have once or twice passed,
according to the patient's statement, into a hffimorrhage which has
been the first evidence of cancerous disease ; but, of coui^se, the
cases in which tlds is observed are rare and exceptionah
In the early stages of cancer, the bleeding is, as the table shows,*
most frequently unaccompanied by pain, though to this there are
some exceptions. With the advance of the disease, pain is
generally associated with the haemorrhage ; for with the exception
of cases of epithelial cancer, in which the delicate vessels give
way under the slightest cause, congestion of the womb generally
precedes each outburst of bleeding, and is relieved by its occur-
rence. The source of the haemorrhage continues to be the same
after ulceration has taken place as it was before, and the blood is
furmshedmuch less by thediseased surface than by the whole mucoua
membrane of the womk The expulsive uterine pains which in
many instances accompany the hiemorrhage are due to the same
cause as in ordinary menorrhagia — namely, the formation of
coagula within the cavity of tlie womb, and the efforts of the
womb to expel them; etlbrts which are all the more painful
owing to the resistance which they encounter from the unyielding
tissues infiltrated with cancerous matter. There is no stronger
evidence tliat the ulcerated surface furnishes but a small part of
the bleeding than is afforded by ita invaiiable diminution, often
• See p. 37ew
ITS SY3CPT0MS: LEUCORRHCEA.
383
by its complete cessation in the advanced stages of cancer, while
in not a few instances in which the proLress of ulceration has been
most mpid, and the destmction of tissues most extensive, there,
has been but little bleeding, or the haemorrhage has been entirely
confined to the outset of the disease. A woman, aged thirty-ei^lit
came into St Bartholomew's Hospital to die of cancer of the
womb, and sank on the second day after her admission. The
posterior lip of her uterus was completely destroyed, and the
finger passed up at once into its ca\ity, whence there projected an
iiTe»^nlar, sprouting growth. The anterior lip of the uterus was
firmly adherent to the anterior vaginal wall, along which the
cancerous disease had extended to within an inch of the vulva,
while tlie lip itself was irregular, tliickened, and in great measure
dastroyed by ulceration. A single attack of haemorrhage lasting
for live hours, was the index of the commencement of her illness
eight months before. Abundant and often fetid leucorrhcea had
been present for many months, but no blood appeared at any time
in the discharge, except on the single occasion which I have
mentioned.
lastly, with reference to the discharges in cancer cases. They
differ much in different forms as w^ell as in different stages of the
disease. An iticreased mucous, or muco-purulent discharge, is by
no means uncommon in the early stages of medullary cancer,
dependent on the general congestion of the womb, which, as we
have seen, accompanies the disease at its outset. This dischai-ge
is not in general offensive, but sometimes patients will complain of
an offensive dischaige as having been the tirst sjTnptom of the
disorder, and thm in cases where it cannot be doubted but that
no breach of surface at the time existed. In this, however, there
is notliing remarkable ; offensive leucorrhiea accompanies uterine
congestion and uterine inflammation in many instances, or results
in cases of menorrhagia, or of polypus, or of hlirous tumour, from
the decomposition of blood which has been poured out ; and our
patients at any rate, are not to be expected to discriminate
between bad odours from one cause or from another. With the
advance of the mischief the discharge becomes almost always
unmistakably offensive, though the variations in this respect are
even in the same case not a little r^^markable. It has been seen
that portions of the diseased atrnoture not infrequently slough off,
384
CANCER OF THE UTERUS :
a&cl are detached from time to time, leaving behind, when they
separated, a comparatively clean surface, on wliich for a tuns
sort of attempt at heakhy granulation may even he perceptible
While the tisaues are dying and being renewed, the discharge from
the cancer will generally he a dirty, highly ollensive sanies ; after _
they have been completely thrown off the secreticm may be bat |
scanty, puriform, and comparatively inoffensive ; while in almoet
every case, supposing proper precaution to he taken by syringing
the vagina, and by due attention to cleanliness to remove the
secretion completely and frequently, the offensiveness of the dis-
char^^e will depend in very gi*eat measure on the activity witli
wliich the processes of sloughing and separation of portions of the
cancerous substance are going on. When the disease is in a com-
paratively indolent sttite, as it sometimes continues for months
before the death of the patient, who sinks in that case under the
cancerous cachexia rather than under the advance of the local
mischief, the discharge is often neither very profuse nor very
offensive. In the indolent state of the disease, too, the secretion
has seldom anything of the purulent character wldch is observable
wlien ulceration and its allied processes are going on actively, but
is usually watery, sometimes blood-stained, at other times com-
paratively transparent In epithelial cancer, also, the discharge
is generally serous, and often almost inodorous, it being rather a
secretion from the surface than the result of any decomposition
and destruction of tissue. This same absence of any marked
offensive odour continues likewise very freciuently even after
ulceration and dostraction of substance have commenced in an
epithelial cancer, tliough, as its characters become merged, as they
often do in those of medullary cancer, the discharge almost always
acquires a much worse smell than l>efore. In cases approachiug
to caulidower excrescence, where the patient dies of hicmorrhage,
and also in cases of the so-called corroding ulcer of the os, the did*
charge continues inoffensive even to the last. These, however,
are exceptional cases and in no way interfere with the correctness
of the general rule, that offensive discharge is one of the symp*
tonis of malignant disease scarcely ever absent in some part of its
course.
One or two practical inferences may be drawn from what haa
been stated, which it will Ije worth while always to bear in mind.
I
I
I
I
1
k
d
ITB OONSTITDTIONAL SYMPTOMS,
385
First of all, the presence or absence of offensive discharge must in
no measure be allowed to influence us in deciding on the nialig-
nancy or non-malignancy of any disease of the womb. Mere
irritation of the organ from inflammation or congestion may be
associated with it, decomposition of blood within the sexual
organs may occasion it, or the decay and disintegration of a fibrous
tumour or polypus. On tlie other hand, tlie discharge from an
epithelial cancer is often for a long time inoffensive, and some-
times continueg so thi"oughoufc, whOe in other cases the presence
or absence of an offensive character in the secretion, may depend
upon whether the disease ia in an indolent or in an active state.
Even in the latter case, if an examination is made just after the
dead tissues have been thrown off, it may be found that no bad
smell Ls given out by discharges which but a few weeks before
were intolerably offensive.
It would, I apprehend, answer no really useful end were I to
endeavour to group together those symptoms which we have
hitherto examined, and out of them to form a general portraiture
of uterine cancer. The degree in which each symptom is mani-
fested, the order in which the symptoms succeed each other, the
time during which they are associated, the increase of one and the
diminished urgency of another, all vary so much in different
instances that no general description could be applicable in all ita
details, and I therefore forbear from an attempt which might mis-
lead, and could scarcely instruct you.
Hitherto, however, no mention has been made of the signs of
general constitutional disorder which sooner orlater manifest them-
selves in almost every case of cancer, whether of the womb or of
other organs, and which add much to the patient's distress. The
cancerous cachexia, which is absent only in some few instances of
epithelial carcinoma where death takes place from pure loss of
blood, is something more than the mere ani^mia produced by
hoemorrhage, or by the exhaustion that follows long protracted
suffering. " The fount of all the blood is touched corruptedly ; "
food does not nourish, the strength faik, the body wastes, the
stomach refuses to perform its proper functions ; nausea dia-
treasea the patient, or sickness wears her, and the red, raw, glazed
or aphthous tongue indicates but too cleariy the state of the diges-
tive mucous membrane, and explains the urgency of that thirsb
386
CANCER OF THE UTERUS :
which driak cannot quench, which it is so often scarcely alii?
even foE a few momeuts to allay. The state of the bowels is fre»i
quently an additional source of trouble, constipation alternat
with diarrhcjea. The former condition is frequently induced
measure by the mechanical obstacle which the enlarged and
hardened womb offers by its pressure on the rectum to tboJ
passage of the fteces, and is stiU further maintained by the lack
of muscular power in the intestines themselves, which are no
longer able by vigorous peristaltic movements to propel their con-
tents. When once diarrhoea comes on, the same want of power
allows it to continue till the intestinal canal is completely j
emptied, while to the same cause may be in a large measure attri*
bated the flatulence which often distresses the patient^ producing I
mucli abdominal pain, and not infrequently issuing in an attack j
of diarrhtca. The sleep is always disturbed and nnre freshing;!
opiates indeed may relieve the pain, but they often aggravate thai
other ailments ; the patient feels too ill to sleep, or if she dozes,
the parched mouth and burning tlxroat awake her, or else the
sense of utter prostration and exhaustion, and the sufferer returns
to consciousness with the feeling tliat but a little more, and the
sleep would have ended, as indeed it does not very rarely, in
death. In this state 1 have on five occasions known convulsions
to come on, which ended in coma, and in three of the cases the]
coma ended in death, which took place twic^ in twenty-four]
hours, and once at the end of eiglit days. These head sjnnptoms, I
however, are not by any means indicative of actual disease of the |
brain, for two of tlie patients being examined after death, no trace
of mischief wtis disco^^erable there ; and two others having rallied
from the convulsions, lived for many months, while the hemipl^s J
wliich in one instance had followed the fits disappeared by
degrees, but completely. In a sixth case great impairment of J
sensibility of the left side occurred causelessly and disappeared in
the course of a few days, a month before the death of the patient,
during whose illness no other sign of cerebral disturbance was
observed. The cause of these cerebral symptoms is obscure. The
only explanation of them wit!i which I am acquainted is that
suggested by M. Aran,' who regards them as dependent on Iiydro-
nephrosis, and the consequent abolition of the function of tho ,
• Op, eit, p. %^%,
ITS CONSTITUTIONAL SYMPTOMS,
-m
kidne}" ; but I did not observe^ and I am not aware that others
have noticed suppregsion of nTine as accompanjdng the convul-
sive attacks of cancerous patients* I do not know how far the
recovery for a season of patients in whom the^e symptoms have
occurred, and their subsequent death from the ordinary progress
of carcinoraai may he fairly re^^arded as militating against this
theory. In two instances of extreme hydronephrosis, produced
by the pressure of the cancerous womb on the ureters, no sign
of head-disturbance preceded death ; and in the two who died
there is no account of remarkable hydronephrosis Iiaving been
discovered at the post-mortem examination.*
But these are exceptional cases, and death is not in general
preceded by any marked cerebml symptoms. The powers of life
by degrees wear out, the local mischief often remaining for weeks
or months quite stationary, and when at last the patient dies, it
may be ditticult to say why deatii came just when it did, why,
with tiisease so far advanced, it did not come sooner, or why, life
having lasted so long, it should not have continued still for a few
days or a few weeks longer ?
In one case, indeed, the general poisoning of the blood gave
rise to the symptoms of septicemia which ushered in the patient's
death, though, singularly enough, previous to her fatal illness the
signs of the cancerous cachexia had lieen by no means extreme.
She was fifty-six years old, the symptoms of uterine disease had
existed for only four months, and the mischief was so almost
exclusively limited to the uterine cavity that a moment's hesita-
tion had been felt as to whether the disease was really of a malig-
nant chanicter. At the time of her admission slight feverish
symptoms were present, which at the end of a week became more
intense, and wei^e associated with pain in the upper extremities
precisely like that of rheumatism. This pain continued, though
it did not increase in severity, but the fever rapidly assumed a
typhoid character, the pnlse rose to 140 in the minute, the tongue
became dry, and on the sixth day she died.
This case, indeed, stands alone in my experience, though there
is a great diiTerence in the intensity of the symptoms of cancerous
cachexia and in the rapidity of their course, while no constant
• [See a paper by Dr Wiltshire, '* On ITrinomia in eertain fasea of MftEgniuit
D\s&mo of tlitf Ut<:rua.'^ O^me/iological Trat^mdwna, vol L p, 301.]
388 CANCER OF THi: TTTERU9 :
relation appears to exist between the amount of the local diseiisii
and the amount of constitutional disorder* When most rapid,
however, the constitutional symptoms still nearly always continue
of a passive kind : and even the peritoneal inflammation which
has been referred to as a not infrequent cause of h^Tpogastric pain,
and as producing adhesions between the pelvic \a3cera, does not
seem to have any tendency to assume an active character, and
does not materially contribute to shorten the patient's life. The
diarrhcea often has this tendency, sometimes asauming a dysen-
teric character, and being found aftt^ death associated with great
©ongestionof the rectum and lower jiart of the large intestine, and
great enlargement of the solitary glands. It is very unusual for
great local pain to attend the last few days of the patient's life, and
in the very few instances in which I have observed it, it was asso-
ciated with the development of cancerous disease in the abdomen,
and did not appear to be attrihuttible to the affection of the womb.
Two deviations from the ordinary course of cancer muBt be
noticed before we leave the subject of its symptoms. Reference
has already been made to the occasional absence of one or other
of those symptoms whicli are usually regarded as characteristic of
the disease. But there are also occasional instances in wliich not
merely one customary symptom is absent, but in which all the
aymptoms are so little marked as to throw the nature of the
disease completely into the shade. It is not very unusual for
patients to apply for the cure of suppose*! menorrhagia, in whom
examination ascertains the existence of far advanced cancer of the
womb ; but the most remarkable case of the latency of all its
si/mpto7m which has come under my own notice is the following :
— A woman, aged forty-five, who was following the occupation of
a oook, came to me at the Middlesex Hospital, complaining of
constipation, and of some uneasiness in defecation, which she
attributed to piles, She had no haemorrhage, and no uterine pain^
and it was only on closely questioning her that she admitted the
existence of slight leucorrhtea. There were no hfemorrhoids, nor
was there any disease about the rectum, but the utenis was large,
less movable than natural in the pelvis, its anteiior hp hard and
nodulated, its posterior destroyed by ulceration. For more tlian
three months she continued to come back^^arda and forwaula to
me, and during the whole of this time she retained her plac^
I
I
1
ITS LATENT, AUB ACUTE POEilS.
389
expreBsing great relief from simple aperient medicines which I
had prescribed for her, hut I then lost sight of her,* Two years ago
a widow lady, forty years old, consulted me on account of
slight uterine discomfort, and slight disposition to over frequent
menstruation. She thought so little of these ailments that, as
she told me, she should not have consulted me alx^ut them, hut
that she was ahout to enter into a second marriage in a few
weeks» and she was anxious therefore to he perfectly well*
Her uterus was large, fixed in the pelvis, vntli a gaping os,
thickened and irregular lips ; ulceration hod not yet hegim, but
otherwise her case was a typical one of medullary cancer. I ex-
plained her condition to the friend who accompanied her ; but
never saw her again ; and, indeed, should have been surprised
had she returned. Our patients prefer not unnaturally the doctor
of whom they are sure that he will always ** prophesy smooth
tldngs."
The practical inference from cases such as these is, that we
must take nothing for granted, that a very little warmnts suspi-
cion, and I may add, that we must not place implicit reliance on
our patients' statements when they deny the existence of some
symptom which is either known, or popularly believed to be of
evil import. They earnestly desire its absence ; they will not
allow themselves to believe in the existence of what they so
intensely dread*
The other variety of cancer is an oeute farm of the disease which
I believe to be very rare, but which runs its course with much
febrile disturbance, and vsrith symptoms of an active character
such as may be taken by the superficial observ^cr for those of in-
flammatory mischief* It is a form which I have seen only in
young persons, and soon after delivery or miscaxriage* In one
instance, a woman who had miscarried at four months, and had
had a single profuse attack of hEemorriiage two months before she
came under my notice, was received into the hospital in a state of
profuse salivation, in consequence of mercury given her for the
cure of alleged uterine inHammation, The disease, of which she
soon died, was cancer in a state of far advanced ulceration ; but
there had been so much febrile disturbance and so much aklo*
miual pain as to throw an intelligent practitioner ofl* his guard,
* A case of the kind is related by Sir J. Slmpsoti, op. inL p, 190*
390
CANCER OF THE UTERUS :
and to lead liiin to neglect what might seem the very Qh%
duty of making a vaginal examination. Another case soniewhil
of the same kind I have also seen, in wliich the disease ran iU'
course in three months and seventeen days ; it« commencement
being reckoned from the date of the patient's delivery, pre\*ioQS
to which she was not aware of any symptom of uterine disease*
In this case the patient died in a state of coma which had suo*
ceeded to convulsions, and her state, even at the time of her
admission, was one of very great urgency. She, however,
had a hot skin, and a furred tongue, and a rapid pulse, with
considerable abdominal pain, and I can readily conceive that
at its outset these symptoms might, as in the other case, have led
into error.
We have already seen that on the one hand tlie presence of a
disposition to cancer does not interfere at all with a woman's
fertility, and on the other, that the changes that succeed to cliild-
birth seem to favour the advance of the disease. It now remind
for us to look at the influence which cancerous disease of the
womb exerts on the process of labour itself, when a w^oman so
atl^licted has the misfortune to become pregnant The e\idence of
statistics bears out fully what one would anticipate to hnd, and
ebowstliat the rugged aud tbiekened os uteri dilates slowly, pain-
f ally, and imperfectly ; that it is often I'ent dm'iug the parturient
efforts, and that formidable ha^morrliage takes place, or dRngerons
iniiammation succeeds ; and that sometimes so insurmountable
are the obstacles, that the child cannot pass at all, and the
mother and her unborn babe either perish together during the
parturient elTorts, or that gestation is prolonged far beyond its
ordinary term, and that death at length takes place without any
decided effort having been made by the uterus to expel its
contents*
Hereafter we must return to the subject, in order to inqaire
into the means wldch will give us the greatest chance of carrying
the mother and her chOd safely thi-ougli these dangers. For the
present, it is enough to have adverted to them, and to have shown
their nature and extent.
I
I
I
• As in Dr ileuzies* very rvmnrkabJe cak iworded in Qlnsgow McdimI JtmnuU,
vol i. |i. 129, July 1853.
ITS INFLUENCE ON LABOUR,
391
Table shoming the Eesuli of Sti^enii/'five Case3 of Cancer of
the NecJc of the Wotfih cmiiplicaiing Labour,
Died in or
Recorered
Authority.
Total Cftaeii.
very 8<*on
from the elTecta
iLfter Labour*
of Labour.
♦Puclielt . . .
31
18
13
tOliOmm . . .
5
2
d
t Co mi tick . . .
1
...
1
§ Sim peon , . ,
fl
2
4 {
11 Arnott . * ,
3
...
2
irScnnzoui . . .
4
4
..*
•* Domngton < .
1
1
...
4
4
-,*
J:tMenries , . .
20
10
10
H Spitfgelberg . .
1
,.*
1
76
41
34
• Ik Tumorihua in I^lm\ kc, 8vo, 1840, cnp. iii. and iv.
t Londm JtmrmU qf Medicine, 1 851 , {». 204, and Ouff'a SospUal Re^crU, 2nd senes^
ToL viL p. 427i X Lond<m Journal of Medicine^ 1851i pu 212.^
§ Op. ci^. p. 1148. II Mfd. Chir, Tram., voL xxxL p. 87.
If Lehrhuh dtr Q^^mH^Ulfe, vol. ii. 258.
♦♦ iV<w. Med. J0umak *3ct 7, 14, 2U 1843. ft Op. dl vol. i p. 540.
Xt MetUEiea, hx^ ciL In Menziefl' tabk* of 27 cauaa aro iueluded ihme of Dpoman,
contained in Puchelt'a t^bk^ and nome ea«ies of Oldham aud SimpAoUf which are
separately referretl to by me. These being omitted, 20 i:a*ea remoiii.
f§ MonaJsMchn/t /. QehirUk., Feb. 1858, vol xi. p. 110.
Wliilf* these shwts were passing through tlu* press the twentieth volume of the
€}hstHrical TransacUms hiia apjjeared, contuiiiiiig a paper of great interest and
value from the pen of Dr Herman of the London Hos|iital, on ** Pregnancy compli-
cated with Cancerous t>iaea.«4es of the Giniital Canal." It ia to be hoped that
this is but one of many contributions to follow frtmi him to our better knowledge
of many subj^'ots, in the department of Obatetries and Gynsucology.
His table compris4^i* 180 cases of cancernus disease of the uterus or vagina, many
oE which are the same as those given in the text, but it may well servo to Gon'c<:t
and confirm the conclusions to which they lead.
Of 134J cases in which labour occurred, and its results are ftdly stated.
Total. Recovered. Died.
Delivered, naturally, •
61
35
16
„ by force lis.
9
6
4
„ by version,
14
6
8
„ by incision ^f cervix,
14
11
S
„ Cramotoniy, .
12
8
0
„ Cfesarean secttoo, .
12
4
8
,, Uterus ruptured,
11
...
11
Not delivered,
13
...
18
136 61 72
In 94 cases the fate of the i^hildren ia mentioned, and 58 are said to have been
bom aUvc, 36 dead« Of the latter, 12 were putrid, and 13 were premature.
CANCER OF THE UTEEUS :
In 8titmdy4wo Cases (h-c Fate of the Children is tnenii
Authoritj.
Total Canes.
DeacL
Bom alive.
Puchelt* . . .
30
19
11
Oldham ,
5
i
l
Connftck .
1
...
1
SinipsoQ
s !
2
4
Arnutt . , .
2
2 twioj.
1
Scanzoni .
4
4
DorriDcton
Kiwisch
1
1
...
i
4
...
Menziea
18
11
7
Spiegelbeig
1
...
1
72
47
26
In the fomgoing Lectures I have occasionally notic^^d the maiii
distinctions between ioEocent and maligEant diseases of the womb,
and it may at first sight appear needless to enter into details ceii-
ceming the diagnosis of uterine cjincer, since its characteristics aro
80 well-marked as seldom to leave room for doul>t, or to allow tlie
possibility of error, except to the grossly ignorant, or the wilfully
careless.
But though this is usually the case, yet it does sometimes
happen that error is fallen into by persons who can neither be
charged with want of knowledge^ nor with want of care, and such
error most frequently takes the form of regarding an innocent
disease as one of malignant character, and thus entails much '
needle.ss anxiety on the patient and her friends. At a time w^hen
induration of the cervix uteri was commonly supposed to be due
to scirrhous deposit, this mistake was much more frequently com-
mitted than it is at the present day ; but even now the practical
error survives, as is its wont, the pathological blunder in which it
originated.
Hence it becomes by no means superthious to lay it down as a
rule, so far as I know without any exception, that long-standing
induration and hypertrophy of the cervix uteris with or without
superficial alirasion, but unaccompanied by thickening of the roof
of the vagina and by diminished mobihty of the uterus, are due to
chronic inflammation, not to ciiiicerous deposit.
So great ia the impoiiance of distinguishiug between these two
m HIAGKOSIS.
393
conditions, that it may be worth while, even at the risk of being
tedious, to contrast them with each other : —
IN INFLAMMATORY rXDORATION.
The history of the patient's
ailments genemlly goes back for
a period of several years, and
her symptoms have come on gra-
dually.
A tedions labour or an imper-
fect convalescence from labour
or miscarriage, is very frequently
referred to as the commencement
of the patient's ailments.
Pain is a more constant and an
earlier symptom than httmor-
rhage. Menstruation is often
scanty ; luemorrhage, if it occurs,
ob8er\^es a monthly or sometimes
a fortnightly type, is very seldom
1 persistent, and is almost always
attended by mnch sufiering.
The cervix uteri is always
tender, often exquisitely so ; the
mobility of the uterus is but
little modified ; the enlai^ged lo-
bules of its lips radiate from the
orifice*
Ulceration of the os uteri is
either a simple abrasion of the
epithelium, or a red surface of a
finely granular, velvety texture,
sometimes raised a little above
the level of the adjacent part,
never depressed beneath it. The
margins of the ulcerations are
always smooth and regular, and
the discharge is sometimes puru-
IN UTERINE CANCER,
The average duration of can-
cer does not exceed eighteen
months, and the fii^st symptoms
are generally sudden in their
occurrence.
Though cancer occasionally
develops itself out of labour or
miscarriage, yet such cases are
usually so rapid in their course
as to render mistake impossible*
Htemonhage is an earlier, and
in the first stages usually a more
urgent symptom than pain. It
is causeless, sudden, often persis-
tent, not governed by the men-
strual type, and the season of
flooding is generally one of miti-
gated suflering.
The cancerous cervix is often
but little sensitive ; the mobility
of the uterus is early interfered
with ; the enlarged lobules of its
lips are irregular in theii- posi-
tion, and not divided by fissures
ratiiating from the orifice.
Cancerous ulceration is never
a simple abrasion, but either a
sprouting coarsely granular out-
growth with everted edges, or an
excavated ulcer with a dark sur-
face, and jagged margins ; often
partially covered by a dark-
greyish slough. The discharge,
W'hich is furnished from the
diseased surface rather than
394 CANCER OF THE UTERUS :
lent, oftener glairy, occasionally from within the uterus, is either
a little l)lood-8treaked, hardly thick, yellow, purulent, highly
ever ofifensive, and furnished oflFensive, or thin, serous, often
more from the interior of the blood-stained, never transparent
uterus than from the ulcerated and albuminous,
surface.
Attention to these distinctions will, I believe, suffice almost
invariably to prevent the confounding of mere chronic induration
and hypertrophy of the uterus with maL'gnant disease. I have,
however, met with two instances in which the diagnosis between
the two conditions was extremely difficult, and in which time
alone removed suspicions that had appeared but too well founded.
Both of these cases presented considerable resemblance to each
other ; and the symptoms, which came on in both some months
after delivery, were probably due in reality to a condition of im-
perfect involution of the uterus. In both instances profuse
haemorrhage burst forth suddenly, endangering the patient's life,
and being in one case restrained only by the use of the plug. The
uterus was in both cases greatly enlarged, its lips were swollen
and everted, and its orifice was open, so that its condition closely
resembled that of the womb affected by fungoid cancer ; while the
serous discharge which flowed in the intervals between the attacks
of haemorrhage gave out that offensive odour commonly regarded
as almost pathognomonic of malignant disease. The nature of the
case, too, was, with one of the patients, rendered the more doubt-
ful by the circumstance that she being turned forty years of age,
having given birth to her last child eighteen months before, and
having weaned it seven months, had yet had no Betum of men-
struation, while her health was failing, and she had suffered much
from dull lumbar pains. In this case, which I had frequent
opportunities of watching, the haemorrhage recurred at irregular
intervals for between two and three months, when it ceased, leav-
ing the patient completely exhausted. Slowly she regained her
strength ; and at the end of another three months the menses
returned naturally. After having twice recurred at their proper
periods, the menses once more disappeared ; their cessation, how-
ever, was accompanied by the signs, not of disease, but of preg-
nancy, which terminated in the birth of a living child at the
ITS DIAGNOSIS,
395
seventh month of utero-gestation. Very serious haemorrhage
attended the labour, but convalescence was uninterrupted, and no
sign of cancerous or other uterine disease has reappeared, though
the patient has now entered her forty-ninth year, and the menses
are becoming irregular in their return^ preparatory no doubt to
their final cessation.
In this instance I was not alone in the unfavourable opinion
wiiich I entertained of the patient's prospects ; but looking back
upon the case, now that time has corrected my judgment, I can
recall to mind that there was a uniformity in the enlargement of
the uterine lips, and in the degree of their hardness, which is not
usual in fungoid cancer, and that there was an absence of that
nodulated character which is generally obvdous in the uterus
aOccted by mabgnant disease.
Between fibrous tumours of the uterus and malignant disease
of the organ, a vaginal examination usually enables mb readily to
discriminate. Still it must not be foigotten that in those com-
paratively rare cases in which the body of the uterus is affected
by cancer while its orifice is free from disease, we may find a
tumour perceptible in the abdomen, coupled with marked increase
in the dimensions of the uterine cavity, and sometimes with
irregular thickening in the substance of one or other uterine wall,
closely resembling that produced by the presence of a fibrous
tumour, while sometimes a distinct outgrowth is perceptilile
through the os. Our diagnosis, however, \dll usually be directed
aright, by the health being more impaired, and the local su tiering
more persistent than is usual in a ease of fibrous tumour ; by the
loss of mobility of the utenis being more considerable than even
its increased size would account for ; and by the extreme vague-
ness in the outline of any tumour proceeding from the uterine
walls.
Eeference has already been made* to the possibility of mistak-
ii^ a fibrous tumour just passing through the os uteri for can-
cerous disease of the organ j and I have known the disintegrated
sloughing surface of a pedunculated fibrous tumour or polypus
hanging down into the vagina to be taken for advanced ulcerated
carcinoma of the neck of the womb. Such an error, however,
ought not to be committed, for on a careful examination, the
* See p. 285,
396
CANCER OF THE UTSBUS :
absence of the os uteri from the lower end of the tumour, its oval
or pyrif orm shape, its smooth and uniform surface at those parte
which are not in a state of ulceration, and the possibility in almost
every instance of reaching one or other lip of the os, if the fingn
is carried high up along the tumour, will reveal the real nature of
the case.
One point only still remains to be noticed in order to complete
our history of cancer of the womb, and that refers to its duration,
which seems, indeed, to be shorter instead of longer than that of
many other forms of the same disease.
In twenty-two instances I was able to fix accurately the dura-
tion of uterine Cancer, and found that it was —
Under 4 months . . ,
. in 1 case.
» 0 „ . .
M 3 „
„ 6 „ . .
.. i„
„ 9 „
„ 1 ..
„ 12 „
i> 3 „
Exactly 1 year . .
» 2 „
13 months . .
„ 1 „
Between 1 and 2 years
if 5 M
„ 2 — 2J „ .
» 2 „
„ 2i-3 „ .
i> J- »
Exactly 3^ „ .
i> -'• »
Said to be 5, but doubtful
» ^ M
22
Average duration, 17*3 months.
The average of thirty-nine cases, as given by Lebert,* is sixteen
months and a fraction, a result very nearly approaching to my
own, and less than the average duration of all forms of cancer,
which is stated by the same authority at eighteen months, the
progress of the disease being slower in the mammary gland, the
testis in the male, the eye, the bones, the lymphatics, and the in-
testinal canal ; though even in the breast and the testis, in which
its advance is most tardy, the average duration of the disease does
not exceed three years and a half.t
Op. cU, p. 270.
t IMd. p. 122.
ITS DURATION. 397
In the next Lecture we shall pass to the investigation — I wish
we could do it with brighter prospects— of the remedial means,
whether medical or surgical, by which we may hope to retard the
course, to alleviate the sufferings of cancer, sometimes to obtain
for the patient a brief respite, now and then, perhaps, to accom-
plish her cure.
LECTURE XX.
MALIGNANT OR CANCEROUS DISEASES OF THE UTERtJS,
Trsatmknt ; Tarions opiniona (Mit«rtaitit.tl at different times conceTTiiiig it
PAtLIATirB Tkbatmbnt ; of the hcmorrhiigej, of the pain, of Ibe dischAigci^
fiiftnttgenient of the general health, and of flymptoma of cancerous eachexu.
Prtjgnftncy and kbour complicated with cancer ; question of indue tian of pre*
mature labonr ; fnanagement of the labour itself*
CiTRATivR Treatment ; eitiqmtion of the whole uterua ; reaulta of the operattoti*
and reasona for rejecting it Esccision of the nucic of the womb ; etrofs irhidi
brought it into diacrtidit ; cases suited for it ; modes ofjperformiiig the opeivtioii;
ita dangers.
Other means anppoaed to be remedial ; employment of eoldf of aiaitics, and of tkt
actual cautarj' ; observations ou each.
Yery numerous heave been the fluctuations of opmion with
reference to the management of cancer of the womb. When
knowledge concerning it was most imperfect, alleged remedies
abounded, and various medicines had the reputation of eliminate
ing the cancer poison from the system, and, acting thus through
tlie medium of the constitution, of removing the local disease.
Next came a period of adventnroiia surgery, of attempts to root
out the whole evil, over which it became evident that internal
means had but little influence* Soon, however, practitioners
were affrighted at the dilliculties and the dangers of such opera-
tions, and then resorted to a combination of local and general
treatment, and believing that between cajicer and inflammatory
induration there was some close bond of afiinity, they endea-
voured by dejjletion, and by other means calculated to retard the
changes which inflammation produces, to keep at bay the advances
>f cancer. An attempt was made, too, to vindicate to sui^ry its
"ahare in the removal of this diflease, even when medicine waa of
no avail* and for a time the amputation of the scirrhous neck of
the womb was vaunted aa a mode of almost infallibly arresting
I
I
I
Q4NCER OF THE UTERUS ; ITS TREATI^rENT.
the otherwise inevitable danger. Time and increased knowledge,
however, have led ns to unlearn much in which onr predecessors
had an unfaltering faith* We have renounced all credence in the
specific remedies once beUeved in ; we have abandoned, as too
hazardous to l>e warrantable, the extirpation of tbe whole uterus ;
we have found out that there is no relation between inflamma-
tion and cancer ; that antiphlogistic means which remove the
effects of the former, have yet no power to control the progress of
the latter ; and, moreover, that the supposed triumphs of surgery
in cutting short the disease, by remo\^ng that small part of the
organ whence, if let alone, it might have spread to surrounding
tissues and neighbouring viscera, were , for the most part, purely
imaginar}^ ; and the trophies once displayed in our museums are
now generally put out of sight, as the mementoes of a pathological
blunder and a needless operation.
It seems, then, that in the greater number of instances, our
duty, in the treattmnt of uterim cancer, is the very humble one of
mitigating sufferings which we cannot remove ; of depriving death
of some of its teiTors, though we may feel ouraelves powerless to
delay its steps. Carefully to study, religiously to carry out this
duty, calls for much care, for much and most untiring patience.
But there are some few cases concerning wliich we must admit the
possibility of a better issue being attainable, and we shall advance
all the more steadily in our quest of means of cure, now tliat we
have learnt with greater certainty than before to distinguish the
different varieties of the disease ; to know the cases in wliich
recovery may be possible, fmm those in which we shall assuredly
err if we aim to do more than palliate the more urgent symptoms.
T propose, therefore, first to pass in reriew the different means
by which we can minister present reUef to the patient labouring
under cancer of the womb ; and then to consider the exceptional
cases in which we may attempt something more, and the merits
of the various proceedings by which a radical cure of the disease
has been attempted, has sometimes even been achieved.
In cases of cancer generally, our attention is divided between
the relief of the local symptoms, and the maintenance, as far a^
possible, of the general health, I know of no means l>y which the
progress of cancer can be arrested in its first stage, and the disease
kept stationary ; a source, indeed, of constant apprehension, but
400
CANCER OF THE UTERUS :
tbe occasion of little present discomfort, and of no imxned
danger. Almost all tbe vegetable, almost all the mineral poisons 1
have been tried, extolled, and rejected in turn ; tonics have been
administered, and again the patient has been placed under the
so-called hunger cure — that is to say, her food has been reduced
to the smalleat quantity on which life can be maintained j and
thia with the result which the empirical trial of remedies almost
always merits, almost always attains.
The hmriwrrhage is usualty the first symptom which so exciidd
the patient's alarm as to induce her to seek for medical aid. But
unfortunately, ere then the disease has often made considerable
advances, and its nature is already but too evident. The haemor-
rhage at the outset of the disease being, as already explained, due
to congestion of the womb, our first endeavour must be by every
means to abate it, and thus to prevent, if possible, the return of
the bleeding. It is self-evident, that with this object in view^
every direct excitement of the sexual organs must be injurious,
and hence there can be no exception to the rule which interdicU
marital intercourse whenever there is the least suspicion of can»
cerous disease. The state of the bowels is the next point to
attend to, and they must be kept freely open, if possible, by mild
saline aperients, wlxich unload the hiemorrhoidal vessels, as well
as prevent the accumulation of faeces in the intestinal canaL A
mild, unstimulating diet is equally important; and I have no
doubt but that in the early stage of cancer an opposite plan is
injurious to the patient's general health, and indirectly accelerates
the advance of the disease. When to these precautions are added
tbe avoidance of all active exertion, and the most absolute rest st
the return of each menstrual period, I fear there is little more
within our power. The local employment of depletion, which
has been recommended in the early stages of cancer, is very rarely
admissible, and I am txot disposed to advise that the blood should
ever be drawn from the uterus itself, but rather from the hypo-
gastrium or the groin, since I have known very serious difficulty
occur in arresting the bleeding from leeches applied to the neck
of the womb in these cases.
At a later fieriod of the disease the haemorrhage may be so pro-
fuse as to call for direct restraint, and the necessity for immediately
checking it is of course urgent in proportion to the degree of
TREA'nrENT OF THIS HiEMOnitHAGE.
401
anjBmia wMcli already exists. The gallic acid is of all astringeDts
that which has least often failed me, bat in order to obtain
decided effects from it, it shouhl be j^ivea in doses of six or eight
grains every four hours. The infusion of matico, as a local
application, is also of much use in some of these cases j but the
management of the injection can never be safely entrusted to the
patient, who either employs it inellectually, or else causes herself
much suffering by striking the neck of the womb in her endea-
vours to introduce the instrument far enough into the vat:^ina.
There are obvious ditlicultLes in the way of plugging the vagina
in cases of ulcerated carcinoma ; and, indeed, the mode in which
the profuse bleedings usually take place, by sudden outbursts of
haemorrhage, followed by a long pause, is tliat against which such
a proceeding is least of all calculated to guard. In some crises of
soft medullary cancer, or of epithelial cancer, when the con-
tinuance of hwraorrhage becomes a very serious source of danger
to the patient, we may break down the tissue with the finger, and
then inject into the midst of it the solution of the pcrchloride of
iron. The bleeding vessels are thus destroyed, and the coagula*
tion of the extravasated blood by the chemical agent prevents the
occurrence of any further haemorrhage, while the whole mass
which has been thus treated sloughs away in the course of a few
days, leavang l>ehind a healthier surface or one at any rat^ less
liisposed to bleed. This proceeding, which was to the best of my
belief first recommended by Kiwisch* is not accompanied by much
pain, nor has it, in my experience, ever been folluwed by serious
constitutional disturbance, while the improvement which for a
time succeeds the checking of the previous drain upon the system
is often very remarkable, f Of late years the perchloride of iron
• Op, cit vol. L p, 547.
t Ifi the LamH for Decern Vr 2fl, 1856, is a vory remarkable caae relttt«*d by
Dr Boulton, of Homcastle, in which the breaking down of the tissue of « large
epithelial cancer of the een-ix uteri, and the arrest of the snlmei^ucnt bleeding by
caustics, of which the murk ted tincture of irou appeari) to have answered best^
had boPH persevered in for five yeara^ not only with gn^at improvetneut in the
patieiit*3 condition, bat, &a would si'em, with the final result of completely destroying
the diseaie, of which for aixteen months previous to hi» commtuiication the ob
uteri had preaeuted no trace. In a fiub8ei|i]L^nt report, dated Oct. 1857, Mr Boulton
adds, that after tlie lapse of three yeara from the laat operation the patient continui*d
perfectly well ; that for twelve inonths all diacharge had ceased, and that the stato
of the fw and cervijc uteri was perfectly uonnaL
2c
402
CANCER OF THE UTERUS :
has come into general use aa a means of arresting hiemorrliase.
The saturated solution in glycerine, as re commended by the lat#
Sir J. Simpson,* is one of the most cunvenient forms for its appli*
cation to the ulcerated or bleeding surface, and Dr Barues $ plog
speculum affords a convenient means for its iutrotluction on t
pledget of lint, or on a piece of cotton wool, when, as is often tlit?
case, the use of an ordinary speculum would be inadmissible. I
have no experience of the chimic acid, which has also been recom-
mended for the same purpose. As a rule it is wise to withdraw
the stronger applications in the course of an hour or two^ as
they are apt to irritate the vaginal walk. Kiwisch also speaks
of the employment of the actual cautery as a very eHicacious
means of restraining bleeding, in cases where the surface is of
too hrm a texture to he broken down. I have not tried the
actual cautery specially for tins purpose, tliough I believe that
in some cases of uterine cancer I have obtained by it much tem-
porary improvement, both in the general health of the patieot
atid in the condition of the ulcerated Burface, Of this, however^
more hereafter.
The pain is, of all the symptoms, that from wliich the pniient
moat earnestly prays for rehef, while, unfortonately, we are often
but little able to afford it. There is a permanent pain or at least
a permanent sense of discomfort, which most w^omen expeiience,
and besides there are occasional paroxysms of severe sutlering
from wliicli some are fortunately exempt. The backache, the pain
in micturition, and the distress in defalcation, are usually to be
relieved rather l>y attention to the functions of the bladder* and
the state of the bowels, than by direct anodynes. The Vichy
■water as a drink, the extract and decoction of uva ursi, with small
doses of liiiuor potassre and tincture of henlmne, often gi\o much
relief t^^ the irritable bladder wluch trouldes the patient in the
early stages of cancer, while, at a later period, when organic mis-
chief has commenced there, and the urine is loaded with phos-
phates, small doses of hydrocldoric acid, with the extract and
decoction of pareira, will in their turn lie of service. The estab-
lishing a habit of regular action of the bowels w^ill save tlie
padent from many of the distressing bearing-down sensations fn>m
which she hud previously suffered. Mild laxatives, such a^ the
* Th< DiMOMs qf Womtn^ Sro, Edinbujgli, 1S72, p. I$4.
TREATALENT OF THE PAIN.
403-
confection of senna, or verj^ small doses of castor oil, are generally
beat for this purpose; enemata are not in geneml expedient, for
their administration is often very pain fid, u\^'ing to the presence
of hteuiorrkoids, wliOe the presrnire of tiie distended rectum
against the womb sometimes brings on veiy sever© suHering.
Plasters of belladonna, or opium, applied to the back or above the
pubes, sometimes relieve the permanent pain in those situationsj
while any casual aggravation of it is often nutigated by the local
application of chloroform, or of cotton wool soaked in a liniment
of equal parts of chloroform and oil, and covered over with oiled
Silk to prevent evaporation.
The longer the patient can dispense with the habitual emph»y-
ment of anodjues, the better is it for her general health* In
time» however, they are sure to become necessary, and the need for
them is usually fii'st experiuuL-ed at night, for almost always at
that time the pain becomes more severe than it had been during
the day. Whether employed at nighty however, or given more
fiiiquently, it is always desirable to begin with the mildest form
of narcotic, and to pass only by degrees, and as eacli in turn
ceases to be efficacious, to those which are more potent, and to
the preparations of opinin. I usually begin with camphor and
henbane or hemlock in the form of pill, giving five grains of each
at bed time* If the anodyne begins to lose its power, it is not
always necessary at once to increase its ^strength, but the same
dose will often continue to act if it is combined with a draught
containing ether, or some other dittusible stimulant. Twenty
minims of the compound spiiits of ether, and fifteen of the chloric
ether, will often, when added to the anodyne, lull the pain which
had previously been importunate, or procure the rest which tha
patient had before been unable to obtain. The same fact holds
good through the whole course of the disease, even at a time when
opiates in lai*ge and fretpiently repeated doses have become abso-
lutely necessary. After henbane, I generally make trial of the
Indian hemp ; for tliougli it is an uncertain medicine, and one the
effects of w^hich seem to be much modified by the idiosyncrasies
of the patient, it does not in general either constipate or produce
headache, or disorder the digestion to so great an extent as opium.
Chlorodyne has also many of these advantages, and though
perhaps more apt to constipate than the Indian kemp alone, ita
404 CANCER OF THE UTERUS :
action is more certain, and its influence less speedily worn out
Belladonna does not constipate, but it occasions headache, and if
given in doses sufl&ciently large to control the pain of cancer, it
is sometimes followed by an alarming degree of depression. We
come then to opium and its different preparations, and of all of
these the tincture is generally borne for the longest time, and
with the greatest relief. There are peculiarities in different cases
however, which lead us sometimes to prefer one form and some-
times another of this remedy. The black drop, I think, causes on
the whole less sickness than the other preparations of opium,
morphia not excepted, while, in spite of the many recommenda-
tions of the latter medicine, we are sometimes compelled to
abstain from giving it, in consequence of the extent to which it
aggravates the irritability of the skin, and the disposition to
urticaria, which are not very unusual attendants upon uterine
cancer. I have not found any such advantages from the employ-
ment of opiate suppositories or of opiate enemata as to induce me
to prefer that mode of giving opium to its administration by the
mouth ; and I may further add, that the local employment of the
vapour of chloroform or of carbonic acid gas has now been aban-
doned as inefficacious*
The idea of employing the inhalation of chloroform to relieve
the violent paroxysms of uterine pain, naturally suggests itself
to our minds. It is not, however, of as much service practically
as might have been anticipated. Sometimes the pain is of such
intensity that chloroform scarcely mitigates it ; not infrequently
sickness and vomiting come on before the patient is fully under
its influence ; while in a large number of cases so much depres-
sion follows its use, and such long-continued irritability of the
stomach, that the patient herself is unwilling to purchase at so
dear a rate a very short and sometimes very imperfect immunity
from suffering. Still it is one of the means which we may try,
and in some few cases it is well borne, and gives much temporary
relief. Lastly, the use of hypodermic injections of morphia fur-
nishes us with a means which rarely fails us for procuring relief to
even the severest pain, and certainly produces far less sickness,
* In the last edition of this work at p. 895 full details concerning the use of
carbonic acid gas will be found. The question was then sub jiwiicc, but it may now
be considered as settled.
TREATMENT OF THE DISCHAItOES.
4m
less constipation, and less depression than large doses of anodynes
do when either taken by the mouth or administered hy the
how el.
The disdiarges which occur in the course of uterine cancer call
for medical int-erference, eitlier to restrain their excess, or to cor-
I'eot the otieoaive odour that attends them. In the absence of
these indications, no interference Ls desirable beyond such as mere
attention to cleanliness dictates, and for which tepid water is pre-
ferable to any kind of medicated injection. Direct astringents,
such as the matico or tannin, or the decoction of oak bark, are
useful in restraining the profuse serous discharges which occur in
some cases of epithelial cancer, and are, I think, generally prefer-
able for thLs purpose to lotions of lead, or zinc, or alum, which
more frequently produce pain, while they are of less efficacy in
checking the superabundant secretion. Sometinjes the discharge,
though of a mucous or nmco-punilent cljaracter, is extremely
profuse, and this is often diminished, and the condition of the
ulcerated surface secreting it is improved by a very weak acid
lotion such as 3j of dilute nitric acid to Oj of water ; while mora
decided astringents will either fail altogether of the intended effect,
or will pnjduce an increase of pain. Sometimes, however, an
abundant secietion fmui an irritable ulcerated surface is checked,
and tlie sensibility of the part diminished, by the use of an injec-
tion of 3j of sulpliate of iron and 5iij of extract of conium to a
pint of water. Now and then the extreme sensitiveness of the
ulcerated surface is diminished by a lotion of 5ss of opium to a
pint of lead-wash, but as a general rule, the local application of
anodynes to the diseased siirface is by no means ellicacious ; and
much more relief is atlbrded by agents of greater power, and which
tend diinactly to alter the state of the part. In this way great
relief is sometimes given by strong solutions of caustic, w^hich, at
the same time, are a moet powerful means of destroying the
horribly otlensive odour that attends upon the sloughing and
detachment of portions of cancerous outgrowth. A solution of 9j
to Jss of nitrate of silver in Bj of water injected immediately into
the diseased tissue, has the eflect both of destroying the bad odour,
and also of hastening the separation of the shnigh. The employ-
ment of this daily for one or two days generally suffices, but at
the same time a weak solution of cliioride of lime, such as would
406 CANCER OF THE UTERUS I
be formed by 3ij of the solution to Oj of water, or the some quan-
tity of Condy*s fluid, may be^ used several times a day with the
eifect both of diminishing the fetor, and of improving the condi-
tion of the ulcerated surface. In far-advanced carcinoina these
remedies may cease either to be useful or to be admissible, but
then the creasote lotion, made with 3j of creasote to Oj of some
mucilaginous fluid, will have a remarkable influence in removing
the offensive smell which adds so much to the distress of the
patient and of those about her, or still more efficient is the car-
bolic acid in the proportion of half a drachm to a drachm of the
glycerine of carbolic acid to a pint of water. When the bladder
or rectum has been injured by the advance of the disease, we
are unfortunately reduced to mere ablution, and the use of lotions
of tepid water. When this accident does not happen, it fortun-
ately occurs, as has already been mentioned, that the disease of
the womb often remains stationary for months together, and that
the patient is spared at the close of life many of the painful local
symptoms which distressed her during the earlier period of her
disease.
And this brings me, last of all, to consider the management of
the cajiceroKS cacliexia ; of those symptoms of general constitu-
tional disorder, which, springing from an irremediable cause, are
sure at length to baftle our skill. Most, and the most distressing,
of the patient's symptoms, are referrible to the state of her
digestive functions. She not only loses strength with the loss of
blood, but digestion itself becomes generally impaired. In some
cases, indeed, as in those of epithelial cancer, in which the most
prominent sjinptoms are those of mere anaemia, iron is often well
borne, and is then of much service. I usually employ the
ammonio-citrate of iron in five-grain doses, three times a day,
giving it in some effervescing medicine, such as the citrate of
ammonia. The stronger chalybeate preparations, or large doses
of the milder, often disagree, producing headache and feverish-
ness. The failing appetite is sometimes for a time restored by
the preparations of bark ; but rather by the infusion or by small
doses of the liquor cinchonas in combination with acids, or by that
very excellent French medicine the Vin de Quinquina, than by
quinine, which in many instances is not borne. A combination
that often suits is the nitro- muriatic acid in the infusion of
TREATMENT OF THE CACHEXU.
407
clo%TS or of orange-peel ; wLile throughout the whole treatment
of the disease, our remedies must be not only gentle in kind, hut
must be given in small doses.
In most cases the stomach after a time grows irritable, and tlie
tongue becomes mw and red, and aphthous, The irritability of the
stomach is relieved by all food and drink being taken cold, by
sucking small morsels of ice, by very small quantities of effewese-
ing drinks, or of eftervx^scing wines, sneh as Cliampagne or the
sparkling Moselle, Sometimes, too, a mustard poultice or a slight
vesication over the epigastrium will give relief, or even the appli-
cation of a piece of lint soaked in the aeetiim opii. Tlie hydrocy-
anic acid may be tried, and sometimes it gives i*elief, but its
benefits are usually more marked w^hen combined with ether than
when given alone. The sense of sickness and faintness, unaccom-
panied by actual vomiting, which often becomes very distressmg
as the disease advances, is in many instances relieved hy sal
volatile, in doses of forty to sixty drops, or by the compound
tincture of ammonia.
The soreness of the mouth, however, sometimes precludes the
administration of stimulants, and even renders the taking food a
source of extreme suffering. This state is often nmch relieved by
the chlorate of potash, of which a quarter of an ounce may be
taken in the course of the day, in a pint of barley-water flavoured
with a little orange or lemon j»eel; but the unpiejisant soopy taste
which it leaves behind often disgusts the patient, and comjiels ns
to discontinue its use. In some of these cases the soreness of tlie
mouth and the dry burning sensation in the throat jire relieved by
aspennaceti draught,* wliich also fuiTiishes a convenient vehicle
for opiate pi^eparations in cases where diarrhcra is present. The
diarrhcea is usually a temporary symptom only, and yields for
the most part to aromaties and opiates tolerably readily, though
when it occuns at a very advanced stage of the disease, and when
the viud powers are much weakened, it sometimes carries off the
patient The disposition to constipation is a much more frequent
• <Na 8).
a Cetawl 9j
Pulveris TrngncouthiPj . . . Bj
Syrtipi Pttpftveria alhi , . . * Jj
408 CANCER OF THE UTEKUS :
source of distress; and it is of great moment not to allow the bowek
to remain many days without being acted on. From n^lect of
this precaution, I once knew constipation to continue for eighteen
days, when the patient died with an enormously distended ab-
domen and ill-marked symptoms of peritonitis. There was
no mechanical obstacle to the passage of the faeces, but they had
been allowed to accumulate till the feeble muscular power
of the intestines was insuflBcient to propel their contents ;
medicine irritated the stomach, and caused vomiting, without
producing any action of the bowels, and peritoneal inHanimation
at length came on, just as it does in a case of strangulation of
the intestines.
I know no other ordinary incident in the course of uterine
cancer which calls for special notice now ; but I would have you
bear in mind that when there has long been no hope of cure, it is
yet often within our power to minister very largely indeed to the
comfort of the patient, to soothe distress, and mitigate sufifering
which otherwise would be utterly intolerable.
Reference was made in the last Lecture to the dangers which
attend on pregnancy and labour when associated ivith cancerous
disease of the neck of the woitib. In not a few instances of this com-
plication, abortion or premature labour occurs, owing to the disease
not allowing of those changes wliich with advancing pregnancy
ought to take place in the lower segment of the uterus. In such
circumstances, greater suffering, and more considerable haemorrhage
than ordinary, usually attend the miscarriage. I have indeed
known the loss of blood to be so considerable as to occasion the
patient's death in a few days ; while though she should survive this
danger, and the subsequent risk of peritoneal inflammation, the
cancerous disease generally advances more rapidly than before.
Still the dangers which attend upon the miscarriage are not to be
put in comparison with those that accompany labour at or near
the full period of pregnancy. In some instances labour pains have
come on, but the os uteri not yielding, the contractions of the organ
have again subsided, and the patient has at length died painfully
after gestation protracted for montlis beyond the full period. More
commonly, either the womb gives way during the labour, or the vio-
lence inflicted on it during the passage of the fatus or its instru-
mental extraction, proves immediately or speedily fatal; and on
ITS TREATMENT WHEN COMPLICATING LABOUR.
409
thifl account it is laid down as a general rule, that al>ortioii or pre-
mature laVioiir should be iudiiced in cases of tliis descriptioiL The
rule is duuhtless a sound one, though something of its applicability
must depend on the extent of the disease, and the stage of preg-
nancy at the time of the patient coniini^ under our observation.
If the mischief sbonUl ap])ear to be already so far advanced as to
preclude any reasonable expectation of life being prolonged by
medical or surgical treatiiieut, w hiie at the same time there does
not seem to be any insupemble obsUicle to the passage of the child,
it would lie the better plan to allow pregnancy to go on without
intermptioQ : inasmuch as while the life of the child might be
thereby preserved, the mother herself would be nioi^e liiely to
retain comparatively good health during the remainder of gesta-
tion, and the disease to make less rapid progress than during an
equal space of time after the womb had been emptied of its con-
tents. In some instances, too, tlie disease is found to be so exten-
sive as to olier an apparently insurmountable obstacle to the
rupture of the membrimes, or t^ any other mode of bringing on
miscarriage, and here the great irumediate peril of interference
murtt be allowed to counterbalance the remoter risks of delay.
When labour actually comes on, it is often the cage that free
iucisions into the os uteri and the cervical ctmal are the only
means by which such a dilatation nf the passages can be obtained
as will allow of the birth of the child. Still it is important not
to be premature even in these cases in resorting to operative
interference. I remember, yeara ago, when a student in Paris, a
patient was received into the Clinique des Accouchemens in an
advanced stage of pregnancy, and su tiering at the same time from
extensive cancerous disease of the womb* Professor Dubois
mentioned her case to the class, and spoke with considerable
certainty of the necessity for incising the neck of the womb when
labour should come on. Contrary to all expectation, however,
the OS uteri dilated readily to admit of the passage of the child,
and the labour was but of a few boui^' duration. That which
happened in this case, I myself observed in ant^ther instance,
where the comparatively small part of the lower segment of the
womb which was not implicated in the disease stretched beyond
what might have been supposed possible, and in spite of the un-
yielding condition of the bulk of the cervix^ thus made room for
410 CANCER OF THE UTERUS t
the passage of the cliild. But so soon as labour has advanced far
enough for us to be really satisfied of the necessity for interference,
and to determine the direction in which incisions should be made,
and the extent to which they should be carried, any further delay
would add to the patient's danger, without any corresponding
advantage.
The question has been raised whether, in cases where the dis-
ease is very extensive, and the impediments to the passage of the
child, or to the employment of instruments for its extraction very
great, it might not be less hazardous to remove the child by the
Csesarean operation ? Dr Oldham,* however, is, to the best of
my knowledge, almost the only person who has carried out the
idea in practice ; and the favourable result of his case, as far as
the issue of the labour was concerned, proves the wisdom of the
choice which he made. Desperate, however, must be the state
of a patient, when of two alternatives the Caesarean section is the
less hazardous."!"
And now, having considered the indications which, in the great
majority of cases of uterine cancer, we may have to fulfil, and the
best mode of accomplishing them, we come, in conclusion, to the
examination of different proceedings that have been recommended
either for the extirpation of the diseased organ, or for the removal
of the diseased portion of it, or for retarding by various local
measures the rapid progress of the evil.
First among these proceedings we must consider the removal of
the vjhole utcriis, though in spite of one or two temporary suc-
cesses which have followed its performance the unanimous voice
* Chiy's Hospital Reports^ 1851, second series, vol. xi. p. 426.
t It gives me much pleasure to quote in corroboration of the views expressed
above, the conclusions deduced by Dr Herman from his own careful investiga-
tions:— "1. That where it is |)ossible to remove the disease, eitlier during
pregnancy or at the time of labour, it ought to be done. 2. That where this
cannot be done, the safety of the mother is best consulted by bringing the
pregnancy to an end as soon as i)ossible. 5. That when labour has actually come
on, expansion of the os uteri should be aided by making numerous small in-
cisions in its circumference. 4. That dilatation of the os uteri being in progress,
if uterine action should be deficient, and it become necessary to accelerate labour,
the use of the forceps is, as a rule, better than turning. 5. That when dilata-
tion of the cervix cannot take place, even after incisions have been made,
either from rigidity or magnitude of the tumour. Cesarean section should bo
performed."
ITS StrHGlCAL TBEATSfENT.
411
of the profession has pronounced it to be overbold, and has
rejerted it from among the legitimate opemtiona of surgeiy.
The only instance with which I am acquainted of permanent
recovery after the complete extirpation of the cancerons uterus, is
that in which the elder Langenheck removed the long procidciit
organ from a woman, who lived free from disease fur twenty-six
years afterwards.* In the first place, however, it is by bo means
certain that the induration and ulceration were due to anything
else than the irritation of the organ from long exposure to
external injury; and even though it were, you will yet remember
that the sensil>ilitie8 of the womb become so lessened by long
residence out of the pelvis, that no inference can be drawn as to
the danger of operations on the organ when in dlu from the
results obtained when it has been long pi-ocident^ 80 favourable
a conjuncture as that met with in Ltmircubecks case, and
which no doubt much facihtated the difficult task of shelling
out the organ fi-om its peritoneal investment, must be of ex-
treme rarity, and few, indeed, are the instances in which it haa
existed."!"
Attempts have been made artificially to produce a state of pro-
lapse of the womb, and thus to approximate the conditions of the
operation to those which existed in Langcnbeck's case, but with
little success ; while some have removed the organ through the
vagina without any attempt at altering its position ; and once
the abdominal cavity was kid open, and the womb removed
• The pnrticulars of whkh lire detailed, and drawings Hhowing the apiM^ariinct'S
after death nre given, together with niiieb imfKjrtnnt infonntttion eoiiceraing the
opration, by the present Professor Langtnbetk, in his maugoml dii^sert^itioD iJe
totiua uteri extirjiatUme, 4 to, GottiDgw, 1842.
t A case is on pe<?ord of the Bucci*safnl extirpation of the utema, said to 1^ cnn-
CMtma, by means of the ligntnre .ind knife, iwiifomicd in the ye^r 1783^ by M.
Mawchall, of Straaburg, and reported in ,Sahb. Med. Zcihmg, 1794, vol. i. p. 1S6,
and anothtT inort? recently^ by Bellini, in (haodii AmuiH Uniter»tH^ for 1825, voL
xlvii.p* 365. In the ktter e^i^e, however, the removal of the litems was only piirtial.
Palettaa case, in whiirh the patient died on the third day^ reported in Omvdei
Annali, 1822, vol. xxiv, p, 43, cannot with propritfty he inclnded among these
eaaea, inaamuch aa the removal of the utema wa^s nniiitentitmal, and the dis^fase
Mema to have been rather a largi? fibrous tnnionr dragging the nterns beyond the
Aitemal parta, than any forni of eaneerons atfeetion, Recamier removed the pro-
ddent cai^ceronH uterus by ligEtnre {Archiirs dt Mai. vol xxx/J The patient
recovered, but died of dysentery in three months.
412
CANCER OF THE UTERUS:
through the incision. I need not enter into a long critique of
these different proceedings, when I have told jou that of 30 cases,
24 terminated fatally in consequence of the operation, and that
two months, four months, and a year, were the respective periods
during which the patient survived in what are termed the suc-
cessful cases.*
Of the 24 fatal cases, 4 terminated within six hours, and 4
more in twenty-four hours, 7 in two days, 2 in three days, 2 in
four days, 1 in a few days, 1 in ten days, and in 1 the duration of
life is not stated, though the patient is said to have died from the
efifects of the operation.
In 21 cases the cause of death is stated, and appears to have
been the pain or shock of the operation in 8 instances, haemor-
rhage in 3, haemorrhage and shock in 2, peritonitis in 6, peri-
tonitis and shock in 1, and a so-called nervous fever in another
instance.
But while facts such as these amply justify the general verdict
of the profession, as to the impropriety of attempting the complete
extirpation of the cancerous womb, no such general verdict of
condemnation can be passed on that less hazardous operation
which aims at the cure of the disease in an earlier stage by the
removal of the afiected part. Not to lose ourselves in fruitless
antiquarian investigations, we may date the introduction of the
amputation of the cancerous neck of the womh among the operations
* Tlie subjoined table gives, I believe, a tolerably accurate account of all re-
corded cases of total extirpation of the uterus on account of cancerous disease : —
SuccEBSFUL Cases.
Operator.
Reference.
Period during
which Patients
survived.
Recamier .
Sauter . .
BlundeU .
Freund . .
\ Reekerchea sur Ic TraiUinenldu Cancer, 1829,
1 vol. i. p. 519
Die gdnzliche ExtirpcUian d. Care. Oebdr-
inuUer, 1822
(Lancet, Oct 1828, Med. GazeUe, vol. ii. ^
1 p. 294, and voL iii. p. 797, and MS. note
1 at commencement of his Researches^ &c.,
L in Royal College of Surgeons ....
( Three cases, the uterus being removed )
< throuffh the abdomen by a new operation, >
( quoted by Gusserow, op. cit. p. 207 . )
2 months
4 months
1 year all but a
few days
r^ ITS SURGICAL THEAT^IENT. 413 ^^H
of sarj^ry from the year 1802, when it was successfully performed ^^H
by the late Professor Osiander, of Gottingen, Between that time ^^^|
and the year 1816, Osiander amputated the neck of tlie womb in ^^^|
twenty-thi-ee instances,* and so strikini^ an innovation as this ^^H
proceedinj^ not unnaturally excited much attention in Germany, ^^^|
The openition did not, however, meet with much encouragement ^^^|
among Osiander's countrymen, for the sometimes formidable, and ^^^|
in some instances fatal hiemorrhaE^e which often succeeded it, not ^^^|
unnaturally deterred many from attemptint^ it, wliile it was ^^H
further alleged tliat even in its originator*s hands the operation ^^H
IlKSt'CCESSFUL CA818.
■
1
Operator.
Btiference.
Date of
Death after
Operation.
Alleged Chu«<;
of Deatb.
^^^^^1
Blnnden .
J*
LaDgenbeck
»f
II
Holscher
LaTieet, Nov, 22, 1828, Tot, xv. p. 255
2} hours
39 M
24 „
2dayB
10 ,.
24 houTB
Sbock
ft
PeritonitiJi
Nervous Fever
Shock
Ibid
Langenbcck, jnn., Bi^terUUitm^ p. 62.
Ibid. p. 66 , .
Ibid, p, 68 . . ,
j Gmefeu. Waliha-'sJoumal.yoLvl
1 p. 638
Ibid. vol. vii. p, 478 ... * . .
Jmirml f. OiburUhiil/e, vo!. iv. p. 507
Ibid, vol vil p. dOO
Lancft, Oct 11, 1828, vol xv. p, 57
Ibid. Nov. 29» 1828, toL xt. p. 269
Wolff . .
Siebold , .
Banner . .
Lizara . ,
2 days
ft5 houra
2 days
4 f»
32 boars
PeritonitiB
t»
j Hiemorrbage
j and Shock
^^^^H
Roux . *
ft
Rbcamier .
Dtiblod
( Jrehivts OSu de Midacinc, Oct |
} 1829. p. 238 }
Ibid, p. 241
Jmtrnal ffehdom., vol. vi. p. 120 . ,
Ibid. vol. viii, p. 123 , ♦ . . ,
S8 „
24 ,.
2 days
22 hours
Shock
\ Hrcmorrhftp',
Faiu, Shock
Hjcmorrhtigtt
1
Dieffttnbaeh
Operalive Chirurgie, vol. ii. p. 800 .
4 days
f Shock, Pen-
\ tonitis
^H
Dttlpech
T. Walthw .
Wtrrea . .
J Boivin ct Dug^ Miladies de ,
VUUrua, vol. ii. p. 85 ... '
Kilian'i OperadwjvtUhrt, kc,^ vol. ,
i iii. 3nd wl. p, 261, note . .
1 Jw. Juimml of Med, 5fci^iw^,1829,
\ voL iv. p. 536
3 .,
Immediate
3d day
Pain, Sbock
Haamorrhage
I
Bodenstab .
Fabri , .
J Neue Zeitixhriftf, Qtburtjiktitide,
vol, xvili. p. 232 . . . , .
Fmriep*8 NUizm, vol. xii. No. 20,
p. 319 ...:,...
Two cas**s referred to by Gufis«row,
j 0/7, di. p. 207
Immediate
N(
Shock
>t8teted
I
Freirnd . ,
H
* Sq stated la Langenbcck, cp cU. p. 26, note 5, from 80UJce« there indicated*
J
414
CANCER OF THE UTERtJS:
failed more frequently tlian it proved successfuL Tbere
also persooal defects of character which always stimulated into
activity numerous hostile critics of Osiandera doings and sayings;
and hence, until quite recently, the cases were very few indeed it
which the amputation of the neck of the womb w^aa had recoone
to in Germany, In Fmuce, however, wliere no such causes were
in action, the operaticm met with numerous advocates, and it re-
ceived the sanction of Dupuytren, who performed it on several
occasions. The remarkable results obtained by M, Lisfranc, whu
alleged that Le performed the operation ninty-nine times, and in
eiglity-four instances with lasting success, obtained for a time
great notoriety, both for the proceeding itself, and for the sui^geon
who had constituted himself its most clamorous champion. Before
long, however, doubts but too well founded were LhrowTi on the
accuracy of Lisfranc's statements, and his former pupil, M. Paiily,
published a book in which he asserted, and his assertions Iiave
never been disproved,* that M. Lisfrauc overstated tlie number of
the operations he had performed, and falsified their results ; and
further, that in many of the eases in which he had removed the
cervix, the disease was not cancer at aU, but mere induration of
the neck of the womb.
Though not altogether abandoned, yet both in France and in
this country, where it has been occasionally performed, this
operation fell into comparative disuse, till it was recently revived
with better knowledge of the subject, and a juster appreciation
both of the eases which are suited for it, and of those for which it
is not fitted.
There can be no doubt but that formerly in many instances in
which the neck of the womb w^as amputated, no cancerous disease
existed; and I have myself seen the cervix uteri excised, and the
patient exposed to the present risk of hamiorrhage and to the
subsequent dangers of uterine inHammation. for the removal of
mere induration of the organ. On the other hand, the excision of
the neck of the womb was not infrequently had recourse to in
* Those who wiali to pui^uo the particular of this quarrel, not cr«4HUlit« to
either party, but leiist so to Lihfranc, wiU find the nifit^rijils in Pmily. MnUtdns de
rUierua^^yQf Pnris. 1836, pp. '12r-4Sl ; and Lisfmnc, CUnique Chir%trgical<^ 8Ta»
Pirit, 1843, vol. n\. pp. 6a3-Cii7. Liafranc'tt feeble defence amounts idmoat to m
pleft of gtiilty on hii jiort
ITS SURGICAL TREATMENT,
415
cases of fungoid carcinoma of the orgEn ; a form of disease which
beginning in the substance of tlie part, has already made exten-
sive progress when it i*eaohes to the surface, and does not in
general give rise to any obvious ayaiptoms of ita presence till it
has advanced so far that any attempt at its extirpation must be
worse than useless.
Such were tlie two opposite errors by which this operation was
lirought into discredit ; by the one it was performed when need-
less, by the other when useless. I have, liowever, described a
variety of malignant disease to which it is applicable, and in
wliich its performance has been found to be most salutary. Cases
have long been on record in whicli the removal of cauliflower ex-
crescence of the uterus has been followed by the patient's com-
plete recovery ; and there are other forms of disease of more solid
texture, and endowed with smaller vascularity, which present the
same character of bej^iuning on tlie surface of the os uteri, and
only by degrees extending to deeper tissues. Now precisely these
epithelial cancers of the uterus are they which have been cured
by the removal of the affected part, and to such cases I believe
the operation ought to be almost exclusively hmited. Perfect
mobility of the uterus is a condition essential to the admissibility
of the operation. Wlien the organ is fixed we have positive
evidence that the disease has already involved the broad ligaments
of the uterus or other adjacent parts ; and that all hope of its
complete extirpation must be abandoned. It is to he feared,
however, that the conditions which even in this form of the dis-
ease warrant the performance of the operation, are comparatively
seldom to be met with- for though I have been constantly looking
out for cases suitable for it, two instances only have come nnder
my observation in which there could be no hesitation as to the
propriety of the proceeding. One of tlie patients was operated on
by Mr Arnott in the Middlesex Hospital There existed in her
case perfect mt^biiity of the uterus, so that but little difficulty was
experienced in drawing the organ down beyond the external
parts ; while the neck of the womb was of sutiicient length, and
seemed sufficiently nnaltered at its upper part, to warrant the
expectation that the incision might l>e carried tlirough Iiealthy
tissues, and that the disease might be completely eradicated. The
htemorrhage in this case was very formidable, a large arterial trunk
416 CANCER OF THE UTERUS :
pouring out blood in great abundance, and this was restrained
only by the employment of the actual cautery, while on the
separation of the slough a second outburst of haemorrhage rendered
it necessary to plug the vagina. These dangers surmounted, the
patient's subsequent recovery was very rapid ; she r^;ained flesh
and strength, and for nearly six months continued in the enjoy-
ment of perfect health. Symptoms of her disease then reappeared,
and she died in the course of two months, eight months after the
performance of the operation. Even six months of life, of hope,
of freedom from pain, of health and happiness, cannot be thought
dearly purchased by an operation which, even without the aid of
chloroform, is by no means very painful, and whose one former
great danger, that of haemorrhage, is now almost certainly averted
by the use of the wire icraseur. In the second case, indeed, the
use of the 4craseur entirely prevented the hemorrhage which in
the other instance had been so formidable, while its result was
most satisfactory, for life was prolonged for more than a year,
and death then took place from an accidental attack of bronchitis
without any symptom of the recurrence of her disease having
manifested itself.
Although the icramuriiA away almost completely with the risk
of haemorrhage, it yet did but substitute a new danger for the old
one, and one so grave as to more than counterbalance the safe-
guard which the icrastur aflFords against hemorrhage. The instru-
ment appears so apt to draw within its chain or wire parts not
involved at the time of its first application, that the peritoneum
has on several occasions been wounded in the attempt to amputate
the neck of the womb. This objection was recently urged against
it at a meeting of the Berlin Obstetrical Society, by Dr Mayer,
who referred to an instance in which this accident had occurrerl
to a patient of Professor Langenbeck ; and Dr Biefel on the same
occasion mentioned a case of fatal injury to the bladder and peri-
toneum by the instrument.* A case of injury to the vagina, and
protrusion of the intestine through the opening, is likewise related
by Dr Breslau,-f but his patient happily survived, as also did
another whose case came to my knowledge, and in whom a
portion of the peritoneum behind the uterus was removed with
* Afonat88chr. /. Oeburtak,, March 1868, p. 169.
t Scanzoni's BeUrUge^ yoL iiL Wurzburg, 1858, p. 80.
ITS SURGICAL TREATMENT,
417
the diseased cervix. It has been proposed by M. Simon, of
Darmstadt,* in order to avoid this danger, that in all cases where
the uterus admits of being drawn -down beyond the external
parts, a needle, or two needles, should be thrust through Uie neck
of the womb, and the ^^e-n^sr^ir should be applied below them. He
rejects the ecraseur, however, absolutely in all cases where the
uterus cannot be drawn down externally, though it is doubtful
whether, even here Middledorpffs application of the red-hot
galvanic wire may not stand us in good stead, and avoid the risk
of haemorrhage without substituting for it a new peril This
opinion, too, which I expressed some years ago, has been justified
by subsequent experience, and the galvano-caustic wire, by which
the parts are rather burnt than cut through, is now universally
employed for the amputation of the cancerous cervix uterL
The cases in which any of these proceedings are applicable,
mast obviously be comparatively few and exceptional ; since the
disease admits of being extirpated only when comparatively
limited in extent, and at a comparatively early stage of its pro-
gress. Is there then no resource in these circumstances but to
watch the daily advance of the evil ; or can anything be done to
retard, if not to cure to alleviatCi the patient's sufferings, and to
postpone for some weeks or months the inevitable result ? Dr
James Arnott,t to whose ingenuity we owe many very important
suggestions in medicine and sui^ery, believed and adduced evidence
to show that by the systematic applLvutioii of a verif hio tempera-
ture to parts affected witli cancer, the pain of which they are the
seat may be greatly diminished, the advance of the disease may
be considerably retarded, and ulcerations of their surface may even
be made to assume a comparatively healthy character. Practical
difficulties in tlie way of applying the freezing mixtures so often
as might be desirable, have interfered with the trial of his plans
upon a large scale in our hospitals, while some degree of dis-
appointment has been experienced in consequence of the proved
inadequacy of cold to annul the pain of surgical operations in
other than a very few instances, and those of the very simplest
kind. Notwithstanding a very kind letter of explanation which
* Monataaehriflf, QtbiirUkande, vol, xiii* pp. 418'I34.
f Of^the TrtatmevU of Cancer % ike regulaUd applkcUian c/tm Anmtihdie Tempera^
iure, 8vo^ London^ 1S5I,
2d
418
CAKCEE OF THE UTERUS I
Dr Arnott was so good as to send me, I have yet found ver
difficulties in the attempt at employing freezing mixtures i]
of utt^riue carcinoma The necessary removal from bed to a
coucli, tlie discomfort of the position, the almost impossibility of
pi-eventiug the patient's person from becoming wet, and the
tenderness of the vagina and external parts produced by the
frequent introduction of a large speculum, which, even when of
grtmt size, seldom embraces the hypertrophied cervix conipletdy,
have precluded my making such a number of trials of the agent
as would alone warrant me in speaking with any measure of con-
fidence as to its powers.
Other agents more potent, and more easily applied, have been
used in cases of uterine cancerj but with results ao indecisive
that opimon is still much divided as to the propriety af their
employment. In coming to a conclusion with reference to th«r
use of any of tliese remedies, the object with wdiich in each
instance it has been had recourse to must not be lost sight of, I,
have already mentioned, tliat a strong solution of nitrate of silver
apphed to a cancer of the womb, in some stages of the disease
both diminishes the excessive fetor of the discharge, and also
expedites tlie separation of sloughs from its surface, aiding in this
manner the attempts at a cure, which, though abortive as far as
permanent recovery is concerned, are yet most welcome pauses in
the eoui-se of the disease. For this purpose, I believe, a stroni^
eolntion is of greater service than the solid nitrate of silver, proba-
bly because in this form the remedy penetrates more tlioroughly
into the affected tissue, I have also sometimes employed the
acid nitrate of mercury to check those granulations wliich iu cases
of uterine cancer not infrequently sprout from the interior of
the cervix, and I think that in both of these ways the use of
emtstiA^s has been advantageous as a palliative, not as a curative
proceeding.
Tliere are some forms of external carcinoma, in w^hich the
employment of the more powerful escharotic^, as the chloride of
zinc, luis been of great ser%dce ; but I need scarcely remind you
that the benefit derived from such agents hag depended aknost
entirely on the possibLlitj of completely destrtiying the affected
^tissue, and that, as a general nile, its partial destruction has been
followed hy a more rapid development of the disease than befor>^
I
I
LOCAL USE OF COLD, CAUSTICS, AND CAUTEEY.
419
Now, in the case of the uterus, it is obvious that the thorough
application of any deliquescent sabstance is impossible ; that the
risk of injiiriug adjacent parts must lead to the inefficient
employment of the caustic, and conae(|uently to the aggi-avatiun
instead of the amendment of the disease* This circumstance
leaves us no alternative but to resort to the adual cantery in any
case in which it is intended to do more than modify the state of
the surface of the aflectod parts. The idea of the operation is
much more formidable than its reality, for it is not very painful
in itself, while it can always be performed under chloroform ; and
the only real danger attending it, that of injuring adjacent tissues
by the radiation of the heat, can always be effectually guarded
against by the use of a boxwood speculum.
I have not myself used it, or seen it used sutficiently often to
have formed a very decided opinion with reference to the amount
of benefit whicli may be anticipated from it ; but I feel satisfied
that there is no danger to be apprehended in its employment, and
that it does not tend to make matters woi*se. Genei-ally tliere is
a very decided, though often very tempoi-ary mitigation of the
patients previous sufferings, an improvement which has seldom
outlasted the separation of the eschar. A diminution in the quan-
tity and fetor of the discharge has generally continued for a longer
time, hut I cannot say that as yet I ha%^e been able to attribute
to it any delay in the progress of the evil, partly, perhaps, from
not having repeated it sufficiently often, and in stiU greater measure
probably from the disease >>eing already far advanced when the
patients first came under my care. I believe, however, that like
other proceedings intended to effect the real cure of cancer, the
actual cautery is seldom indicated except in cases of the epithelial
form of carcinoma, for in that alone is the mischief at all likely to
be confined within limits wliich we can hope to reach by any local
treatment.
Tliese remarks are, I know, anything but detailed enough to
furnish a safe and sufficient guide as to when and bow, and bow
often, tliis kind of interference is likely to be useful, or may e%'en,
by good fortune, prove actually curative. They are merely sug-
gestive of the direction which your observations should take, and
in which your efibrts should be made. Your duty and mine is,
not to sit down in apathetic indiflerence, doing nothing, trying
LECTURE XXL
DISEASES OF PARTS CONNECTED WITH THE UTERUS.
IKFLAMMATION AND ITS RESULTS.
Inflammation of Uterine Affendaobs : — of the Celluxar TiB&trK*
C«UiM.*tt of affiMitmii ; generally coiuiequeiit ou delivery or liboition ; it< VRiious
seata, and motiea of termination ; alVectioii of the peritoneum in its ctiurse^
general tendeui^y to end in suppumtion. Morbid <ip(>eiLr&ncea.
RelalioD of tkii» i^ffection to inliaiiiniiition of the ov«rie8 ; its analogy to other
intii&mmatlonfl of the celinljU- tisnue,
SymptoauB ; mode of attack twofold. Fcrmatiou of ahdomiua] tumour ; occurrence
of auppu ration, hut chronic chiii.M!i«r of the ubscess ; various outlets by which
it discharges itself. Diagnosis of the affection. Chaitietera of intra-pelvic
tumour ; its similarity to uterine hji^matocele. General uketch of its syraptom.*
fttid ooarse.
There are many phrases which, though still daily used in
medical writiags, express not merely the opinions but also the
erroi's of a bygone time. It is thus with the term Uterine Appmi"
d/rgcs, long applied to parts connected ^dth tlie womb, eome of
which, indeed, are secondary to it in importance, and subsidiary to
its functions, but others are physiolugicaUy of higher moment
than the uterus itself, and originate those acts to whose due per-
formance the womb does hut minister.
I have no fear, however^ le^t by I'et^inhtg the phrase Appe7idagcs
of th^ Uterus, or by speaking to you about their diseiises, I should
be suspected of ignoring the office of the ovaries, or of implying
that they are of less importance than the womb in the sexual
system of the woman. I shall be understood to use the term
merely as a convenient epithet, expressing without waste of words
the broad hgaments of the uterus and all the various parts and
stnictures contained witliin or intimately connected with them ;
parts whose physiological import just now concerns us less than
do the ailments to which they are liable.
422
INTLAMMATIOy OF THE UTERINE APPENDAGES :
Wlien speaking of the diseases of the uterus itself, we coM-
dered first those which are the result of ititlammation ; and it
will, I think, be convenient still to retain the same arrangement,
and before passing to other subjects to study the in^nmrnaUrnf
affediom of the apptmdnges of tJie immh. These admit of heij^
classed tinder two heads, according as the inflammation attacks the
ovaries themselves, or as it is chiefly limited to the cellular tisene
in the immediate neighbourhood of the womh. In the latter cas«
the symptoms are of course modified according to the precise seil
of the mischief, which, though most frequently involving the
cellular tissue between tlie folds of the broad ligaments^ some-
times attacks that which intervenes between the womb and the
adjacent viscera, or extends to that lining tlie pelvic walls, or even
to that wliich lies between the outer surface of the peritoneum
and the aMominal muscles.
Inflammation of the cellular tissue in the neigh bourhfXKl of the
womb takes place as a consequence of abortion or of delivery much
more frequently than from any otiier cause. The gi^eat tendency
that it has, too, to terminate in suppuration, familiarised practi-
tioners of midwifery from a very early period with it ; or at leafll i
with the abscesses to which it gives rise, though misconception
long prevailed witlt reference to their nature. They were
generally imagined to be secondary deposits, the result of a sup-
posed metastasis of the milk, or of an outpouring of its elements
^vlien present in too great abundance in the blood. It wae
imagined, too, that this occurrence sometimes took place in one
situation, sometimes in another, and the most various sequelae uf
delivery wem attributed to this m their remote occasion ; a theo-
retical error, which as Puzoa' essay, " Sur lea Depots Laiteux/**
abundantly proves, did not at all interfere with the most accurate
description of some of the most important ailmenU of the puer-
peral state.
With advancing knowledge the erroneous theory was discarded,
but the inflammatory atl'ections of the uterine appendages ceased
to attract attention, or were passed over as occasional complica-
tions of puerperal fever, until attention was once more drawn
to them by the essays of Duherty, ChurchiU, and Lever, in
* In liU TraiU des Ae^u^tmtn*, ito, P«ns, 1751>. See esx'ecijilly pp,
see.
I
ITS CAUSES.
423
this country,* and by those of Grisolle, Marcbal de Cal^-i,"!*
and others, in France. Even at the present time, however,
and io spite; of the recognition of these ailments as attendants on
the pnerperal state, their occurrence independent of pregnancy
and its consequences has scarcely been ajipreciated as generally as
it deserves, and it is this circunistanec whieh is my i^-hief reason
for bringing the subject now under your notice.
An attempt has been made by some writers to discriminate
between inHamniation of the uterine ajipendages occurring after
delivery, and the same affection when coming on in other circum-
stancea I do not tliink, however, that thm distinction is called
for either by the symptoms of the disease, or by the treatment
which it requires in the puerperal state, though the peculiar con-
dition of tha uterus at that time often imparts to disease in its
vicinity a more acute character than would be presented by the
same ailment at another season.
The subjoined table aliows very clearly the influence of labour
and its consequences in giving rise to inflammation of the appen-
dages of the womb, and of the cellular tisBue in their immediate
vicinity. It shows, too, that almost invariably even wdien labour
did not precede the attack, some accident induced it, which acted
immediately on the womb, such, for instance, as miscarriage, or
disorder of the catamenia ; while tlie cases were only 7 in 59, in
which tlie attack was not brought on by some local ailment of the
sexual system.
Occurred after Delivery in ...... 32 cases.
„ „ Abortion ....... 11 „
« „ Disorder of Catamenia , , » 7 „
„ „ Seduction, and some probable
violence to Uterus ... 1 „
„ „ Ulceration and lutiammation
of Uterus 1 „
„ „ No ailment of Uterus . • • 7 „
59
• Dubtin Jmmalf vol xx\l 1843, p. 199 ; llnd., toL xxiv. 1844, p. 1 ; and
OuyU ffotpital Report^ Second Series, vol. ii., 1S44, p. 1.
t Arehims Oin, de Midtcim, Thml Series, 1S39, vol iv. pp. 34. 137, 293 ; md
du AbeU Fhiefprumcux Inlra-Fdmenj/f Svo, raris, 1814,
424
INFLAMMATIOK OF THl UTERINK APPEirDAGES :
In 10 of the 32 cases in wliich the affection succeeded t
very the patients were primiparLt ; or if to iny own cases ihost el
Xever, of Marchal de Calvi, and of M'Chntoek* are added^ 56 <nrt
of 112 cases were those of women who had heen delivered for tie
first time. The supposition, however, which this fact might seesn
to suggest, that protracted or difficult hdiour siiecially predisposes
to this ailment, is scarcely borne out by further inqtiiry ; since in
21 of my 32 caaea, and in 7 out of 8 of those recorded by Dr
Lever, labour was in all respects natural. In 4 of my cases il
was protracted, though in none was instrumental interferenee
necessary ; in Lever's case turning was performed on account of
arm -presentation ; in 1 case of mine extensive laceratiuu of the
perineum seemed to have been the point of departure of the wliole
of the subsequent inflammcitory mischief, and in the remaining 4
labour was attended by profuse hamiorrhage, an accident which
also complicated one of the cases of tedious labour. From these
data all that we can venture to affirm is tlie preponderance of
frequency witli which the accident occurs in primipaiie, and an
increase of liability to its occurrence when labour is more than
usually protracted, or when it is accompanied by ha^morrhiigp.
M. Grisolle expresses his belief that the omission on the part ol
the mother to suckle her infant is one of the most powerful pre-
disposing causes of the disease, and this opinion is in the highest
degree probable ; but in this country it is so nnivei-sally the
practice for women, especially among the poor, to suckle their
children, that none of my observations bear at all on that point.
The nature of the influence of abortion, of disorder of the
catamenial function, or of other accidents which directly interfere
with the sexual organs, is too obvious to call for explanation.
Why under the influence of such causes a woman should lie seized
in one case by \iolent general peritonitis, in another by an
ailment chronic in its course, and seldom dangerous to Ufe, it is
perlmps impossible lo explain. In so farjiowever, as this disease
is a consequence of labour, it must be borne in mind that it is
essentially diQerent from any of the com plications or eequehje of
puerperal fever, t Puerperal fever is a disease of the whole con-
♦ Op. tilt p. 8.
t IRefercjtJc© nuij here bo made to the clasaioal piiper ol Virchow, drtkivfliF Path,
Ami, and Phyi, 1862. Bd. xviiL, in which he dutoiibta the diffuse inflamnmiwty
I
KOT IDENTICAL WITH PUERPEEAL FEVER,
425
fititution, associated with important chaDges in the circulating
system, probably \vith other alterations too, whicli we have not at
present the skill to discover ; but the local miscliief which may-
be found after death was no more its occasion, than are the
nlcerations of Peyer's glands the occasion or the essence of
t^^jhoid fever. In puerperal fever, there may be evidence of
injury to the uterus, or to its appendages, or to its vessels, or to
the perikineum, but tliere is this and soniething more ; and this
something more, the dhuntim aiiqnid, the to hm of Hippocrates,
has puzzled our philosophy, eluded our research, and outwearied
the speculations of the most ingenious theorists who have laboured
vainly to unriddle its nature.
Hence it is, however, that these inflammations of the uterine
appendages, or of the adjacent cellular tissue, do not usually come
Wfore us in cases where puerperal fever has threatened lifCj for
that disease either destroys the patient speedily, or with the
abatement of the general disturbance of the system* the local evil,
unless tlie mischief done was irreparuble, abates too, and soon dis-
appears completely. This ailment, on the other hand, begins as a
local affection, its early symptoms are often so slight that it is
overlooked for days or weeks together, the constitution synipa-
tliising just in pmportion to its extent and intensity, and gentral
health returning as the consequence of the mitigation or of the
cure of the local disease.
There does not seem to be any rule that determines absolutely
either the part which sliall be the seat of intlummation, or the
course which that intlaniniation shall run, and whether it shall
issue in suppuration, or may by good fortune terminate in resolu-
tion* The celUilar tissue anywhere in tlie neighbourliood of the
womb may be the seat of the mischief, though that contained
witliin the folds of the broad ligament is attacked, as the subjoined
table shows, far more often than the same structure in any other
situation, or 38 out of 59 times,*
chongeB in th« ceUulor tissue, at tbt aides of tbe utoruie oetfix {pairantutviHt) wliidi
ftre found in cases of puerpeial septicemia or the nugoxttf of cmea of BO^salkd
puerfttral fevfr].
* I must l>e jillowed to correct an inadyertence ou the part of AL Anui, who,
op» nl. p. 680, Bote, states that I aUege the tissue betweeu the QtcrUH aod rectum
to be the moat frequent scat of this affection. The stateiiiunt in tlie text is wonl
for woi*d the same as iu the previous editioiL
426
INFLAMMATION OF THE UTERINE APPENT>AGK3 !
)r-lr^ f-i ae^404 i-i lO » 09 *H «i^^©l ip^
^JJ
P
t
I
«Di-ie4i-«e4ia*^i-ie'i(»:4?4^4«Q
ITS BELATION TO FEKITONrTIS.
427
The tendency of recent investigations, too, is to show that here,
or rather in the ovary and FaUopian tu1>e of one or other side, is
the almost invariahle starting-potnt of the miscliief, be the parts
eventn^illy involved in it what they may. The inHEinvmation
further seems to extend from the appendages of the woml> ttj the
peritoneum lining the pelvis j it often ties down tlie appendages
behind the uterus, or forms adhesions between them and the
intestines, or mats together the intestines themselves, while matter
is sometimes formed in the ii-regular cavities left between adjacent
surfaces of the peritoneum* or of the false menil^ranes which con-
nect different parts together. The importance of this pdri-peri-
tmiitis, as he terms it. has been much insisted on by M, Rernutz *
who seeks iu it for the adequate explanation of all the phenomena,
both local and general, which have nsnally been supposed to
depend on inflammation of the cellular tissue about the uterus.
He would propose this solution not of those cases only in which
the parts at the side of the womb are the seat of this affection, but
for those also (14 out of my 59 cases) in which the inflammation
appears to be seated between the uterus and rectum, for here, too,
the matting together of the intestines may form a tumour in the
recto-vaginal pouch which m\iy present the characters supposed
to belong to pelvic abeess. "WTien^ however, he denies the
possibility of indammation of the cellular tissue about tlic uterus,
with the exception of that contained between the folds of the
broad ligament, he goes furtlier than I am at present prepared to
follow him. In 4 out of my 59 cases the tissue intervening
between the uterus and^ bladder was the seat of inflammation
which in three of the cases went on to suppuration, and the
matter so formed twice escaped spontaneously, and once was
evacuated by means of a trocar introduced through the anterior
• In the Archit^s d*: Midecine, March and A|iril 1857, and afterwards at very
j^reat length in vol. ii. of his and M. GoupiFs work, Sur hjt Maiadks dcs Femrncs^
alresdy referred to.
[la Mb work on Prrimetritia and Paramdnlii^ t<j wLiih the reader is refurred,
Dr Matthews Duncan adopts and expounds views more nearly allied to those of
Bernntz than to those expressed in the text On this subject recent valualilc j^aprs
ihould be cAiisalted ; on Olaliausen, Ueber puerperah Perimetritis und Parametritis,
and Spiegelberg, Ueher Exsu4i/tie in der UmgthunQdcr toeiblichen OenUaltanaks ; both
in YolloD&nii'fi Sammlmig. For a carefnl bnt not vety aucceaaful attempt to
dkgnoie Peri me tri tin from Parainetritln, Thomas's work on DimoMs of U^ncji
ahoold be consulted].
428
INFLAMMATION OF THE UTEKINE APPENDAGES :
i^aginal wall. To these cases it is obvious that the explanation of
5L Berautz eanuot apply, nor do I thiak it holds gocd with
reference to many instances of retro-uterine tumours ; while, with
reference to the broad ligament itself, M. Bernutz admits the Jk»-
sibility of inMammiition and suppuration involving the tissue
between its folds-.
The inflaratiiation is in many instances not limited to its
original seat, but extends, and that not always by dii'ect oontinuitT
of tissue, to the cellular tissue lining the pelvis, or attacks that
which is interposed betw^een the abdominal muscles and the peri-
toneum, constituting the external peritonitis of some writers. In
tliese cases, too, the mischief may I'ecede from the parts wliich it
originally attacked, and tlie gravity of the secondary ailment may
entirely obscure the perhaps transitory affection in which it origi*
nated, a supposition that w^iU probalily apply to not a few of the
instances in which affection of the pelvic cellular tissue and tliat
external to t!ie peritoneum has seemed to be idiopathic.
Like other inllammations, go these sometimes pass aw^ay, and
leave no trace. Oftener they issue in the production of penziA-
nent swelling and indiimtion, due either to the results of the local
]ieritonitis, or to actual thickening of the cellular tissue which has
been the seat of the attack ; or, lastly, they may end in the
formation of pus, and probably in its dischai'ge through the
rectum, vagina, or bhidder, or now and then in its escape into the
cavity of the abdomen. This termination by suppuration appears
to be very frequent in the case of those inilammations which
snccejed to delivery or abortion, I tind it noted as having
happened in 23 out of 43 instances in which the inflammation
succeeded to delivery or abortion; and the large experience of Dr
M'Clititock* leads to the same conclusion, since he met with it
in 37 cases out of 70. My own impression, U}q, formed chiefly
on bygone hospital experience, is that the same rule holds good
even in those cases where the disease occurs independently of
puerpeml causes. My table shows 9 instances out of 16 as hav-
ing terminated by suppuration, and in this respect agrees with
the statement of M. Grisolle. who found it take place in 38 cases
out of 51. General experience, however, it must be confessed*
does not bear out these statements. M. Aran demurs to their
♦ Oji ci4 p. »•
I
I
I
I
ITS TEKDESrCY TO SUPPUKATIOK.
429
correctness,* and M, (rallard.t in a very carefully written essay,
regards the occurrence out of tlie pueri>eral state as so rare as to
have been met with only in 4 out of 53 cases* I have no longer
the opportunities of large hospital obgervation by which to control
and correct my own impmssions, but it seems to me probable that
the cases which came under my notice in a small ward for admis-
sion into which there were many applicants at St Bartholomew's
Hospital, were of a severer kind than those which formed the
basis of M. Gallard's thesis ; and further, that many of theshghter
forms of what M. Bernutz terms pdvl-perUon'dis may have been
taken into account by observers recently, though they would not
have entered into their calculations some few years ago.
While I indicate, then, as I have already done with reference
to other questions bearing on this subject, the differenced of
opinion which prevail, I am not at present in a position to modify
my original statement, that the occurrence of suppuration, or, at
least, of nsdema, with infiltration of sero-punilent fluid, is in all
these cases the rule rather than the exception, and tliis even
though no discharge of matter should at any time take place
externally. The extreme mpidity with which a tumour forma so
as to be detected through the abdominal walls, or to be felt iii
other cases in the vagina, is explicable only by the sudden pour-
ing out of fluid into the loose cellular tissue ; while its varying
extent, its ill-defined edges, its occasional disappeamnce from one
side, and reappearance on the opposite, all serve to show that,
whatever may have been its starting-point, the mischief does not
in general seriously involve the substance of any solid organ such
as the ovary, and consequently to explain the completeness of the
patient's recovery, and the subsequent integrity of aU her sexual
functions, even when the attack has been most severe and the
symptoms have appeared most formidable.
The original seat of the mischief in the cellular tissue im-
mediately adjacent to the uterus is illustrated by the subjoined
case, where I had the opportunity of observing after death the
process by which nature had e fleeted the cure of an inflammation
of the cellular tissue contained within the folds o£ the left broad
ligament The person on whom this observation was made was a
young woman who died of abscess of the liver fourteen months
* C/. dL I* 707. t ^^ PhkguKm Piri-uUrii^ 4to, ParU, 1855,
430
INFLAMMATIOK OF THE UTERINE APPENDAOES :
after her recovery from inHammation of the uterine appendages of
t!ie left side. The results of exaoiinatioii when she was originaDj
admitted into the hospital six weeks after her delivery, were m
follows : the abdomen generally was soft and painless, but immedi-
ately over the s>Tiiphy8is, extending about two inches above it*
leveli and about the same distance transversely, was a firm globo^
lap enlargement, very slightly movable, tender on tirm pressure.
Tlie vagina was hot, its anterior wall from aliouthalf an inch from
the orihce of the urethra was swollen into a distinct ehistic
tumour, which gave the sensation of containing fluid, and projected
80 as to contract to half its ordinary dimensions the calibre of the
canal. In this tumour, which waj^ not modified by the introduc-
tion of the catheter, the anterior lip of the uterus was lost, while
the posterior lip wxs small and natural. The right side of the
uterus was free from any unnatural condition, the swelling exists
ing to the left and anteriorly. The uterus and tumour, when
pressed on, moved together, but their mobility was very smalL In
a few days the tumour felt per vaginam %va3 greatly lessened after
a profuse discharge of pus, and when the patient, after six weeks*
sojourn, left the hospital, there was said to be no other morbid
condition than a thickening at the left side of the uterus, by which
it was almost completely fixed in the pelvis.
The appearances found after death explained this thickening, and
accounted for the non-mobility of the womb, for the folds of the
broad ligament, from tlie upper part of tlie vagina to the lower
surface of the ligamentum ovarii, inclosed a mass of dense cellu-
lar tissue of almost cartilaginous hardness, crpng under the knife ;
dense white bands intersecting each other in all directions, and
having a firm, yellow fat between them. This mass was closely
adherent along the whole left side of the uterus, tliough the uterine
tissue was in no respect implicated in it. The left Fallopian
tube was tied at two or three points by long adhesions to the '
ovary and its ligament, and the ala vespertilionis on that side waa
thickened and uneven, as if from okl deposits of lymph. The
Fallopian tubes were pervious, and the o%^aries were quite healthy^
and contained several Graafian vesicles. ^^H
Between the affection we are now studying and inflammatio^^^
of the substance of the ovaries themselves the dilierences are _
obvious and manifold The extreme rapidity with which matter
ANALOGEES OF THE AFFECTION.
431
is formed, and the large quantity of it which is secreted in so short
a time, are not compatible with the seat of the disease in the sub-
stance of an organ furnished as is the ovary with a dense fibrous
capsule, which, though elastic and admitting of vast expansion in
the coulee of time, is yet not capable of yielding so as to allow of
the accumulation of a large quantity of matter in a few days.
The termination of ovaritis by suppuration is, I believe, quite ex-
ceptional, la the puerperal state it is the peritoneal investment
of the ovaries which is usually alTected ; while when inflammation
even of the acutest kind attacks the substance of those organs, and
ending in the formation of matter proves speedily fatal, it does not
lead to any great increase of their size, hut to softening and com-
I»lete disintegration of their tissue. When, in other circumstances,
large collections of matter form within the ovary, their origin ia
usually traceable to some cyst in whose wall inflammation has
been accidentally set up ; and such ovarian abscesses generally
remain for a long time as distinct, well-circumscribed tumours,
whose contents are very slow in making their way outwards,
Generally, indeed, ovaritis is not only a far more chronic evil than
inflammation of the cellular tissue about the womb, and is
attended by pain of a vejj difTerent character, but the enlargement
of the organ is almost always inconsiderable, and its situation is
often inferred from pain produced by pressure at one spot rather
than clearly pointed out by any considerable increase of ita dimen-
sions, while the thickening and hardening of the vaginal walls,
scarcely ever absent from that side of the canal on wliich the
affection of the cellular tissue is situated, is never met with in
cases of simple ovarian inflammation.
The analogies of this affection are, I believe » rather to he found
among those inflammations of the cellular tissue which, succeeding
to operations, adv^ance with great rapidity, and teriniuating soon in
the formation of enormous quantities of matter, constitute oue of
the most untoward of those accidents by which the skill of the
eui]geon is disappointed of best merited success. The rapid forma-
tion, and occasional rapid disappearance of the swelling, show, if
further proof were wanting, that it is not due to changes in the
solid tissues of any oi^an, but rather to oedema or the infiltration
of a loose tissue with fluid. This fluid, too, like that which is
formed in other inflammations of cellular tissue, is not at first
/
432
INFIAMMATION OF THE UTERINB APPEXD^i
geTimne ptis, but a thin sero-piirulent matter, and often
this cliar.icter long aftet" it has heen formed in quantity j
to impart to tlie iiuger a most marked sense of fluctuate
Theae characters then correspond to those of diifu
inflammExtion, or ** acute purulent cedema," as it has
termed by the distinguished Russiau surgeon, PirogoCT.*
take this view, which he indeed suggests, even the most e
lou3 features of the affection will become comparatively f
iindei'stand. We shall not be surprised that the dbeaa^
occur in the weakly rather than in the strong, thatfl
hmmorrhage or other debilitating influences should fav€
development, that while often attended by comparativelj
local sufiering, it should yet run rapidly through its earlier I
but still now and then come suddenly to a standstill, and t
trace of it should then quickly disappear. »Since we kno
that the seat of the mischief is not in the sex:ual organs then
but only in their connective tissue, we shall find nothing d
of explanation in the re-establishment of menstniation, o^
recurrence of pregnancy, or in the regular performance o^
generative functions, even after symptoms which had »
most formidable, and had appeared as though they must
that injury had been done passing the power of nature to 1
In those cases in which the affection succeeds to delivery oi
tion, its mode of aiiack S£€fjis to he twofold. Either it sets i]
well-marked symptoms of constitutional disorder, such asg
feverishness and heat of skin, sometimes, though not often, pit
by shivering, and accompanied by abdominal pain, which is a
ver)" intense ; or else it comes on gradually, the local evil
developed almost imperceptibly out of a state of Incomplet
valescence ; while it is quite an exceptional occurrence for i
puerperal peritonitis to precede the inflammation of the it
cellular tissue. In the majority of instances tlie tendemea
pain, though referred chiefly to the lower part of the abdome
not at first distinctly limited to one or other side, and not
quently the discovery of swelling, induration, or even of a d<
tumour in one or other iliac region by the medical attends
the first circumstance which directs the patient's notice to on(
as the special seat and source of her suflerings. The symptc
• KHniache CMmrfie, Drittos Huft, 8to, Leipxig, 1854, |>p.
l>p. 3M
ITS SYBIFTOMS,
433
general CDiistitiitional disorder, even when moat marked at the out-
set, very rarely go on increasmg in severity with the progress of the
local mischief, but, having set in on the second or third day after
delivery, subside at the end of a fortnight or three weeks. This
subsidence of the symptoms often takes place quite independently
of the employment of any medical treatment ; but the appareut
convalescence thus established is not only imperfect from the first,
but becomes every day more and more inteiTupted, as the local
ailment advances, and now, if not earlier, distinctly manifests
itself by abdominal pain, by jiainful micturition or defecation, or
by some other sympt^im which clearly points to its situation.
It depends upon the situation of the affected parts, whether or
not any timiour is perceptible ext-ernally ; for while always more
or less manifest in cases where the parts contained within the
broad ligament are tbe seat of inflammation, it is generally absent
when the miiichief is limited to the cellular tissue between the
uterus and bladder, and always when it is confined to the parts
in or about the recto-vaginal septum. The somewhat vague
character of tbe symptoms in many of these cases, and the too
common neglect of vaginal examinations, lead in cases of this
description to very frequent mistakes as to the nature of the
patient's ailment, and mistakes all the less excusable since there
are few ailments whose diagnosis is more simple if the investiga-
tion is properly conducted. It is not easy to say at how early a
period after the commencement of the attack a swelling forms, so
as to be detectable on examination ; but my impression is, that
though often not discovered till after the lapse of many days, it
usually occurs very speedily. Caref id examination, even t#o or
three days after the symptoms began, will generaUy ascertain the
existence of fulness in one or other iliac region, will find that on
pressure there the complaint of pain is greater than elsewhere,
and that percussion in that situation yields a dull sound and
conveys a sense of solidity not perceptible on tbe other side. Iv
such circumstances, local depletion will not only afford inmiediatts
rehef to the patient's sensations, but that relief will be accom-
panied by a disappearance of the swelling so complete and so
speedy as to raise a momentary doubt in our minds as to whether
the impression of its existence was not a mistake. The doubt
however, would be unfounded : the swelling was vexy real, due
2£
434
mFLAMMATION OF THE UTERINE APPENDAGES :
possibly to oedema of the cellular tissue, in wbich, but for <mr
treatment, suppuration would soon have taken place, as indeed
it does in the great majority of cases, and then condemns ^
patient to a tedious illness and a tardy convalescence* The sisit
rapid formation, and rapid disappearance ot the swelling, recein
another illustration in cases where a sort of metastasis of Utt
iutiammation takes place, or where, to speak more correctly, the
mischief, originally situated on one side, attacks without apparetil
cause the other also j and the new complaints of pain in a
ditTerent situation are accompanied by tumefaction there, whidi
may be very temporary ; or may^ if the inflammation thew
advance, become as solid, and prove as permanent as that on the
other side. It is not possible to fix the precise limits of time
witliin which resolution of the swellings may take place. My
impression, however, is that the period is very short, and that
after the lapse of a few days at farthest, the changes are far too
considerable for any rapid cure ; and that pus is early for:
though the processes by which it makes it way to the surface m
generally very tardy, and those are slower still by which, without
any escape of matter externally, its complete absorption is now
and then efi'ected. The formation of matter is by no means in*
variably followed by any marked increase in the sufferings of the
patient; and it is surprising how the constitution bears its
presence even in considerable quantities, the mecbanical incon-
veniences produced by the pressure of the abscess being not infre-
f^nently those from which the patient suffers most, and which
drive her at length to seek for medical assistance. Thus, a young
woman, aged twenty-five, was admitted in the year 1849 into St
Bartholomew's Ho9pitaI, having been ill since her deUvery seven
months before. On the ninth di\y after her confinement she was
attacked by abdominal inflammation, the more acute symptoms of
which subsided under depletion, and she attained a state of
imperfect convalesence. She went about some of her household
tluties, though with difficulty, and even cohabited with her
husband in spite of the pain by which sexual intercourse was
attended. Wlien she sought for admission into the hospital it
was on account of increased difficulty in micturition, and frequent
diisire to pass water. On examination of her abdomen an oval
tumour was discovered in the mesial line reaching midway
I
I
A
ITS SYMi*TOMS : TENDENCY TO SUPPURATION.
435
between the symphysis pubis and the umbilicus, and produced by
8 collection of pus in the cellular tissue between the uterus and
bladder, ten ounces of which escaped on a puncture being made
into it through the vaginal walL The patient alleged that the
tumour had existed only for three weeks ; a statement which can
scarcely be received as correct, since she had never thoroughl}^
recovered from the illness which followed her deliver)^ ; but
which may be accepted as evidence that the abscess had produced
no special effeetB, till by its increased size it began mechanically
to occasion diaoomfort, and to interfere painfully wth the func-
tions of her bladder.
Another illustration of the same fact may be adduced in the
person of a young woman in whom constipation from the fourth
to the eighteenth day after her first confinement was foUowed by
inflammation of the cellular tissue behind the rectum. The action
of her bowels was from this time attended by great pain, and
costiveness alternated with diarrhtea, the evacuations being not
infrequently intermixed with pus. In spite of these symptoms,
however, she gradually regained her general health, and menstrua-
tion returned, though not regularly. Seventeen months after her
confinement she had been visiting the Crystal Pakce, in Hyde
Park, and wliile returning home in an omnibus, the jolting of the
veliicle occasioned the sudden bui'sting of an abscess, and the dis-
charge of about three pints of matter streaked with blood per
annm. For the next three months from that time, more or less
copious purulent dischai-ges took place from the bowel, behind
which the abscess whence it proceeded was situated, forming there
a tumour of about the size of a small apple. Occasional local
leeching, and the most sedulous attention to the state of the
bowels were succeeded by the cessation of the discharge, and the
ultimate complete disappearance of the tumour, of which six
years afterwards no trace existed*
The presence of any collection of pus so considerable as that
which existed in these two cases is decidedly unusual; but thoogh
the size of the abscess is not in general very great, it not infre-
quently passes into a chronic state, and emptying itself, for the
most part» through some narrow passage of communication, into
the bowel, the patient continues for months or years liable to occa-
sional discharges of pus per anum, the commencement of which
436
HTFLAMlf ATION OF THE UTEHINE APPENDAGES :
dates back to some attack of inflanimatioii of the cellular
years befora In the case of a poor woman who died after lo^f
siifferiog from ulceration of a quasi-mahgnant character about hei
urethra and rectum^ a collection of matter was found in the midM
of the thickened and condensed celhilai tissue by the side of the
rectum, and between it and the uterus » Tliie abscess, too, wis
lined by a membrane so distinct, so smooth and polished, as for §
moment to raise the question whether it was not a distinct cyst
in which suppuration had Vjeen accidentally excited. A patient
was some years ago under my care in whom iudammation of the
cellular tissue between the uterus and rectum having gone on to
suppuration, it was considered expedient to puncture the tumonr
which w^aa found in the vagina. Not more than two ounces of
fiero-purulent duid were evacuated by this proceeding, but from
the puncture flowed for the ensuing seven wrecks many ounces of
pus daily, its quantity, however, diminishing, and the discharge
at length completely ceasing as the patient advanced towards
recovery, and as the swelling behind her womb diminished. In
another instance, occasional discharges of matter took place from
the bowel, and pus was often intermixed with the fseces, five years
after the first symptoms of inflammation of tlie cellular tissue)
about the uterus, the chronic results of which were still evident
in a tumour which was closely connected both with the rectnm
and the womb. These chronic abscesses generally contract, and
the fistulous passages which lead to them become by degrees
obliterated, but exceptions to this now and then occur, two ol
which have come under my own notice, and Sir J. Simpson^ bis
reported some very interesting case^ where permanent iistalous
communications have formed between the abscess succeeding to
inflammation of the pelvic cellular tissue, and the bladder, uteniSi
or intestinal canal.
Often, though perhaps not always, the formation of absceflses
having so chronic a character as those to which reference has just
been made, might be prevented if the nature of the ailment were
recognised at the commencement. The dvi^/nosis, too, is not
attended by much difficulty if only it is borne in mind that when-
ever after deliver}' or miscarriage or after sudden suppression of
the menses, or now and then independently of any obvious exciU
* Obtkkia Menwirs, voL L p. 2d2,
I
ITS CEROBTIC FOEM ; ITS DIAGNOSIS.
iBg cause ill-defined febrile symptoms occur, accompanied by
abdominal pain, inflammation in the vicinity of the uterus i3
probably present, and this even though the constitutional disturb-
ance should not be considerable, nor the pain ex|:»erienced by any
means severe. If now the iDflammation is seated in the broaiL
ligament, there will at first be found in one or other iliac re^^on a
vague sense of fulness ; percussion in that situation yielding a
dull sound, and pressure being painful ; and afterwards a mora
definite swelling. At no time, however, is this swelling so
circumscribed that its border ciin be tUstinctly traced, nor is it
movable like a fibrous tumour of the womb, or an enlarged
ovary, but it is felt like a hard mass, extending laterally to the
inner surface of the pelvic wall, and firmly adherent to it, reach-
ing down into the pelvic cavity so that its lower boixier cannot be
felt, while its upper and inner margin are both but vaguely
marked ; the thickening in those situations seeming rather to pass
away by degrees than suddenly to cease. The dimensions of this
swelUug are always much more considerable from side to side
than from below upwards ; dififering in this respect from tumours
of the uterus or ovaries ; its surface is even,, but extremely hard ;
it seems very superficial ; the abdominal walls are not readily
movable over it, but often seem as though they were adherent to
it. This, too, they doubtless are in some cases, but the same
sensation is very often communicated to the hand in instances
where there is no reason wliatever for 8up[K)siug that adhesion
has taken place between the opposite surfaces of the peritoneum,
while further, the rapidity with which in some cases the apparent
union is dissolved, shows that it must have depended on some
cause of a much more temporary natui^. My impression is, that
it is in a measure due to cedema of the cellular tissue between the
abdominal muscles and the peritoneum ; a condition which not
infrequently terminates in suppuration, and thus constitutes what
has been termed external peritonitis^ but which in many cases is
but an attendant on inflammation of the more deeply-seated
tissues, increasing as that advances, remaining stationary when
that comes to a stand-still, and rapidly disappearing as that begins
to subside. An obvious lessening of the geneml fulness of the
abdomen, and a sense of the mobility of the abdominal w^alls over
the tumour, is one of the first signs of the patient s amendment,
438
IKFLAMMATION OF THE UTERINE APPENDAGES :
and one wluch often long precedes any alteration in the i
contour of the swelling; while next, as its size lessens, the pie-
vious adhesions between it and the pelvic wall become less fimt,
and its chief connexion is felt to be not with the side of tlie
pelvis, bnt with somebody at its centre ; in other v^rords, withlhi
uterus itself* Up to the last, the indistinctness of outline whidi
has been already noticed as characteristic of these swellings con-
tinues to distinguish them, and a vague sense of fulness in the
iliac region remains long after all other evidence of their presence
Las ceased,
Wlieu suppuration takes place, the matter makes its way out-
wardly through the vagina, or through the intestinal canal, in
almost all crises in which the inflammation is limited to the pazts
contained within the broad ligaments. In those cases, however, ia
which the pelvic cellular tissue is implicated, the matter not infre*
quently makes its way round lictween the muscles and the external
surface of the peritoneum, and the abscess points and diachaigea
itself through the abdominal walls somewhere in the course of
Poupart's ligament, or a little below that situation. It sometimes
happens, however, that even after fluctuation has become dis-
tinctly perceptible thix)ugb the abtlominal avails, the abscess even*
tually bui'st^ either through the vagina or the rectum, and in one
instance a communication formed apparently about the sitnatioo
of the sigmoid flexure of the colon ; and after the escape of matter
by tlie bowel, air was for many days distinctly perceptible in the
sac of the abscess.
In cases of uncomplicated external peritonitis, and also in thoee
where inflammation in this situation occurs simultaneously witll
that of more deep-seated parts, the tendency naturally is to the
escape of matter externally. The swelling in crises of external
peritonitis is harder and tenser than when the mischief is more
deeply seated, the integuments become red, shining, and brawny,
and this condition extends lower down than when the iutlainma*
tion is seated in the parts within the folds of the Ijroad ligament,
and reaches quite into the inguinal region. The €|uantity of
matter formed in these cases usually amounts to several ounces ;
the abscess pointing at one spot, and the whole of its contents
escaping at a single aperture, JSometimes, however, in cases w here
mflnnnuation of the uterine or pelvic celhilar tissue is present, the
I
I
i
ITS COURSE : EXTERNAL PERITONrnS,
439
tissue external to the peritoneum becomes affected secondarily ;
not by direct extension of the miacJiief to it, but rather by a sort
o{ sympathy, aBd in this case two or three small circumscribefl
collections of matter are not infrequently formed, each of which
may require to be separately evacuated.
An examination per vaginam throws additional light upon the
case, except of course in those instances in which the external
surface of the peritoneum is alone affected. The vagina is hot,
and puffy, and tender ; and, according to the seat of the ioilamma-
tion, either its anterior or its posterior wall is felt to be thickened,
and hard like brnwu; and the uterus itself is fixed by this thicken-
ing of the vagina more or less completely in the pelvis, and at
the same time is carried by means of it higher up than natuml,
so as not to come as readily as usual within reach of the exploring
tinger. As the cellular tissue within the fohls of the broad liga-
ment is of tener affected than that in any other situation, so it is at
the roof of the vagina, towards one or other side, and commonly
extending somewhat round belund the uterus, that these characters
are most marked Soon, too, a distinct tumour is perceptible in
addition to the general thickening, swelling, and hardness of the
vaginal wall, and the swelling, if considerable, pushes over the
uterus towards the opposite part of the pelvis. If seated at the
fiide it does not in genend dip down deeply into the pelvic cavity,
and though it may be seized between the hand externally, and
the lingers in the vagina, the state of the abdominal integuments,
and the thickening of the roof of the vagina interfere with the
accurate determination of its size and contour. If the mischief
extends, as often liappens, either in front or behind, a definite
swellmg is very likely to be fonned, and this swelling is usually
larger and more distinctly circumscribed when situated behind
the uterus than when occupying the cellular tissue in front of the
organ. If the cellular tissue between the uterus and bladder, and
along the anterior vaginal wall is the seat of the inflammation, we
may then find the hardened, thickened, tumefied state of the
vagina reaching down to its very outlet, and tlie os uteri pushed
(juite out of reach by a swelling in front of it, not distinctly
circumscribed, but passing over into the substance of the thickeneil
imterior vaginal wall If any large quimtity of pus is formed in
this situation, it does not commonly seem to increase very much
440
IKFLAlfMATTON OF THE UTERINE APPE^*DAGES .
the size of the pelvic tumour, but forms a distinct, well-defined'
Bwelluig between the uteniB and bladder, which rises up out d
the pelvic cavity, and may be felt through the abdominal walk
occupying the situation, and having much the contour of the hall-
distended bladder. It is when seated behind the utemB, on tbe
other hand, that the occurrence of suppuration is apt to give ria
to the most definite pelvic tumour ; for there is in this Bituation
a greater obstacle than elsewhere to the extension of the swelling
upwards out of the pelvis, while the cellular tissue in the recto-
vaginal septum is looser and more abundant than anywhere else
in the immediate vicinity of the uterus. Here then matter very
speedily forms, and gives rise to a sw^elling w^hich occupies the
whole posterior part of the pelvis, bulging out into it, just as iH
ovarian tumour is apt to do when seated in the recto-vaginal
pouch, but more elongated in form, less globular, and while
generally tense, yielding usually at one spot, perceptible through
the vagina or through the rectum, a peculiar boggy sensation,
suggestive of a thinning of its covering having taken place there,
and of matter being likely to escape in that situation. The oa
uteri, too, w^ill be found to be carried out of reach more completely
than it would be by an ordinary ovarian cyst of equal dimenaions,
and the tumour itself to reach lower down, nearer to the oiilice of
the vulva, since, it is not a mere swelling seated in the recto-
vaginal pouch, but is formed in the substance of the septum itself^
where the matter naturally gravitates lower and lower.
I do not know of any enor which with moderate care can he
committed as to the nature of these swellings, except in cases of
extravasation of blood behind the uterus, uterine hwfuaiocele, as it
has been called ; and in them the tumour very closely resembles
that produced by suppuration in the same situation. The sudden-
ness of the attack of uterine h hematocele, its independence of
delivery or abortion, and the general absence of thickening and
hardening of the vaginal wall aronnd the sw^elling will, I should
imagine, usually enable us to discriminate between them ; while
happily there is no serious practical error to which a mistaken
diagnosis would give occasion.
It is scarcely necessary to trace the fuither progress of these
smllings, except perhaps, to add two cautions : fii-st, that the
sense of fluid laeing cDutained within them is not infrequently
A
Its dugnosis, am) cofrse*
44t
deceptive, so far at least that it would seem to iBiply in many
iBstances the existeooe of a state of general rodenia of the cellular
ti&sue, and not such a definite collection of matter as could be
evacuated by the trocar ; and, second, that even after the actnal
evacuation of pus, there h seldom that immediate aud great
diminntion of the swelling which vee might beforehand anti*
cipate ; but the thickening of the cellular tissue which remains
behind is not only considerable, but is many months before it
is entirely removed.
The s}Tnptoma of the disease, even after it ia fully established,
and after the formation of a distinct tumour has taken place, are
not in general of a very definite character. The patient's condi-
tion is one of wetdcness, illness, feverisJiuess, with evening exacer-
bations, restless nights, and morning remissions, rather than one
either of very great local sufiering or very urgent constitutional
disturbance, though when the affection has lasted very long, and is
telling severely on the patient's powers, dian-hcea not infrequently
comes on, and the fever assumes a marked hectic character. The
local sufiering varies much, according to the part which is chietly
affected ; the sense of bearing down being most distressing when
the recto-vaginal tissue is involved, and the frequent need of
micturition most troublesome when the tissue between the uterus
and bladder is the seat of infiammation. In all instances, how-
ever, the bladder 8}'Tnpathizes more or less with the iudanmiation
in its vicinity, and some degree of dysnria and over-frequent
micturition are symptoms scarcely ever absent While in all
cases, be the exact seat of the mischief what it may, there is more
or less pain refeiTed to the pelvis, more or less tenderness on
pressure upon the abdomen, the amount of severe snlfering varies
very considerably, and varies, too, without any very obvious cause.
A dull pain, a sense of weight, and a burning sensation seem to
be constant, while very severe sntlering is often produced by the
attempt to stand or even to sit up. SometimeSi too, independent
of any exciting cause, paroxysms of pain occur, of extreme
violence, which last for an hour or two, and then subside, return-
ing the next day, or sooner, being equally violent, and passing oft"
again of their own accord. The severest suffering generally takes
place before the presence of matter in the swelling has become
distinct, while afterwards, during the long period which often
442
l^'FLAMMATION OF THE UTERINE APPENDAGES :
elapses previous to the contents of the abscess finding an
though the coDstitutional disorder may become more serious^
local pain geneniUy abates. With the escape of the matter'
relief obtained is uaually far more decided, though this sebloB
occurs in a sudden gush, so as to give instant ease» bot tie
aperture of communication with the abscess being very small, the
matter for the most part escapes only in small quantities; or beiqg
poured out into the rectum, collects there till a few ounces htw
accumulated, and are expelled during some effort at defecation ;
while for days or weeks afterwards pus is intermingled witii the
feces, or a small discharge of it piTcedes their passage. In caae»
where the cellular tissue between the folds of the broad ligament
is the seat of the inflammation, as well as in those where tha
tissue behind the uterus is affected, the escape of the niatter
generally talces place through the rectum ; very rarely indeed
tliroiigh the vagina. The aperture of communication with the
bowel is uaually low down, though above the internal sphincter,
and though commonly too minute to be detected, its situation may
be guessed with tolerable accioracy, as the finger discoveiB some
spot ill the swelling where its parietes are soft and yielding. Onca
an iliac abscess on the left side, in which fluctuation was distinctly
perceptible, while the redness of the abdominal integuments, and
their firm connexion wuth the swelling, led one to expect that it
would discharge itself externally, bui-st into the intestine, and the
communication was free enough to allow of the entrance of air
into the sue of the abscess, in which situation crepitation continued
for days to be distinctly felt In the meantime suppuration went
on in the tissue beneath the aMoniinal muscles, and a distinct
abscess formed there, which was afterwards evacuated by the
knife. Twice also I saw an abscess discharge itself through the
bladder, though this occurrence was not final in either case ; for
in the one an abscess formed externally, and in the other it burst
likewise into the intestinal canal, and the patient suffered for
several weeks from diarrha-a, with discharge of pus per anuni.
In these cases^ however, and also in others in which after an
abscess has pointed or has actually burst in one situation, matter
afterwards makes its escape in another, it is, I think, very doubt-
ful whether botli discbarges took place from the same source^ or
whether there have nut teen two distinct abscesses perfectly
1
ITS COUBSE ANB TEEMISrATlONS.
443
independent of each other, and the one anterior to the other in
the date of its foraiation* The disposition of this affection not
simply to extend by direct continuity of tissue, but also to attack
similar stmctiireB even when not immediately connected, is a
feature of the complaint to which reference has already heen
made, and one which adds much to its gmvity, and imposes on us
the necessity of watching our patients most sedulously for a long
time after they have seemed to be fairly in the way to conva-
lescence.
The gradual progress of the patient towards recovery during
the continuance of discharge from the abscess, and the slow pro-
cesses by which the thickening and induration of the affected
parts are by degrees removed, are unattended by symptoms call-
ing for special description. Their history is one of a convalescence
as irksomely slow in some inRtances, as in other cases where the
mischief having been seen and understood, and appropriate treat-
ment having been early adopted, it is surprisingly rapid. The
disposition to relapse, too, to the reproduction of fre^sh mischief in
its old seat, or to the kindling of inflammation in some part pre-
viously unaffected, is never to be lost sight of, both as governing
our prognosis and as regulating our treatment.
LECTURE XXIL
DISEASES OF PARTS CONNECTED WITH THE UTERUS— I XFLAM¥1-
TION AND ITS RESULTS, AND KINDRED PROCESSES-
Inplammation of Uterine Apfen'ijaoes : — of the Cellular TtsstfB.
Ex^'eptioaa] caaeSi consmxuetit on peritouitis without s|>ecml uterine dlaonler ; im*
portaiit, but apt to be overlookod.
TrLatiJjeiit iti recent stage, care daring convftle»c«nce. in chronic etAge ; questkii
of punctiiris, delay generally advisable ; treatment of sequelae.
H^MuiiiiHAOE ABOUT Uteuus, OR Uterine Hjsmatocelk. Sent ftnd csaasts of
extra vasiLtiou of blood. 8yttiptonis and course, changes in the efliiaed tdood ;
cases in QluBtration. Diagnosis ; from extra-nterinc pregnancy, from fetiovcr-
sion of the ut«rus, from pelvic abik^ess, from ovarian tumour, and fhun fibrous
tumour of the ntema, Progiiosia and cauaes of death.
TrcAtmont ; comparativo merita of interfereuc^ and expectancy.
In all the cases of mflammation of the cellulax tissue in the
vicinity of the uterus which engaged our attentiou in the laat
lecture, the disease was spoken of as succeeding to delivery or
miscarriage, lu such cases the disorder of the puerperal processes
by which it is accompanied usually gives to the attentive observer
early notice of its occurrence. The offedioii may, however, come
on quite indtptndentl^ of puerperal causes, and may sonjetinies,
though I believe rarely, be wholly unconnected with any pmviouB
disorder of the uterus, or with any previous disturbance of its
functions.
In cases of this last description, the local ailment seems usually
to develop itself out of the symptoms of a general peritonitis of
no very great severity, which, though relieved by treatment, have
not altogether disappeared, but have become limited in extent^
and have been referred to the uterus and the pelvic region, where
a careful examination discovei-s just the same changes to have
taken place aa succeed to inflammation in the puerperal state.
A woman aged thirty -nine, married twenty- one years, thrice
pregnant, her youngest child being eleven years old, was attacked.
INFLAMMATION OF THE UTERINE APPENDAGES*
445
while following her occupation at a mangle, by sickness, retching
and \niin in the ahdomen, severest at its lowest part. She kept
her bed for a week, then attended at the out-patient room of the
hospital for ten days, during which time leeches were applied to
the abdomen ; and being afterwards admitted as an in-patient,
she was fiirtiher depleted, and subjected tci a mercurial treatment,
by which her mouth was made slightly sore. Her severer symp-
toms were relieved by these means, but as she was not cured she
was transferred to ray care at the end of ten days more, or just a
month from the commencement of her illness. At this time she
i'omplained of very severe pain at the lower part of her abdomen,
extemling to her back, and increased in paroxysms that came on
causelessly ; as well as of constant sickness after taking any food or
drink, and of troublesome diarrlicea. Her abdomen was distended
and generally tympanitic, but percussion yielded a dull sound
in the right iliac region, though there was no distinct tumour to be
there discovered. The uterus was found on a vaginal examination
carried forward, and to the right aide, by a tumour of stony hard-
ness, smooth surface, and globular form, extending from near the
left sacro-iliac synchondrosis, pushing the rectum before it and to
one side, and occupying a great part of the peh'ic brini. Tenesmus
and pain accompanying the frequent eflbrts at defaecation were
for a time very distressing, but the appearance of pus in the
evacuations, and its occasional discharge by the bowel unmixed
with fieces, were followed at the end of a week by much relief.
At the end of six weeks the patient left the hospital, the tumour
being much diminished, and the uterus having returned more
nearly to its natural position, though being still firmly fixed in
the pelvis, as indeed it continued thirteen months afterwards.
In this case the opportunity was afforded of watching the evil
while still in progress, but accident sometimes brings cases l>efore
us where, though the mischief already done is extensive, we can
gather but little information as to the circumstances in which it
originated. Inquiry may perhaps elicit a vague history of fever,
or of an illness accompanied by disorder of the bowels, or by
abdominal pain, but unattended as far as the patient knows by
uterine ailment ; and yet the womb may be firmly fixed in the
pelvis, and thickening of the adjacent parts may plaijdy show
that at some distant period the cellular tissue in its \acinity had
446
INFLAMMATION OF THE UTERnfE APPEEmyUinf
been the seat of serious infiammation. In such cases thei
reason for doubting our patient's veracity j the symptonifl
slighter ailment were masked by those of the more grave c
or perhaps were really by no means urgent in their charact
were regarded as only the ordinary discomforts of a tediot
valescence. They are of great practical importance, aa il
tions of the necessity for watching very carefully the convale
of patteiitg who have been the subject of any illness in the
of which abdominal inftammatiou may by possibility occur,
mischief may perhaps not entirely paas away, but with fe^
to betray its existence, may become limited to parts with
pelvis. It may then be confined to the peritoneal surface
viscera, matting the difterent organs together by firm adhi
which interfere with the elevation of the uterus out of the
cavity, and thus in the event of pregnancy occurring give
sion to its premature termination, though absolute sterilifc
no means an infrequent consequence of the attack. Or^
of being limited to the peritoneum, the inflammation maj
affect the cellular tissue iu the vicinity of the uterus, and
issue in suppuration, or in deposit and permanent tbicki
which may remain long after the acute disease is over, dome
even after the memory of it has almost passed away. It be'
us then to bear these risks in mind, not to take the decline <
symptoms in such eases as a certain pledge of their completi
appearance ; but so long as there is any pain or disco:
referred to the lower part of the abdomen or the neighboui
nf the uterus, to have our suspicions alive to the possible o
rence either of circumscribed peritonitis, or of inflammation i
cellular tissue comiected wjth the womb or its appendages.
In considering the trmimefU of this affection, we mufit be
mind the diflerence between the results likely to be obt«
before suppuration has taken place and after it has occurred.
the former case, a few days will suffice for the complete tgxl
of all traces of disease ; in the latter, weeks or months will c
issue in but a very incomplete recoveiy. Whether treated ij
acute or in its chronic stage, indeed, our prognosis may ah
always be favourable as far as the life of the patient is concei
Wlien the disease, however, is of long standing, it is idl
attempt any reply to inquiiies as to the probable duration M
4
rrs TREATMENT.
447
patient's illness, or as to the time that must elapse before the
]>elvic organs return to their previous state, and to the regular
performance of their wonted functions.
It m not a heroi*^ plan of treatment, however, which ig necessary
when we see the disease at its onset, in order to cut short its
further progress. A dozen leeches applied to whichever iliac
region is the seat of pain ; a warm poultice frequently renewed,
and continued for thirty-six or forty-eight hours, a gentle aperient,
some mild febrifuge medicine, and opiates to subdue pain, and to
ensure for the patient quiet re^t at night, with a generally mild
and nnstimulating diet, ai-e the simple, and as I believe, the fully
siUHcient means by which the symptoms may be combated.
Should the pain and tenderness not be removed by the first deple-
tion, half a dozen leeches ought to be reapplied within the next
tweuty-four hours ; but the frequent abstraction of blood is
undesirable. The tenderness and pain which sometimes remain
even after blood has been drawn to as great an extent as seems
expedient^ and which are often accompanied by considerable
fulness of the affected side, are generally much relieved, often
altogether removed, by the application of an ointment composed
of two drachms of extract of belladonna, and six drachms of
mercurial ointment, which may be tMckly spread on lint, covered
with oiled silk, and renewed every twenty-four hours. The relief,
too,' is obtained quite independently of the production of any
specific mercurial influence on the system. If, in addition to the
pain at one or other side of the abdomen, there should be difficulty
in micturition, or tenesmus, or bearing down, or much pelvic pain
or discomfort, it is probable that a vaginal examination will dis-
cover the mischief not to be limited tr* the uttjrine appendages,
but to involve the cellular tissue between the uterus and rectum,
or between that organ and the bladder. In this case the applica-
tion of four or six leeches to the uterus itself, by means of the
speculum, will often afford an amount of relief that would be
vainly sought for by the employment of four times their number
if put on externally.
After all general febrUe disturbance has subsided, and when
notliing remains but a httle local pain and tenderness, and perhaps
some stiflness in the limb of the affected side, the application of
a small blister, so as scarcely to vesicate, will often yield great
448 INFLA.MMATION OF THE UTERHf E APPENDAGES :
relief, and this may be repeated two or three times, at intervals of
as many days ; its situation being varied just suflBciently to
obviate the production of a troublesome sore. In many instances,
however, if the case is seen quite at the outset, the symptoms dis-
appear at once after a single application of leeches, and our chief
difficulty then consists in persuading our patient to submit to
those restrictions, and to observe those precautions which may
seem to her to be dictated by our over-carefulness rather than by
the actual necessities of her case. The avoidance of fluctuations
of temperature, and of premature exertion of any kind, is indeed
a matter of the greatest possible importance during the whole
period of convalescence. So long as there are any considerable
remains of pain, or as there is much tenderness on pressure in the
iliac region, or over the pubes, it is unsafe for the patient to leave
her bed, or even to move much from the recumbent posture ; for
there is risk, not simply of a very slight cause producing an ex-
acerbation of the inflammation at its original seat, but also, as has
been already explained, of mischief attacking the opposite side;
Now and then, too, phlegmasia dolens has come on under my
observation in cases where all active symptoms had already passed
away, and where no special cause could be assigned for its occur-
rence. Even after complete recovery, the return of menstruation,
or even of the period at which the menses ought to occur, calls for
fresh solicitude, and any recurrence of pain, or even of uneasiness,
any rekindling of febrile disturbance must be at once met by a
repetition of local bleeding, and a renewal of former precautions
and former treatment.
Unfortunately, in the great majority of cases, the evil, before it
attracts attention, or receives appropriate treatment, has advanced
further, and there is not merely a general sense of fulness at one
side of the abdomen where the patient complains of pain, but a
distinct tumour is already perceptible on external or internal ex-
amination. In these circumstances a speedy recovery can no
longer be anticipated, but something may still be done to prevent
any abundant formation of matter, to favour the absorption of the
sero-purulent fluid already poured out, and to bring about the
resolution of the tumour. The application of leeches is as appro-
priate here as in the earlier stages of the complaint, though, as it
will probably be expedient to repeat them several times, it is
ITS TBEATMENT.
8eldom desirable to apply more than six or eight at onca The
warmth of tht^ poultice is as grateful as at the outset of the affec-
tion, while, if the pain is very severe, the use of laudanum instead
of water in mixing it will render it a very powerful local sedative,
and its employment need not at all interfere with the use of the
helladonnaand mercurial ointment of which I spoke just now. I
am not, however, accustomed, in cases which have already advanced
to the formation of a detinitB tumour, to rely exclusively on the
etlects of depletion and of general hygienic measures, but usually
give small doses of some mild mercurial preparation, and contmue
their use sufficiently long to proiluce slight soreness of the mouth.
A five-grain pill, composed of equal parts of Dover's powder and
gray powder, given twice a day, usually has this efl'ect in a week
or ten days, and thus employed it seems to have the twofold result
of preventing the extension of mischief on the one hand, and of
promoting the absm-ption of the products of inflammation on the
other. If the symptoms are urgent, I sometimes give the pill
every six hours, but am not in the practice of giving calomel, nor
even of persevering with the more frequent doses of gray powder
if they should apj>ear to irritate the bowels. As in most local
inflammations^ the night is usually the time of the greatest sufler-
ing, and an anodyne is generally needed towards evening ; cam-
phor in five-grain doses being a very useful addition to any opiate
whicli may be employed.
It is seldom that any rigorously antiphlogistic plan is suitable
in tins stage of the afifection. Good beef-tea ia indispensable,
wine and tonics are generally needed ; I think I may say always
when any even vague sense of fluctuation shows that matter in
Bome considerable quantity is already present. A disposition to
iiTiUibility of the bowels frequently contraindicates the use of
quinine, and I therefore generally prefer the liquor cinchon^e, as
being free from any of those objections which may be alleged
i^inst most other preparations of bark.
Slowly, almost imperceptibly, in proportion as the symptoms of
constitutional disorder abate, the swelling itself in some instances
diminishes in size, till at length an indistinct thickening is aU
that is left behini But still this is a more favourable issue than
we often meet with, or than we can ever venture to count upon^
where a distinct tumour has formed. Often, though some abatft-
450
INFLAMMATION OF THE UTERINE APPENDAGES
lit!
ment of the general symptoms takes place, tbe turnoti
becomes tenser, and feels more elastic ; a vague sense <
Beated fliictuation ia communicated to the finger, and m
tinne for weeks without growing more perceptible, till a1
the abscess begins to discharge itself through one or othe
channels which were descrited in the last Lecture. The q
now naturally suggests itself, whether, when suppuration b
occurred, we canuut expedite the escape of the matter, and i
hasten tbe recovery of the patient ? I believe that as a
rule it is safer to leave the emptying of the abscesa ent;
nature, rather than t*> atteuipt the evacuation of its cont^
puncture; those cases always excepted in which the inflfmi
has attacked the cellular tissue external to the peritoneum
the abscess consequently points in the abdominal wall.* 1
cases the very tardy advance of the matter towards the I
may sometimes be accelerated by the appbcation of a blist
even here it is not expedient to make an incision so long
considerable thickness of paits intervenes. In the far m<
quent instances in which the seat of the mischief ia will
pelvic cavity, the pus tends to escape either per vnginam
rectum, and the attempt to anticipate by puncture the exact
which it may take is very frequently unsuccessful and not i
safe ; wliile the danger of the rupture of tbe pundent col
into the peritoneal cavity is by no means so done away iJi
the existence of a counter-opening as might be supposed
my own observation of tbe occurrence of this accident, w
free communication existed with the vagina, is far from b
solitary case. The natural relation of parts is much chanj
the efiects of the inltamniation ; the swelling and tension
* There are few |K)ints of practice concerning which then? i« po gen
ogre^mcnt us this of the inexiwfiiency of early puuctarc of these coUeot
iTtatier, tkniutz, op. eO. p. 134-6, toeepts llie priuciple ; Amu, op. dL
tiiabta oti it moro strongly, und obaoryes— '^Tbens is no evidence of ih
biUty of preventing, by the artificial opeoing of these purnleiit eoUoctio
formAtioD of spontaneous openings in other sftimtions, and e«pcdaUy ii
petitoneal cavity. There are^ on the contnuy, many obscrvationa on rvoard
oocarretice of these perforations, sometmiea on the very day, aometimes
days after tbe pnncturt; of the abscena.'^ Beoqnerel, Traiii dts Mtiladitt tU V
8vo, Parii!, 185ft, vol. L p, 464, expresiei tbe same opinion stUI more dec
ftnd kys down the nde that ** tbe aboceM it never to be opened^ even
apparent pointing in one situatiou abonJd aeom to invite interference. '*
ITS TREATMENT.
451
vaginal walls extend far beyond the limits which circumscribe
any actual collection of matter, and it is very likely that the
trocar may be merely thrust tlaroiigh hardened textures, and
though passing vuiy near to the coUection of matter, may entirely
fail to enter it. The extent and relations of the tumour can be
most accurately determined, and puncture can consequently be
most safely performed, when the cellular tissue between the
vagina and rectum has been the seat of the inflammation ; and a
Pouteau's trocar introduced by the vagina will generally reach the
matter, if the indications of its presence have been distinct. In
one case, where inflammation of the cellular tissue between the
nt-erus and bladder had issued in suppuration, the escape of ten
ounces of pus on puncture being made proved the expediency of
the interference. In a few days, however, the vaginal tumour had
reacquired almost its former size ; the puncture was ix^peated, but
no pus followed, for the trocar had at once entered the bladder
through the firm and cedematous vaginal wall ; an accident which
fortunately was not followed by any bad consequences. The pre-
vious introduction of a silver catheter into the bladder in the one
case, and examination made simultaneously with one finger in the
rectum and the other in the vagina in the other case, will suffice
to prevent a mistake which otherwise is more easily committed
than might be supposed possible.
The management of the patient after the discharge of the con-
tents of the abscess calls for no special rnle^. The chief difference
indeed between those cases in which the discharge of pus takes
place, and those in which it is either not secreted or is absorbed,
consists in the greater degree of debility to which in the former
circumstances the patient is reduced ; a debility which is often
extreme if the suppuration has been extensive, or if the discharge
of pus is of long continuance. Even then, however, and in spite
of well-marked hectic fever, and of sweats alternating with colli-
quative diarrh(Ea, by which, and by the exhaustion produced by
continued suflijring, life seems sometimes to be seriously threatened,
the disease terminated fatally only in thrive out of the fifty-nine
patients on whom these remarks are founded*
With reference to the thickening left behind after the cessation
of all active inflammation, I do not think that we can do much
more than trust to time for its gradual, often indeed for its partifil
l1lti
452
UTEEmE HiEMATOCELE :
removal. Blisters, indeed, occasionally applied in the ilmcfij
something to relie\'e the pain and uncomfortable sensations
may long outlast the other s}'mptoms ; and they may, p
somewliat accelerate the removal of thickening in the snl
of the broad lii^^ament, I have little faith, however, in the
nal appUcation of iodine, or in its introduction as an ointme
the vagina ; nor do I think that the subjecting a patient to a
of mercurial remedies, or of prepamtiona of iodine, is lil
effect any local good at all equivalent- to the impairment of the <
tntional powers which auch remedies can scarcely fail to prod
Attention has been called of late years chiefly by J
writej'S * to cases in which tumotirs hnve hecn /a
* Ctmen of pelvic tumour, giving issue not to matter but to more or
blood, »re scattered here and there through our medical records, ftod i
mny be found referred to by M, Huguier, in a lectura on uterine
vbich be gave before the i^urgical Society of Paris on May 2B, 1851. As
1843, M. Yelpeau^ at p. 1'25 of his Recherekei mtr Its CetvUM Closes, gaTe mn
of flu instance in which he evacuated the sangni neons i3ontents of out c
nwellinga, and aftt^rwarda injected & solution of iodine into its cavity. Ho
too, to have entertained a correct idea as to the nature of the aflfection ;
miatiike into uhich It. Malgaigne full in the year 1850, who, thinking to ei
a fibrous tumour of the posterior uterine wall, opened one of these collect
blood behind t\w womb {an operation which was followisd by fatal hasmoi
sliows that the subj^'ct^ even down to this time, had attracted very little atl
In the year ISfil M. Ntjlaton gave some lectures on the subject of ulerinM
he tt'rnied it from its usual dtuiition, rrtrO'Ulerine heemuiijcclcf which wero pa
ill the GaztUr- <i/* HSpituux, Dec, 11 iind 18» 18M. In them he refers to ]
*— namely, 6 of his ow^n^ 2 rieiwrtetl by Bonnion aa occuring in the pmctio
B^oamier, 1 reported by M. I^ugier, in voL v. of the DicHmnaire m, 30 m
2 caiSi which Kelaton saw in the practice of M. Beau, 1, Malgaigne 'a nnfo:
ease, 1 of M. Dufraignei 1 of M. Lati.*^, I of M. Buguier. He has since n
another lase in the M&nitcur des Hdpiiaux, August ?3, 1856, and has mad
ttoufti reiniirkH on the attecrion in the GaxetU des Hdpiiausc, 1S5&, No. 23, in
be advocates an expectant mode of treatment Other cases are reoMndcd
Gallardp t7W«wi MUkak^ 1855, and Oiueltc HfMmiadaire, Oct. 9, 1867; Lab*
OazdUs dca JjapiUnut, 1364, No. 149 ; Bcmutz, Archives de IHdeeine^ June
p. las ; Piogey. Bull, de la SociW Artniornuim, 1850. p. 91 ; Bobert, BuL
SociiU d€ Chintrgie, May 22, 1651, p. 136, and 0<xseiU du ffdpittMm, May &,
p. 201 ; Foltin, GatetU tUs Hdpi^uiu; 1855, June 5, p» 260 ; Labardarie, ibid.
No. 149 ; Monod, Unit, dt la SociiU de Chirurffie^ Jone 4, 1851, p. 15^
Marotte, thid., p. 152 ; and Engelhard, ArrJiims de Miiedm, June 1857. T
bei«ide» ranch valuable information to be gathcre<l from the discussion on tl
ject which took place in the SocUU d6 Ckintnjie^ May 14, 21, and Jnne 4, 1&2
which is reported at pp. 182, 164, and 151 of the Bulletin, and in the ins
thesis of M. Vign^ Des Tumewn 8am^ifU9d« TEiBeavalion Pr.lvunne dtiz la I
4to, Tarts, 1860, with which, however, I am acquainted only through an a]
4
ITS NATUKE.
453
^gkuum of hhod in the immetliate vicinity of the uterus. The
name of uterine, niro-^eri'M, &r peri-uterim hmmatocde has been
employed to designate these effusions which take place usually
into the ctd-de-mc between the uterus and rectum, and are
generally consequent on some disorder of tlie menstrual function,
often on its temporary suppression.
The source and seat of the hnemorrhage in these cases have been
a subject of much ditlereuce of opinion, and while some writers
have believed that the bleeding may takfi place aUke into the
peritoneal cavity, or into the ceUidar tissue around the uterus, or
lining the pelvis, others am disposed to believe tbat the Mood
invariably occupies the cavity of the peritoneum. The weight of
evidence is decidedly in favour of the latter view, which is that
taken by Virchow, as well as by Bernutz and Aran, and I do not
know of any post-mortem examination made with due care in
which the seat of the effusion has been cleaxly proved to be extra-
in Scknudt'fl JakrifMchBr, Bcsidea the»e commanicatioiiA, all of which are of ft
directly practical diaracter, one of a theoretical kind was addressed by M. Laugier
to the Acad^mie dea Sciences, and Lb published at p. 455 of vol. xL of the Cmnpt^t
Mendm* Its object h to connect the occnrretice of these eflfbaiona with the escape
of the omle at or about the menstrual period. Tlrese historical details are ren-
dered almost «uj>erllnoiis since the publication of the works of MM* Bccque?rel,
Anm, and Nonat, in ail of which full notice ia taken of this affection. M. Voiain,
in an expansion of his inau^ra! tbeisUt^ lias publij^hed, under the title Dc
fEimaiotikU lUirv* Uteri ne^ Svo, Piiris 1860, an essay which enilxjdiea to a great
degree the opiniomi of M, Nelaton ; and M. Bernutz^ whose claima to priority in
reeognitiou of this affection I cannot, however, admit, has treated the subject with
has usual elaborate detail in the first volume of his work on Diaca^ea of Wotnen,
In Germany these etfoiiiona of blood have been less carefully studied than iti
France. Seanzoni's deacription is avowedly drawn from French sources, And he
ezpreases bis opinion that the frequency of the alfection baa been much overesti*
mated. Some notices of it is taken by Crwle, Monalsschri/tf. fsSurtskuntk^ vol ix.
p. 1 ; Breslau, ibid, p» 155 ; Hirtzfelder, ibid, voL x. p, 312 ; and Ht^gar, voL xvH,
p» 418, as well m by Braun of Vienna, whose pfti>er, however, 1 know only indi-
Tectly. Vircliow, in his new work, I}ie Krankha/ten GtsehwiUde, Svo, Berlin, 1863,
baa also studied it» morbid anatomy.
Dr Tilt is the Hrst Euglish writer who noticed the atftHstion in the second fdi-
tioD of his work on IHscastf of IVojneii^ p. 251. Since then it haa received due
attention in this coon try ; the lectures of Sir J. Simpson, and the treatiaea of Dr
M'CMntock and Dr Graily Hewitt^ containing notices of it ; while the interesting
case published by Dr Madge, in voL iii. of the Tmnmciiom of the ObatrJrieal Soeietf,
and the very valuable paper of Dr Mattbewa Duncan in the Edinbtinjh MetOcal
Jounutl , Nov. 1862, must not be passed unnoticed, any more than the able thesis
of Dr Tuck well of Qiford, On Efuaiom of Blood in the Neighbourhood of ihs Ulenu,
8vo, Oxford, 1863.
p
UTERINE H-^MATOCELE :
|»eritoneai The blood eeems to be poured out, in the grc^
majority of instaoces, either from the rupture of the congested
ovary itself, or else from the Umbriated extremity of the Fallopiia
tube of one or other side, whence it gravitates into the relio-
iiteriue pouch, and forms there a distinct tumoar wlxich posha
the uterus forwards and Boniewhat upwards, A few cases are oa
recoiil where the blood haa been thus poured out in such qnaotitjr
as to destroy the patient almost at once ; and though some d
these have been instlnces of extra-uterine foitation and of the
rupture of the Fallopian tube, yet this explanation does not hxM
good of all ; and suddenly fatal bleeding from the uterine appen-
dages into the peritoneum must be admitted as a possible occur-
rence in the unimpregnated condition. Any haemorrhage so pro-
fuse a3 at once to destroy life is indeed quite an exceptional
occurrence, and usually the blootl poured out speedily coagulalfia
It then excites inHainmation around it, and becomes inclosed
within a sac formed partly by the adhesion of the coils of intestine
to the uterine ajipendages, and to each other, partly by false mecn-
brane. Within the sac thus formed the same changes now take
place as occur in blood effused elsewhere. In the most favourable
cases it becomes by degrees absorbed, in othei's inflammation is
set up (usually consequent on some increase ol local congestion, and
fresh outpouring of blood) in the cyst wall : pus become-s inter-
mingled with the blood, and instead of absorption of its contents
taking place, the suppurating blood-cyst empties itself through tJie
rectum,the vagina, oruuhappily sometimes into the peritoneal cavity,
I The source of the bleeding in the uterine appendages them-
selves is sometimes very obvious, as in one instance where both
Fallopian tubes were found distended with blood, and a partially
decolorised clot hanging frf)m the extremity of one of them. In
Other cases a distinct rupture of the ovary has been observed, and
the congested or even apoplectic condition of its tissue has left no
doubt as to the origin of the bleeding. In other instances again,
where a longer interval had passed since the first occurrence of
hiemorrhage, its source was not so clear ; but the grave alterations
which the uterine appendages presented, or the absolute impos*
sibility of discovering the ovary or Fallopian tube of one side
showed plainly that in them the evil had originated. Thus, in
one case where I made the post-mortem examination of a patient
II
I d
SOUECES OF THE HAEMORRHAGE.
455
ill whom for a year symptoms of uterine hsematocele had existed,
one ovary could not be discovered even after the most careful
aearch, while the other, in addition to a serous cyst of the size of
a pullet's egg, presented an extravasation of blood into its sub-
stance as large as a sugared ahnoni The bleeding, then, takes
place frum the ovary itself or from the tube ; and now and then
perhaps in this latter case from the reflux of blood to whose out-
flow from the uterus some impediment existed* though usually
from the congested lining of the tubes themselves.
Blond poured out from other sources may indeed collect in the
neighbourhood of the uterus, in obedience to the mere laws of
gravity, but it would, 1 think, be an error to call such exceptional
occurrences cases of uterine htematocele. One theory of the
source of these haemorrhages must, however, be noticed, if for no
other reason, at least on account of the reputation of its author.
It is that of Virchow* who says—" In my opinion the blood in
these cases is usually derived almost or altogether from the newly
formed vessels of false membranes produced by previous pelvic
peritonitis.** Even Virchow's theories ought U} have some clear
evidence to rest on. I know of none that would prove pelvic
peritonitis to be an ordinary precursor of uterine htematocele.
We learn, then, from tliese observations the existence of a
previously unknown hazard attendant on disordei\'5 of the sexual
system in women ; that not merely may intense congesti(jn lead
to profuse and dangerous lloodings, or functional disturbance issue
in inHaramatiun of parts in the vicinity of the uterus, bat also
that vessels may give way, and haemorrhage take place inwardly,
in situations where it is hard to discover, and still harder to
suppress. As might be expected, the accident is one which takes
place only during the period of sexual vigour,"!- it having occuiTed
in 79 w^omen at the following ages : —
Under 20 in 4
Between 20
and 30 „
51
ft
30
•1 35 „
17
»
35
.. 40 .,
6
At
40 .,
1
79
• 2>u Krankhajttn Otschwllhte^ Svo^ R^rlin, 1863, vol i p. 152,
t Sm tlie tftblei appeoded to Dr Tuckwell's Uicsts.
4S6
UTERIKE H^EMATOCELE :
Cases have not at present been recorded in sufficient m
to prove the couiparative infttience of marriage and child-
on the production of the affection. It seems, however, to adiid
but rarely in any direct relation to pregnancy or miscai
while the fact that it has sometimes been induced by
excesses is but another illustration of the connection subeistiBg
between congestion of the pelvic organs and the outpoaringof
blood in the neighbourhood of the womb. The time of tbe
occurreuce of such special congestion at the return of a nieDstroil
period is allowed by all writers to furnish the most freqaent
occasion for the efiusion of blood ; and thou^'h there is an abseim
of unauiraity as to whether liahitual nienorrhagia or hahitnai
dysmenorrhcea most frequently precedes it, yet menstrual inegu*
larity of some kind or other will be found to characterise tbe
hisfcoiy of the greater number of patients. The liability
menstrual disturbance in the way either of excess or d
indicates usually sometlung wn:mg in the state of the gem
health ; and juat as occasional attacks of mcnorrhagia may occur
in the chlorotic girl, so may the out- pouring of blood into the
peritoneal cavity be in a measure due to constitutional caused.
The profuse, and sometimes even fatal htemoiThage, from the
vulva or into the peritoneum, which has been known to occur in
some cases of purpura and of the eruptive fevers, is but an
exaggerated illustration of this fact ; and my own experience by
no means leads me to the conclusion that the women most liabW
to these accidents are the healthy and robust.*
Be the circumstances in which these hemorrhages occur what
thej may, there is usually a certain family likeness among the
cases that will enable the attentive observer to recognise their
nature, or, at any rale* will excite his suspicions l^^th refereuite to
it. After some disorder of the menstmal function — ^sometimes
after its tempomry suppression from cold, fatigue, or moral shock —
severe abdominal pain comes on, referred usually to one or other
Ciac region. It is by no means constant for the menses to remain
suppressed adter the occurrence of this pain, which no doubt marks
the outpouring of blood into the peritoneum ; but usually they con-
tinue, tlioiigh prtibably mc»re scantily than in health ; while now
and then a profuse loss of blood takes place from the vagina, in
• See BernuU, op, eU. roL L pji. 4I1-I60,
ITS CAUSES, AND SYMrTOMg.
457
spite of the evidence of internal hremorrhage. The pain, though
severe, is selilora intense, nor is the shock which accompanieB it at
all comparable to that extreme depression which indicates the
occurrence of intestinal perforation, or the rupture of the sac of
an extra-uterine Irritation, I cannot say how soon after the shock
and pain a swelling is commonly perceptible in the abdomen, nor
wliat proportion is home to the other cases by those in wldch tlie
swelling is entirely absent, though without doubt the latter are
quite the minority, I have detected tlie swelling within 48 hours
after the first symptom, as a vaguely defined hard lump in the
iliac region, apparently of the bigness of the fist, not quite even,
not movable, tender on pressure, and feeling so similar Uy the
swelling which is felt in cases of inflammation of the uterine
appendages, that, apart from its history, one w^ould be likely to
make a mistake as to its real nature.
Pain, exacerbated at uncertain intervals, as is all pain associated
with uterine ailment, tenderness limited to the neighbourhoo4l of
the painful part, and general felvrile disturhance, though usually
not very severe, continue te be experienced, accompauied \^ith
difficult micturition, with pain and difficulty in defiecation, and
generally with an increased pain on moving the leg of theaflected
side, or on attempting to assume the sitting posture. The febrile
symptoms usually subside of tlieir own accord, the pain also
diminisiies, a sense of weight in the pelvis, bearing down, difficult
micturition ami defiecation remaining behind, with difficulty and
discomfort in walking, and lead, by the discomfort which they
occasion, to a vaginal examination, and to the discovery of the
pelvic tumour.
Tliis pelvic tumour differs much in its size, situation, and char-
acter ; and in some cases where the symptoms point unequivocally
to the existence of hfcmatocele, no bulging of the vaginal wall
has been present.* For this occasional absence of the pelvic
tumour I do not know how to account, though I think it is most
frequent when the effusion has been extensive. The fact at any
• As in cftse 1, in Dr Dun run's paper. I reeollect two casea wbiuh came tinder
my own ob&ervntioo, and which I now heUeve to have iMjen caacs of uterine
hematocele, whtre the abeence of any sweUing in the vagina confuseil me, ami
prevented iny foniiing a RAti;^fiietory diagnosis, I think that now, with lai^ei*
vzperience, I should read them rightly.
458 UTERINE hj&matocsle:
rate is of much impprtance to be borne in mind, mo ^ ^^^ggj^
the errors in diagnosis which we sbonld faJl into , ^otA^S**
pelvic tumour as an invariable attendant on these ^^ ^^^
Usually, indeed, the pelvic tumour is present, ^^^tiUSMifc
resembles that observed in cases of inflammation \jv\ixa»3tf^l
appendages. It is equally firm, seems to be ^^^^ - iotis^»^^
connected with the uterus, and has the same g^^^^^^^x A^?^ ^
ing perhaps chiefly in this, that it produces a g^ ,,^o\vi ^^ ®^
displacement of the womb than is observed in a t^ t^^ ^
size due to inflammation in the vicinity of the ^^ V^r)\i\t;y ^rifti
cumstance is, I think, readily explicable by tbe ^ ^^^mfti
which blood is effused, as compared with the greatet ^ ^yy action,
which the changes take place that are due to ^^^J^^^ T)06itioii,
and by which, moreover, the womb becomes fixed i^ ^ that take
and therefore less liable to displacement. The cba^S
place in the tumour do not seem to be governed T^T ^^^, \L
ing law. It often becomes extreraely firm, owing ^^ douDttothe
removal of the more fluid pai*t of the blood a-^^ it IB m con-
sequence of this change that a blood swelling bas occasionallj
been mistaken for a fibrous tumour. The supposed solid tumoui
however, will be observed, if carefully watched, to diminish b]
degrees, and at length to disappear, leaving behtind OflJy a littl
thickening and resistance at the roof of the vagina - andif ^^
commonly the case, aswelling also existed in the ili^rB^onM
too, will dmnmsh at the same rate with the one Mu^^^m
or will even be removed with still greater r^ ^y^^P^^^**^ ^^
instances, the tumour having shrunk from th ^^^^^/' ^^^ ^i,- \
it presented at first, will once more sudd ^^^ioiU3 ^^
increase coinciding with a more or less disfc* ^ increase ^ ,
often with actual menstruation ; and in a d ^u "^^^^nzai ^ .
nothing more characteristic of its true nat ^^^^ ^^^ ^il^^^^ ^
increase of the swelling coinciding with am ^ ^^^^ ^ie ^^^uddex
The gradual absorption of the blood, and th^^^^^^ perioc^^ —
the tumour as the patient becomes convales ^ ^^Ppeaisa-^'^ice o\
mode, and that by no means the most com ^^' ^ ^^^ om^i^^y ^^^
accident terminates. Of eight cases of which r k' ^^ ^hics^^Mi tbiB
record, there was but one in which the tmnom. ® pres^ z^crved s
process of simple absorption; and in this iixof ^ ^^ov^^^ii bj'«
was limited to the right iliac i-egion, and produ^^^ ^^® ^^s/^^elUng
CASES ILLUSTRATIVE OF ITS S\^rT0M3.
459
the vaginal wall In two cases a discharge of blood, partly fluid,
partly coagulated, took place from the rectum ; in a fourth, sup-
puration preceded its discharge, and blood-atained pus escaped by
the rectum ; and in a lifth, the sac burst into the peritoneum, and
the patient died. In the three remaining cases the tumour was
punctured by the VE^ina ; and in the last of them the ailment
was already chronic, and the blood-cyst bad become an abscess
long before the patient came under my ctirt!.
It may be worth while to nan-ate briefly the particulars of these
cases, since in the various circumstances in which they supervened,
and in the varying courses they ran, they may serve to illustrate
more completely the history of this affection. In oil the cases
but one the patients were mamed women, of w^bom three were
sterile ; four had given birth to children. This exceptional case
was that of a young immarried woman, aged twenty-two, who,
having long sutlfered from attacks of pain of a pai-oxysmal char-
acter in the left Uiae region, was surprised at the age of nineteen
by a profuse discharge of a diity reddish-brown colour from the
vagioa, which continued in varying quantity for many weeks, and
was then succeeded by a puriform discharge, occun-ing in gushes,
which continued down to the time of her coming under my care.
A tumour in the iliac region, and another felt behind tlie uterus,
fixing that organ in its place, were tlie evidences of some bygone
int!ammation— of an old pelvic abscess, in short, the origin of
which in an effusion of blood was rather inferred from the patient's
previous history than actually demonstrated. Puncture of the
abscess, and the injection of a solution of iodine into its cavity,
were followed by its complete cure, and the patient afterwards
married, though she never became pregnant. The second case was
likewise one in wliich the evil terminated in suppuration ; but the
symptoms ran a more acute course, and there was no recollection
of the matter after its spontaneous discharge by the bowel. Th«
patient was a woman aged thirty-fouj, who, though married for
f ouiteen years, had never become pregnant. For two years she had
habitually menstruated profusely, and for two months the discharge
had been actually menorrhagic. On the return of the third period,
however, the loss was extremely scanty ; she experienced severe
pain in the back and legs, with tenderness and some difficulty in
micturition. Scanty menstruation liad still been going on for some
460
UTERINE H.^MAT0CELE:
days when the patient came under my care. There wai
distinct swelling in the left iUac reUgion with much thick
the recto-vaginal pouch. In the course of fourteen d
thickening and fulness assumed the characters of a defijiite
which increased in size» until at the end of sLk weeks it b\
discharged per rectum a discoloured pus, and a fortnight i
patient left the hospital welL Tlie patient's previous hisi
character of her syinptoms, and the discoloured pus which
from the bowel, suffice, I think, to point to the origin
pelvic abscess in a previous sanguineous eflusion aioi
uterus. The third patient I saw but once, though I hear
subsequent history ; and I refer to it here because it ill
the most favourable course which may be taken by these
their less sevei'e forms, A lady who was between twe
thirty years old, and had given birth to several childreOj
cold during a menstrual period, and the discharge, tlA
suppressed, was immediately much lessened in quantity.
taneously with this diminution of the menstrual flc
experienced considerable abdominal pain, aggravated in pare
and at the end of three days a distinct swelling was discos
her right ihac region. This swelling, when I saw the
about four days from the commencement of her illness, waa
but in the direction of Poupart's ligament, of about the sisc
tist, but of a more elongated form, not movable, tenderjj
intensely so to the touch ; and it was unaasociated wit^
displacement, or with more than a vague sense of fulness
roof of the vagina. Absolute rest, and an expectant ji
treatment, were followed by the complete disappearance
swelMiig, and by the patient*a restoration to perfect health
fourth case is of special interest, on account of the devek
of the symptoms out of the sequelfe of an abortion, not out
disturbance of a menstrual period. The patient, aged thirty
having miscarried at the sixth week, followed her occupatic
' washerwoman without pa}4ng any attention to her condiLit
this exertion wiis followtjd by great increiise of the sangu
discharge, which continued for twelve weeks. At the end
time a vaginal examination detected a tumour behind the
of the size of an apple. On being punctured it gave issu
reddish-brown discharge, the continuance of which
CASES ULtJSTBATrTE OF ITS SYMFTOMS.
461
weeks was followed by the complete disappearance of the
swellin|T. lo the fifth patient, aged twenty*four, who for five
years had lived in sterile marriage, the symptoms gradually
developed themselves during the persistence for two months of a
discharge supposed to be menstrual Here, too, a tumour beliind
the womb gave issue when punctured to a black oflensive
discharge, which evidently consisted of decomposed blood ; and
the patient, having surmounted an attack of peritonitis, perfectly
recovered. The sixth ca.se so well illustrates the symptoms and
the dangers of the afifection, that it seems to me deserving of
relation somewhat in detaiL
A tall, stout, and tolerably healthy-looking woman, twenty-five
years old, who had been married for seven years, bad been
pregnant four times, and had given birth to three living children,
of whom the youngest was twelve months old, was admitted into
St Bartholomew's Hospital on February 22d, 185 L Her general
health had been good, her labours had been natural, and after all
of them she had menstruated regularly during the whole period
of lactation. Af t^^r her tliird labour matters went on as usual
imtil Christmas, wheti she menstruated naturally, but ever since
that time a stinguineous discharge, neither very profuse nor inter-
mingled with coagula had been constantly present. For a month
she had had pain of a bearing-down character, aggravated by
exertion, but not notably reh'eved by rest, nor by any particular
position; and slie had also for the same time suO'ered from
occasional fainting fits. Micturition was frequent and painful,
and her urine was reported to be both scanty and high-coloured.
A medical man whom she had consulted told her tliat" her womb
was down.'*
The abdomen was large and somewhat tense, its enlargement
being due to the presence of a tumour, the surface of which was
slightly uneven, occupying the whole of the left side, extending
three inches above the umbilicus, reaching about two inches across
the mesial line, though gradually sloping downwar^is, so that on
the right side its upper margin was an inch and a half below the
umbilicus. The tumour was firm, non-fluctuating, very tender to
the touch, especially in the left iliac region.
The finger on being introduced into the vagina came almost
immediately on a somewhat fiim, elastic tumour, of an ova! shape,
462
rXERIKE HEMATOCELE:
of about the tldckiiess of the wrist, and which had ptishf
it the posterior vaginal wall This tumour seemed to j
into tlie substance of the uterus about half an inch hi
orifice, the whole organ being so misplaced that the os t
felt lying horizontally immediately bebiod the symphys
The finger passed up in the front and right side of tl
mthout encountering any resistance ; but at the le|fl
posterior part of the pelv-if^ a firm tumour was felt appafl!
tLDUous with that immediatciy behind the uterus. The^
the tumour pulsated very forcibly. About three ounces ^
fluid were drawn off on the tumour being puncturM
grooved needle through the vagina. The microscope di
nothing but blood corpuscles in the fluid, and with the
emptying the tumour if possible, and of thereby reliei
painful pressure on the rectum, which occasioned much di
Pouteau's trocar and canula were introduced, but only ab
ounces of fluid of the same character as l:»efore were let oi
tumour was not thereby much diminished in size, nor
patient's discomfort much alleviated. On February 27th J
interference having been resorted to, she was seized wil
tonitis, during the course of which there was manifest inci
the turaijur, which extended more towards the right side
abdomen. By the 3d of March all active symptoms we
dued, and on that day the patient passed two copious evac
which were perfectly black, and apparently consisted ent:
altered blood. The same afternoon, too, she experienced e
tion as of sometbing giving way internally, and tl
immediately followed by an abundant gush from the va
very fetid fluid, resembling coffee-grounds in appearance
fluid flowed at first very abundantly, afterguards more scan
morning, when it ceased, though another gush of it took p
the following day, and afterwaitls recurred occasionally for
days, acquiring l>y degrees a Ughter colour, and becoming a
dirty sero-puruleut matter. Very slowly the patient's j
health improved, while at the same time her abdomen dim:
in size, and having measured forty-sis inches on her adn
had shrunk to forty inches on March 24th. The tumour
left hypogastric region at the same time manifestly diminii
size and became more mesial in its position ; and on April I
CASES ILLUSTRATIVE OF ITS SYMPTOMS,
463
uterus had nearly regained its natural situation ; there was no
longer any distinct tumour behind it, but a hard, semicartUaginous
thickening, ill-ilefined as to its extent and relations. On April 1 7th
all discharge from the vagina finally ceased, and on May 5th all
trace of abdonn'oal tumour had completely disappeared, the
position of the uterus was q^uite natunil, the thickening behind it
was much lessened. A year afterwards I again saw the woman ;
she was in perfect health, menstruating^ regularly ; there was no
trace of abdominal tumour, the uterus was perfectly movable, and
there was scarcely any thickening to be felt behind it, or to its left
side
The seventh case is important, as well on other accounts as
because the extreme firmness of the vaginal swelhng raised the
guspicion^ more than once diuring the patient's illness, that it was
due to a fibrous tumour connected with the posterior wall of the
uterus. The patient was t^venty-sbt years old, and had given
birth to three children during seven years of married life. Four
months before she came under my notice she was attacked during
a menstrual period by pain in the abdomen accompanied by
expulsive efforts of such severity that her medical attendant
thought her about to miscarry* The pain by degrees subsided,
jmd the menstrual fiow was neither increased nor lessened ; and
the two succeeding periods were punctual in their return, though
accompanied by an unusual amount of pain. Her third period
was postponed for nearly three weeks ; and for two days before
the discharge appeared the patient suffered pain similar to that
which she had before experienced, but more severe. The menses
were on this occasion unusuidly scanty. Their Mow was accom-
panied by an increase of pain, by sicknea«j, and by so much
difficulty in micturition, that it was necessary on more than one
occasion, to have the catheter passed ; and deffccation also was
attended by an increase of suffering. It was on the sixth day
from the commencement of these symptoms that the patient came
under my notice. The uterus was then carried forwards and to
the right side by a swelling which occupied two-thirds of the
post-erior and left side of the pelvic cavity. The tumour was firm
but elastic ; its surface was smooth, its vessels did not pulsate,
and there was no increased heat of the vagina. It was not until
a week later that an abdominal swelling was detected, though it
464
UTEKIN'E It^MATOC£I.E :
■^
had been previously sought for ; but possibly the
abdominal tenderness interfered with that nimute exai
which waa practicable so floon as it had subsided This
was situated in the left iliac region, it reached for abo
fingers' breadth above Poupart'a ligament, and from
the iUac spine ; but its outline was indistinct. Fori
fourteen days this abdominal swelling increased to neari;
its former size, and at the same time its upper border
much more distinct, but no change took place in the pelvic
other than that the elasticity which at first it liad so d
presented became much less marked. Without any d
having taken place, the abdominal tumour now began to
the uterine lips and cervix, which, on the patient's admisi
the hospital, were full and pufly, lost these characters con
while the hardneaa of the tumour gave it a most d
resemblance to a fibrous tumour. A week afterwarda^
thirty days from the patient's admission into the hoepi
thirty-six fmm the commencement of the attack, a disci
blood took place from the rectum, partly fluid, partly i
and this recurred more than once. The abdominal inmi
found three days afterwards to have much diminished, £
in the pelvis to have altogether disappeared, the uterus
nearly resumed its natuml position. Fouiieen days la
patient left the hospital, a vague induration about P
ligament indicating the former seat of the abdominal tumc
a little tliickening about the roof of the vagina, and in th<
of the broad ligament interfering somewhat with the freMj
of the uterus. |
The eighth and last case was one which I saw at intervi
with Dr Kirby, of Gordon Square, to whom I am indel
many particulars of her history. The patient was a lady,
two years old, who had been raarried nine years, had give
to one child between seven and eight years before I saw ]
had never afterwards been pregnant Her labour was fc
for some time by irregular and excessive menstmation,
w*as at length suddenly checked by treatment. For seven
afterwards menstruation became scanty, postponing, often
altogether, and always associated with much pain and s
Not infrequently, too, the constitutional disorder
CASES ILLUSTEATITE OF ITS SyMPTOMS.
465
unaccompanied by menstruation, and at la8t relieved by vomiting
of blood Gradually the more urgent sjrmptoms subsided, but
for some two or three years before the commencement of her
f tital illness, she had much dysmeuorrhcea, ovarian tenderness, and
uterine pain, though there was no change Jiscovemble on a
vagiDal examination. On October 19, 1862, a meni^truul period
came on which w^as very abundant and protracted, the discharge
being intermingled with small coagnla and matter like dyamenor-
rhoal membrana Oo the return of the next menstrual epoch,
though discharge had not commenced, the patient suddenly
complained of a sense of fulness and bearing down, of fain tn ess,
and of inability to empty the bladder, and a tumour was now
discovered in the right iliac and hypogastric region, and the
uterus was cai'ried forwards by a swelling seated between it and
the rectuna. Botli these tumours continued, varying indeed in
size, and in the tenderness of which they were the seat» aod the
abdominal tumour was sometimes difficultly distinguished, though
that felt per vaginam under^^cnt much less considerable alteration.
The patient suffered from frequent and severe attacks of par-
oxysmal pain, and this pain always accompanied menstruation, the
periods of w^hich were tolerably regular. Pain in the tumour, too,
interfered with any attempt at moving, and sleep w^as seldom
obtained without the use of opiates* In April 18G3, about five
months after the commencement of her illness, the patient began
to have frequent attacks of shivering, with rapid pulse, night
Bweats, and other hectic symptoms, under which her health failed
though very gradually, and temporary improvement took place
now and then.
The swelling in the abdomen did not notably increase, but
remained about half the size which it had first presented, while
the internal tumour underwent no alteration, and though not
ahsolutely solid, yet yielded nowhere any sense of fluctuation.
It was at length determined, after the lapse of eight months,
that an exploratory puncture should be made %vith a fine trocar,
and that this should be enlarged if, as there seemed no reason for
doubting, the collection of blood or matter were reached. This
was accordingly done by Sir J, Paget; but though to his own
sensation as well as to the bystanders, the trocar seemed to have
entered a cavity, nothing flowed but a drop of blood. A good
2g
466
TJTERDTE HjEMATOCELE
deal of constitutional disturbance, mucli sickness, some al
tenderness, but no severe pain, succeeded this punctun
was made on July 11th. The patient's pulse, too, becai
frequent, and her condition altogether, though not sue
indicate immediate danger, excited much anxiety, as it se
point to the existence of cyst inflammation. In the mo
July 20th, the above named symptoms having lasted
marked aggravation^ the patient made an attempt to vol
but finding heraelf unable to empty lier bladder, sent for Di
who found her in a state of collapse, and she died at 4
the same afternoon, having manifested aU those symptom
usually follow the perforation of any important viscus.
The abdomen was found to contain a turbid, brownish
mixture of thin jjus and blood, which had issued from thi
cavity and flowed among the intestines. There was a
fulness of vessels of both surfaces of the peritoneum, and
isurface of the intestines, and a little lymph thinly deposit
and there evidently of comparatively recent formation* —
this, belo%v the umbilicus, and especially in the left iUH
there was a good deal of roughening of the peritoneuni aa
old peritonitia, and there were many smsdl blackened sp
ecchymoses, an the roughened surface. The pelvic conten
bounded above by a coil of intestines which was adhereni
upper surface of the pelvic viscera, and thus formed a ]
cyst or sac, in the left side of which there was a small tri
rent about half an inch in length, through which its coute:
escaped into the abdomen. This sac, which was boondad
left side of tlie uterus, still contained about eight ounced ol
pus, such as was found in the abdomen. The reason of i
escape on the puncture being made per vaginam was disi
in the presence of a layer of extremely firm black clot an
of an inch in thickness, which lined the lower half of the a
was almost as firm as a piece of leather, so that the point
trocar had failed to penetrate it but had detached it £n
walls of the cavity and thus failed to evacuate its contents
The right ovary contained a cyst the size of a pullet's e|
also a large recent clot the size of a sugared alraoni Ni
muni cation could be made out between either tube and ti
but the left ovary, after the most careful search, could ;
lid nolfl
ITS DUGN0SI3.
4G7
out among the folds of the thickened and altered broad ligament.
The pelvic tumour had completely disappeared after death.
This ease calls for but little comment, though it illustrates
extremely well some of the more characteristic features of uterine
hiematoeele. The disturbed menstruation^ the pain in the per-
furmance of the function, the appearance of the pelvic tumour,
the firmness which, but for the knowledge one had of the state of
the womb before any such swelling existed, would have raised th«
question, whether by possibility it could be a fibrous growth, are
all phenomena with which our previous study of the subject has
made us acquainted. Next comes the discovery of the swelling in
the iliac region, always tender, often the seat of acute pain,
aggravated in paroxysms, and increased specially at the menstrud
periods, the cause of which pain is partly explaioed by the
evidences of old pelvic peritonitis. Next may be added the
variations in the size of both the internal and extemal swelling,
coincident, no doubt, witli the occurrence of fresh effusion of
bh^od, or with its partial absorption, and the difltrent sensations
of tirmness and elaatieity which the internal sw^elling communi-
cated at ditlerent times to the finger. Lastly, we have the
occasional rigors, the ill-marked hectic, the fitful advances towards
a convalescence which seemed as if it were about to he arrived at ,
but was never actually reached ; and then the surgical interfer-
ence, which 8ufticed» though so slight, to call the slumbering
mischief into activity, and to dispose the frail wall of adventitious
membrane to give way, which at length it did under the slight
effort made in the attempt to empty the bladder.
There are several conditions wuth which thi.** uicrm^ h^mnloait'
may he confov^idcd ; viz., extra-uterioe pregnancy, retroversion of
tlie pregnant uterus, inflammation of the cellular tissue between
the uterus and rectum, and fibrous or ovarian tumour ; and the
points of similarity between each of these are quite sufficient to
lead very readily into error* The suppression of the menses,
the abdominal or pelvic discomfort, and the sense of bearing
down backwards, are symptoms common to effusion of blood
beliind the uterus, and to an extra-uterine ftetatton between the
second and fourth months; while the general contour of the
tumour is very similar in the two cases, and there is often the
same remarkable pulsation of the vessels distributed to it in both,
468 UTERINE HiEMATOCELE:
thougli, I believe, this is by no means so constant in the case of
uterine hjematocele. The attacks of pain in extra-aterine foeta-
tion are, however, usually more intense and more paroxysmal,
while the discomfort in the intervals is less; the sangoineoiu
discharge is absent, and the uterus, if examined with the soimd,
is ascertained to be increased in size ;* and even without it the
condition of the os uteri and portio vaginalis of the cervix, with
the puffy lips, the closed orifice, and the swollen tissue differs
widely from the completely undeveloped state of those parte in
cases of haemorrhage about the womb.
The effusion, when considerable, may cause, as it did in the
case which I have related, complete retroversion of the womb, a
condition which, when associated as it is sometimes with sup-
pression of the menses for two or three months, may raise the
suspicion of pregnancy, and lead to the tumour being taken for
the fundus of the enlarged and misplaced uterus. Professor Cr6de,
of Berlin, relates an instance in which these very circumstances
led him for a moment into error, and in which he endeavoured
vainly to replace what he supposed to be the pregnant and
retroverted womb. Further observation soon led him right, and
the same considerations as rectified his diagnosis may keep us
from error. The cervix and os uteri presented none of the
changes of pregnancy; the bladder was not affected; and the
uterine sound, which entered readily in the natural direction, could
not be turned round with its concavity backwards, nor be made to
enter the tumour, intimately though it seemed connected with the
womb.
The characters of the tumour in cases of inflammation of the
uterine cellular tissue very closely resemble those of uterine
hicmatocele, and the history and symptoms present a very near
analogy in the two affections. There are, however, some points of
difference between them which are generally sufl&ciently marked
to preserve the attentive observer from error. Pelvic abscess is
very generally the consequence of delivery or of abortion, while it
* With reference to the inference to be drawn from measurement of the aterine
cavity, Dr Matthews Duncan gives the important caution that "the utenu wu
found greatly elongated in every one of the instances he had recorded, when the
haimatocele waq large, and in all it contracted with the contraction of the Uood
sac."
ITS DUONOSia 469
is scarcely ever associated with any other form of menstrual
diaorder than its sudden suppression ; the itiflanimatory symptoms
developing themselves directly out of that accidents Uterine
hfematocele, on the contrary, is seldom the imnudmte consec^uence
of a single suppression of menstruation ; it is not infrequently
preceded by menorrhE^ia, and is often accompanied, at any rate
for a time, by a copious sangiiineous discharge, a symptom Avhich
never attends upon inflammation of the cellular tissue in the
vicinity of the uterus. I am not sure that the consistence of the
tumours furnishes any very trustworthy clue to a correct diagnosis,
since the degree of firmness of a uterine hjematocele is liable to
very wide variations, but considerable value may be attached to
the circurastauce that at no period are there the same thickening
and induration about it which are so remarkable in that part of
the vaginal wall adjacent to any collection of matter.
Ovarian trysts may occupy when small the same situation as
uterine hiematocele ; they are not, however, so sudden in their
occurrence, nor so rapid in their increase ; while, though their
development is often associated with menstrual irregularity, they
are not attended by any constant sanguineous discharge. The
ovarian tumours, too, do not descend equally low into the recto-
vaginal pouch, and consequently do not produce the same difficulty
in defivcation, while, further, they are not so intimately connected
with the uterine wall, and the womb can usually by means of the
sound be completely isolated from the adjacent swelling.
Though this be true, however, it must yet be borne in mind
that the existence of an ovarian tumour is sometimes suddenly
discovered, owing to some special inconvenience, pain, or unusual
menstrual disturbance which it may have occasioned ; fm-ther, that
the two conditions may co-exist ; and, lastly, that bulging of the
recto-vaginal wall in cases of ha^matocele, although usually very
marked, is sometimes altogether absent, and this even though the
collection of blood may be very extensive, and the abdominal
tumour may have attained a ver}^ considerable size. In the first
case related by Dr iJancan, though the tumour reached as high as
the umbilicus, so that its contents were let out by puncture of the
abdominal walls, yet the evidence of the collection of bloo<ly fluid
not having bceri contained within an ovarian cyst appears to me,
as it does also to him, decidedly to prej)onderate. Many instances
470 UTERINE HJKMATOCELB*
of the same kind, too, are on record, and one ^^,iNf\A<*^^
notice (though I have not included it «^^^ ^^ size «*^
observations are founded), in whicli tlie veryW^^j^^W
by the abdominal tumour, coupled witli the ^^^^g^J^^"^^
ing of it into the vagina, led me to regard the 8^ ^^ coti«***^
though I have since entertained grave doubts a8 ^
of this opinion. . c-U©^ ^ vii \^
In the great majority of instances the^ ^^^tt^tv^ \^
fibrous tumour and an effusion of blood will he ^^^je ^^ ^^
difficulty, though we know that very able ^^^ ^"^^^.^ ^^
mistaken the one for the other. It nnust not be ^ ^i^^^^ . -u
history one receives of a patient's illness is to^ ^cot^^^
exaggerated, or even in many respects altogetl^^^^* t^^^^ ^
the next place, the presence of a tumour in the i>^ |\iift\» »ft"''5^
means clears up the difficulty as to the nature til^^^^^
vaginam, since both may be fibrous growths, or t^^ ^ inegolw
to the effiision of blood, while pain and xnexiBtX'^^ -rmueas ol
may attend on either affection, and the degree of ^^ ^-^^
swelling is a most inadequate ground on w^hich to sr^^
and, when a mistake has been committed, has l:>^^^ ^^ ^
source of error. I believe that a* fibrous tumour so situated fi
be mistaken for a hsematocele, Mrill displace the ut^xms more <
siderably than an effusion of the same dimension's^ and fart
that such displacement will rarely be lunited to tii e mere eh
tion of the womb, and the pushing it to one side hut that
organ wiU also be retroverted. or its position will be others
manifestly changed. Time, however, will almost cerfcainJv rem.
the doubt, tfae immediate solution of which is seldom vei/,™
and It must not be forgotten that three-fourths of oirr X^
errors arise f xom the needless haste of our decisions. ^^^^^
Inclusive of my own eight cases, I have collected lO^ ir. ^
of uterine l^^matocele, of which 20, or almostZ^^Zi^*^
fatal. There can, I apprehend, be little doubt hZth^- ^^'
fatality is e^nsiderably less than would appear fr^V.^ ^^ ^^
feet data; f^r, on the one hand, some of the casTi ^^tf^^
ported as p^athological rarities; and on the other ^^^ *^^«^
have had a :^avourable issue have been unrecorded. ^M^ ^^^^
have certaijc^ly passed unrecognised, for the disnoa-H "^P^**
spontaneous absorption of the effosed blood, unlessth^^ ^^lU
ITS PKOGNOSIS. 471
poured out has been enormous, seems to be very gi^eat, bo that
menstrual disorder and abdominal pain ba%'e probably often
passed away without a suspicion having arisen of their connexion
with htemorrhage around the uterus, or into the cavity of the
peritoneum.
The aubjoined tables will throw light on many points connected
with the pathology as well as with the treatment of the atiectiou*
Of 55 Citses of uterine h^ematocele, treated on the expectant
plan, 4:i recovered^ 12 died.
Of the former —
The blood was absorbed in 30
„ escaped by the rectum in ... . 7
„ „ „ vagina, .... 4
^ „ „ uterus, 1
^ ,, into cavity of peritoneuiu, 1
43
Of the 12 deaths—
1 took place from phthisis.
1 „ „ phthisis and albuminuria*
1 „ „ supervention of dysentery.
1 „ „ great debility and extensive abscess
of the thigh,
and are therefore only indirectly due to the sanguineous effusion.
Of the remaining 8 —
1 took place from pytemia after the tumour had burst
per rectum.
1 „ „ hfiemorrhage by the bowel
2 „ „ hamorrhage into the cyst.
1 „ „ „ „ ,, and per vaginam.
1 „ „ rupture into abdomen, and peritonitis.
r peritonitis without cyst rupture, the
2 „ „ 4 inflammation being acute in the one
I case and chronic in the other.
8
Of 48 cases in which sui^ical interference was had recourse to,
40 recovered, 8 diei
472 UTERINE H^fflMATOCELE:
In 38 of the 40 recoveries, the puncture was made by the
vagina.
In 2 of the 40 recoveries, the puncture was made in the abdomen.
Of the 8 deaths—
1 took place from peritonitis after puncture of the abdomen.
In the other cases the puncture whs
made by the vagina.
1 „ „ cyst rupture after ineffectual puncture.
1 >, » pyaemia, symptoms of which had pre-
ceded the puncture.
1 „ „ pyaemia, following the puncture.
2 „ „ haemorrhage through the wound.
1 „ „ „ into the sac after closure of
the punctured wound.
1 „ „ peritonitis.
~8
[It will be observed that in one of the cases death was caused by
pyaemia, symptoms of which had preceded the puncture ; and, in
connexion with this, I may mention a case of a large retro-uterine
haematocele, apparently uncomplicated, which was taken for a
fibrous tumour till death, which, on its approach, was recognised
as arising from septicaemia. The post-mortem examination dis-
covered an ordinary intra-peritoneal haematocele of the size of an
adult foetal head. It was filled with clots and tarry fluid, in a
state of putrefaction which had been no doubt going on during
life. There was, after careful search, no discovery made of any
communication with the bowel or other route of access for putre-
factive germs].
Lastly, we come to the important question of the appropriate
treatment of this affection. It happens rarely, though unques-
tionably it does happen sometimes, that the blood is poured out in
such great abundance as to occasion immediate hazard to the
patient's life, and in such circumstances the local application of
cold, the employment of stimulants, and the use of opium, given
as in cases of intestinal perforation for its stimulant rather than
for its sedative properties, is clearly indicated.* I once saw a case
* In a book far less known than it merits, Medical Problems^ by Messrs Griffin,
of Limerick, is a most suggestive chapter on the use of opium as a stimnlaot,
which should be well studied by all especially who are engaged in obstetric practioe.
ITS TREA'nfENT,
473
which I imagme to have been of this kind* It occnrred in a
woman between thirty and forty years of age, the mother of one
child, who bad for some few times menstruated irregularly* On
the third day of an extiemely abundant menfitniation she suddenly
sank into a state of great exhanstiun, which the external ba-mor-
rliage was quite inaedquate to account for. She fainted, and lay
long in a condition of syncope, her pnlae was almost imperceptible^
her surface was as cold as that of a patient in the stage of collapse
from cholera, and I thought her djing when I saw her about five
hours after these symptoms had come on. A vaginal examination
threw no light upon the case, as no tumour w^as detected in the
pelvis, but one feared that the sac of an extra-uterine fa*tation
had burst and that the shock depended on tliis cause. Ice was
applied to the vulva and over the piibes, opium and stimulants
were administered, and attention was paid to keeping the surface
warm. Tlie next morning I saw the patient after an interval of
eighteen hours. She bad rallied slightly, and I heard* for I never
sawheragain,.that she slowly recovered, without having presented
at any time symptouis of fieri tooeal iDllammatioD.*
Such occurrences as these are rare, and usually the symptoms
which one has to deal with are very similar to those of inflamma-
tion of the uterine appendages, and are to be treated in the same
way by absolute rest, by poultices, by sedatives, and by the care-
ful use of mercurial remedies^ Witli tlie return of each menstrual
period, all precaution must he redoubled, since it is under the
conditions of general excitement of the circulation and special
congestion of the sexual organs which then exist, that fresh
hiemorrbages are apt to take place. I have occasionally applied
a few leeches in the iliac region, when the tension seemed very
considerable and the tenderness extreme, but have never resorted
to large local depletion as a means of controlling the ba'morrhage
and hastening the absorption of the blood already eiFuaed»
M. Aran,! however, has adopted a much more active plan, and,
as he alleges, with very remarkable results. In a case where the
effusion is recent, and the constitutional condition of the patient
does not forbid it, he applies from twenty to thirty leeches over
• [An iiat4?fe«tmg aud clonely similar caie, with remarka, ia recorded in the
Edinburgh Afedical Journal, for April 1868],
t Op. ciL pp. 817-522.
the abdominal ewellmg; on the next day from fifteen
in the same situation j from twelve t€ fifteen on the thiit
the strength of the patient admits of it ; and it is extremelji
that a fourth application is needed. The patients are su
by nutritious diet while this local depletion is carried <
thia is succeeded as soon aa possihle hy the use of blial
frictionB, or other applications of iodine, to the abdomeo
these means/' says M. Ai'an^and lie details cases in su]
Ms assertion—" I have reduced to fifteen days in some c
from twenty to thirty in others of a less favourable kt
course of an afiection which has been estimated by ail j
winters on the subject at a period of many months/*
The experience of one so cautious and so trustworthy
Aran demands consideration, and the practice based oiifll
a trial. V
But whether an antiphlogistic plan be employed with ]
less activity, the great question which presents itself in
number of instances concerns the expediency or inexpedi
surgical interference. Opinion on tliis point dillered fc
much more widely than it does at the present momei:
there seems now to be a general approach to unaniniitj
French writers as to the inexpediency of meddling wit
coUectiona of blood. The cases wliich I have collected f
sources, and in doing which I have been very careful not to
the same twice over, are quite inadequate to decide the pc
think, liow^e ver, they tend to show that the dangers of pi
are less considerable than some of its opponents have su
them to be ; and further, that they are of just the same I
one has to encounter in cases which are left entirely to nat
The much dreaded har^morrhage is evidently a very exoe^
occurrence, and the supervention of fatal pya^mic or peri
sjTUptouis IB by no means limited to cases where interfere!
been had recourse to. Still, these symptoms have unqnesti
been lighted up by puncture of the cyst, even in many
which eventually recovered ; wiiile the hazard of rupture ii
peritoneum is by no means certainly prevented, even tb
* Dr M, Duiicon'ft cttMi Are e^uaUj yoliuiblfl as illuatnitire of the m
pun e til re of these oollectioiif of blood, vhetli«c erne Accopta or rejects hk
na to thtir oniinary mtrft-pcritoneal aite.
4
ITS TREATMENT.
free communication has been established with the vagina or
rectum. lu three oat of four of my cases, where the cyst was
punctured per vaginam, the operation was followed by peritoneal
inflammation which was once of gi'eat severity; and the existence
of an opening in the vagina did not in that instance prevent the
establishment of a communication with the boweli and the dis-
charge of a large quantity of blood per anum. Even an explora-
tory punctmre is not always free fmm risk, as my eighth caso
shows ; while the cause of its failure has also been met with in
other instiinces, where the coagulation of the blood has formed a
thick layer of hbrine wiiliin the sac, and has thus prevented the
escape of its fluid contents.
Weighing the reauJts of my own experience with what I can
gather from that of others, I should be disposed
Not to pwuture the ctfsi —
Ist, so long as the effusion is recent, and there is therefore
reasonable prospect of its being absorbed.
2d, So long as the effusion, although of long standing, is in
course of gradual, even though very slow diminution.
3^, Nor 80 long as the periodical increase of the effusion
coinciiling with the return of a menstrual epoch, shows the cause
which originally produced it to be still in operation.
/ shmdd ptmdure tkt cyd —
1st, WTien a long standing effusion shows little or no disposition
to become absorbed.
2rf, When the occurrence of rigors and the supervention of hectic
symptoms prove suppuration to have taken place ; and in such
circumstances I should puncture through the abdominal walls,
provided the swelling were not readily accessible by the vagina.
LECTURE XXIIL
DISEASES OF PARTS CONNECTED WITH THE UTERUS— INFLAIDIA-
TION AND ITS RESULTS, AND KINDRED PROCESSES.
Inflammation of Uterine Appendages ; — of the Ovabiss.
Inflammation of the ovaries, imperfect state of our knowledge. Morbid Appev-
ances, inflammation of their peritoneal surface frequent ; inflammation of
their substance rare. Changes produced by inflammation in the Oraafias
yesicles : suppuration, and ovarian abscess.
Symptoms of ovarian inflammation ; of its acute form ; of absoess of the oraiy ;
cases in illustration.
Chronic inflammation of the ovary, its frequency probably overrated ; neoralgSe
character of symptoms attributed to it. Occasional occurrence of sab-acnte
ovaritis ; relation to it of the so-called displacement of the ovary.
Cirrhosis of ovary : Slavjansky's observations on ovaritis.
Note on Hernia of the Ovart ; and on Serous Ctstb of Utxbub.
Frequently in the course of these Lectures I have had occasion
to lament tlie incompleteness of our knowledge, the imperfection
of the evidence on which we are compelled to act ; and have been
fain to content myself with hints and suggestions; with com-
municating mere fragments of information where yet I felt that
definite statements and positive rules were most needed.
Much of the subject of to-day's Lecture can, I fear, be treated
by me only after this imperfect fashion, unless I widely overstep
the limits of my own knowledge, and assume a positive air where
yet my convictions are far from settled. Some facts, indeed, are
well known and universally admitted, such as the frequency of
acute ovarian infiamm^ion as a complication of puerperal peri-
tonitis, its rarity in other circumstances ; but the frequency, the
symptoms, and the importance of the more chronic forms of
inflammation of the ovaries, are questions which have received
very discordant replies, and for whose final decision data appear
to me to be still wanting.
The difliculties to which I have referred do not, indeed, arise
INTLASOrATION OF THE OVAEIESt
477
from the rarity with which morbid appearances are discovered in
the ovaries, but rather from the uncertainty wliich prevails as to
their nature or as to their importance. In 21 out of ij6 instances
in which I examined the uterus and its appendages in the adult,
the ovaries themselves, or parts immediately connected with them,
presented changes more or less obviously due to inHammatory
action* In 10 of the 21 casea the main evidence of inflammation
consisted in traces of old peritonitis of the uterine appendages, and
in 5 of the number there was no evidence of otlier or of more
recent mischief. The amount of this peri tonitis varied exceedingly.
In some instances it was confined to one side, and its results were
nothing more considerable than a thin and partial layer of false
membrane on the surface of one or other ovary, and long Mlament-
0U8 adhesions between the ovary and Fallopian tube. In other
cases a complete web of false membrane enveloped the ovaries,
thickened the broad ligaments, and by its contraction short-enetl
the ovarian ligaments^ thus drawing the ovapies much nearer than
is natural to the sitles of the uterus, wliile at the same lime they
and the Fallopian tubes were firmly and inextricably matted
together. Now and then, too, the ovaries were not merely drawn
nearer to the uterus, but their position ivas in other respects
changed, they being tied down behind it; as in the following notes
of the examination of the body of a woman who died at the age
of thirty-seven, of chronic bronchitis and emphysema, and all of
whose four labours were alleged by her husband to have been
perfectly natural The uterine appendages on either side were
doubled back behind the uterus, and matted together in that
situation by firm old adhesions, in the cellular tissue of which a
good deal of firm granular fat was intermingled. The Fallopian
tubes on either side were convoluted, dilated to the size of the
little finger, by the presence in them of a thick red secretion, like
a mixture of blood and mucus. Each was firmly adherent to its
corresponding ovary, &o that it was almost impossible to dissect
them apart Though twisted round as above described, they did
not pass tlie mesial line, but wound about on either side of the
uterus. On opening them they presented the ap|>earance of a
number of freely communicating sacculi, not unlike a section of
the Fiiciis mariJitis ; and the right, wliich was the larger of the
two, measured at its widest part, which was one inch from the
478 INFLAMMATION OF THE OVABIES:
uterus, just an inch and a line when laid open. This eiu ^^ ^^
continued, though diminishing till about a quarter of *^ , ^ tabes,
the uterus, where it ceased ; the short remainder o ^ ^f the
though pervious, not being wider than natural T*^® vably ^^
tubes were very dense, their muscular structure re^^ ^^\xe&ixom
tinct, and their lining membrane stout, tough, easily ^ polish©!
the subjacent tissue, and presenting somewhat o
surface. diftculty ^da-
The left ovary was much atrophied, and was '^ ^j^^ue and the
tinguishable in the midst of the thickened ceU^^ ^ within the
fat which abounded on either side of the utet^ much, lateet
folds of the broad ligament The right ovary ^^^^ ^^ ^^^,
than natural, though very little of its proper ^ ^^^ walnut, wag
guishable. Its size, which was that of an unsl^^ v * i
chiefly due to a cyst, lined by a smooth, polish^ . . * , ,
filled with thick, grumous blood, as weU as ca^^^^ ®^^® ^^*
coagulum, which required a little force for its (J^*^^™^^*^
In other cases I have met with a less degree ^^^ ^^^ ®^™® ^^'
dition of the uterine appendages, and have found t>^6 ovary wasted,
apparently as the result of its compression by -fcle form&tion of
false membrane around it, an occurrence to Tvhioli must probably
be attributed the sterility that frequently foIXow5 an attack of
peritonitis, and the permanent suppression of t j^ menses that
occasionally, though less often, succeeds to the Sai22e cause.
More important than the changes produced bjr i,^^^^^/^^ ^^
the exterior of the ovary are those alterations w^i^.'^u 'j.
^. . , , , • n • 4.1 n ^ ^nicb It causes m
their substance, and especially m the Graafian voo,-^i ^m
, ^ c' . ^ , 4. • J J ^^sxoles. The mere
substance of the ovaries does not, indeed, except in th l
state, often present appearances indicative of infl«^ .
its results. The softening of their tissue, the ir^^ii. ^ }^^ ^^ ^
, . , . .. 1 . " ^^Wtration with
pus — which IS sometimes poured out so suddenly ^ •
abundance as to produce rupture of the organs — orth t ^ ^^
of their substance occasionally observed in the bodies .^'^^^
who have died during epidemics of puerperal fever, are ^P^®^
which, to the best of my knowledge, are not met with in th • °^
pregnated state. Affections of the ovarian tissue, apart fm ^i^"
puerperal condition, are, I believe, almost always second
subordinate to those of the Graafian vesicles themselves Th
when the functions of the ovaries are no longer exercised ^*
PATHOLOGICAL CHANGES WHICH IT PRODUCES.
479
ovules are not in course of production and maturation, we find the
substance of the organs shrunken, dense, and frequently inter-
sected by white lines of firm cellular tissue ; and just in a similar
way do we find them swollen, coDgested, and infiltmted, in conjunc-
tion with a turgid state of the Graafian vesicles, and with the
presence of evidences of inflammation about their coats. In these
circumstances, indeed, we find the whole of the ovary considerably
increased in size; hut my own experience corresponds with that
erf Kiwisch, who says that it is extremely unusual for the organ
in the unimpregnated condition to he enlarged by any infiamma-
tory afliection of its stroma to more than double its natural si^e.*
It is in the Graafian vesicles themselves that we find, m indeed
might be anticipated, the most important results of inflammation ;
and such infiammation is of great moment, from the circumstance
that in some instances it is probably the fii'st step in the produc-
tion of ovarian dropsy. In the case of women who liave died
during or soon after menstruation, it is, as you know, very usual
to find a atate of general turgescence of one or otlier ovary, with
great prominence of some of the Gmafian vesicles, and minute
injection of their external membrane, while a large clot occupies
the cavity of that one of the vesicles from which the ovule has
escaped. Such appearances of the ovary are physiological, and
pass away with the subsidence of the periodical congestion that
produced them, the clot itself being gradually removed, and the
contracted vesicle disappearing by degrees. Appearances of a
jiomewhat similar kind are met with, however, independent of
menstruation, and in circumstances that point directly to inflam-
mation as their cause. Thus, in the case of a prostitute, twenty
years of age, who was suffering from severe gonorrhcea at the time
ol her death from pleuro-pneumonia, the whole interior of the
ca\ity of the uterus was covered by a copious puriform secretion,
the surface beneath being of a bright red, just like red velvet.
This condition ceased abruptly w^here the plicated structure of the
cervix uteri began, but was continued along the whole tract of the
Fallopian tubes. They w^ere pervious at their uterine ends,
obliterated at their fimbriated extremities, filled with thick pus,
whicli had distended the fimbriae into little pouches, while their
lining membrane w^as of a finely flocculent appearance, and of the
* Op, dt, ToL ii. Becoml edition, p. 47.
w
m
I
stagj
>nt9l
d in
I
most vivid red The ovaries were rather large ; they W«
what congested, the Graatian vesicles were both numc
turgid, and their membrane presented a most beau Li fill ap]
being traversed by very minute vessels, and looking aa if I
vermilion injection had been thrown into them.
I do not know exactly what the subsequent
disease would have been if the patient's life had nc
short by the pneumonia. Probably, however^ the cont
vesicles would next have been obviously changed, and jb
lihood would have eventually become purulent S13
were the contents of many of the Graatian vesicles ii
ovary of a girl who died of very acute peritonitis ; and
there was found a cyst distended with pus, of the size of an
connected with that organ, while many of the Graafian
contained little drops of pus, though there was no suppun
its general tissue, and the other ovary was ciuite healthy.
The large cyst in this case had probably existed for a lo
before the commencement of the patient's fatal illness, i
supervention of inflammation in it was very likely the {
departure of aU the subseciuent mischief. As we aha
occasion hei*eafter to observe, the occurrence of inHammati
BUppui*ation in an ovarian cyst is an accident by no
unusual, and one which sometimes takes place without gir
to symptoms so severe as might have been anticipated*
cases, however, are perfectly distinct from those of prL
abscess, which latter are also, I believe, of much grea
For the most part the increase of such abscesses generally
rather slowly, and their development is usually attende
spnptoms of far more serious constitutional disturbaao
accompanies the growth of an ordinary ovarian cyst ; thoug
a time they not seldom become stationary, and remain so e^
yeai-s. Thus, in the case of a patient who died twelve yeai
her first attack of inflammation of the uterine appendage
four years after her second and last seizure of a similar kh
right ovary was beset with numerous yellow dots of a
which looked like softened cheese, probably the result ol
change in the contents of the Graatian vesicles, while U
ovary, to which the corresponding tube w^as hrmly ad]
formed an abscess the size of an orange and full of pua,
4
ITS ACUTE FOHM.
4«L
cavity of this abscess was sinuous, as if several collections of pus
had eventually been fiL^ed by the removal of tlieir septa into otie,
and at its lower part there was a mass of cretaceous matter of the
size of a chesnat
There are, besides, some appearances of no great rarity presented
by the Graafian vesicles, which have been supposed, and with
considerable probability, to be the results of a chronic, or, at any
rate, of a bygone inrtammation. Such is the loss of transparency
of the coats of the vesicles, and especially their entire conversion
into firm, whitish, or yellowish-wbite, shot-like bodies, of the size
of a small pea, and of a homogeneous, somewhat friable, texture.
In some instances the stroma of the ovaries has appeared unaltered
around these bodies, but at other times I have found it also the
seat of a yellow matter like fibrine, either infiltrated into the
centre of the organ or deposited in striaj which intersected its
tissue^ This condition, too, has always been associated with con-
siderable thickening of the ovarian capsule, and with a dead white
colour of its surface ; and the ovary generally has been small and
shrunken, and contained few Graafian vesicles, and sometimes
none but those which had been the subject of this change. It is
not, however, as might be supposed, a result of mere wasting from
the advance of age and the cessation of the generative function,
for I have met with this state in the body of a woman who died
at the age of twenty -five, and in whose ovaries there were not
merely other healthy Graafian vesicles, but also in one a large
menstrual clot, and other evidences of recent menstruation.
AeiUe iriflam^naimi of the substance of the unimpregnated
ovary is of such rare occurrence that no case has come under my
own C4ire, and but one has presented itself to my observation. To
that case I have already referred, as affording an instance of sup-
puration in the Gmafian follicles themselves, but the cause of
death was the supervention of general peritonitis.
The patient's history afforded no clue to the cause of her illness,
for she w^as a young unmarried woman, eighteen years old, living
in comfort as a domestic servant, and never having had any dis-
order of her catamenia, or any uterine ailment. Her illness had
come on spontaneously four or five days before her admission into
the hospital, and not at a menstrual period, with pain in the back
aud abdomen, fever and langour, for which, however, no treatment
INFLAMMATION OF THE OVARIES •
was adopted before she entered the hospital Her sympb
just tlioae of general peritonitis ; a dry skin, a small pul&
urgent thirst, and constant sickness, great headache, a fix
and tender abdomen, and much pain in the abdomen fl
Her condition did not seem to admit of active treatmenlf
next day the pulse had risen to 160, the sickne^ss was it
the matter vomited being of a doxk greenish colour ; the a
was more tense, its tenderness undiminished, but the pa
recurred in paroxysms, between which were intervals of oi
tive ease. In eighteen hours mora she died— about ffl
from her admission into the hospital
There was universal peritonitis; two pints of purulei
were present in the abdominal cavity; and inflammati'
extended to the diaphragmatic pleura. The uterus and 1
ovary were perfectly healthy. Connected with the righi
was a cyst filled with pus, which reached as high as the 1
the pelvis, and pus coated the outer surface of the ovary
as occupied the Graafian vesicles.
So rapid a coui*se of the disease, and so serious atermitij
it, are of great rarity. Inflammation commencing abc
uterine appendages on either side seldom extends beyo
peritoneum in the immediate vicinity of the uterus ; an
when the substance of the ovary is afl'ected, and inflammatii
in auppui-ation, it is for the most part from a slow and \
illness that the patient suifers ; the abscess attaining a ver
size, and possibly even persisting for years. Such at leasi
experience of Kiwisch,* and my o^tl more limited obse;
leads me to the same opinion. He notices the disposition
symptoms to come to a standstill, so that sometimes the ]
suffers chiefly from the mechanical inconvenience of the ti
while in other instances the arrest of the symptoms is of \
imperfect kind ; the patient continues to lose flesh ; oca
febrile attacks come on, till at length a condition of hectic
fests itself, indicative in many instances of decomposition
^ Kiwijch, op. cit, vol. ii. p. 67, montiotiB b&Ting aeen an absoefs of tl
which contained sixteen pints of pus. I haTfi aeen thirty- five pints of {
evncQoted from ftn OTwiaii cyat ; but this waa in a case of dropsy in wl
flammattou of the cyst wall had mipcrvene<i, an accident to which I
Hill be made iu aeothar lecture.
TEEMINATIOK IN ABSCESS,
483
contents of the abscess, and death takes place either before or soon
after it has discharged itself. All of these occurrences have come
under my observation in cases of ovarian cysts in which inflam-
mation has supervened, converting their contents into purulent
matter ; but I have only once met with an instance in which there
was reason to -believe that the tumour had been from the com-
mencement an abscess, and bad not originated in the inflammation
of the cyst wall of a dropsical ovarium. In this instance the
patients illness commenced with suppression of the menses five
months after marriage, she bein^' at that time twenty-six years
old. The suppression of her menses was followed by pain in the
right side of the abdomen, about the situation of the crista ilii, but
extending to the opposite side, aggravated by motion or exertion,
and confining her by its severity, and by the general constitutional
disortler which accompanied it, almost constantly to bed, during
the six raontlis which preceded her adnmsion into the hospital.
Very soon after the commencement of her illness a tumour
appeared in the right iliac region, which was said by her medical
attendant to be an abscess, A month after the swelling was first
perceived a discharge of pus took place from the urethra, which
continued at intervals for some weeks, though without any marked
change in the swelling. The discbarge then ceased for a time,
but at the end of three months it again recurred, and continued
to take place occasionally until the patient came under my care,
though in spite of this, the tumour had gone on slowly increasing
in si^e.
On her admission the patient looked very ill, her countenance
was anxious, her pulse frequent, her tongue red at the tip and
edges, and thickly covered with aphtha?. Her abdomen measured
twenty-eight inches in circumference at the umbilicus, its enlarge*
ment being due to a pyriform tumour in the mesial line, which
occupied the hypogastric, umbilical, and lower part of the epigastric
regions, and extended laterally to the lumbar and lower part of
the hypochondriac regions. The tumour yielded a distinct sense
of fluctuation, and was very tender on preasure, especially in the
hypogastric region. The uterus was low down, and carried for-
wards nearer than natural to the anterior pelvic wall It did not
seem to be altered or enlarged, neither was it fixed in the pelvis,
nor waa there any thickening of the vaginal walls. The move-
484
INFLAMMATION OF THE OVAHIES ;
ments of the organ were, however, impeded hy some tninoiir*
which, though not dipping down into the pelvic cavity, nor pre-
senting any distinct outline, was yet to be felt» as offering a
geooral resistance on pressure being made in any direction agdnit
the roof of the vagina.
Three weeks after the patient*s admission pus began to be <&•
charged from the bowel, and in the course of a little more than i
fortnight, nnder the continuance of these discharges, the tumotir
almost entirely disappeared, thungh much pain continned to be
felt in the right iliac region, and a little pus occasionally re-
collected in the sac of the abscess, and was from time to time
discharged per rectum. Tlie progress of her recovery was retarded
by an attack of phlegmasia dolens of tlie left leg ; but about two
months after her reception into the hospital she was dischai^ged
perfectly well, and no trace of the tumour was to be detected
anywhere.
In this case the suddenness of the attack, the acute character of
the symptoms which attended its onset, and the rapid formation
of the tumour, are alike incompatible with the supposition that
the case was one of dropsy of the ovary. On the other hand, the
situation of the swelling in the abdomen, the mobility of the
uterus and the absence of thickening by the side of the womb, or
at the roof of the vagina, clearly show that the case was not one
of pelvic abscess, or of inflammation of the cellular tissue within
the folds of the broad UgameuL We thus arrive at tho conclu-
sion that the matter was secreted from an abscess in the ovary doe
to inHammation excited in all probability by the sudden suppres-
Bion of the menses which marked the commencement of tlie
patient's illness.
I do not know that practically there is very much to gather
from the details of a case such a^ the preceding, beyond the know-
ledge of the fact that acute ovaritis, ending in suppuration, may
come on without apparent cause, and that the tumour thus formed
may acquire a great size, and may present all the characters of a
dropsical uvary. As far as treatment is concemeil, it would^ I
think, in the case last related^ have been the wiaer course to have
punctured the tumour and have evacuated its contents eoon after
the patient's admission.
It is not from the observation of cases such as have Utheito
ITS CHRONIC FORM.
485
been related, and which are confessedly as rare in their occurrence
as they are formidable in their character, that has arisen the
general impression of the importance and the frequency of ovarian
inflammation. The ovaritis which is chiefly dwelt on by medical
writers is said, for the most part, to be either sicbficuU or chranic
in its character. It is an aflection snpposed to be capable of
lasting for many years without leading to any grave alteration of
atrncture, though occasioning much functional disorder, ami pro-
ducing much local suffering. Disturbance of menstruation of
various kinds, sterility, and pain in the abdomen, moi-e e^specially
pain referred to one or other Uiac region, are the symptoms
commonly assigned to this chronic ovaritis ; and, indeed, a very
large proportion of the ailments that have been referred by some
observers to inflammation of the cervix uteri, and ulceration of its
oritiee, have been attributed by others equally confidently to
chronic inflammation of the ovary.
My own impression is, that a larger share has been assigned to
chronic inflammation in the production of these symptoms than
can be proved to be really due to it In no class of ailments is
pain so incorrect an index to the nature and importance of the
morbid process which gives rise to it as in the disorders of the
sexual system of women. On the one hand, diseases of the most
formidable character sometimes run their course without the pro-
duction of any sufl'ering till they reacli a stage utterly beyond
remedy, while, on the other hand, pains of the severest kind recur
in some instances for weeks or months, or even for years, and yet
neither during life nor after death can any aderiuate explanation
be discovered of their occurrence or their persistence* It seems,
indeed, as if the sorrow which women are peculiarly heirs to were
not confined to the time of parturition, but as if the sentence
extended in a measure to the performance of all the sexual func-
tions. Pregnancy and menstruation, as well aa child-bearing, are
very generally times of suffering ; and sexual intercourse itself is
not infrequently attended or followed by the same kind of pain as
has been referred to ovarian inflammation. Pain in the ovarian
region is a very general attendant on prolapse of the womb, and it
suffices but to introduce the sound into the cavity of tlie uterus in
order to produce, and often with great intensity, pain referred to
the situation of the ovaries.
486 IKIXAMMATION OF THE OVARIES :
But w]iile such symptoms are of frequent occturemje^ are some-
times as causelessly pei-sistent as in others they are caufleleaity
evanescent, the researches of morbid anatomists do not make Qi
acquainted with such changes in the ovaries as can be supposed to
occasion them. We often. Indeed, find the evidences of circiifli-
scribed peritonitis about the ovaries, but we find them in c$mB
where there have been no symptoms of an urgent character duriti;
life, often, indeed, where no symptom of any kind has eausted.
But with the exception of those evidences of inilammatory actioa
on the serous surface of the ovaries, the signs of a morbid prooeei^
too, which must soon have run its course, there are but few
changes in those organs which an examination after death reveals,
and those limited, or nearly so, to the Graafian vesicles, and
nsuaUy to a few only of their number. In many of the instanoes,
too, where such appearances are discovered, it has been tnatt^ of
absolute certainty that during life all the sexual functions were
performed with complete regularity, and without any silvering.
I could not acquiesce in the opinion that almost all the numermis
ills of womanhood ai-e due to inflammation of the neck of Uie
womb. I can as little see in tliem the evidence of ovarian indam*
mation, and I believe that in " nineteen cases out of twenty in
which the ovarian regions are the seat of deep, dull, aching pain,
and appear tender and rather swollen, there is no actual ov^arian
disease whatever,"* I cannot finish the sentence by saying with
the author whose words I have quoted, that the symptoms are
almost invariably the result of some uterine lesion, for I brieve
that in many cases the symptoms are purely neuralgic in Uieir
character, independent of any local lesion, and curable leea by
local treatment than by remedies addressed to the general stsate
of the constitution*
My opinions on this subject, indeed, con-espond very closely
with those expressed by Dr Churchillf of Dublin, who has
described this class of affections as the result of ovarian irrUaium^
To this term, for my own part, I see no kind of objection, though,
if preferred, the simpler designation of ovarian pain wiU f^nswm
every purpose, and serve equally well to impress upon your minds
the fact that mere suffering does not of necessity imply either the
• Dr H. B«nnet, op cU, p, 222.
t IMiin Mfdiail Journal^ vol ;di*, Aoguftt 1851> p. ML
I
NOT mTABIABLE CAUSE OF OVAHTAN PADT,
487
presence or the previous existence of inflammation* Pain is in
itself the patient's ailment, and this even varies greatly in
diHerent persons, and causelessly and within very short intervals
in the same person hoth in its character and intensity. It is
ordinarily dull and aching, is accompanied by tenderness in the
iliac iregion, in which situation a degree of fulness may often be
detected, though careful percussion will discover that this fulness
is due rather to the presence of flatus in the intestines than to the
existence of any solid tumour. Though this pain seldom subsides
completely, it is apt to be increased iu paroxysms; walking, riding,
exertion of any kind, and sometimes even the remaining for a
short time in the erect posture, considembly aggravatiag it^
Menstruation almost always adds greatly to its severity, and
sexual intercourse nearly invariably increases it, sometimes even
induces a paroxysm of great violence. The extent of the pain is
very variable. Always severest in the situation of one or other
ovary (and for some unexplained reason generally in the situation
of the left), it is sometimes limited to that spot, but in other
cases extends more or less to all the pelvic viscera; difficidt,
freqaent, and painful micturition are then always experienced,
and defjBcation is likewise often attended or followed by severe
flnffering. While pressure in the iliac region is always painful,
a vaginal examination sometimes causes Httle inconvenience. In
other cases, however, it is productive of pain which lasts for
several hours, and this even though no trace of disease may bo
detected. In some instances, indeed, in which the suffering pro-
duced by examination was most severe, the uterus was smaller
than natural, a condition which, when coupled with the sterility
of the patient, seemed to indicate an imperfect development of
the whole sexual system. In those instances where the patient^s
sufferings were severest, there were almost always umnistakabla
signs of the hysterical temperament^ — often very obvious sjioap-
toms of hysteria— while even when this was not the case, the
sudden aggravation or sudden cessation of the pain was sufficiently
characteristic of its neuralgic character.
Though frequently independent of actual disease, pain such as
has been described is also, in a very large number of cases, a con-
comitant or sequela of various uterine ailments. Of course, when
disease of any kind exists, its removal forms our first duty ; but
488
THEATMEXT OF OVARIAK PADf,
even when this has been effected, the pain often outlasts the cttne
which first excited it ; or when it seems to have completely dis-
appeared, may return during menstraation, or be rekindled by
any imprudent exertion, or by sexual intercourse.
Just like that backache which bears so large a part among the
minor ills of women, so this ovarian pain, while easy to mitigiit^,
is very hard to cure. Leeches do not relieve it, or if they give
any ease, it is only for a few hours, and the pain then returns as
severely as before. BUsters sometimes alibrd ease, though not
often in those cases where the pain is most severe, while some-
times they seem rather to aggravate discomfort by the soreness of
the surface which they occasion. In some instances I have found
great comfort experienced from constantly wearing a wet compre«
on the painful side of the abdomen. Chloroform applied to the
side generally gives temporary relief, even when the paroxysms
of pain are most severe ; whUe a piece of lint soaked in a mixtore
of equal parts of chloroform and oil, and covered witli a piece of
oiled silk, is an application which, while in bed, the patient may
employ constantly with much benefit The camphor liniment^
with extract of belladonna, or the Linimentum Belladonnxe of the
Pharmactjpti^ia, is another external application which I have found
advantageous; and when these means have been fruitless, I have
employed the tincture of aconite with advantage, applying the
undiluted tincture by means of a brush, or lajing a piece of lint
soaked in it over the seat of pain.
These s^onptoms sometimes wear themselves out, the pain by
degrees subsiding as the patient's general health improves ; but I
have never been able to trace the permanent cessation of suffering
to the unaided use of any local measures. Some caution, too> ia
necessary in their employment ; for as witli many neuralgic and
almost all hysterical pains, so here any kind of local treatment
which directs the patient's attention very much to the seat of hep
flulferings is apt to defeat its own object, and to perjietuate the
evil instead of removing it. Attention to the general health must
always go hand in hand with the local treatment— must indeed,
I think, hold the first place. It would be useless to endeavour
to go into long detail here with reference to this subject. I will
only observe that there are two tonics w^hich in cases of this kind
generally do the most service. One of them is the sulphate ol
i
SYMPTOMS OF OVARIAN INFLAMMATION.
quinine, which, when tolemted by the patient, does the same kind
of good as in other cases of neuralgic pain, though not so certainly,
nor to the same extent. The other is the valerianate of zinc, to
which I generally have recourse, wherever quinine is contra-indi-
cated or cannot he borne, I know of but one drawback from its
eniplojTnent, and that is the permanent taste wliich it is apt to
leave iu the mouth, and the unpleasant eructations with which
patients are fiometinies troubled hours after it has been taken,
though when given iu the form of a pill silvered this inconvenience
is often avoided. There are indeed some cases, though 1 believe
their number t-o be inconsiderable, in which the existence of
mjiammation of the ovaries is less questionable. The attack in
these cases is usually detinite in its onset, and for the most part
succeeds either to sudden suppression of the menses, or follows at
least some considerable disturbance of the menstrual function, or
occasionally comes on not very long after a miscaniage, though
once or twice I have met with the aflection without being able to
assign any probable cause for iLs occurrence. General febrile dis-
turbance, usually of no great intensity, and by no means invariably
ushered in by shivering, is accompanied by pain referred to the
hypogastrium, or t^j one or other iliac region, and by frequent
desire to pass water, which is usually high-coloured and deposits
lithates. In the main, indeed, the symptoms are such as attend
an attack of uterine inllanimation, except perhaps that they are
less severe, A vaginal examination suthces to show that the
nterus is not the part aflected, for, though the heat of the vagina
may be somewhat increased, the womb is neither enlarged nor
tender, nor are its lips pully ; whQe, at the same time, pressure
against the roof of the vagina, at one or other side of the womb,
not only produces considerable pain, but very often detects the
indistinct outline of the enlarged ovary. Sometimes, indeed, the
ovary may be very clearly felt, especially if, as is usually the
case, it occupies the ad-dt-sac between the uterus and rectum,
and it may then be much more clearly distinguished by the
finger introduced into the bowel than by a mere vaginal examina-
tion.* The general symptoms, combined with the absence of
* Br LbweDbardt uus tlie first person to draw special attention, in \i\A IHagifioaiucJi^
pmlditckt Abhandlungrn, Ac, Svo, PrenzUn, 1835, p, 297, to tliese cams of ovamn
ition, and to tliu value of oxami nation per rectuni as a meims of diagnosiA.
490 INFLAMMATION OF THE OVARIES :
affection of the utenia, and the pain on pressure at its side, 8i
to point to the ovaiy as the aeat of the patient's suSerings. Whan
the tumour can be distinguished, it may be recognised as ifae
ovary by its oval shape, its smooth surface, its elasticity, a certain
degree of mohihty, of which it is found susceptible, as well as by
the peculiar sickening sensation which pressure upon it producer
These symptoms for the most part have a sufticieDtly active
character to enforce the patient*s attention, while the employmenl
of local leeching, of the tepid hip-bath, the use of anodjTie and
mild antiphlogistic remedies, and the observance of absolute rest
— the same remedies, in short, as would be applicable in cases of
inflammation of the uterus itself — generally suffice for their
removal in the course of a few days.
Some exceptional cases are, however, occasionally met with, in
which, in a somewhat mitigated form, the above-mentioned symp-
toms continue for months or years, and are found to be associated
with the presence of the enlarged and congested ovary in the en/-
d€'sac between the uterus and rectum. The late Dr Kigby^ was,
I beUeve, the first person who drew attention to this condition
under the name of displdcement of the ovari/, and the cases of it
which have come under my notice bear out the accuracy of his
description ; except that I have not observed the paroxysnia of
pain to have anything like that intensity which they assumed in
some of his coses.
The condition seems to be one of considerable rarity, for I have
a record of but four instances of its occurrence, though I have seea
a few other cases of which I have failed to preserve an account.
Tlie patients in all my cases were married women, of whom the
eldest was thirty-two, the youngest twenty-three years of age ;
but Dr Rigby relates an instance in which he met with the con-
dition in an unmarried girl only eighteen years old Two of my
patients were sterile j the other two had given birth to children*
and both of these latter dated their symptoms from their last
delivery. In all of them the severe pain attendant upon sexual
intercourse had by degrees compelled its discontinuauce, and had
much to do with the apphcation of the patients for medical aid.
Besides this, however, there were compluinta of pain referred to
* MMeal TimMt, July 6, 1850.
I
I
I
TKEIR CHKOKIC CONGESTIOK.
the lower part of the abdomen, though severest on one side,
aggravated by exertion, by menstruation, often induced with great
intensity by deftecation, and generally being severer at night
than in the day-time, thus preventing sleep, or causing the rest
to be very diatiirbed. In one patient menstruation was natural,
except that it was attended by unwonted suflering ; but in the
other three the discharge was both excessive in quantity, and
anticip«ited the proper period of its return* Pressure in one iliac
region always aggravated the pain ; but the paroxysms of suH'ering
%vhich were every now and then superadded to the abiding dis-
comfort, and which were attended by a sense of darting and
shooting referred to the w^omb, lasting sometimes for several horn's,
came on without any assignable cause.
These symptoms were present with considerable uniformity in
all the cases, and in all, on an examination per vaginam, there
was found behind, and rather to one side of the uterus, or else
quite in the cul-de-sac between the uterus and rectum, an oval
body, slightly movable, elastic, intensely tender to the touch, and
immediately recognised by the patient as the point whence all her
sufferings proceeded.
In all of these cases, rest, abstinence from sexual intercourse,
and the appUcation per vaginam of leeches to the neighbourhood
of the painful part, were followed by the gradual cessation of
suffering, the diminution in size of the swollen ovary, and the
almost complete removal of the tenderness* In no instance,
however, was there any such disappearance of the tumour felt
through the roof of the vagina as to suggest the idea that the main
element in the production of the patient*s illness had been the dis-
placement of the organ, or that tlie improvement in her condition
was attributable to the ovary having regained its natural position.
My own impression is, that cases of this kind are to be regarded
as instances of a ckramc congestion of the ovary and slow increase
of its size, rather than as illustrations of any mere change in
the position of the organ* The enlarged ovary almost always de-
scends in the pelvis, and in the early stage of ovarian dropsy the
organ may often be felt per vaginam at a time when no tumour is
perceptible in the abdomen. But though the organ may by
growth thus apparently change its situation, and though, besides,
its ligament elongates readily enough, aa we see in cases where
OTABIAK DISPLACEMENT.
the ovarian cyst lias already ascended into the abdominal cavity,
we should yet, I think, be in error if we fancied the origan so
loosely tethered in its place that \^ithout any other alteratioo it
could fall down into the cxd-d^-sac between the vagina find
rectum, and be made to resume its pi-oper position merely by the
patient placing herself in a prone posture. The persistent swell-
ing, which in my cases remained perceptible, although ita sin
was reduced by treatment, would seem to me to indicate tbil
inflammation had afiected the peritoneal surface of the avaiy«
and tied it down beliind the womb just as in some of the cases
which I referred to at the commencement of this Ijectiire. The
subsidence of the inflammation was followed by diminution of
the enlarged ovary, by lessening of its exaggerated eensibiUty, but
not by its return to its previous position, I imagine, too, that
whatever relief a patient may experience in these cases from
assuming a prone position may fairly be refeiTed to the removal
from the congested and tender ovary of the weight of the super-
incumbent intestines, to which, either in the sitting or in the
recumbent posture, it is 8uhject{^d.*
* There are two conditions which I do not like to ptss over eDtirely- vitlKnit
notice, though neither of them has come under my own oliaemition, Oii« of
thorn is Hrrnia qfthe Ovary ^ of which the best account is still that giren bj
Den^nx, in his Jkch^rches tut la Htmie de tOvairt, Svo, Puris, 18 IS, who \mM tli^tfn
collected the particulars of all caseii recorded down to the time of the pubticstieB
of his essay. Thij toropik'ra of Uie BihiioUUque du Medfdn^Fraticim ; Jiaiadim
des FaHiiU3^ vol i. p. 643, have a long article on the Hubject, for which, howerer,
they are chiefly indebted to Deueux ; wliile Meissner'a laborious work, roL ii
p. 240, contains additional references to cases of oranan displaoementa, and othets
more recent are to he found in Olshauscu, KrankheiUn dcr OvoKeii, 8vo, SUittgmrt.
lS77f p. 14 ; and the copioua bibliography in Boinety MsUadieidei Onune^ 2d «d,
8vo, Funs, 1877, pp, 8&-&5.
The other alfection ia one for onr knowledge of wbkh we ore almoit entirely indebted
to U. Huguier, who describes in the Mimoir§9 de la SocUH de Chirurfis, voL L, 1847,
p» 295, Serous Cyatg on the exterior of the uterus. In the lecture on Caoeer
l«. 354, 1 deHcribed productions of a similar kind whicli had occasionally corns
under my own notice, though their relation a[^Jn•a^cd to be somewhat different
from those of the cysts of which M. Ouguier speaks. Aeoording to htm, they an
soiuetimes developed iuimt^diatrly beneath the pentonecun ; at other times in tlia
sub^peritoneal cellular tisaue ; or, lastly, are mbjacent to that layer of fihro-cellii*
lar tiflsue which connects the serous invoatment of tlie utci-us with the substance
of the organ. Their ino«t frequent scat seems to be tlie posteiior surface of the
Uterus, since they were found occupying that iiosition in §even out of thirteen
, while they were situated o* ~ ^ - times on its anterior wall, and twioe cm
tmUSUAL FOBMS OF OVAMAN iNFIAMMATIOlf.
493
[A rare condition of the ovaries, which has been called cirrhosis,
occasionally accurs. It was well exemplified in a strong, healthy
young woman who was my patient for amenorrhcea which came
on suddenly after long continued regularity, and two yeara before
her death. Medicines did her no good, and she passed from being
under my care ; but I occasionally heard of her, and attended the
examination of her body after death from disease unconnected
with her genital system, when slie was thirty-five years of age.
I have her ovariea preserved, and they are shrivelled in appear-
ance, densely hard as a piece of fibrous tissue, and nut larger than
a somewhat elongated field-bean. Their tissue was sohd through*
out, presenting no traces of distinction into follicles and stroma ;
yet the puckered external coat or albuginea is even denser than
the interior tissue.
In describing endometritis we have mentioned its occasional
connexion with fever, especially tj^ihoid, and have*narrated an
example. Tlie authors who most carefully describe this form of
inflammation insist also upon its connexion with ovaritis. Among
these Slavjansky deserves special mention.* He gives reference
itt fttodua. Though generillj Mssile, thc^y are now and then conaecteii with the
uterus by n narrow zteok, which BoiTK^ttnies l\m Hhruuk to a ilender pedicle of
Gcllular tissae. Tlieir tixe varies from that of a tiiiUet*seed to the hignesB of an
i^gg, or erea of an onuigc ; and the Urger cjsta mighty esf*ectJilZy if pt^dicuktc^i,
be readily taken for cysts of the ovary. The diiiguosiB lietwecn th^^ two wooJd
seem, md««d, to be acaroely possiblOf though no practical eril wciuld arise from an
error. H. Huguier connocta their occurrence with prerioiis attack?) of Dterin«
<!l>^g(^BtiaQ, or of {leritoneal inlUiiiimation ; accidents, howsTer, which are so coin-
mou in comparison with tbu cysU to which they are sappoacd to give rise, that
th«Lr influence rousts. I tbiak, be regarded as very doobtftiL The symptoms
which they produce, judging from the two caaea in which they were discovered
duriog the patient's life, would appear to be entirely mechanical* and to result
from their preestuv on adjacent organs. In one instance the cyst was pvioctared
per vagi nam; abont 5U of transparent scram were evactiated^ and the cyst wall
was lightly touche^l with the nitrate of silver. The floid did not ni-eoUect, and no
serioUH symptom followed the pnnctore.
The chief importance of these cysts is, perbaps, from their intnKiucing a new
element of uncertainty into the diagnosis of ovarian tumour m an early stage.
The subject is noticed by M. Demarquay at pp. 285-292 of his valuable work to
which I have had so many occauoua to refer ; and a case is there related in which a
uti^rine cyst had not only attained nioh larga size as to be mistaken for a cyst of
the ovai7, but under tliat mistaken impression gastrotomy was performed, and the
nterujt partially r45moved ; the patient died 36 hours afterwards from the effects of
the opeimtioQ*
♦ AreMvfQr Oynakolo^, B. iii. S. 183,
494
DIFFERENT FORMS OF OVARIAN IKFLAMMATlOir.
to cases where pliosphoms and arsenic are alleged to have had
the same toxic influence as the fever poison ; and in connexion
with this I wish to express my conduction, founded on much
clinical observation, of the same influence being exerted by
alcoholic drinks. I have seen too many cases of this kind to
leave me in any doubt of their evil potency. The inBammatioD
has been generally accompanied with enlargement as well as
tenderness of the organs ; and in many, though not in all, with
sterility.
Slavjansky carefully elaborates a distinction, which has already
been fully made in an earlier part of this chapter, between the
parenchymatous or follicular ovaritis and the interstitial or stro*
matous ovaritis. WIdle we shall mention the principal clinical
difierences as given by this author, we add that in a large field of
observation of both acute and chronic cases we have not been able
fully to satisfy ourselves of their accuracy^ Post-mortem in-
vestigation no doubt justifies the distinction, and Slavjansky'g
attempt at carrying out the same in practice deserves considera-
tion. Tlie parench^Tnatous form he regarrls as not common in the
puerperal state, as not causing considerable enlargement of the
organ, as not accompanied with much perioophoritis, as be^t seen
after fevers, and naturally as a more frequent cause of sterility
than the other form. The interstitial form he regards as mosl
frequent in the puerperal state, as leading to enlargement or
hypertropliy of the ovary, as generally accompanied by perio-
ophoritis, and a8 interfering less with fertility than the former J
LECTURE XXIV,
OYAHIAN TUMOUBS AND DROPSY,
Special di*po9ttioii to formation of oyiitic growths in the ovary,
Yaiiitiei of cyita — the simple ctbts ; cy«ts of tho Wolffian bodies or Paroranan
cyvts ; their peculiar ohAncters ; occaAioail Ini^ m^ ; tendency to rnpttire ; lialile
rarely to inflammatian and other changefi. Cyats tmly OTarian ; their relation to
(Iropijj of the Graaliao reaiclea ; their structure and contents; modiJieatioti of
their form when several are present. Qnvstiona an to their cause*
CoMPOinm, or PHOLiFEROtrs oysts ; possible developiueDt from Bimple cysts.
Structure and contents of compound cysta, and of eyitoatroomatous growths.
Alveolam oa colloid oROwnis of the ovary.
Cutaneous ok fat cysth : their pecTiliarities of atructure and their cootenta.
OomparatiTa frequency of affection of one or both ovaries, and of different forma of
oyarian tumour.
I HAVE bad occasion io the course of these Lectures to make
frequent incidental reference to enlargement of the abdomen as an
attendant upon various ailments of the sexual system ; the con-
sequence and one of the signs of tlieir presence* To-day, however,
we are about to enter on the examination of a class of diseases
whose most important and most fre€|uent characteristic is, that
they bring with them enlargement of the abdomen, — that this is
often the firat symptom of their existence, and that to it is due no
small share of the patient's sufferings.
But, while they have this one symptom in common, Tuvmurs of
the Oiyarus differ most widely in all other respects. They occur in
tlie young and the aged, in the single and in the married, in the sterile
and in women who have given birth to many children* They are
formed sometimes by simple cysts containing serous fluid, at other
times they are composed of solid matter, while in very many
instances their structure is identical with that of groi^lhs which
morbid anatomists have unanimously designated malignant.
Their rate of increase is sometimes quick, at other times slow, and
OVAEIAN TUMOUES :
the disease which had seemed in course of rapid development
becomes occasionally stationary, and so remains for monthd or
years ; while now and then nature herself interferes, and, excel-
ling all that the most skilful physician could do, completely takes
away the ill which medicine is usually impotent to cure. Their
diagnosis, in some cases most easy, is in others attended by
extreme difficulty; and yet there are scarcely any ailiuents in
which so much is involved in a right decision. The determiiii*
tion that the supposed disease is in reality due to the existeofie
of pregnancy, or that the suspected pregnancy is hut the evideooe
of disease, often lias moral consequences which touch more nearly
the profoundest sources of human happiness or misery than any
which would follow the mere assurance, though never so positive,
of coming health, or the admission that the future has no other
prospect than that of a lingering and painful death, Need I
remind you of the tragedy of Mary Tudor — the queen who
caused so much suffering to others, who bore so much sorrow
herself— to whose sad domestic history the poet has not beenaUe
to add any touch of pathos deeper than the simple words of the
annalist ? The prognosis to be formed, and the treatment to be
adopted, bring with them, too, their own peculiar difficulties
liecovery, wlien there seemed small ground for hope ; death
when little had appeared to call for apprehension ; medical treat*
ment rejected because it has been proved ineflicacious ; surgical
proceedings shrunk from because they are known to be bazardooa ;
Buch are the difficulties which beset ns on every side, when we
try to answer the questions, Wliither is the disease tending?
What is the course which, in the midst of so many uneertaintiaSb
we should advise our patient to adopt ? Something, indeed, of
the sombre tint with which the picture once was shaded, has Ijeen
lightened by ovariotomy, that triumph of modern surgery ; but
still a mortality of one in four among those who submit to tht
operation is a warning against hasty diagnosis or precipitate treat*
ment ; a reason, if any were needed, for my claiming for the sub-
ject your most patient attention. '
In each of the different organs of the body we find a disposition
more or less marked to diseased fornmlion similar to its own
proper healthy structure. This peculiarity is observable in
tumours of bone, of muscle, of nerv^e,or of fibrous tissue, andaven
;
A
CHIEFLY CYSTIC : SIMPLE CYSTS,
497
in the case of those formations which, from their non-identity
with healthy structures, have received the name of heterologous,
something of the same disposition is still perceptible, Thus the
cancerous tumour of bone, wliile interfering with and destroying
the structure of the part in which it is formed, is yet itself built
up upon a bony skeleton or fabric ; and I have already pointed
out to you how, even in cancer of the womb, the bulk of the organ
is increased, not merely by the morbid deposit in ita substance,
but also by the development of its natural structure.
It is in accordance with this law that, in the ovary especially
(as to a less degree in all glandular organs, such as the thyroid
body, the testicle, and the mamma), there exists a peculiar liability
to cyst-formation ; and that nineteen out of twenty of all ovarian
tum&urs are eystic growthSn
Verj^ various classifications of ovarian apis have been proposed
according as they have been regarded simply from a pmctical
point of view, or as the minuter differences in their anatomical
structure have also been taken into consideration. It is, however,
so desirable to avoid multiplied diraions and subdivisions, that
I propose to conform to the arrangement adopted by Sir James
Paget,* and to speak first of Simple or Barren Cysts, and secondly,
of Compound or Proliferous Cysts. Tliis arrangement, too, will,
I think, be found not simply anatomically correct, but also practi-
cally convenieut.
The Jirsi kind of Simple Ci/st is one which, though in the
immediate vicinity of the ovary, is, strictly gpeaking, not con-
nected with it ; but which I mention here because until com-
paratively recently its nature was misapprehended, and erroneous
conclusions, baaed on this misapprehension, have been applied
to real ovarian cysts.
In examining the bodies of female infants, and less often of
female adults, we may sometimes notice hanging from the under
surface of the Fallopian tube, nearer to its fimbriated than to its
uterine extremity, small delicate cysts, varying in size from the
bigness of a pea to that of a cherry, furnished with a slender
pedicle from one to three inches in length, and containing a
transparent, serous, or slightly gelatinous flui4 Now and then a
* Surgical Pcdhoh^f voL IL p. 26.
2i
498
SIMPLE OYAEIAN CYSTS:
similar cyst may be seen bearing the same relation to the Fil*
lopian tube, with the exception of being sessile instead of pedi*
cnlateJ, Sometimes, too, a cyst of larger size may be observed
within the folds of the broad ligament situated between the ovary
and the Fallopian tube, but obviously not originatiiig in eithar;
and the cysts of this latter kind, unlike the others^ are ohsenred
only in the grown subject. The diflerence of their seat seems
to be the only point of dissimilarity between them, for the whU
of both is composed of a thin, structureless membrane, incapebte ^
of division into layers, often, though by no means constantly^H
furnished with a lining of nucleated epithelium ; while their
contents, though usually serous and colourless, are sometimes
reddish and gelatinous.
The delicacy of the cyst-wall, the absence of any support, and
the slenderness of its foot-stalk, are doubtless, as has been suggested
by M, Verneun,* the reasons why the pendent variety of cyst is
seldom met with after early infancy, while the support which the
peritoneum on either side furnishes to the sessile cyst which is
Situated between the folds of the broad ligament, allows of its
readier enlargement and of its attainment of a greater size. An
examination of the pedicle of those cysts which hang from the
Fallopian tube furni3hes the clue to the understanding of the real
nature of these growtha This pedicle is often found to be hoUow,
though in the course of its gradual elongation and attenuation it
becomes converted into a slender cord. The canal, however, some*
times even communicating with the cyst, points to its origin in I
the dilatation of one of the small ca^cal tubes which make up the
Wolffian bodies in the foetus, and the slight remains of which,
difficultly discernible in the adult, have received from their
describer the name of the Corpus Eosenmiilleri. ■
The 5126 of an egg, an apple, or an orange, is the magnitude to ™
which these cysts probably in general attain, and the j»endent
cysts very rarely indeed reach dimensions suflicient to make them
recognisable during life. With the exception, too, of the giving
* By far the best account of these cysta, whkh coDtniiui also « notice of Um
obfteiTttioiiA of prerioiu writers, la Lhut of Dr Venieui], Hetherehu Bur Ua Jt^^tmdi
rOrgatie de Woif^ in the Mhmires de la Sociiti de Chh^tfie^ 1864, vol. It, p. S8i
Vircliow, whogivtt {Dia KrankhafUn OeschwUUU, vol. i. p. 202) an •ccount ofthoM
imall cysts, demnrs to the correctness of ibis Lypotheais, and believos ibism to bo
iwoAllyp if not Iniramb^, new formations.
CYSTS OF THE WOLFFIAN BODY.
499
way of the pedicle of the pendent cyats, and the probable rupture
of the delicate walls of both kinds of the'^e growths, ther^ are no
changes which have been observed to take place in them ; and
in DO instance has cyst formation occarred in their walls or into
their cavity, though several distinct cysta, especially of the
pediculated kind^ are by no means infrequently seen in the same
subject
Before proceeding to examine the other and more important
cysts which really spring from the ovary itself, we must for a
moment notice a circumstance which has given to these cysts of
the broad ligament, as they have genei'ally beep termed, a greater
pathological value than really attaches to them. It has been very
customary for medical meni whenever they met with a simple cyst
tolerably movable, and of moderate size, to assume that such a
cyst was not ovarian, and to console their patients with the assur-
ance that it is a le^s serious disease, and one much less likely to
increase. Now, while it is of great moment to give to our
patients every legitimate comfort, and to encourage all reasonable
hope, it is yet no less important, in the interests alike of science
and of humanity, that we should not make large promises, or give
positive assurances without adequate grounds.
[Clinical experience and investigations in morbid anatomy show
that the growth of a cyst of the Wolffian body — now frequently
considered and called parovarian, or of the broad ligament — to
large dimensions, as compared with the multilocular ovarian
dropsy, or ovarian cystoma, is uncommon. Yet fine examples
of it are occasionally met with. Such cysts may grow to a great
size, far exceeding that of natural pregnancy, and in their growth
they produce the same general series of phenomena and symptoms
as arise in the course of an ordinary ovarian dropsy, with one pre-
dominating cyst, and are to be presently described.
These cysts distend the abdomen in a smooth-surfaced semi-
globose form, for they are generally unilocular. Examples of
bilocular cysts, and even of three-celled cysts, have been described,
arising probably from one, tw^o, or three, of the still more
numerous coecal tubes of the parorarium being involved in the
disease.* The cyst wall is of considerable thickness, and after the
removal of the cyst can be shown to present a character, which,
* See Thorn ttja. Traiisactumt of PcUholoffical Sociely, vaL xxvi,, 1875, p. US,
000
SIMPLE OVABIAK CYSTS :
besides the cyst's origin apart from the ovaiy, is distinctive;
namely, the easy peeling off of the peritoneal iu%estment la the
case of ovarian dropsy, patches of fibrous tissue, more or kai
sheetlike, can be detached, but a healthy parovarian cyst is eaaOy
peeled out of its peritoneal investment* If the contents are
drawn off from wliat may be called a healthy cyst, they present t
striking contraat to the dense, albuminous ovarian fluids, rich in
mucous and colloid matter ; for the fluid Is like limpid water or
has the slightest opalescence, contains no albumen, has a specific
gravity of about 1008, and owes this density chiefly to the
chlorides of sodium and potassium in solution*
The tapped cyst is easily emptied, and the collapsed bag may
be felt gathered into a lump, or it may not be discoverable, aa il
lies empty and widely spread out An ovarian cystoma is probably
always mnltilocuIar,f and after tapping generally presents seveial
cysts so bulky as to be easily found by the practitioner's hand
Surgeons often speak of the great ovarian cystoma being unilocn*
lar; but doing so, they either mistake an ovarian for a parovarian
cyst, or they mean unilocular only so far as practical interests are
concerned, A multilocular ovarian cyst is often found to present^
so far as its walls are concerned, and during life, charactera lilsfi
those of a parovarian ; but if a large ovarian cyst of this kind is
carefully examined, smaller cysts are to be found in its walls,
rendering it scientifically multilocular, though practically unilocu-
lar. A parovarian cyst is in both aenses^ — scientifically and
practically — unilocular.
A parovarian cyst is liable to burst spontaneously, and may
never refill. When emptied by trocar and canula it may nevef
refill* Of both of these events I have seen instances: and for
them a great allowance must be made, when we read of the dis^
appearance or spontaneous cure of ovarian dropsy, or of cure by
iodine injection and other means. A case of this kind is given by
Professor GairdnerJ where opx>ortunity occurred of verification post-
mortem. An unilocular cyst had at one time filled a large part
of the abdomen, and was ruptured (probably by sudden violence^
* On thia «iil>ject s&a a puperby Bantock in vol xv, of the Obddrical JVammdimmt
where are gireQ other refervooea. See aJao the Medical Eniamintr^ Feb, 21^ 187^81
t 8eQ a re{iort of cose, which is not quite conclusive, by Thornton, JVoiii. ^
FaJthdogical Society, vol xxvi,, 1B75» p. 161.
t BriMi Medical Jtmmal, Feb. 2S, UU, p. 261.
rnOM ENLARGEMENT OF THE GRAAFIAN VESICLES.
501
with collapse of the cjnat^ but without peritonitis, or at least
\rithout such peritonitis as to leave appreciable changes cor-
responding \*ath the date of the rupture. Death occuixed sixteen
months after the rupture, from Bright's diBease. The cyst waa
found flaccid and empty. It could be easily inflated to the size
of a child's head, but the corrugated condition of its lining
membrane showed that at one time it had been much larger. The
seat of rupture was discovered, quite healed.
But all parovarian cysts are unfortunately not of a healthy
kind. They are liable to inflammation and to ha^morrhaga
These produce adhesions, and render the contents more or less
mixed with lymph, pus, and blood. In such circumstances, diag-
nosis by tapping will be impossible, or at least diflicult ; and the
simple treatment by evacuation may be inefficient. The treat-
ment, indeed, of such examples is not decided, I have seen them
successfully extirpated ; but they are probably amenable to more
simple methods^ as by free evacuation, washing out, and other
means, such as will be described in the analogous pi-oceeding in
true ovarian cases.
In his work, already often referred to, Olshausen describes a
case of parovarian cyst, which proliferated like an ovarian cystoma,
and was of malignant character.]
But we may now pass to the study of those various kinds of
C7/sts and cysioid grmvths which have their Qrigin in tJu^ ovari/ itself.
The simplest of these, the least dangerous — I fear, however, by
no means the most frequent — are those which are produced by
the dropsy, or over-distension with fluid, of one or nwre Graafian
vesicles.
The structure of these simple ovarian cysts plainly indicates
theu* origin. They are furnished with three coats ; the first, the
peritoneal investment of the ovary; the next the capsule of the
organ, on whose surface ramify the vessels that supply it ; and
the third, the wall of the Graafian vesicle itself, wluch is usually
mnch thickened, generally divisible into several layers, and has a
lining of tesselated epithelium. The laminated structure of the
ovarian cyst is, as w© shall hereafter see, not without its practi*
cal importance, inasmuch as it sometimes increases the difficulties
of the operator, who cannot, if adhesions exist, always distinguish
readily whether his finger is breaking down the connexions
502 OVABIAK CTSTS FROM ENLABOED QBAAFIAK VE8ICUE8 :
between the enlarged ovary and the peritoneum, or whether it is
eeparating the layers of the cyst-wall.
The surface of these cysts is generally white and glistening, and
their interior smooth and polished ; sometimes of a dead white
colour, or even of a mother-of-pearl lustre; unless the growti
has been the seat of inflammation, when it will in many parts
be dull, roughened on its interior by old deposits of lymph, and
its walls will be found to present various degrees of firmness,
density, and thickness. Even independently of previous inflam-
mation, the thickness of the cyst-wall often varies at different
parts, and is by no means most considerable in all cases close to
the pedicle of the growth.
The vessels of these, as indeed of all ovarian cysts, are usually
of considerable size ; while their distribution is uncertain beyond
the fact that all converge towards the pedicle of the cyst. They
almost all present a venous character, or, as Cruveilhier aptly says,
in describing the structure of a large ovarian cyst,* " They are
venous sinuses analogous to those of the dura matter,'* and, ramify-
ing immediately beneath the peritoneum, their delicate outer wall
seems wholly formed by that membrane. The large size of these
superficial veios is to be borne in mind as an occasional source of
danger in tapping ; while their convergence towards the pedicle
of the tumour constitutes one of the principal objections to the
operation of tapping per vaginam. The branches which pass from
these trunks towards the interior of the cyst, and which ramify,
sometimes very abundantly, on its inner wall, are small in size,
but still retain their venous character, and this preponderance of
the venous over the arterial system is the great peculiarity of the
vascular supply of these growths.
Be their size what it may (and this is liable to very wide
variations; for while sometimes no larger than a pea, they
contain in other cases a gallon or a gallon and a half of fluid),
their contents are usually of the same description — namely,
serum, often of a rather low specific gravity, and very seldom
exceeding 1020, highly albuminous, of a slightly greenish colour,
and though generally transparent, yet occasionally more or less
stained with blood. Sometimes, indeed, the fluid contains a
large admixture of pus, and now and then presents characters
* Anatomie Palhohgi^iue Cfinirale^ 8to, Paris, 1866, yoL uL p. 408.
THETB ANATOmCAX CHAEACTEHS,
503
but little distiiaguishable from those of healthy matter. This
too, may be the case even when few local symptoms of inflam-
mation have been present, so that it is not possible to foretell
with any certainty the nature of the fluid which even a simple
ovarian cyst may be found to contain ; or to infer the absence of
infiammation from the absence of pain. Tbe circumstance which
imparts to this fact its practical importance is that inflammation of
the interior of the cyst ia in veiy many instances accompanied by
inflammation of its peritoneal surface, of extent and intensity
suflicient to produce very considerable adhesions with adjacent
viscera, while even this peritonitis may give rise to no severe
pain. The feasibility of various suipcal proceedings for the cure
of ovarian dropsy depends to a great degree on the absence of
adhesions. The want of any certain means by which to deter-
mine their presence or absence is one of the most serious of the
difficulties that beset all operations for the extirpation of diseased
ovaries.
I have described this affection hitherto as it presents itself to
onr notice when confined to a single Graafian vesicle* It is, how-
ever, seldom that the disease ia so strictly limited^ but usually
other vesicles, sometimes tn both ovaries, show a disposition to
the same dropsical condition. Not infrequently too, we meet
with cases in which the affection of several vesicles has appeared
to have commenced simultaneously, all being equally enlarged ;
and the ovary containing as many perhaps as ten or fifteen cysta
no bigger possibly than a large pea. As these cysts increase in
size, they lose by their mutual pressure the regularly globular form
which at first they present, becoming flattened, or somewhat
wedge-shaped, with their broader end outwards. When, however,
the ovary has attained to dimensions greater than those of an
nnshelled walnut, or of an egg, the development of one or two of
the cysts generally goes on at the expense of the others, and a
multilocular tumour ia thus produced, made up of a number of
simple cysts, of very various sizes, from that of the adult head to
that of an apple or an orange. The contents of these cysts, too,
may vary as much as their size ; for while some are filled with
transparent serum, others may cont^ain fluid deeply tinged vrith
blood, and others again a sero-pumlent secretion, according m
hemorrhage or inflammation has occurred in one and has not
Ill
occurred in another, even though munediately adjacent;
varieties in the same tumour have sometimee given occ
the opinion that a gi-owth ia a compound cyst, when in n
is only an aggregation of simple cysts in which morbid p
of various kinds have heen going on- It is by no nil
unusual occurrence, too, with tumours of this description, J
pressure on each other to produce absorption of the dividin
and for an aggregation of tumours to be thus in the conise
converted into a single cyst. The openings of conunnx
between the dilierent cysts are usually of a circular tom
smooth edges, as if a portion of the wall had been rem<
some cutting instrument, and while small at hrst, the adv
the process of absorption by degi-ees enlarges them ; till at
a slight irregularity in the external contour of the turn
mains as the only evidence of its original structure. The <
stances that regulate the process are, however, by no means
understood ; for while the absorption of the septa sometimi
place at a time when none of the cysts are lai^ger than a :
it is far from unusual to find the partitions still entire whe
of the cysts have reached the size of the adult head, or hai
attained still larger dunensions.
It is perhaps needless to say that dropsical enlargement
Graafian vesicles is by no means the only source whence
ovarian cysts may bo produced. There can indeed be m
but that the development of cysts may go on in the ovaiy
it does sometimes in the kidney, not by any enlargement
existing cavities, but by a process which is one of new foi
from the very beginning, StUl the whole tendency of pathi
research is to increase the number of instances in whic
are formed by the enlargement of pre-existing caviti<
besides, the question has been set at rest as far as the oc<
production of ovarian dropsy from enlarged Graafian ve
concerned by Eokitansky'a discovery of the ovule withiti
in a case of incipient cystic disease of the ovary.* ■
* Wiener H^oehmhiaU, 1866, No. 1, aa quoted by Scanzoni, LehrhueA dt
AcOm der vHHichm Saual-Or^wu, Sro, Wien, 1867, p. 364. Se« tlio
JM kramkhoftm GtickwMkUj toL L p, 269* Tbe quesLion ia on« of
moBient with refereBce to the prognosis of ovarian dropsy, and the opii
high an authority as Dr Bright (see Ouy^s Hospital ReporU, vol iiL, 18S8
mid 198) U so dot'idtfdly unfavoiifable, that one n?joice8 at obtaining any
THEIH CHABAGTEES, ANB MODE OF PBODUCTIOK.
505
The preciae mode in which the dropsical condition of the
vesicles is produced, is indeed, and probaWy will always remain,
to a great degree miknown* It seems, however, to be very likely
that in some cas^ at least a state of congestion of the vesicle, and
haemorrhage into its cavity, are the first steps towards the pro-
duction of the subsequent elusion. In the museum of Guys
Hospital, to which I was most courteously admitted, are a series
of preparations which appear to illustrate this mode of origin of
ovarian dropsy. In some of them a clot alone is seen within the
vesicle ; in others the clot occupies only a portion of the cyst,
adiiering to its wall by a sort of pedicle, white the remainder of
the cavity is occupied by a serous tluid j the relative proportions
of the clot and the fluid varying much in difterent specimens.
Now, just as haaraorrhage into the sac of the arachnoid is followed
in many instances by the subsequent ettusion of serum so far
exceeding in quantity that of the blood originally extravasated, as
to produce one form of chronic hydrocephalus, so there can be
no reason for doubting but that hfemorrhage into the sac of a
Graafian vesicle may in like manner be followed by a einiilar
hypersecretion.
A tlaeory, indeed, has been propounded, the very opposite of
this* by Professor Scanzoui/ who suggests that the dropsical con-
dition of the Graafian vesicle may be due to the flow of blood to
the ovary at a menstrual period having been insuiScient to produce
the rupture of the sac and the escape of an ovule, but sufficient
only to occasion a certain degree of congestion, terminating in an
increased elusion of fluid into its cavity. This theory is based
chiefly on the alleged frequency of amenorrhcea, or of scanty
menstruation, as a precursor of ovarian dropsy ; an allegation
which, as we shall see hereafter, is scarcely substantiated,
I know of no other facts, nor of any other plausible theory bearing
on the production of dropsy of the Graafian vesicles ; and 1 fear
that I must confess my inability to determine the proportion of
instance in which simple cysts of the ovary are due to the
which esablea us to soften the very dark hues of the picture whkh he Ims drawn.
** This CBM," nyi he, loe. eiL p. 193| "adds to the doubt I hftve already exprx^sscd
of hftTing met with any very dtstanct coBe of dropsical accumulntion in the GntA*
£ian TesicleSv as dlstiDguiflhed .from the diseaM which mua iiilo the malignant
ovarian tumour*"
• Op. ciL p. 353.
606
COMPOmrD OVAEIAK CYSTS :
enlargement of these cavities, and of those in which the cjrsts ara
themselves of new formation* That simple cysts may arise here,
however, as in other ports, by the mere collection of fluid in the
parenchyma of the organ, and the gradual fonnation of a cyal
around it, I see no reason to doubt* Possibly some of the very
delicate and thin-walled ovarian cysts which we occaaionally meet
with may have this origin ; but my conviction is, that this is not
the general mode of production of simple cysts, but that most ais
formed by the distension of a pre-existent cavity.
Another question of greater practical moment is whether single
cysts always remain single or whether they may not become
prdifenrm or compound cysts in the course of their development.
Here, too, it is to be regretted that our data do not suffice for a
satisfactory answer to this inquiry. The practical consequenoes
involved in the decision of tliis point are very obvious ; for it is
apparent that if at any period a simple cyst is capable of passing
into an active state, and of enlarging not by mere distension of its
cavity, but by growth in its interior, or by cyst-formation in its
walls, the expediency of having recourse to early and very decided
therapeutical proceedings becomes far greater tban it otherwise
would be. My belief is, that such a change may take place, and
that a cyst originally barren may become proliferous; that its
continuing simple is rather a happy accident than a condition on
the permanence of whicb we can calculate with any certainty.f
A young woman who had been the subject of ovarian dropsy for
two years and a half, and who had been tapped a year before her
death, sank under the effects of peritoneal inflammation indn^
by an attempt to inject the cyst with iodine. The cyst was found
to be a thin- walled simple cyst ; but at one point, near to the pedicle
of the growth, four little cysts, the largest of which was about the
size of a bean, projected from its internal surface, and round this
group the lining itself was more vascular and rather softer than else-
where. Larger opportunities than I have ever possessed of making
examinations after death would, I doubt not, have furnished me
* A mode of cjit^prodactioii mo«t folJy Uluitnited by Profewor Brach, Zur Eht*
wkktung^-gescMckU der pathologischen Cy^teMiekmifm, in ZeiUcAr, /. raiumdk
MMm, vol TiiL, 1849, p, 9L
f Tbii opiDioQ is &1bo thAt of Spencer IVellik ** It mnj 1iay« the mme origiii At
other cysts, and its early conditioa wonM b« tbjit of ft common nnOocukr oyiW
In fact, any epitheliiil cyats may become proIiTervaa** Op, at, ToL ii p. 3S«
I
THEIR ANATOMICAL CHABACTERS.
with oilier illustrations of a fact which is entirely in accordance
with the result to which analogical reasoning would lead us.
Without the stimulus of impregnation, a Graafian vesicle does, we
know, sometimes produce hair, fat, teeth, cartilage, and bone, and
the proliferoug power, of which these are the highest instances,
may also, without doubt, exert itself in lower forms in the pro-
duction of endogenous growths in its interior ; and though pos-
sibly leaa often, in exogenous cell formation from its walls.
In some of the cases of endogenous cyst development, the
growths that occupy the interior of the cyst spring universally
from its walls, and consist of an immense number of small
pedunculated cysts or vesicles, multiplied apparently by the same
simple process of growth as haa been so well studied in the
hydatid disease of the chorion. Such growthfl may, too, be so
numerous as to fill nearly the whole of the interior of a very large
cyst.* In other cases the endogenous growth, though similar in
its character, does not arise from the whole of the interior of the
cyst, but is connected with it by a pedicle, from which a pyriform
mass of cystic growths proceeds. Cysts presenting these charac-
ters ai-e often termed papillar)^ or dendritic, to distinguish them
from the ordinary glandular cysts. The growths from within the
cysts are sometimes so considerable as to burst tliem, while at
other times they sprout from their exterior.
Besides these forms of endogenous growth, there is another in
which the cavity of the parent cyst is more or less completely
occupied by others of a smaller size, but springing from it by a
broad base^f and containing within thcmaelves others of a third
order, of smaller si^e, and with thinner walls. As these cysts
grow, some probably empty themselves completely into the parent
cyst, and, collapsing, become adherent to its walls, thus giving to
them that thickness and resistance which in some cases, even of
laige ovarian cysts, are very remarkable. At the same time, the
progressive increase of the smaller cysts, and the constant forma-
tion of new cysts, help to make up that enormous mass to which
ovarian tumours sometimes attain.
But while there is perhaps room for doubt as to the nature of
the original growth whence the.ae forma of complex cysts arise,
* Ai in a very rptnarkablc preparAtioti. No. 2245** In Guy*i Bo«pital Moseum.
t As Ko. 2622 in the Himteriui Museum,
508
coMPdtnn) otamak cysts:
there can be no question but that some cysts assume theei
character from their very commencement, and are not del
out of any transformation of the Graahau vesicles. In thes
we find the ovary converted into a tumour of irregular foi
firm, fibrous capsule, some quarter or third of an inch in thii
enclosing a number of cysts or cells, one or two of whic
greatly exceed the dimensions of the others, and he oapi
contaimng many quarts of fluid, while the remainder vary
from the bigness of a marble to that of a pigeon*3 egg, or of an
While some of them may appear as separate cysts, adhei
the othera, but apparently developed independently of
others have obviously been formed in the thickness of the
wall itself, and pix^ject, sometimes inwards, at other times t<
its exterior. When the growths have attained to any coosic
size, inflammation generally roughens their originally amo
temal membrane, and deposits of lymph thicken it ; or tl
lapse of some of the smaller cysts, and their incorporation w
dividing walls of the different cavities, thicken as well as oth
alter the septa. At the same time, too, similar c-auses modit
contents, so that while one cyst is filled with a serous fluids a
contains a glairy, albuminous matter, or its contents are <
tinged with blood, or are of a dark chocolate colour ; while
contain pus, or sero-purulent fluid, or a liquid in which sci
cholesterine sparkle like the brilliant particles in Dantzic eau
It is usuaUy towards the pedicle of these tumours, where the s
cysts are mostly situated, that their structure can be best si
They are then seen to be formed by a smooth, polished mem
tough and resistant, though thin, scarcely semi-transparent,
E white colour, and supplied by long slender blood-vessels,
ramify on their outer surface. Their general fonn is oval, but s
increase in size this is much modified by their mutual press*
each other ; while besides, irregular spaces exist here and
partly produced, perhaps, by the fusion of two or more cyi
gether, partly by the intervals left between several adjacent
The smaller size of the cysts near the pedicle of the turn
apparently due to their being subjected to a greater deg
compression than the others, for sometimes a large cyst w
velop itself downwards into the pelvic cavity ; while again,
the increase of the tumour has been very rapid, a number oi
XnEIl BTBDCTtJBE, AKB VARIITIKS. 8M
cysts may sometimes be found towards its upper part, where ap-
parently the resistance offered by the transverse colon, the liver,
stomach, and diaphragm, has also prevented their increase *
The amount of solid matter which enters into the composition
of these cystic tumours of the ovary varies exceedingly. In many
cases^as in those just descril>ed, the whole mass is but a collection
of cysts whose walls, even when tliiekest, bear but a small pro-
portion to the quantity of fluid which their cavities contain. In
other instances, however, these propartions are revei'sed, and the
bulk of the solid matter far exceeds that of the fluid. Thfs is the
kind of tumour to which the name of Ct/stosarciyma has been
applied by lliiller.t who describes it as principally composed
of a more or less firm, fibrous, or vascular mass, but invariably
containing solitary cysts in its substance. The fibrous maases con-
sist of an albuminous substance, and sometimes contain granules
scattered between their fibrils, and the fibrous tissue forms the
stroma in which the separate cysts are imbedded.
I do not feel myself competent to decide how far these growths
really require to be referred to a separate category. The structure
of the cysts, and their various contents, are analogous to what one
observes in other compound o^^arian cysts. Perhaps, however, it
should be added that fat cysta, or cysts containing hair, teeth, or
other products of cutaneous tissues, when not existing alone, are
most frec^uently associated with cystosarcoma ; and, further, that
these comparatively sohd growths do not attain to the enormous
dimensions of other compound ovarian cysts, and very seldom
exceed the size of the adult head.
Another form of emti^mmd ovarian c?/,?^, allied to the preceding
kinds, but I believe essentially different &"om them, is that in
which the organ is the seat of alveolar or colloid cancer^ a disease J
whose precise relations to other varieties of carcinoma are as yet
undetermined, Tlie grand characteristic of colloid degeneration
of any part is, as you know, the development in its substance of
inniunerable cells, containing a tenacious, gummy secretion, which
* A veiy good drawing of a oompoand oyanati cyst is given by Dr Bright,
op. cU, pi V. p. 276.
t On Cancer, 3tc, English traSAlation, London, Svo, 1840, p. 170.
X A good repr^eoUtioii of alveoUr cancer of the oTory is given by CmTeilhier,
Atla»^ etc I livr. t, pi. 8,
510 COMPOUND OVARIAN CYSTS :
vary from a size too small to be discerned bythe naked eye, toan
inch or rather more than an inch in diameter. These cells in-
crease, though by no means exclusively, by endogenous growth, and
the presence of a countless number in the same stage of develop-
ment shows that the formation of very many occurs simultane-
ously. If their contents are washed out so as to leave behind
only a skeleton of the growth, it is then perceived that very
many of the cells or sacculi communicate with each other ; the
whole mass having a honeycombed appearance, or resembling,
perhaps, more closely a section of the lung of a reptile. The septa
between the cells are in general of a somewhat firm, though deli-
cate fibrous tissue, of a whitish, sometimes of a dead- white colour ;
though while the cells are very minute, their waUs, or the septa
between the areolae, are semi-transparent, and their jelly-like con-
tents shining through, they look not unlike grains of boiled saga
In the ovaries this colloid disease assumes'many different forma.
Sometimes several rounded masses make up an irregular tumo r
which is solid to the touch, and firm on section, presenting
trace of the proper tissue of the part, but a structureless su ^^^
in which are imbedded countless semi-transparent S^^ p^
scarcely any of which are larger than the h»^^ ^^ ^ deVicate,
Again, in other cases the cell walls generally ^^^. ^^. ^xxd fiflfiA
while large spaces are left between, of irreg'*'^^! ^^\)eco\\ectfi^
with the characteristic gelatinous secretion, wll^^ -p. ^\SLc\i «^acfi»
to the amount of sevewd ounces or of a pint, or ^^ sovxSi >^^^ dto^^'^
however, do not appear to be cysts enlarged iT^^^teva^'^'^^*^^
sions of those which surround them, but to be ^^^^ C3(?iel«^^^^^^ .
irregular form produced by the absorption or \^^ cot^^^^ ^
cell walls, and the consequent escape of their"'^^^^
common receptacle.* ^esja^ ^^ ^^^
♦ Remaina of the septa may in these cases bo discoverea Ysy^^^^^'^^T ^^^^
scope, in the midst of the coUoid material. It i^'is th ' \^^\^J*!^ ^tax^cea
which led Virchow, YerhamdXwngm der Gesellschc^^^ Oebu.*^ ^ *^^^^^ ^ ©{ tVv©
the assumption that all compound ovarian cysta are in ^^^^ ^>^^^ it ^^
disease of the oxgan i& which this liquefaction and diaan^^^*^ j^^^<^ b ^^^
taken place. This theor]f^ however, in the extension iri*'*^*L<^^^^^^^^^^4tt '^
now creni»ra.llv reoardfid aa lintenRble. Indeed. i«- «- -i ^ tcK'^^^^^^ -v
now generaUy regarded as untenable. Indeed, it is by tc^^^^^ ^ ^
with compound ovarian cysts which present no similaritv .''*®**^^ ^-^^ ^dd
or in the nature of their contents to alveolar cancer • and T* k ^^ --^^^^
scope fully bears out the verdict which abservation wit>i . ^
us to return. ^^* ^^
COLLOm, CANCEEOUS, AND FAT CYSTS.
511
* Besides the instsinces in which colloid disease exists alone, cases
are by no means unusual of its association eithi^r with compound
cysts of the ovary, or with fungoid or medullary cancer of the
organ. In the former ease it is far from UQcommoo for one or
two of the cysts to have attained to a very great magnitude ; and
the colloid matter may be in part poured into them from some of
the adjacent cellSj so as to give to their contents almost the same
degree of tenacity as is observed in the secretion within the small
cells of alveolar cancer. Even though this should be the case,
however, and though there should be very close juxtaposition of
the two structures, the differences between them wHl, I think, be
sufficiently obvious.
la the case of the association of genuine fungoid cancer with
the colloid disease, it is usually about the pedicle of the tumour
and near its base, that the great mass of cancer is situated. It ia
not, however, limited to this part, Bud sometimes a mass of soft
brain-like substance is found in the midst of the tumour, sur-
rounded by the delicate cysts and gelatinous substance of alveolar
cancer ; while at other limes the medullary matter seems alto-
gether fluid, and on cutting through the tumour iasnes forth from
some of the irregular cavities which have been already spoken of.
The peculiarities of the matter contained in the cells of colloid
cancer have been frequently referred to ; and even in growths of
considerable magnitude tliese characters are sometimes still present
in a marked degree. Often, however, they are more or less
modified by the same causes as influence the contents of other
forms of ovarian cysts, and the viscid secretion is often dark from
the admixture of blood ; sometimes even of a dark chocolate colour,
sometimes grumous ; but I do not think that it becomes purulent,
aa ia not infrequently the case with the secretion of the other
ovarian cysts.
One form of ovarian cyst still remains for notice, and it is one
concerning which some problems still remain unsolved. Cysts ^re
sometimes formed in the ovary, either alone, or associated with
common ovarian dropsy» or with cystosarcoma of the organ,
containing fai, Jmir, teeth, or oilier products of cutaneous tismts*
The presence of scales of cholesterine, or of small quantities of fat,
is indeed often observed both in simple and in compound ovarian
cysts, and ia due to the rapid formation and rapid desquamation
i^
512
CUTAKEOTJS, AUD FAT CYSTS OF THE OVABT :
of their epithelial lining, and to the alterations which 1
puacles undergo. In these cysts, however, fat is present i
larger quantities, so that it forma a )ayer on the sur^
fluid removed by tapping as firm as lard, or even firmer ; fl
perhaps into l^vge irregular flakes or masses, or else into s
of small halls like marbles, of a yellow colour, and of the
ence of tallow, shaped into these symmetrical forms bjr
attrition in the fluid which partly filled the cysts, of whic
is a remarkable specimen in the museum of Guy's He
Sometimes the cyst contains no fluid, but a substance
appearance and consistence of pnttj, possibly int-ermingl
hair, or it may contain various matters, such, for instance, £
cells, or striped or unstriped muscular tissue. Hair, indeed,
met with in these cysts, sometimes in shapeless, tangled
but more frequently rolled together into round balls ; sn(
bone, and bone cartilage are also all found iu many im
"Wlien it had been clearly ascertained that these structures
independently of impregnation, it was next assumed eiti
they were the relics of some imperfectly developed germ j
by accident within that ovule which had gone on to ;
and they were therefore congenital formations, or else '
ovule itself was capable of a certain imperfect attempt at (
independent of its appropriate vivifying power, and thus pr
incompletely, and with no orderly arrangement, some
materials of the fietus.
In a measure, too, both of these theories are probably \
though cutaneous cysts are found in circumsfcances which
seem to admit of either of these solutions. In all such cjrs!
may be found any of the products of dermoid tissue rq
formed, as though growing in their natural situations ; th
implanted in a perfectly normal manner into the cutaneous
which is found to be supplied with perspiratory and ael
follicles, while the teeth, in different stages of developmi
imbedded in tooth sacks. We owe the observations whic
removed cases of this kind from the domain of the wonderf
have shown how method and order reign, where a more im
knowledge could discover nothing but mere freaks of nal
^ No, 2237**. Eokitansky also rcktea a remArkaMe caao of a aomewlm
kind, op. cii^ voL iii, p. 597.
sel
d
THEIR ANATOMICAL CHARACTERS.
513
the acuteness of a Grerman physiciatL* Another of his country-
men has done much to complete our information, aod I will briefly
etate to you the results at which he has arrivei I>r SteinUD,f on
examination of the body of a young woman from whom seventy-
eight pounds of pus were removed in four successive tappings,
found that w^hile the left ovary contained several small cysts, none
of which exceeded the size of a hazel nut, the right ovary was the
principal seat of disease. It was made up of many cysts, all of
wliich, w^ith the exception of one large sac containing several
pounds of pus, were fat cysts, varying from the size of a grain of
linseed to three or four inches in diameter. The fat was in
different conditions in different cysts, and in the older cysts was
often intermixed with hairs intertwined into a mass. All the
contents being removed, the greater part of the cyst-wall was seen
to he smooth and shining, but there were odc or more round islands,
of a dull whitish colour, with a wart-like prominence in their centre,
overgrown with hair ; and other similar spots without the wart-like
prominence, and withont the growth of hair, hut mth several
teeth or portions of hone more or less buried under their surface.
The cyst-wall admitted of division into several layers. Of
these the outermost was composed of loose cellular tissue, beneath
which was a denser layer made up of fibres, which, though
interlaced, had on the whole a parallel aiTangement ; under this
was a layer of elastic tissue, and innennost of all a coating of
epitiielium. The epithelium was ever^.'^where of the tesselatad
kind, and at the polished parts the cells were round and regular, but
at the dull parts the superficial layer was arranged irregularly,
though round cells were regularly disposed beneath. On denuding
the wart-Hke prominences of their epithelium, the subjacent surface
exactly resembled that of the true skin, having well-developed
papilla*, and the whole of the cyst-wall beneath the impolished
islets had a similar structure. The hairs growing here sprouted fmm
a regular bulb, and there were sebaceous glands and perspiratcny
folhcles in varying number. The quantity of hairs is accounted for
by their being deciduous, though formed in the natural manner, and
the fat is not secreted by the whole interior of the cyst, but by the
sebaceous glands, just as the vernix caseosa is in the fcetus. The
* Dr KohlraoBch, ia Miiller*8 ArcJdv, 1843, p. 365*
t Zeitschri/t/. rationelk Medizin^ Band ix. 8. 346.
?AT CYSTS OF THE OVARY.
i
igtB
presence of teeth is explained by their being trae product
moid tissue, so that wherever that tissue is founci there alwa
the possibility of teeth being developed ; and their preseo
jaws is a sort of accident by no means essential to their fc
Dr Steinhn concludes that the development of the cyst
secondary occiirrence ; that the first step in tliese
formation of a tissue exactly identical with the ext
the iiccumulation of its secretions by degrees distending !
ing membmne. The earliest appearance of one of these
is as a small, fteshy-looking mass, of the size of a grain of
in the situation of a Graatian follicle, and surrounded by
sac. In the course of time this small body becomes detacl
the sac except at one point, where its stem remains, aD<
vessels having a looped arrangement enter it. Next, a tfa
of fat is found between the small lump and the sac, and (
ful examination of the former the sebaceous tbllicles are o
developed. With the increase of their number the fat ii
and the sac becomes distended, while tlie perspiratt>ry
modify by tlieii" secretion the contents of the sac. If to
scription one adds that the intimate relation between pus
globules may be taken as explaining the general presence
in fat cysts of any considerable size, I think that the (
of this, as of the other forms of cystic ovarian tumoi^
regarded as complete, in so far at least as the practicaf
these lectures is concerned. Two points, however, still
which recpiire a brief notice : namely, the comparative b%
of disease of one or other, or of both ovaries, and the com]
frequency of the different varieties of ovarian disease.
With reference to the lirst of these questions, the
evidence of statistics, as the subjoined table shows, goes 1
the preponderating frequency of att'ection of the right oval
Right Ovrny, Left Ovary. Both i
Cases collected by S. Lee* 50
„ „ Chdreaut 109
„ „ Scanzoni* 14
„ „ the Author 35
~208
• On Tvmown qf th^ UUrvs^ dhr,, 8vo, London, 1847, p. li
t iU quoted by BoiiiJBOiii, op. cU. j^ 418.
vsusx
3Ufl
catc
35
8
78
28
13
14
38
19
164
69
FREQUEKCT 07 DIFFERENT FORMS OF OVARIAN DISEASK 515
This table, however, can be regarded only as a very rough ap-
proximation to the truth in this matter, since it is mainly deduced
from observations made during the life of the patient, while it is
often a matter of considerable difticulty 'to determine whether a
tumour is formed by the right or by the left avan* ; and harder
still to decide that the disease m limited to one ovary, and that
the organ on the opposite side is healthy. In two instances,
indeed, in addition to those enumerated in the table, I found
myself quite unable to determine which ovary occasioned the
tumour, and very likely in some other eases the conclusion which
I did come to was erroneous. This diihculty, too, arises not siniplj
from the mesial position of the tumour at the time when the case
comes under observation, and from the inattention of tlie patient
to her own early symptoms, though that is very frequent, but also
from the circumstance that the ligamentum ovarii becomes twisted
occasionally as the organ increases in size, so that a tumour of the
left ovary sometimes produces enlargement of the right rather than
of the left half of the abdomeD.
Obeervatiou after de^tth, too, fails to bear out the alleged greater
&ec[uency of the disease on one side than on the other, and I think
we may accept Olshausen^s* conclusion that no important ditTerence
exists in this respect. Tliere is no doubt but that it is com-
paratively seldom, that the disease is far advanced in both
ovaries ; but the inference that it is so constantly limited to one
side, as observations during life would lead one to suppose, is not
borne out by post-mortem examination. Scanxonis figures were
deduced from post-mortem examinations, and if to them are
added 24 of my own, and 15 of Dr R Lee^s cases,f a total is
obtained of 80 cases, in 28 of which the disease occupied the
right side, in 26 the left, and in 26 both ovaries, although only in
54 of S. Wells* 800 cases were both ovarie.*? so involved as to
necessitate their extirpation. This result, too, tallies with that
which we might reasonably anticipate beforehand, for, to the beat
of my knowledge, there is no ground for the special liability of
one ovary, or for the special immunity from disease of the other.
Professor Scanzoni is, I believe, the only writer who has
attempted any numerical estimate of the comparative frequency
• Op. riL p, 77.
t ChL Ovariun and UUritu Biseaus, Loadou, 1SS8,
516 FBEQUSNCT OF DIFFEBENT FOBMS OF OYABIAN DISI
of the di£ferent varieties of cystic disease of the ovaries
cases and my 24 yield the following results : —
Simple cysts in 16 ca
Fat cysts „ 2
Ck)mponnd C}rsts, and cystosarcomata „ 23
Colloid, or alveolar tumours ... „ 21
Cancer with cyst-formation • . . . „ 3
Total
66
It must be reserved for the next Lecture to coni
becomes of these tumours ; to examine how nature e
too often fruitlessly, to effect their cure, and how the dii
too generally and too inevitably to increase, and as it i
bring added suffering, and to hasten the approach of de
♦ Op. cU. p. 418.
LECTURE XXV.
OVARIAN TUMOURS AND DROPST,
G£KEEAL oounsB OP TKB AFFBOTIOK ; exceptionftl cluTacter of the cjsts of the
Wolffi&n bodies — their dlspoiition to rGmain staiionorj. Oecuional utTeat of
growth of aimple cyitB luiaftlly temporar)-' — their complete tvmoval Teiy rare,
Cjst aonietimes dischargas its cout^nts though Faliopkn tube, vagina, inteatinep
externally, or iBto peritoneum.
Changes in CTri*rSj their gradnsLl softening. Inflaraniation of cysta. Disorder of
health from pressure of cysts on Tiicem ; cachexia atteoding the increase of
cyst Various modes of death.
CAtJsEa predispoaiug to pvariim dropsy — iniluence of age, marriage, and child-
bearing.
Alleged exciting causes of the disease.
The study of tlie anatomy of ovarian cysts and tumours winch
occtipied us at the last Lecture, has enabled us now to advance a
step further in our investigations, and to inquire what is their
cmirs^t au^ what their teruUney, what efforts nature vmk^^s to effect
ificir aire, and what are the different wmjs in whkh they prove
fatal f
It has been already stated that practitioners^ though ignorant
of their real nature, were long familiar with the oceasional pre-
sence of thin-walled cysts between the folds of the broad liga-
ment, which, unlike other cysts connected with the substance
of the ovary, had but little disposition to increase beyond
comparatively small dimensions. Not unnaturally, however, they
indulged the favourable anticipations which were justified only in
the case of a f*eculiar and infrequent affection, with reference also
to a great number of simple ovaiian cysts. Utterly unfounded
expectations of the disease eventually becoming stationary have
thus on several occasions within my own knowledge deterred
patients from justly estimating their own condition and prospects,
and from consenting, while there was yet time, to the adoptioa
518
SBtPLE CYSTS OF THE OVABY ;
of any curative measures. It is therefore of importance to 1
in miod that the only cysts coDcerning wkich the diapofiitioB In
remain stationary can Le predicated as their general charewsUrilic
are the cysts of the Wolffian bodies ; and, further^ that these cyite
have but rarely been met with exceeding the size of an ormng^t
while even such dimensions are unusual, and in by far the greater
number of instances they reveal themselves by no symptoms
during life, and present themselves to the anatomist for oftener
than to the physician. One case, indeed, and but one, has coiae
under my own notice, concerning which I could feel justified in
Assuming that the cyst was not ovarian, but was conncscted wi^
the remains of the Wolffian body. The patient, who, when she
first came under my notice, was fifty years old, remained for eight
years under my observation ; and the tumour which was connected
with the right uterine appendages continued during the whole
time of the same dimensions, being rather smaller than the fetal
head until, without any symptom, it suddenly disappeared, its thin
walls havmig doubtless given way, and its (*,ontents having escaped
into the peritoneal cavity. Tlie tumour was extremely movable,
floating loosely just above the pelvic brim, but occasionally sink-
ing down into its cavity, and tlien producing discomfort of various
kinds, by its pressure on the parLs situated tliere, and especially
by the obstruction it offered to emptying the bladder, syiDptoms
wliich, with its disappearance, completely ceasei This, however,
is in my experience a gohtary instance of a cyst connected with
the uterus remaining quite stationary at a email size for yean;
so that I fear we must regard the chances as being against the
more hopeful view of the nature of any of these tumours* and
must further look upon the mere fact of the cyst having attained
a greater size than that of a large orange^ or of the fetal head, as
decidedly negativing it. The arrest of the disease may indeed
still be hoped for as a lucky accident ; it can no longer be county
on as a probable occurrence,
I said tliat the arreM of th^ dimam may in any case of simpli
ovarian cyst be looked for as a lucky accident j and, indeed, 1 do
not know how more fitly to designate it, for the nice adjustment
of the balance between exhalation and absorption depends on
conditions which remedies cannot bring about, which diagnostic
skill cannot even foretell It is not in general while in the pelvic
OCCASSIONAL AKBKST OF THEIB PI10GEES8,
519
cavity that this arrest occurs; for though the growth of the
tumour may then be slow, it is while situated there liable to he
pressed on, irritated,' excited hy the varying conditions of the
adjacent viscera* After it has risen above the j)elvic brim, this
fortunate occuiTence sometimes takes place, though it takes place
hut very rarely, for, thoygh the cyst is no longer irritated as it was
before, its increase is not now reatmined by unyielding boundaries,
and hence it frequently enlai^es with gi-eiiter rapidity. As a gene-
ral nde, the enlapjement goes on, not continuously, indeed, but by
fits and starts, till at length the size of the abdomen causes distress,
and necessitates interference. The exception is met with in in-
stances where the cyst having attained a size somewhat less than
that of the adult head» begins, to the patient's surprise and pleasure,
to diminish, becomes notably smaller than it once had been, though
it scarcely ever entirely disappeai's, but remains for years, possibly
even for the remainder of tlie patient*3 life, a source of apprehen-
sion and an occasion of some discomfort, but not of much actual
Buflering, or of serious injury to the health.
In March 1853, 1 saw a single woman, aged thirty-one, in whom
the development of an ovarian cyst had succeeded to a heavy fall
on the nates three years before. Her abdomen on admission
measured thirty-seven and a half inches at the umbilicus ; and its
increase was alleged to have been going on with rapidity ; and the
patient was anxious even to undergo some risks for the chance of
being cured of an ailment now threatening to become the source
of much suffeiing. She was ordered to keep her bed for a few
days, in order that a careful examination of her abdomen iind of
the relations of the tumour might be made. In a week the abdo-
men measured only thirty-five inches ; and in another fortnight
only thirty-four. I need hardly say that in these circumstances
the patient was advised neither to be tapped nor to have any other
operation attempted* She returned to the country^ and to her occu-
pation as a village schoolmistress. In April 1855, her abdomen
measured little more than thirty-five inches ; and tapping did not
become necessary until between four and five years afterwarils,*
• Arery remarkable case isrelnted by Dr Peaplee, Ovarian Tumours, London, 8vo,
1873, of a woxoan who having heen tapjied several timea betwecD the age of 27 and
41, during which time she gave hirth to three children, passed the ensuing 23 years
mthoiit being tapped at all. The fluid then r6<;oUected and the patient wa£ tapped
520
SIMPT^ CYSTS OF THE OVABT ;
To a slighter degi'ee, and for a shorter time, the partial aheocp^
tion of the contents of an ovarian cyst is hy no means uncommoit;
and no one can have seen much of ovarian dropsy without havuig
been atrnck by the different degrees of tension which the
at diflerent times presents. Sometimes it is so tense and finsl
to seem almost solid, and, indeed, if the growt-h is but small, tim
extreme tension of its walls may fio obscure the sense of fiuctoa*
tion as to lead the observer, unless very cai-efuUy on the watch,
into error. At other times not only is fluctuation most distin^
but the cyst- wall is so flaccid that if the tumour is large it may
not be very easy to distinguish between an encysted dropsy and
ascites.*
Jt is not easy to determine the cause of such fluctuations in the
condition of the cyst. A connexion may now and then be
served between the approach of a menstrual period and an enla
ment and increased tension of the cyst, while it once more grows
smaller, and its walls become flaccid as menstruation pa
In the majority of cases, however, no approach to regular ;
dicity in these changes can be observed, tliough even when the
disease goes on tolerably uninterruptedly from bad to worae^ there
are yet almost always seasons during wluch it remains stalionaiTv
followed by times of rapid increase. The increase of the tumour,
too, sometimes takes place noticeably in the course of twelve or
twenty-four hours ; the suddenness of the enlargement showing it
to be due to a rapid effusion into the cavity of the cyst, not to the
comparatively alow process of growth.
If the contents of an ovarian cyst may then vary from time to
flCYenken times between then and her death ^xhansti'd at tJie ige of acT«ntj-«ix,
[For a carefully obseired cane of ititTeiuse and decreaae of iiie of on oTu^an cjsl^
see a paper by Dr P* Ritchie in ObsUtrical Tranmeiiona t^f Edinbur^ -roL ii p.
26.]
* Cmveilliier, AnaUtmit Pdthoh, vol iii. p. 400, speaks of a variety of onmn
cjsts an hjiUs uniloculaires Jiaaques^ and dvscribes tbcm as ivtainiiig a remarkable
fljircidily of tbvir walla in apite even of having attained a very conaiderable aue*
He further gives the details of a case in whitb these characters led two yerf dia-
tlngiiinhed physiciana into th« error of mistaking an ovarian dn>p$iy for aacite*.
Thfse flaccid cysta »epm to cause comjiarHtivcly sniiill discomfort, to interfere but
little 'With the general health, and to give rise to no symptoms such as to jnatify
tQpping. One 8Ucb case I saw quite recently, in which it waa not till after I bad
carefully examined the abdomen aeveral timea that 1 mm^ to tbedeciaion tkattlio
fluid was enoyatedi
QOCASIONAL ABBEST OF THEIR PBOGKESS.
521
time, there certainly can be no reason why, in flome instanc^a^ the
process of absorption may not go on so as to eftect the entire re-
moval of the tiuid and the complete cure of the patient Such an
Qcctirrence, howeverj appears to be of extreme rarity, and some
most competent authorities have even discredited it altogether.*
In one case I believe that I witnessed it in the person of a young
married woman, who had vague symptoms of discomfort about
her uterus for nine months, and had been aware of the existence
of a tumour for four months before her admission into the hospital.
The tumour, which was connected with the left ovary, was tapped
I*er vaginam, and sixteen ounces of highly albuminous fluid were
withdi-awm It was determined that so soon as the cyst had
regained its former dimensions, tapping should he repeated, and a
solution of iodine be injected, in order to prevent the reaccumu-
lation of the fluid. On the forty -second day after the first tapping
this operation was to have been done ; but it then struck some
who were present that the tumour had seemed larger a day or two
previously tlian it was tlien. The operation was postponed ; and
day by day the tumour slii'ank, not suddenly as if from rupture
of its walls, nor with any discharge per vaginam suggestive of a
communication existing between it and the Fallopian tube, but by
degrees, as if its contents were gradually absorbed* Fourteen days
afterwards, or on the tifty-sLxth day from the first tapping, all
traces of the tumour had disappeared. Another case has come to
my knowledge of the disappearance of an ovarian tumour in a
lady from whom seven pints of deep amber-coloured glutinous
fluid were removed by tapping five weeks before the birth of her
fourth child. Her labour wm quite natural, but nineteen days
afterwards, while seated on the sofa, she was attacked by sudden
violent pain, with great faintness, and symptoms of rupture of the
cyst, foUowed by tliose of general peritonitis, for which she was
treated very actively. Her abdomen at this time became swollen
to double the size which it had presented when she was tapped.
In the course of two months, however, this general enlargement
subsided, disclosing a distinct elastic tumour occupying the
* Kiwiech tatd Sc&DZoni, two of the moat recent and of tbe Uigliest ant]] ori ties,
nioBt (ximpIeUdy discredit its occurrence. A CMae m which it certainly seems to
have taken place is record^ by Dr Helii^ of Kantes, and quoted by Dr Muurioc at
p. 607 of the French timnslatioD of this work.
522
OVABIAN CYSTS :
hypogastric and right iliac regions. This next shrank gradtiajly;
80 that at the end of nine months from the patient's confinemeot
I could scarcely find any trace of it ; and after a natural pr^-
nancy she was con£ned of her hfth child, two years and a momli
after her former labour. On this occasion, the medical mail who
attended her, and who had watched her through all her preTidtt
Dlness, searched in vain for any traces of the tumour. In tliw
second case there can be but little doubt but that some connexion
existed between the attack of peritoneal inHanunation in which
the cyst itself was involved and the subsequent complete dis-
ajjpearance of the tumour. In the foruier instance, howeve?, no
symptom whatever attended the removal of the fluid ; but though
we do not understand the means by which it was eflfected, still the
removal of the tiuid is scarcely more inexplicable than the pen»A-
nent cui'e which occasionally follows a single tapping, in cases
where yet neither constitutional disturbance nor local sutferifig
has followed the operation.*
The simple absorption of their contents is, indeed, the mrest ol
all the changes which take place in ovarian cysts and there is an
increasing consensus now, especially since our better knowledge of
so-called parovarian cysts, to tho etlect that an ovarian cystoma
never cLL^arjpeiirs. It may grow smaller, its contents may Income
inspissated, but there is no evidence at present to show that the
cyst itself is ever entirely removed. A much more common
occurrence, and one by wliich their increase is for a time arrested,
and their complete cure now and then efl'ected, is their ruptuji%
and the escape of their contents through various channels, the
empty cyst ceasing, perhaps for a time, perhaps for ever, to per-
form its secretoiy function.
An avarian cyd may cmpti/ itself (hrou(/h (lie FalUj/piAtn tulte, the
most fortunate, but by no means the most frequent, outlet for its
contents; through the vagnia, through the intestine, or even
through the bladder; or it may bumt into the cavity of the
peritoneum, or, forming adhesions with the aMominal walls, may
pour out its conlenta at or near the umbilicus.
Each of these outlets needs a moment's notice ; and, first, of
that which is fonned by the dilated Fallopian tube. Cases are
* A c*se of gradual dinappeamsce of a welUixiiirked ovamo cyit ta related by
Dr Hum in MwmimchHJtf. Otburl$kunde, Feb. 1857, vol ix. p, 118.
EMPTY THEMSELVES THROUGH VARIOUS CHANKELa
523
Bometimes met with in which, on examination of the body after
death, the fimbriated extremity of the Fallopian tube is found
adherent to an ovarian cyst, and expanded over it, while the tube
itself is distended at its abdominal extremity, and presents all the
characters of dropsy. On pressure nj»on the cyst, however, it ia
found that the fluid c^n pass readily from it into the tube, while
in most instances, and quite contrary to what inight be expected,
no mechanical obstacle is found closing the uterine end of the
canal. The communication between the cyst and the tnbe is,
however, free enough to admit the point of the index finger, a slight
contraction marking its situation, and the longitudinal arrange-
ment of the fibres indicating the commencement of the tube.
The mere tonicity of the parts prevents the rt^ady escape of the
fluid at the uterine end of the tube. It collects in the canal, dia-
tendin;^' by degrees its abdominal extremity, and at length eseap-
ing through the womb only when it has dilated the whole length
of the tube, and overcome the natural resistence of its walla. A
gush of fluid then takes place by the vagina, and the cyst is
partly or even completely emptied, though such discharges do not
in general effect a permanent cm'e, but the cyst refills, the tnbe
becomes redistended, and the same process may be several times
repeated. Such at least appears to be the opinion of M. Adolphe
Hichard,* who has described these cases very minutely, and who
suggests, and with much plausibility, that many of the instances
of alleged communication of ovarian cysts with the vagina were
in reality instances of their opening into the Fallopian tul:)e.
No opportunity of studying this process has presented itself to
me after death ; and, indeed, I am disposed to believe that it is a
rare occurrence, since I have met with but one instance, out of
the ninety-four cases on which my remarks are founded, where the
cyst appeared to empty itself in this manner, constituting what
has been called Hi/drops ovarhrum projlueiis. The patient in that
case was a married woman, thirty-six years of age, whose abdomen
♦ Mim<nr«9 de la SodUi de Chirurgief vdL iii 1853, p. 121. The absencu of any
evidence of past inflftnimatory action about tbe communicAiton between the oTary
and the tube, leads II, lUt-hani to suppose that the origin of tlie condition diit«8
bock to a bjgone menstrual period ; th&t the Graafian vehicle having discharged
its oTule, did not coUapae and wither aa it usually docsp but »till RHaitiing ita
communieation wtth tbe tube, enlai^god, became dropsical, and tbus formed what
he proposes to term a iabo-Qvarian cy9t»
524
OVABUH CYSTS :
first began to enlarge six years before her admission into tk
hospital. Alter having acquired a considerable size, the swellii^
suddenly disappeared during a profuse watery dischaj^e from Uie
vagina ; and the same occurrence took place afterwards eight or
ten times. The fluid thus discharged was colourless; it escaped
with a gush, amounted sometimes to several quarts, and the
suddenness of its flow not infrequently prodnced faintness or
actual syncope. Sometimes it escaped during the eflfort at d<
tion, but most commonly its flow was independent of any anc
exciting cause. I myself ascertained the presence of a distinctly
fluctuating tumour, its sudden disappearance fourteen days
wards, and then the slow return of abdominal eulargement di
the ensuing three weeks, when I lost sight of the patients
The symptoms however, were so characteristic, that I inii
one is perfectly justified in assuming the case to have been one
communication of the cyat with the Fallopian tube. The uterus
itself was perfectly movable, rather high up in the palvis, no
aperture existed in the vagina, nor, indeed, was the tumour to be
distinctly felt through it ; but it evidently floated in the abdominal
cavity loosely tethered, as an unadherent ovarian tumour often is,
by the elongated uterine appendages. How the communication
brought about between the ovary and the tube in thase casee
uncertain ; but it has been suggested, with considerable plausi-
bihty, that the process is one of a physiological rather than of a
pathological character. In the other instances, however, inflam-
mation, the formation of adhesions, and the absorption of the wall
both of the cyst and of the adjacent viscus, are all implied in the
escape of the fluid.
Many instances are on recoM* of a eyd emptying Usdf per
vagiiuim ; and tlds, too, even if we exclude those concemizig
which it is doubtful whether they do not more properly belong to
the class described by ML Richard Far more frequent, however,
is the formation of a commimimtion between the cyst and the
intestinal mnaL Generally, though not invariably, this com-
munication takes place quite low down, and seems to be due to
the pressure of that portion of the cyst which occupies the pelvic
cavity upon the rectum, and the consequent absorption of the
* Moisaiter*^ Fm^unkrankhsUm^ Baud ii a. SI 8, contaloft titttiifiroQi tdx^xifsm
inuHtratiye of this subject
EMPTY THEMSELVES THBOUGH YARIOUS CHANNELS.
525
walls both of the intestine and of the tumour. Not long since a
communication took place in this manner, in the case of a patient
of my own, between a large sac which formed part of a compound
ovarian cyst and the rectum a little above the internal sphincter.
Through the opening, which was of the size of a crown-piece,
many quarts of a dark grumous fluid escaped during the last few
daya of the patient*s life, with much alleviation of her sullerings,
and with complete removal of the obstinate constipation that for
a long time previously had been maintained by the mechanical
pressure of the tumour on the intestina The observation of this
and of similar cases sulcata the expediency of attempting to tap
the tumour per vaginam whenever serious inconvenience is pro-
duced by its pressure upon the intestine, and paracentesis through
the abdominal walls has either proved unsuccessful, or has aflbrded
but partial rebel In the instance just referred to very little fluid
was obtained by punctiu'e of the abdomen, while, had a trocar
been introduced into that part of the growth that projected into
the pelvis, the principal cyst would have been emptied, and the
patient's auflerings, which nature mitigated but too tarthly, would
long before have been aaauaged.
Sometimes, however, communications form between an ovarian
cyst and the intestinal canal in other situations, and are not
attributable to the direct effects ol pressure, though their real
cause is very obscure. Thus, in the museum of Guy's Hospital
there is a preparation of an ovarian cyst, at whose upper part an
opening has formed into the bowel A patient of mine, too, in
whom an ovarian cyst had developed itself with rapidity in the
course of two months, and who experienced much abdominal pain
and tenderness, suddenly felt a sensation as if something had
given way within her, and was immediately attacked by violent
diarrhcea. In the course of ten hours the bowels were purged
twenty times ; the evacuations not being feculent, but consisting
of a dark bloody fluid, which, under the miBcroecope, was found
to contain many blood globules, and also many pus corpuscles, as
well as some crystals of cholesterine. The tumour bad now com-
pletely disappeared, and five weeks afterwards there was still no
trac^i of it discoverable, though I am unable to say whether the
cure was permanent.
Openings in the abdominal parietes are another channel through
526
OVARIAN CYSTS :
which ovarian tumours sometimes empty themiselves. In
instance which I saw the cjst had clikted the umbilical ring,
projecterl, hke a hernia covered by the thinned integumeot, a
inches beyond the surrounding abdominal walls. In this thiJi
integument an opening formed, through which on several occastoot
the cyst partially discharged itself. It is, however, more asiil
for the opening to take place below the navel, adhesions first
forming between the cyst and the integuments* The opening
sometimes continues long fistulous, though I hav^e known it to
close, and discharges from it permanently to cease without anr
special change taking place in the condition either of the tnmoar
or of its contents. To the best of my knowledge, a permanent
cure less often follows the discharge of the contents of the cy«t
through the abdominal walla than their escape through some oCher
channeL
The ru^ure of an ovarian cyst into the perUoneal oavUy is, bow-
ever, an accident of far more frequent occurrence than the dis-
charge of its contents through any other channel, and was meH
with in 6 out of 94 cases of which I have a reconi In one of
these cases, a fall on the abdomen produced the bursting of the
cyst, but in by far the greater number of instances on record its
rupture has Ijeen independent of external violence. SnmetUDea
the dehcate cyst gives way from over-distenaion, and tins is pro*
bably the explanation of its sadden disappearance in the case
which I referred to some time ago, as being probably an instance
of a tumour connected with the remains of the Wolffian body ; m
also in another instance wliere a tumour half the size of the adult
head suddenly disappeared, the same accident having occurred to
the patient eighteen months before. In other cases inflammatiop
and softeuing of a cyst-wall have preceded its rupture; and an
examination after death discovera it red and congested, and the
edges of the rent soft, irregular, and jagged Sometunes the sae,
once ruptured, does not refill, and a permanent cure is obtained,
though usually at the expense of an attack of peritonitis ; and t
much fear that there is no direct or constant relation between the
severity of the inflammation which follows the rupture of the cyst
and the non-accumulation of the fluid afterwards. One of my
cases was that of a young lady, aged twenty-six, in whom an
ovarian cyst gave way twice, and whose life on each occasion was
1
1
»u
i
EMPTY TBEMSELTES THROUGH TJLRIOUS CHAKKEIJS.
527
in the greatest jeopardy, but who did not gain thereby the slightest
delay in the rapidity with which the fluid re-collected. In two
other cases of mine the rupture of the cyst proved fatal ; the wall
ha\iDg in both instances given way at the posterior part of the
tumour, where it was closely pressed against the pelvic brim, and
ext4jnsive ec^jhymosis around the rent attested in one case the
mechanical obstacle which had existed to the course of the blood
in that sitnation. In the other case decomposition was too far ad-
vanced to allow of any observation as to the state of the cyst-walL
The mortality of 2 cases out of 6 agrees very nearly with that
which Dr Tilt* deduces from a collection of 34 cases, in 10 of
which death followed the rupture of the cyst, and does not differ
widely from the results of a collection of 155 cases,f of which 128
were cases of rupture into the peritoneum. The total mortaUty
was 63, or about 1 in 2'5. In 20 of Dr Tilt's cases it is said that
the fluid chd not re-collect, hut I feel very doubtful whether a
more numerous collection of facts would be found to bear out the
conclusion that in 2 cases out of 3 the escape of the cyst contents
into the abdomen ia followed by the permanent cure of the
patientj
For the very various results that have followed the escape of
the fluid of ovarian dropsy into the abdomen an explanation has
been suggested by Sir J. Simpson, § and adopted by Scanzoni.|| It
is supposed that the different characters of the fluid in the cyst
determine the occurrence or non-occurrence of peritonitis ; that
the pure serum gives rise to no ill effects, while dangerous peri-
tonitis follows the escape of liuid mixed with blood or with the
products of inflammation, StiU, this is only a hypothesis, pro-
bable, indeed, but not proven, and wholly insutlicient to form the
basis of any therapeutical proceedings.
Other clianfjes take place in ovarian cyds, tending for the most
part less to the cure than to the aggravation of the evil Some of
♦ Lan^^ Aug, 6. 1848, vol il p. 146.
t Nepvcn q^udted by OlshauHeiit op, cU, p, 97,
t In vol. V. p. 226, of Tramadums of Pcdholoffical Society^ a cajw* is neliited by Dr
Bmtowe of rupture of an OToriAn cyst into the abdomett^ the apprttire remaining
penntinent, tlie cyst still continuing to secrete, and ascites resulting from the
Aeenmulntion of the secretion within the peritoDeat cavity. [See aUo Medical
^Bomina; March 7, 1878.]
§ Op, cU. voL L p. 217. iOp,eiL^. 448.
628
OYAEIAN CYSTS :
these changes seem incideDtal to the process of growtli, as bk
ingtaoce the removal of the septa between the cysts, the gmdad
liquefaction of the solid matter, and the consequent eonvemoiicf
a firm into a distinctly fluctuating tumour. This alteration is in
one sense of bad omen, since I believe its occurrence is generaDj
cotemporary with the more rapid increase of the growth ; on 1
other hand, however, it often places within our reach the
of mitigating the patient's sufferings by tapping, which in
earlier stages of the affection was impracticable. With the rapid
growth of the tumour there is in all cases of compound ovaiian
cysts a corresponding increase in the vessels which supply it, i
a conset[uently greater disposition to htcmorrhage into tte cav
Sometimes, indeed, the admixture of blood with the fluid of the
cyst is 80 considerable as no doubt to have had a laige share in
the production of that anaemia, and that extreme exhausUon of
strength which are often observed in patients suffering from laxge
ovarian tumours.
Attention has been drawn within the last few years, and in tin
firat instance by the late distinguished Professor Eokitanaky, to
the twisting of the pedide of the ovary upon itself as an occa&ioiiil
source of peril in the case of ovarian cysts, a still rarer means hy
which nature now and then works an imperfect cure** The cause
of this twisting of the pedicle is not very dear j the peristaltic
movement of the intestines can scarcely suffice to cause it when
the tumour is of any size ; and it is more probably brought about
by the unequal growth of the tumour itself. Now and then the
accident takes place suddenly, and its results are then usually
very marked, but in the great majority of cases its occurrence is
gradual The consequence of the twisting of the pedicle, of
course, is the twisting of the vessels, especially of the large thin*
walled veins, and if it has occurred suddenly and considerably,
haemorrhage takes place into the cyst; it swells, becomes in*
flamed, and suppurates, or dangerous peritonitis threatens the
patient's life. If, on the other hand, the twisting of the pedicle
takes place slowly and not to such an extent as to destroy the
vitality of the growth, it may. by reducing the supply of blood,
bring about a gradual wasting of the tumour.
Though not a common occurrence, Hokitansky met with it in
* Lthrhuch derpaihol, AjMUmk, S^u Aad&ge, Sto, Wion^ 1861, pw I19L
TWISTING OF THEIR PEDICLE: THEIR TNFLAMMATIOK.
529
8 out 58 necropsies of ovarian tumoars, and Speocer Wells found
it in 12 out of 500 ovariotomies, and adds, that in some instances
he doubtless overiooked it It behoves you, therefore, not to lose
sight of it as a probable cause of the occurrence of otherwise in-
explicable grave symptoms appearing suddenly in anycase of
ovarian tumour.
Of all the morbid processes, however, of which these growths
are the seat, injiammation is the most common and the most im-
portant* Few cysts attain any considerable size without having
been attacked by it, and this inflammation is of all the greater
moment, since it is seldom limited to the interior of the cyst, but
generally affects its outer surface likewise, producing adhesions
between it and adjacent organs, and thus forming great, often in*
superable obstacles to the success of various operations which have
been proposed for the cure of ovarian dropsy. In a practical point
of view, too, this intlammation is the more important from being
often unattended by local suffering, sometimes, indeed, accom-
panied by a comparatively small amount of constitutional disturb-
ance, so that it is almost impossible to determine anything with
certainty concerning its occurrence or non-occurrence from the
patient's history. Of this no better proof can be given than is
afforded by the observation of cases where on tapping a cyst, in-
stead of the transparent serum wliich it was supposed to contain,
a turbid fluid largely mingled with pus has been let out, or of other
cases in which, the extirpation of the tumour having been resolved
on, universal atlhesions have been found connecting it with the
viscera, and with the abdominal walls. In many instances the
inflammation issues in the exudation of lymph as weO as in the
outpouring of pus, and the lining membrane of the cyst is found
roughened and thickened by its depc^sit, which is sometimes so
abundant that it may be strijiped off just as may the false mem-
brane deposited on an inflamed pleura. Multiloctlar cysts are, I
think, more liable than simple cysts to this occurrence ; and often,
even where the different cavities intercommunicate, inflammation
and the outpouring of lymph may be found in one cyst, and no
trace of any such occurrence be observable in another immediately
adjacent.
With the increase of the tumour, and the failure of the patient*s
powers, the liability to inflammation of the cyst appears to in-
2l
530
OTARIAN TITMOirRS :
crease also, and its occurrence contribates to hasten the Util
event. It is but seldom, however, except after tapping, ar scmm
other operation, that cyst inSammation of itself proves fatal ; bill
many causes in general combine by slow degrees to destroy tbe
patient.
First among these causes may be mentioned the disorder of Use
functions of otkfr vmera, as the tnmour by its increaaing mse
presses upon and disturbs them. The pregnant uterus, as yoc
know, even when it has attained its largest si;5e, interferes bat
little with the functions of other organs. The intestines find
room on either side of it, while the direction of its fundus forwards
in the axis of the pelvic brim obviates all interference with the ^
descent of the diaphragm, and usually prevents all disturbance of f
the stomach or liver. The ovarian tumour, on the other hand, as
it increases in size, so completely fills the lateral regions as to
leave no room for the intestines except tehind and above it, where
they are often compressed into a very scanty space. No such law
governing the direction taken by the tumour as regulates the en-
largement of the pregnant womb, the descent of the diaphiagm
becomes earlier impeded, and respiration is thereby rendered
laboured. The liver is at the same time pressed on and disturbed
in the perfonnance of its functions, and this just at a time when
the active discharge of its duties is rendered all the more neceasiiy
by the congestion of the alxiominal vessels which the pressure of
the tumour occasions, and the scanty urinary secretion that is ita
attendant and its consequence.*
In a large proportion of cases this abdominal congestion relieT«
itself by the effusion of fluid into the peritoneum, and in some
instances the amount of this effusion is very considerable ; enlai^ i
nient of the superficial veins attests the ol>struction to the circula-
tion, and the ascites becomes the occasion of more distress than
ihe original disease to wiiich it is superadded. (Edema of the '
lower extremities is less frequent than in pregnancy, probaUj
because the peculiar state of the blood which favours its occuirenoe
in tlie latter condition is absent. Where it exists it is often
confined to one limb, being the direct result of mechanical
* Two drawitigH ^ivcti by Dr. Briglitj he, cit. pi vii. ix.,are extremeljr inBtmetire
llustrations of the mnniicr in which tamotirs of the ovary pros o& And diflpJioe the
viwccrm.
THEIR INFLUENCE ON THE GENERAL HE^VLTII.
pressure* This ia not invariably the case, howeverp for ovariaa
dropgy ia sometimes associated with albuminous urine, whether
a3 the result of its accidental complication with granular disease
of the kidneys, or of congestion of those organs produced by the
pressure of the tumour, I do not feel myself able to determine,
Wliile the enlarging tumour thus tends to trouble all the
functions of the body, the patient's strength is further exhausted
by the determination to the growth of a large quantity of that
blood which ought to minister to the general nutrition of the
body. Nor is this all; but a state of cachexia, the consequence and
the evidence of the deteriorated condition of the blood, occurs
frequently in the course of this, as of other forms of malignant
disease, with which, if not actually identical, many tumours of
the ovary are at any rate closely allied* In the simple ovarian
cysts it is true that this latter source of suffering and of peril does
not exist, and the prospecU of the patient are accordingly far
less dark than in other varieties of the disease. These simple
cysts, too, as has already been mentioned, now and then remain
stationary for many years, life being not at all shortened, scarcely
even embittered, by their presence. Such, however, are excep-
tional cases, and exceptions of but rare occurrence ; for generally
the accumulation of fluid even in a simple cyst, sooner or later
necessitate^s the performance of tapping, while when once done its
i^epetition is speedily required, and the patient is thus worn out,
by the frequent collection and frequent evacuation of the contents
of the cyst A certain risk, too, of cyst-inflammation accompanies
every tapping, and is, when it occurs, a hazard of a very serious
kind. The liability to its occurrence appears to be greatest either
after tlie first performance of the operation, or else in the case of
patients who have been exhausted by the long continuance of the
disease, and the frequent repetition of the tapping. In mucli
debilitated patients, especially in those who are suflering from
malignant or quasimalignant forms of ovarian disease, the spon-
taneous supervention of cyst-inflammation, or of a low form of
peritonitis, is of no very rare occurrence, and not infrequently
puts out the life whose flame had burnt but flickeringly for weeks
or months before.
We have now completed our examination of the sti
cystic tumours of the ovarj^, and have also studied t
632
OVAHTAK TUMOURS :
modes whereby, in some rare instances, nature effects fheir
as well as those far moi'e numerous ways by which the patieatii
uanally conducted from bad to worse, and the fatal is^iie is M
too surely brought about. Before we proceed to the in^est^lioir
of the symptoms of these diseases, and to the inquiry as to whii
either medicine or surgery can do for tlieir alleviatiou or thm
cure, there are still aome questions concerning their canaeB^ and
the circumstances that favour their occurrence, to which we ntial
endeavour to furnish a reply.
It maybe asked, when do these affections commonly ooCTrr :
what is the influence of the exercise of the sexual functions npoQ
their development ; whether does sterility or fecundity predispose
to them ; and does a disordered state of the iiterine health oom-
monly precede them ; or are they as likely to befall the person
whose health has been previously good as her who for years hat
been a valetudinarian ? To these inquiries as to the eatmm of
ovarian dropsy, it would seem that very definite and conchiaift
answers mio^lit be given, and yet, strangely enou^rh, the replies are
most contradictory. The young and the aged, the single and the
married, the sterile and the mother of many children, the robost
and she whose uterine functions have been performed with pain
and dithculty, have all in turn been asserted to be specially liable
to the occurrence of ovarian disease.
With reference to the age of patients in whom the diaeaao
occurs, there seems to be no period of life that enjoys an absalut^
immunity from it ; though it is of extreme rarity before puberty,
and its commencement after the cessation of the menstntal
function, though far less uncommon, is certainly unusual. Pro
fessor Kiwisch mentions* a preparation of cystic disease of the
ovary in a child only a year old in the museum of Pmgae^ and
refers to a similar one at Wiirzburg, in which the affection in-
volved both ovaries in the fietus. He states, however, that faur>
teen years is the earliest age at which he himself has observed it ;
and a girl died in St Bartholomew's Hospital, under the care of
Sir G. Burrows, from malignant disease of the ovaries, with cyst-
formation in their substance, who had not attained her fifteenth
year, and I rememl>er a child, I think of not more than eight years
of age, certainly under ten years, dying of ovarian tumour in the
* OjscU, rol. il p> 79, 1 86,
I
I
THEJB FEEDISPOSING CAUSES. 533
Hospital for Sick Children in Ormond Street One of my patients
died of rupture of the cyst when in her sixteenth year, and the
enlaiT^ement of her abdomen, wliich was very considerable at her
deathj was alleged to have been first observed when she was
thirteen years old^ — ^menstruation not having occurred till the age
of fourteen years and six months. In another of my patients the
dtaaase began in her seventeenth year, menstruation having
occnrred once at the age of fifteen and a half ; buf it did not re-
appear till after she was tapped at the age of eighteen. These,
however, are exceptional occurrences, and in between a third and
a half of all cases of ovarian dropsy the commencement of the
disease dates from between the ages of thirty and forty.
This result, at least, is what I arrive at from a comparison of 94
cases of my own with 97 of Scanzoni's * which are thrown into
the foUowiog table. I employ Scanzoni's figures in preference to
those of any other writer, because he alone has taken a^ its basis
the ages at which the first symptoms of the disease appeared,
wlule many writers have constructed their tables according to the
age at which the patients first came under their observation.
Table sfiowing ths Age at which, in 191 W&men^ the sipnj^oma of
Ovarian JJmjmy were Jlrsl pef*eeived.
thor'a
MM.
CHea.
Total
Age at firtt
•jmptoiiifl.
at ditr«rM»t ages.
17
5
22 from 13 to 25 '
jreara
11-5
15
12
27
»
25 „ 30
*t
14-1
IS
21
36
JH
30 „ 35
ti
18-8
23
32
55
r»
35 „ 40
••
28-7
11
14
25
)l
40 „ 45
»
13-0
8
e
14
»9
45 „ 50
ft
7-3
S
2
5
»»
60 „ 55
»
2-0
2
5
7
9»
55 „ 60
II
36
94 97 191
The next question concerns the inflaence of the exercise of the
mriuil fundlmism predisposiug to the disease — an intluence which
you may remember was very decided in the case of uterine cancer,
since only 3 out of 168 patients affected by it were single women
• Op, cU, i>. 365.
su
OVARIAN TUMODTtS :
and only 13 out of the 165 who had heen married were sterile
Of 94 cases of ovarian disease, however, 24 occurred in single
women, 13 in \ddows, and 57 in the married — a statemeDt wUdi
refers to their condition at the time when the disease comiDeiiced
This proportion is not very materially altered by tlie employmenl
of higher numbers, since, adding to my own cases those collectri
by Mr Lee and those observed by Scanzoni* we obtain the follow-
results : —
Single women , ... 94, or 28'7 per cent.
Widows 31, „ 9*4
Married women .... 202, „ 61*7 „
327
or, in other words, considerably more than a third of all cases of
ovarian disease began at a time when the sexual functions were
not in active exercise ; and more than a fourth occurred in women
in whom those functions had never been exerted at alLf*
That the exercise of the sexual functions does not pr6dispoM|
ovarian disease, but that, on tlxe contrary, some connexion sub-
sists between their imperfect performance and the development of
this aftection, is evident from the low rate of fecundity among
married women in whom ovarian dropsy occurs. Of 70 of my
patients, either married or widows, there were 26 sterile ; and of
Scanzoni's 52 cases, 18 who had likewise never been pregnant; or
in other words, in 44 of 122 women who became the subjects of
ovarian dropsy, or in 36 per cent, marriage had never been
followed by conception, while among my patients generally, at St
Bartholomew's Hospital, the proportion of sterile marriages was
only 11^7 per cent. Even those marriages, too, that were followed
by conception showed leas than the average fecundity ; for of my
70 cases, the 44 in which the women were not sterile yielded
only 172 pregnancies ; of these 129 terminated at the full time,
43 ended in miscarriage. These numbers yield an average of 3*9
pi^nancies to each fruitful marriage, or little more than half the
^Op.cU.'p. 36S« I httye included iu ihifi Ust of mirricd womexLi mtoi, vW
tboi^gb mngH hud given birth to one or more cbiMrcix,
t I leave thejse tigurea m they staDd, for I doo't find that the statements ia tlic
text an at rII importantJy modified by the larger numbers dealt with by OlshaaaeiL
Oji. cil. i»p. 75, 76.
THEIH PREDISPOSING CAUSES.
638
TiumLer which occuired in persons in whom cancer of the womb
took place. It may perhaps as well he added, that in 14 of the
total 33 cases, pregnancy occurred but once, and terminated in 3
instances prematurely, in the other 11 at the full period of gesta-
tion.
One question still requires an answer — namely, what connexion,
if any, subsists between the ordinary state of a patitiit's uterine
health, and the subsequent development of ovarian disease ? Now
nothing can seem moi*e probable than that she wlio has menstni-
ated iiTegularly, painfully, or scantily, should be more liable to
sufler afterwards from disease of the ovaries than the person whose
menstruation has always gone on quite regularly. This, too,
appears from Scanzoni's statement really to be the case ; though
my own observations do not corroborate his assertion, and pro-
bably neither his facts nor mine are sufficiently numerous to
decide the question.
Of my own 94 cases, there w^ere 72 in which the ordinary
uterine health was quite good ; 3 had had puerperal inflammation,
but had quite recovered from its effects ; 1 was still weak from
haemorrhage after delivery ; in 8 menstruation w^as always pain-
ful ; in 6 menstrnation was always scanty ; in 3 habitually irregu-
lar ; 1 was chlorotic, and had bad uterine health in all respects ;
1 had aufiered for years from great hypertrophy of the neck of the
womb, and much consequent discomfort.
On the other hand, Scanzoni says that there were but 20 of his
57 cases in which menstruation was always healthy j w^hile 19
patients had sntl'ered more or less from chlorosis, 12 from
dysmenorrhijea, 5 had always menstruated very pr-ofusely, and 1
patient, in whom ovarian disease came on in her forty-fii-at year,
had never menstruated at all Be the truth concerning this
matter what it may, I cannot but think that Scanzoni's figures
overstate the frequency of menstrual disorder as a precursor of
ovarian disease^ as much as mine perhaps err on the opposite side.
We find that in the case of most diseases, our patients like to
assign some cause for the commencement of their ailment, a cause
often indeed quite fanciful, sometimes absurd, It is so in the
case of ovarian diseases ; while if all mere phantasies are rejected,
the instances will turn out to be comparatively few and exceptional
in which any plausible ground can be assigned for the beginning
536
EXCITING CAUSES OF OVABIAN TUMOURa
of the affection:* In 21 of ScaEzoni^s 97 cases, and in 18 of nif
9Jr, or in 39 out of 191 instances, the following were with some
probability alleged as the exciting causes of ovarian dropey :—
Began within a year after marriage ....
Came on during pregnancy ......
Followed not long after delivery
Succeeded to abortion ,..,..».
metritis from cold
suppressed menses from cold *
violent blow on the h}T>ogastrium
v^Lolent blows on the pelvis . *
strains, or over-exertion ♦ . ,
Occurred simultaneously with ascites and
anasarca from exposure to cold , , . ,
in
39
From all these facts, then, we may conclude that the immediately
exciting cause of ovarian dropsy, when any cause can be assigned
for it, is usually connected with some disorder of the uterine funo-
tions or with the recent excitement of their highest forms of acti\^ty*
Nevertheless, too wide an inference must not be drawn fitjm this
fact, since in the great majority of instances the disease comes on
independently of any cause to which it can be reasonably at-
tributed; while further, it occurs in the unmarried oftener than
most other organic diseases of the sexual organs ; and the married
who suffer from it are reniaikable for their low rate of fectmdityt
and fur the frequency among them of absolute sterility.
In the next Lecture we shall leave these incomplete and incon*
elusive details for the more important practical inquiry into the
symptoms and diagnosis of tumours of the ovary.
* Of 30 mstAQcaa collected by Mr Lee, op. cU. p. llfi, there irere 2B in which the
alleged causM had reff-rcnee to the utermf! futictioua, heing in t mnniigr, in 1^
kbour, in S tkborfiati, ib 7 sudden suppression of the menies, in % ccMition of mm<
itnifttion, and in 8 irreg;ukrity of its performance.
I
LECTURE XXVL
OVAEIAN TDMOUUa AND DROPSY,
Stitptoms of the di8EA.se occiisioiifllly absent in early Btage ; generally referable
to five heiids — of funetiotial diaurcier of oTaries, yam, the etfei^ts of pressure,
caciiectic symptoms, and the »yiDptoiuscons«que,nton interference.
Diagnosis, its diflicnlties ; diaguosij* from inlkmmation of broad ligament and
iU eRvcti, from fibrous Intnoux of uterus, midplacemeot of uterus, ascites, dis-
tension of bladder, pregnuiicy, tumours of spleen or li?er^ &c
Note on floats no tumouba of the Abik^men.
Many uterine aUments in their early stage present a puzzling
resdmblance to each other. Paio and menstrual disorder are
common to most, and acc-ompany as well the slight as tlie more
serious affections, while it m ofit^n not until after some time that
the distinctive features of the disease show themselves, and enable
us to determine its uatui-e, and to estimate its importance.
This is especially true with reference to ovarian disease, which
at its onset commonly attracts but little notice, owing to the
vagueness of its eaily sijmpt&ms : while not infrequently, just as is
the case with fibrous tumours of the uterus, its existence is not
suspected till accident all at once reveals the presence of a growth
of considerable size.
Ob a comparison of the 94 cases on which these observations
are chiefly founded, it appears that the first symptom of ovarian
disease was —
Suppression of the menses 11 cases,
Irre^Iar menstruation 5 „
Scanty and painful menstruation , , . . 1 «
Profuse menstruation 2 „
Sudden faintness, acoompanied by symptoms
resembling those of pregnancy . , . , 1 »
538 OVAJtIAN TUM0UE8 1
Pain in the abdomen, more or less distinctly
referred to the aide where the disease began 31 cases.
Retention of urine, or difficult micturition » 10 „
The unexpected discovery of a tumour * * 33 j.
94 „
The want of attention to their own condition, implied in the veiy
considerable si^e to which abdominal tumours sometinnes attain
before they attract the notice of patientis, ib so remarkable as to be
scarcely credible if it were not of every-day occurrence. Not veiy
long since I saw a yomig lady in whom an ovarian cyst of the
size of the adult head was only accidentally discovered in con-
sequence of her sufl'ering from a severe attack of abdominal pain
while staying in the house of a medical man. If tumours so large
can escape notice, it is less to be wondered at that those of smaller
size should frequently be found out only when they become the
seat of pain, or w^hen they cause inconvenience by pressure on
surrounding viscera.
It is not easy to say on what the frequent absence of symptoms
in the earlier stage of ovarian dropsy depends. The immunity
from suftering then is also far from constant, and in many instances
much more pain and discomfort are experienced, while the en-
larged ovary still remains within the pehic cavity, than are felt
subsequently, or at least than are experienced till its size b^ins
to interfere with the functions of the abdominal viscera. While
in the pelvis the large ovary presses on the rectum, the utema,
and the bladder, and maintains a constant congestion of the pelvic
vessels, all of which inconveniences are diminished or completely
removed when once it rises higher, and floats as it were loosely
tethered by the ovarian Ligament When pains are experienced,
too, they generally tell plainly of some cause seated witliin the
pelvia They are usually of a throbbing or burning character, re-
ferred chiefly to one or other iliac region, and are liable, bke all
ovarian pains, to exacerbation in paroxysms. More frequently,
too, in this aflection than in any form of uterine di^ase, pain is
experienced extending down the leg of the affected side, being
sometimes a mere numbness or sense of weariness, aggravated,
however, and rendered positive suilering by walking or exeraae i
at other times it is severe and neuralgic in character. Beaidei
THEIR EARLY SYMPTOMS,
539
this, too, painful defaecation and micturition^ especially the latter,
are frequent ; and occasionally the neceasity for the introduction
of the catheter is an early symptom of the disease ; though, while
the dysuria often persists for a considerable time, retention of
urine is a rare accident, and may even not occur a second time.
Though generally more severe than the same class of sjinptoms
when they accompany fibrous tumours of the utems, they are at
the same time usually of shorter duration, since an ovarian cyst
tends more certainly, and at an earher period, to rise out of the
pelvic cavity than does the Jihrous tumour, whose growth is
slower, and whose close connexion with the womb confines it
longer to its original position.
My own ohservatioDS do not show such frequent disorders of
menstruation as might be expected, either among the precursors
of ovarian disease, or among its earlier spnptoms. Few, however,
indeed, are the cases in which the disease runs to its fatal ter-
mination without the uterine functions being altogether deranged,
I have not the datit to show the influence of the rhsease from its
commencement to its close in this respect* The following table
represents the state of 94 patients, in all of whom the disease was
fully established; but the majority were only a few weeks or
months under observation.
In 7 cases menstruation had ceased before the disease began,
„ 2 „ disease began during pregnancy.
„ 29 „ menstruation had continued quite undisturbed.
In the remaining 56
Menstruation was painful in 1
profuse „ 9
anticipating „
irregular „
postponing „
scanty
suppressed „
10; in 5 was the first symptom.
<Jj II 1- t% n
6
22; ,, 6 „ ,1
66
The general tendency of the disease, then, is to impair the
activity of the ovarian functions, no doubt by the disorganisation
of their tissue. Hence the persistence of menstruation is always
a favourable sign in cases of ovarian dropsy, warranting the hope
540
OVABIAK TUMOURS :
that the disease is simple in kind, and that one ovary onlyii
involved. Complete amenorrhftia, however, is more to be dreaded
aa an unfavourable sign than is even tolerably regular meDstnup
tion to be hailed as evidence of the simpler form of disease^ or of
its being limited to one side.
It is not possible to give any general description of the symp-
toms which attend the later stages of ovarian dropsy. They tie
modified by very many canses, and differ according to the Aatm
of tiie tumour, the rate of its increase, the age of the patient, i
even her civil state, and general condition. They may. how6
be referred to some of the five following heads, which h»v^
already been briefly touched upon w^hen 1 was endeavouring in
the last lecture to point out the various modes in which the fatal
issue of ovarian dropsy is prepared for or actually brought about
Ist^ There arc the various evidences of derangement of the
function of the ovaries, showing themselves in different forms of
menstrual disorder, of which the irregularity, or the total suppres-
sion of tlie discharge are the most common ; ita over-frequent, or
too profuse occurrence are the i^arest Menorrhagia, however,
does now and then for a season accompany ovarian dropsy, so
that we cannot place unqualified reliance on the state of the
menstrual function as enabling us to discriminate between uteiiBd
and ovarian tumours*
2?!^/, Pain and other symptoms are experienced indicative of
changes in the tumour itself. In simple cysts, the degree of
fulness and tension of the cyst seems in great measure to deto^-
mine the presence or absence of pain. Variations in this respect
often take place with great rapidity, and increased pain will be
found almost invariably associated with increased tension, and an
abatement of aufiering with a flaccid state of the cysU The
occurrence of actual inflammatiun is almost always accompanied
with tenderness of the tuzp^^^^iough, unless the peritoneal sur-
face is affected, tht n ir r much pain except on pressure.
Vague constitutiouLil Jls iglly ag^^^is process, and
though it is seldom vt ^ked^^^^Hlfiiute febrile
attacks, shivering, loss
i-egarded^yndicative of
providA^H|h|iominal tt;
The j^m vrois of o\^
with
mH ADVAKCED STlifPTOMS. 541
pain diiring their growth, quite independently of tension of their
walls, or of any attack of intlammation* This, however, is by no
means constant, and no inference as to the simple character of
the disease can be drawn from the painleflsneas of its develop-
ment
[It is not to be foi'gott^n that inflammation resulting in adhe-
sions, and these of great extent, often occurs withont any strik-
ing symptoms, as is exemplified in cases often met with, where
with adhesions we have a hist^Dry of nndistnrbed health. The
progress of this kind of inflammation is fre^inently iUusti-at*?d
clinically when we find over an extensive area on the surface of
a tumour, the indications of dryness and consequent sb'ght rough-
ness of the mutually rubbing surfaces, heard as friction sounds
and felt as fremitus. Examples of such occurrences are not rare
in the case of uterine and ovarian disease, when organs may be
j'ound lixed, or may, under the observation of the practitioner,
become fixed, without any symptoms to attract attention to the
presence of odhesive perimetritis.]
3(/, With the increase of growth various disorders are produced
by its pressure on the different viscera^ and a class of symptoms
appear, whose causes I dwelt on fully in the coiirse of the last
lecture.
Dithcult breathing, impaired digestion, obstinate constipation,
frequent and painfid micturition, diminished secretion of urine
and the effusion of tluid into the abdominal cavity, are but so
many diflerent results of this mechanical pressure. The difficulty
in micturition, however, that occurs in the more advanced stage
of the disease, is produced in a different manner frcmi that which
accompanies its commencement. While the tumour is still within
the pelvic cavity, it interferes with micturition by pressing directly
against the bladder, afterwards, as it rises out of the pelvis, it
drags the uterus and bladder upwards, and thus int4erferes with
the function of the latter organ, while the presence of a portion of
the outgrowth behind the bladder in most cases prevents its dis-
tension in the antero-posterior direction. Scanzoni mentions aJflo
another occasional result of the pressure of the tumour on the
under part of the bladder.* He states that it sometimes prevents
I passage of the urine from the ureters, and thus produces great
* 0^. cO. p. 121.
I
542
OVARIAN TUMOURS :
distension both of them and of the pelvis of the kidneys, and ia
illustration of this relates the case of a ** patient who was tapped
twentj-one times in the course of three years, which opemtioD,
during the last year of her life was rendered necessary chiefly by
the circumstance that the rapid accumulation of fluid in .the
tumour was always accompanied by complete retention of urine,
which could not be relieved by the catheter, since the pressure of
the tumour prevented the escape of the urine from the ureten
into the bladder. For the first few days after each tapping \h»
function of the bladder was undisturbed, but by degrees the flow
of urine became more and more scanty, and in the course of five
or six weeks complete retention of urine was once more pnxiucacL
On examination of the body after death, a cysto-aarcomatoufl
tumour was discovered, twice the size of the adult head, the lowar
solid part of which pressed on the neck of the bladder, and had
produced, by the obstacle to the outflow of the urine, so great i
dilatation of both ureters that the right was two inches, the left
an inch and a half in diameter.*'
The pressm-e on the stomach sometimes causes a serious impedi*
nient to the patient*g taking food, since not only does the oigan
become unable to retain more than extremely small quantities at
a time» but in some instances obstinate vomiting occurs, which no
medicine can in the least degree relieve, and which is arrested
only by tapping the cyst, and thus removing the pressure.
Still more distressing symptoms sometimes follow the com-
pression of the rectum. Not only is most obstinate constipation
thus induced, but even the escape of flatus is in some instanceB
prevented ; the whole colon becomes distended by it to the thick*
neas of the arm ; and every now and then violent attacks of colic
pains come on, during which the movements of the IkdwcIs are
distinctly visible through the thinned abdominal parietes. and, as
in ileus or in strangulated hernia, stercoraceous vomiting adds from
time to time to the patient^s sufierings,
4///, To this class belong a large arr^iy of symptoms of the cachectic
kind, due in some instances to the nature of the disease of the
ovaries ; in others, to the mere diversion to the tumour of a l&ijgB
quantity of blood which ought to minister to the general neeesaitaes
of the body. They are symptoms of the same kind as we aed
towards the close of every lingering disease, betokening the gradual
1
A
THEm ADVANCED SYMFT0M3.
543
failure, first of one power» then of another ; the flickering of the
taper, which, as all can see, must scmdh go out. The appetite be-
comes more and more capricious, and at last no ingenuity of
culinary skill can tempt it, while digestion faila even more rapidly,
and the wasting body tella but too plainly how the little food
nourishes still less and less. The pulse grows feebler, and the
strength diminishes every day ; and one by one each castomary
exertion is abandoned: at first the efforts made for the
sake of the change which the sick so crave for are given up ; then
those for cleanliness, and lastly those for cx>mfort ; till at length
one position is maintained all day long in spite of the crackiEg of
the tender skin, it sufBcing for the patient if in that, respiration
can go on quietly, and she can suffer undisturbed. Weariness
drives away sleep, or sleep brings no refreshing. The mind alone,
amid the general decay, remains undistnrbed ; but it is not cheered
by those illusory hopes which gild^ though with a false brightness,
the decline of the consomptive ; for step by step death is felt to
be advancing; the patient watches his approach as keenly as we,
often with acuter perception of his nearness. We come to the
sick chamber day by day to be idle spectators of a sad ceremony,
and leave it humbled by the consciousness of the narrow limits
which circuniscribe the resources of our art.
[Having just considered the appearance of cachectic sj^mptoms,
in a general way, we may notice, before passing on, the frequency
of their dependence on the malignant character of the growths,
while that malignant character is beyond the diagnosis of the
physician. Speaking of Ms operations, Dr Tliomas Keith* re-
marks as follows: *'In one-fourth of my deaths, the tumours
were malignant, and, with very few exceptions, in those who have
died since their return home after ovariotomy^ some cancerous
affection has been the cause of death. Thus, amongst these, five
young and healthy-looking women have left me, all after severe
operations, the pictures of health and happiness, and have died
Ti^ithin a short time of peritoneal cancer."]
5lht May here he reckoned all those incidents which are
inseparable from every attempt at alleviation or at cure. The ex-
haustion which follows after repeated tappings, the cyst-inflam-
mation which sometimes succeeds to its first performance, the
• § [BrUiah Medical Jtmmed, Oct 1&, 187S, p. 693>
hiemorrhage from vessels divided m the extirpation of th<
or the more frequent, and therefore more serious attack
tonitiia that are induced even by aMempts at its removal, a
to this category. Their study, however, will find its fitt
when we come to consider the treatment of the diiferent
the disease, and the comparative dangers either of letting
or of endeavouring by one or other of the numerous meai
have been devised, either to delay its progress, to mit
evils, or to accomplish its entire removal.
But before we pass to this suhject, there comes the ir
to the di/rgjioms of ovarian tumours — an in*|uiry the im
of which it ia impossible to overrate^ while, though so
attended by no difficulty, it is at others exceedingly obac
calla for large experience and well-schooled observatioj
a correct reply. ™
The difficulties which we enco,unterin the diagnosis of
of the ovary vary according to the size of the growth,
situation that it occupies* So long as it remains pri
within the cavity of the pelvis, it fur the most part yield
indistinct sense of fluctuation, even though its contents si
entirely fluid, and it may then be hard, to distinguish bei
and the results of inflammation of the broad ligament, or
it and a fibrous tumour of the womb, or the retroflecte*
itself, especially if the organ is enlarged by pregnancy.
the growth has ascended into the abdomen, the distended
the prerrnant uterus, the enlargement produced by asci
tumours of the uterus itself or by tumoura of other oi^gaiu
liver, spleen, omentum, or mesentery, present so many i
sources of errori^iinst which we need to be on our guard
last of all, the caution is not superfluous which warns us i
tlie watch against imaginary tumours such as are prodi
flatus in the intestines, or by fat in the integuments, or
the omentum, or by fmces in the large intestine, or againi
still more unreal swelhngs which have no existence at all
the disordered fancy of the patient.
It sometimes happens that the earher stages of ovarian
are aooompanied by a good deal both of general febrile i
ance and of local suffering. In such cases doubt may foi
be entertained as to whether a sweUing which is discovt
d
TnETR DIAGNOSIS.
545
the side of the uteras ia the result of inflammation, or whether a
more serious view must l>e taken of its nature. If the disease lb
ovarian, it will generally be found on close investigation that some
slight discomfort, referred to the afiected aide, had for a consider-
able time preceded the more acute symptoms, or that those
symptoms themselves had been of longer duration than are com-
monly such as betoken pflmc celliditis or infiammation of the broad
ligameM. At the same time, however, it must be borne in mind
that an attack of inflammation is sometimes the first evidence of
the presence of ovarian tumour^ and that this is especially the
case with bail- and fat cysts of the ovary. Still even then the
inflammation does not in general extend to the adjacent tLssues,
80 that the ovarian tumour is very often still movable ; or if it is
pressed so closely between the uterus and the pelvic wail as to
have lost this characteristic, yet we miss that tbickening and in-
duration of the roof of the vagina which are such constant at-
tendants on inflammation of the broad ligament, and of parts
tlierewilh connected. The tumour, too, whether felt per vaginam,
or with the hand over the ramus of the pubes, presents a much
more definite outline than is yielded by tlie swelling formed by
the inflamed broad ligament ; while, lastly, in many instances the
uterine aound enables us to isolate the womb from the tumour by
its side* Even when at first there is most room for doubt, obser-
vation continued for a comparatively short time almost always
dispels the uncertainty. Often the inflammation attat'ks the side
opfMDsite to that first afiected, while it is rare for both ovaries to be
involved within so sbort a time of each other. But even though
this should not occur, the inflammation will nearly certainly issue
in suppuration and the discharge of matter, though perhaps by no
perceptible channel. The swelling will then diminish, though
for a time possibly increasing in hardness, till at length it slowly
disappears; while the ovarian tumour, on the contrary, will in-
crease, and with its growing bulk the presence of fluid within it
will become more and more perceptible.
The history of koBmatocde^ and the conditions under which it
occurs must, I think, guartl against any confusion between it and
an ovarian tumour in the earlier stages ; while later, the rules
which serve to distinguish pelvic cellulitis will be equally appli-
cable in the case of hEematocele,
546
OyAEIAN TUMOUES :
The distinction between Jibrovs tummirs of the utems and
tumour of the ovary m far from being as easy as might befat^
hand be anticipated, esjiecially when the ttunour grows from the
posterior uterine wall The facts that fibrous tumours are seldom
developed at as eariy an age as tumours of the ovary, that they
ai'e seldom solitary^ and that they are usually accompanied by
menorriiagia, are always worth bearing in mind, though far eDou^
from bein<^ caiiclusive in any doubtful case. But, besides, their
surface ia often uneven or nodidated; they present a greater
degree of hardness than an ovarian cyst, though it must not be
forgotten that when small and tense the cyst may yield no
distinct evidence of fluctuation, while a large and rapidly growing
fibrous tumour may, when felt through the abdominuJ walls,
present a sense of elasticity which gives it a most deceptive
resemblance to an ovarian cyet, I know of one instance in which
this resemblance betrayed two very experienced surgeons into an
operation for the removal of a supposed ovarian cyst, but vbo
discovered, when too late, that the tumour was a very laxga
fibrous growth from the outer surface of the uterus. The oppodfe
error I have both seen committed by others, and have fallen into
it myself, in cases where a small thin walled ovarian cyst was still
lying witbin the pelvic cavity, and consequently close to the
uterus, while the pressui^ from above and around it sufficed not
only to destroy all sense of fluctuation, but even to take away
from it that feeling of elasticity which is so rarely absent from
sacs containing fluid. The circumstance of the tumour being felt
at both sides of the pelvis, on wliicli stress has been laid by mmt
writers as indicative of fibrous tumours of the uterus, is in reality
of no great wortli, since, as stated in the last lecture, both ovaries
are involved in the disease in about a third of all cases. Fibrous
tumours not infrequently somewhat retrovert the womb, while
tunioui-s of the ovary do not produce that effect, but merely drive
it forvk ards and to one side. We are very apt, however, to be
misled with reference to this point if we examine the patient in
the ordinary position on her left side, since the w^eight of the
tumour will be likely to drag or to push the womb towards the
side on which the woman lies ; and on this account, the examina-
tion with the view of ascertaining this fact should be made with
the patient lying on her back The sound, too, often helps to
1
I
1
THEIR DIAGNOSIS,
847
dear up doubt, sometimes by distinctly isolating the utems from
the ovarian tumour, in other cases by ascertaining the ca^'ity of
the womb not to be elongated, and thus leading to the highly
probable conclusion that the growth does not spring from its
walls. Valuable, however, as the evidence thus obtained unques-
tionably is, two circumstances detract from its worth. Elongation
of the uterine ca\ity is met with in cases of ovarian disease either
by the tumour as it rises out of the pelvis dragging out the cor^
responding horn of the uterus, instead of merely lengtheoiog the
ligaments of that side, or as the result of adhesions having formed
between the uterus and the tumour, when the cervix becomes of
necessity greatly stretched by the rapid increase of the growth.
In both of these cases the measurement by means of the sound
would suggest an incorrect conclusion ; and hence we are justified
in attaching greater weight to the evidence which the small
uterine cavity affords of the disease being ovaiian than to that
which the large uterine cavity yields of the disease being seated
hi the womk
The grooved needle ought perhaps to be mentioned as assisting
in doul)tful cases, by affording proof either of the solidity of a
tumour or of the presence of fluid within it. [The aspirator of
Dieulafoy is also specially applicable iu eases of this kind.] The
failure to discover fluid in a tumour does not, however^ by any
means disprove its being ovarian ; while further, with reference to -
this aid to diagnosis, I would add that its use is not always
harmless, but that symptoms of serious inflammation are some-
times excited even by the simple puncture with the needle of a
tumour which had not seemed to he endowed with any high
degree of sensibility. In spite of this risk, the character of the
fluid is of so much moment as a means of distinguishing fibro-
cystic uterine from ovarian tumours, as iu my opinion to out-
weigh the rLsk; the clear, yellowish, slightly blood-stained, highly
albuminous fluid, characterising as far as we know the uterine
tumours, and serving as a valuable means of diagnosis between
them and tumours of the ovary*
The tumour formed by the retroverted or retrojiecttd uterus is *
scarcely likely to be mistaken for an ovarian tumour. In the
first place, as has just been mentioned, the tumour of the ovar)'
does not alter the direction of the os uteri, but merely carries it
548 OVABIAN TUMOUBS:
forwards towards the anterior pelvic wall, while, in the next place,
the small size, the solidity, and the comparatively slight mohilify
of the retroflected fundus of the uterus, and the direct transitKm
of the cervix uteri into its substance, suffice, independently even
of the information afforded by the sound, to preserve us from error.
In one instance, however, where retroflection of the uterus had
persisted down to the end of the sixth month of pregnancy, I feD
into the error of mistaking the tumour for ovarian disease.
There were, it is true, many circumstances which in this case
tended to throw one off one's guard ; but I would remind you,
prsty that just such exceptional cases are those for which habits
of observation are to be cultivated, and diagnostic skill is to be
acquired ; and second^ that in every instance of doubtful pelvic or
abdominal tumour, before we attempt to determine what it is, we
must first thoroughly satisfy ourselves that it is not the result of
pregnancy.
When the tumour has increased in size, so as to occupy the
abdominal cavity, there are other affections with which it may be
confounded. In many of these cases, too, we are compelled to
judge exclusively from what comes under our personal observation,
for the patient is often unable to give other than a most imperfect
account of her previous condition, or of the symptoms which
attended the development of her disease. In the case of all
abdominal tumours whose nature is at all obscure, it is therefore
prudent to take certain precautions before we attempt to establish
their diagnosis. It is always useful to keep the patient in bed for
twenty-four hours; and if the abdominal distension is at all
considerable, to apply a bandage lightly, as well as to take care
that the bowels are freely relieved some hours before our examina-
tion is mada The difference between the morning and afternoon
measurement of the abdomen in the case of a person following
her ordinary pursuits is often as much as an inch and a half ;
and this increase in the after part of the day appears to be almost
entirely due to the presence of flatus in the intestines. On the
other hand, the good effects of a day's stay in bed are often veiy
• striking in the diminution of abdominal distension, and the con-
sequently increased facility with which the relations of any
tumour are examined, while, at the same time, the tenderness of
the abdominal walls is much lessened, and they become far more
THEIR BIAGNOSia;
549
tolerant than they otherwifle would be of the pressure of the
hand
The general tendency of ovarian tumours, as they increase in
size, is to yield with more and more distinctness the sense of
fluctuation ; and many growths which, when small, had seemed to
be solid, become evidently, in the course of time, large simple
cysta with fluid contents. This change is brought about either by
the tension of the Qyst diminishing as it grows larger, in confie**
q^uencc of which fluctuation becomes more manifest ; or by the
removal of the septa wliich had previously divided it into many
chambers ; or lastly, by the growth of one cyst at the expense of
the others, which remain with whatever solid matter enters into
the composition of the tumour, at its lower part, near to its
pedicle, where they cannot readily be detected. It is due to the
influence of some or all of these causes that we occasionally find
the abdomen so much enlarged, and the fluctuation in all direc-
tions so uniformly distinct as to render it doubtful whether the
patient suflers from mcUcs or from encysted dropsy. The grounds
of diagnosis, and which in the great majority of cases sulfice .for
the ready distinction between the two conditions, are the follow-
ing : — Ascites is generally preceded and accompanied by consider-
able disorder of the general health, usually of a febrile character;
it is comparatively acute in its development, is often associated
with anasarca, almost always with very scanty secretion of urine ;
in many cases witli albuminuria, in all of which respects it differs
essentially from ovarian dropsy. Examination, too, yields a
different result in the two diseaaea, ^The enlargement of the
abdomen is symmetrical in asciteB ; while in ovarian dropsy one
side la often manifestly more prominent than the other. In
ascitea the abdomen is flattened, spreading out at either side : in
ovarian dropsy the tumour is distinctly most prominent towards
the mesial line, somewhat as is the case in pregnancy, while, when
the size of the tumour is very considerable, it spreads out the
floating ribs, and imparts a conical form to the thorax, which is
not produced by mere ascites. Percussion over the front of the
abdomen almost invariably yields a dull sound in ovarian dropsy
for it scarcely ever happens that any coUs of intestine are inter-
posed between the enlarged ovary and the abdominal walls ; but
to thi^ rule there are rare exceptions, just frequent enough in
S50
OVAKIAK TUMOUKS :
their occnrrence to prevent you from pinniiig your faith implicitly
to it In ascites, on the other hand, the intestines floftt as near
the surface as the mesentery to which they are tethered will
permit ; and hence percussion over the front of the abdomen gif^
out a clear sound,* or should there at first be dulness, owing to
the presence of a large quantity of fluid, it suffices to press a little
firmly, so as to displaxie some of the fluid, and bring the hand
nearer to the intestines in order to elicit a clear sound, or at least
a semi -resonance, which is equally characteristic. As the patioot
with ascites lies upon her back, percussion yields a dull sound in
either lumbar region ; while if she turns upon her side, resonance
is at once perceived on that side which is uppermost When to
this is added that ascites seldom exists long without being
attended by some obstruction of the abdominal circulation, and by
an attempt at compensating for it by enlargement of the super-
ficial abdominal veins ; and lastly, that some trace of the outline
of the tumour can usually, with care, be made out in cases of ovarian
dropsy, I have enumerated all the customary signs of each aSeetion.
Various causes, however, complicate a question which seems so
simple, and one might almost console oneself for one's own errors
of diagnosis in these cases by finding how mtmy and how eminent
• [Tho posaibility of air b^dng in an oriman cyat ia cot to he altogether lost ngM
of, I hdve repeatedly observed the adspiratiou of ftir through the cnnitU &t the end
of ftii ordinary tappingi in what may now be callfld old tuxiea^ when tlie dingfr d
tQch entrance of air was not, as at preaent, juttly apprecint«L In one etmt thii
}iap|iened several timea, the air in the cyst could b« made out by pertusaion ; it nv
LamUess and rupidly absorbed. I know no case of air spontaneotialy generated in aa
ovanau rjnt ; but tbe ana]og]rof mme rare intra-pentoneal abacesses reported ia
the MetHcal Examiner, March 7, 1878, p. 106, renders the occnrrence not Incredible.
The foUowing case in worthy of mention not oaly aa an illnstration, but also on
account of the niKty of the relation of the tumonr to the liver. A woman, a^ed
81, already uioth<^r of throe children, was afll'etcd with ovarian drojisy before her
fourth pregnancy began, Tbii last child was bom apontaneously. After the hirtll
aha was »ei2ed with inflammation of the cyst It was now twice tapped. Then the
came into 8t. Bartholomew's Hospital, about six. weeka after delivery. There wai
a considerable amount of air easily detected in the chief and moat prominent cytL
Peritonitis and septicffitnic symptoms were intense. She died three days after
aririiiasion. Beaides purulent peritonitis and suppurntion of the cysts, the tiunoar
was found to have risen between the liver and diaphragm. To the diaphragm it
had firm adhesions as far l>ack as the cloAe proximity of the spine. To the liver it
was not adherent, bnt this organ lay behind and below it, being dispUc«d down*
irards and backwards. In this case the air was proliably admitted through tho
canula. In some caae^ it gets admission thTi:)ugh a fistulous intestinal opeoiag,]
1
THEIR BUGNOSIS.
are the men who have confessed to the like mistakes, Craveil-
hier* mentions seeing a lady in whom an encysted dropsy of the
ovary had been taken by two very experienced practitioners for
ascites, and it was not until after a second very careful examina-
tion of the patient that they were convinced of the error of their
opinion, and of the correctness of the view adopted by Cmveilliier;
while Boineb confesses^ that lie on one occasion injected the
peritoneum with a solution of iodine, under the impression that
the case was one of ovarian dropsy. Moat of the mistakes which
are committed are of this latter kindj and many circnmstances
contribute to render this the form of error to which practitionera
are most liable. Now and then, indeed, we meet with exceptions
to the development of ovarian dropsy during a comparatively good
state of the general health. A patient, aged forty-two, was
admitted into St Bartholomew's Hospital, in whom the formation
of an ovarian tumour exactly coincided with an attack of geneml
dropsy and albuminuria produced hy exposure to cold* Greatly
impaired health* and a scanty secretion of urine, which was loaded
with albumen, still persisted at the time of the woman coming under
my notice five months afterwards; but the characters of the tumours
were fortunately too well marked for its nature to be overlooked*
The opposite error is especially likely to be committed in those
cases in which ascites — depending on some obstacle to the portal
circulation, such for instance as occurs in cirrhosis of the liver —
comes on without any active symptoms or any important dis-
turbance of the general health. Such a case was that of a
woman, aged thirty-four, who was received into St Bartholomew's
Hospital, suffering from urgent dyspncea, owing to the enormous
distension of the abdomen, which measured forty-four and three-
quarter inches in circumference. Tapping was at once performed,
and thirty-one pints of sei-um were evacuated with great and im-
mediate relief to her symptoms. The patient then stated that
after experiencing vague pains in her limbs, her abdomen,
eighteen months before, began to enlarge, and'as her menstruation,
previously regular, had now become suspended, she at first fancied
herself pregnant. After an interval of three months, however,
the menses returned, and had subsequently become much more
* Anai&mie Fatholoffiquet vol iii, p, 400,
t lodoUUrapU^ kc, 6ro^ Paris, 1355, p, W$,
£52
OTAHIAN TOM0UR8 :
profuse than formerly. This weakened her; but untfl hm
respimtion began to be interfered with by the enormous enlarge
inent of the abdomen, no grave symptoms of ill- health hid
appeared. The skin was not icteroid, and a day or two after the
tapping the patient expressed herself as feeliog quite comforUlik;
her tongue was clean, her bowels were regular, her appetite wu
good, and she slept well. The history of the patient, and hm
general condition, might have misled one; but the followiog eil^
cumstances abundantly guarded against error : —
1st, The fact that no tumour or cyst had been diBtiagiiifilidi
after the first tapping, and that on the re-accumulation of iht
fluid no distinct Hmitation of the swelling in any direction could
be discovered.
2d, The existence of distinct resonance on percussion, in apjte
of the enormous distension of the abdomen, while at the some
time there was none of that bulging outwards of the floating tSm
which a solid tumour of such dimensions would occasion*
3d, The procident condition of the uterus, while that oi^gaii^
commonly, though not invariably, drawn upwards by an ovama
tumour.
4^/^, The enlargement of the sufjerficial abdominal veins, and I
presence of a very obvious ii-regular nodular enlargement of the
liver.
The signs that in tins instance kept fi'om error may be almost
entirely absent ; and then, as in the painful case which I will
next relate for your warning, a little oversight, a little want ol
vigilance and care» may suffice to le-ad us grievously wrong.
A young girl, aged seventeen and a half years» was sent up
from the country, alleged to he snfiering from ovarian dropqr,
w^hich her appearance and historj' confirmed. Her abdomen
measured forty-one inches ; it was generally dull on peroussioa, _
exeept in both lumbar regions, where there was semi-resonance I
on the right side, and a clear sound more mai-ked and more eat*
tended on the left. Her historj'^ was, that having begun to men*
struate at fifteen, the catamenia continued regular for twelve
months, when they ceased in consequence of a fright at a mex^
strual period. Her health, however, still remained pretty good ;
but about five months before she came under my notice the
abdomen began to enlai^, and for a month this enlargement had
I
I
THEIR DIAGNOSia
S93
been going on with great rapidity, and her respiration had become
impeded, whOe some swelling of the legs had tjiken place within
a week There was no enlargement of the superficial abdominal
veins ; the generally dull sonnd on percussion, with the resonance
in the lumbar regions, the patient*s age, her history, all tallied so
exactly witli the opinion said to have been expressed by her pro-
vious medical attendant, that no doubt was for a moment enter-
tained as to her disease being ovarian dropsy. Twenty pints of
clear, yellowish serum were let out witli great relief, a bandage
was appUed to the abdomen, and no bad symptoms followed In
eleven days, the fluid having re-collected, seventeen pints were
once more let out, and Jx of a solution of iodine were thrown in
tlirongh the canula, and so completely was the nature of the case
taken for granted, that this was not preceded, as it ought to have
been, by a repetition of careful examination of the abdomen.
The injection caused some pain and alarming faintness, and until
the patient's death, in sixteen and a half hours, great faintness
was the prevailing symptom. There was but little pain, no
anxiety of countenance, no restlessness, or jactitation ; and though
the pulse was ver}^ feeble, yet for eight hours the heart's action
was gc»od and regular, the patient dozed occasionally, and awoke
sensible. After that time, however, more marked colla[ise came
on, the surface became cold, vomiting occurred frequently, and
sinking thus, she died with very little suffering, and retaining her
intellect unclouded almost to the last.
Examination of the body discovered intense congestion of the
peritoneum, a few adhesions between the coils of intestine in the
upper part of the abdomen, and more numerous adhesions lower
down, but no effusion into the abdominal cavity, nor any general
deposit of lymph on either surface of the peritoneum. The uterus
and its appendages were healthy, there was no tumour anywhere,
but the liver was shrunken to half its natural size, and in a state
of very far advanced cirrhosis.
Both of these cases are instructive, but the latter is especially so.
It teaches the sleepless watchfulness which alone can guard from
error, the importance of not taking anything upon trust, nor of
allowing our judgment to be swayed by any previously expressed
opinion as to the nature of the disease, when once a patient
comes under our care, and we assume the responsibility of her
tu
OYAHIAKTUMOTJHS:
1*f
management. Ifc shows the need, too, of not taking the
hisloiy upon any other person's authority, but of ctobs-^j^
both the patient and her friends ourselves. In this inj
was ascertained after the patient*s death that her sister ]
of disease of the liver, and that the fright which was foil
suppression of the catamenia, was succeeded also by sev
in the right hypochondrium, and by great sallowness of i
plexion, which subsequently passed away. These facti
doubtless have awakened attention to the possibility of I
in the abdomen being dependent on some visceral disease
the existence of advanced cirrhosis of the liver in eo ;
person is undoubtedly an exceptional occurrence. The can
moreover, that enlargement of the superficial abdominal
not a constant attendant on obstruction of the portal ciit
while it further proves that resonance in the lumbar regie
80 trustworthy an evidence of encysted dropsy as is oo
supposed^ The presence of a considerable amount of flatu
large intestine may cause percussion to yield a clear box
this is especially the case on the right side, where the
relations of the cseoum greatly modify the result which wi
Lastly, we may deduce the rule, that the distinct percc
the outline of the tumour is a condition indispensable
attempt at operation, and further, I may add, that this mi
been perceived, not simply on a previous occasion, but ah
very time at which the operation, be it what it may, is att
In the cases which I have related, no solid tumour ex
at least none whose situation at all corresponded with tha
would be occupied by the enlarged ovary. Ascites and
tumour may, however, coincide, but the tendency of any
diagnosis in such a case %vill be rather to overlooking the e
of the tumour, than to misinterpreting the ascites. Son
indeed, the solid tumour is not perceptible untO after the
of the fluid by tapping, while in other instances it is f
careful examination of the abdomen that the hand displa<
superjacent fluid comes down here and there upon a sol:
whose exact dimensions and form it may yet not be poi
determine. It is chiefly as influencing our prognosis \
detection of the solid tumour is of importance. The pre
a small quantity of fluid in the abdominal ca\aty adds
d
THEIR DUGNOSIS,
55^
nothing to the gravity of the prognosis of ovarian dropsy* On the
other hand, the presence of a lai^e amount of fluid in the peri-
toneum associated with a small solid tunionr is always a matter
of great moment Such a tumour is seldom ovarian, for ovarian
tumours, tlioogh when large they disorder the circulation through
the alxlominal vessels, seldom so far interrupt it as to produce any
considerable efl'usion. Solid tumours so situated as to have this
effect are often malignant in character, are very likely to increase,
and are scarcely at all within reach of any kind of interferencet
[Much attention is at present being paid to the microscopical
examination of the ascitic fluid found around an ovarian dropsy.
For this purpose a large quantity is allowed to stand, so that any
floating cells may settle as a deposit for microscopical scrutiny.
Wells, Keith, and Thornton have aU contributed to our literature
on this subject, especially the lasL But the original and most exact
reauits w*e owe to Foulis,^ who describes little proUferating groups
or masses of cells. At the margin of each maas, large cells with
bright nuclei may be seen projecting, and found to resemble other
cells free in the sediment. To these masses and individual cells
he ascribes not only an infallible diagnostic value, but also the
explanation of the ditfusion of cancerous disease on the peritoneum.]
The dutemii'd bladdi'T has been taken for a dropsy of tlie ovary,
but this is an errc»r which ought not to be committed. The exactly
oval form of the tumour, its mesial situation, its tension as ascer-
tained by external examination, the slight change in the position
of the uterus on its being pushed somewhat downwards and back-
wards, the absence of any tumour felt per vaginam, or, if any is
discovered, its situation in front of the uterus instead of behind it,
are characteristic, even if no history of the case were obtainable.
It is almost needless to remind you that in every instance where
the nature of a tumour admits of doubt, the catheter should be
introduced in order to obviate the possibiUty of this cause of error.
The mistake of dropsy of the ovary for prtpiancy is impossible
BO soon as the case is submitted to a thorough examination,
though it is far from rare for idle whispers to be raised prejudicial
to a patient's character before she has come under medical
observation. Examination per vaginam, and the discovery of the
• [British Mcdkal Journal, Nov. 2, 1878, p. 658, vrh&tt all needful rcferenow
will be found.]
556
OTAEIAN TUMOTJBS :
unalteTed state of the oa and cervix and lower s^inent of At |
uterus, as contrasted with the softening of the cervix end tbi ei-
pansion of the lower segment of the womb which accompflOf
pregnancy, cannot but remove all doubt. In those caaes, howeter^
in which a mistake would be most serious in its coDsequeocei;
namely, in unmarried women, we are often precluded from gma^
to any one the slightest hint of our doubts or saepiciona, and m
consequently unable to suggest the expediency of maldng a
vaginal examination. So long, too, as an ovarian cyst doea cot
exceed the size of the womb at the fifth month of pregnancy, il ii
by no means unusual for it to he elastic rather than distinctly
fluctuating, while the position of the tumour is oft-en so nearij
mesial that its sitnation does not aflbrd any means of discriminat-
ing between it and the gravid uterus. The alisence of the
mammary sympathies, and also of any sound like the uterine
souiHe, and of the beat of the fetal heart can both in general be
ascertained, and deserve great rehanoe, as strong negative evidence
against the existence of pregnancy.
There are stiU sams rare conditums productive of enlargemeDt
of the abdomen, which may be mistaken for ovarian tamoum
Such, for instance, are those large accumulations of fluid already
referred to which have been found in the substance of tibroos Of
fibro-cystic growths of the uterus * and such the still mate im-
conunon cases of encysted dropsy of the abdomen, where the fluid
collects in the sub-peritoneal cellular tissue, or between the layers
of the omentum.^ One instance of this latter occurrence has
come under my own observation, in which between four and fi?B
quarts of a dark fluid were found coUected between the folds at
the omentum, and during the patient's lifetime frequent dischai^gBl
of a simOar fluid had taken place from the umbilicus. The dropsy
had during the life of the patient been supposed to be ovarian;
but though malignant disease of both ovaries was discovered.
*
♦ See II reference to these CAses in a note at p. 261.
t On th« subject of cyHta of theabdomioal ciivitysee AheSlVe^TrsUi dm ffp
m>J ^ doi Kyaitu, 8vo, Paris, 1852, pp. 519-087 ; Copland's IHdumaff^
Dropgy, aod the fef^ruDoea iit p. 660 ; 8, Lee on ISimourt cf the CTWtu, p, IS) j
the awf^ of Sir R Brodie, Mmk OaaetU, voL L p. 334 ; Dr Thom»on» lUd, ]k 4^ £
CrtivcilhiiT, TraiU (TAnaJUmvU Faihol. toL iii. p. £18 : and the papera fif Mr CX
Hawkins, Mai. Chir. Tram., yoL %n± p. 175 ;md H. Chjuitourelk, Ardkitmdt
MM^t ISSlp vol ucvii. p, 218,
THEIB niAGNOSIS.
557
neither of them contained fluid at all similar in character to that
which waa found in the omentum ; nor, indeed, could either be
detected till after the fluid in the omental cyst bad l>een let out.
I am aware of no means by which such cases are to be discrimin-
ated frt»m ovarian dropsy ; as far as I know, their nature has
scarcely ever been suspected during the lifetime of the patient.
[I once met with an instance where hydatids in the abdomen
were mistaken for ovarian disease, and where it was intended to per-
form ovariotomy. The hydatids were nearly completely removed ;
the patient recovered, and still sundves. I have since examined
her abdomen, and have found it almost filled again with these
growths. A similar cose complicating pregnancy, and altogether
marvellous, is recorded by Thornton,* and well deserves peruBaL]
The only conditions in which lai^e tununirs of iJu sjdeen or limr
are likely to be taken for growths of the ovary, are when they are
of very long standing, have acquired a very large size, and have
occurred in pei*sons who are either incapacitated by illness from
telling their own history, or who have been so unobservant as not
to notice the beginning, and scarcely to attend to the progress of
their tliaease, StDl, even in these circumstances the prominence
of the tumour at the upper part of the abdomen, the dulneaa in
the li}T:)ochondriac region, and the fact that at some part, if not at
all, the lower edge of the growth can be detected, will keep the
moderat-ely cfiroful observ^er from error [One case came within
my own knowledge in which a surgeon of great eminence insisted
on the performance of ovariotomy contrary to the opinion of his
colleagues, who had examined the patient most carefully. The
case turned out a rapidly fatal splenotomy, I believe another
similar case has occmTei]
And here, I think, we may take leave of the diagnosis of
ovarian tumour.f That faeces in the large intestine have b^en
• IMnikal Timet and Ga2eae, November 16, 1878.]
t I know no place more fitting than the present for a brief reference to tbnse
fioaling aMomhial tuttwun whicb aJl practitionera have oceaaionaOy met with, thongh
much diiri'renc<" of opmlon has proTMled witli reference to their real nntiire.
All of th«^se turiioiirs bear a very cloae resemblance to each other, both in size,
»bai>c, and ftitimtion. They are ovilI in form, rtsuaUy about the size of & turkey**
€gg, and ore generally flitnated in the hypochohdriac or lateral region, their lower
margin eicidom descending below the level of tho iliao crest. In most instanoes
one tamour only is present, but sometimes there arc two in opjKJBite sides, and for
tb6 niost purt Bymnietriual in aU ren^vectfl. They generally admit of displacement
558
OVAEIAK TUMOUBS,
taken for them ; that fat and flatus have raised a suspicion of their
presence j that the abdomen even has been opened to remove a
inwards tovimls tlie mesiid line much more readily tbiin outwutls, and
to a far j^rr^ater extent than downwank^ so that they can fiometimea ht |jiiihcd cp
out of r^ach under the floating ribs, but st^ldom downwardja into the iliAC R^ka,
and never into the pelvic caTity. They are &nn» though not without a c^ertttD
degree of elasticity ; their surface is ainooth and regular ; no worrnd qhm t» 4^
tected in th«m by meana of the stethoscope, and they yield a doll wiiuid mt fth
cussion, modified only by the prebencii of a coil of intestine distended with air bo*
hind them, when they may yield a sort of Bemt'resonance. Fissure on tlita ii
painful^ but the poin^ which is of a peculiar^ sickening character, nsnally paaHi«ff
when they are no longer handled. Sometimes, however, they are tha nat of a
constant wearing pain, which corner on cauHclesaly, and, continuing for hoiin» daji^
or weeks, subsides eq^ually without occasion, though it may be said* as a gcsoal
rule, to be aggravated by exertion and niigitated 1^ rett They hare either 'bea
accidentally found out on examination of the abdomen for some other pnrpoaa, or
the pain txx»crien€ed in them baa led to the discovery of their preaenctf by tht
patient. Their rate of increase must be slow, for though patienta ajfeoted widi
them have for years been under my occasional observation, I have
tained that thtiij* size has undergone any modihcation. 1 know of one
too, iu which a tumour of this description had eIist4^d for more thaa twenty
in a lady of sixty^ unchanged in shape, size, or situation. This lady had tan
seen by the late Dr Warren, by Sir Astley Cooper, and Sir Benjamin Hrodie, tad
it may illustrate the obscurity which prevails with reference to their HAton if 1
mention that each of these eminent men gave a different opinion with refgriaoe
to it, one of them regarding it aa connected with the mesentety, another a« a floal-
ing kidney, and a third believed it to lie ovarian*
I have a record of tliirteen cases, of which the chief particulani ai<o
below in a tabukr form :—
Age.
Tean manied.
Scat of Tisniottr.
F«t1*d Lt liiid csiMjbd,
SjTJiptolWL
( AcddoDtaUy difl. \
1 trcAtment for
\ another aUmcRt
9fl
9
Right Hfpochondrittin
KODA
fT
4
One Y6»r
Pain and dyapepila
3»
H
»i
( fain, whieh raiM
( on mStf'T cxnUoa
rata and dyapopda
io
fliBteTlla
Rlghi Hypochoadrtmn
Eighteen montha
u
H«rr1od
Both Bjrpochoadria
( Rlgbfe, tlirea weeki f
rain
»
14
U\gU Hypochondiiiun
Left 11 tic
One year
^
47
Married
Fain, oecaaioDal
m
f Twioe tnarried,
1 now fe wldfsw
n
Rlffbtniac
Twenty jreaim
$8
ftlirht Ufpocbondrinm
Six months
Oec««i<ina] imIb
10
6
,1
Tbrw ycare ind « half
(Two years, foHow-
DaUpala
46
i, widow
J Loir violoat
SmrbtpalaUiflClil
M *
i coDCtutknoQ (
{ railway }
i TdlTtoen ftmnmUvsr i
'[ birth of a child f
^
40
SOXanled
•« M
Dunpila
SI
«
H W
Aeetdentiaijr iU4~ {
\ covered. f
y«M
\
FLOATING TUMOUES OF THE ABDOMEPf.
559
tumouT which waa found to have no existence, and once in my
own experience a lady came up from the country to submit to
ovariotomy for the removal of a phantom tumour*, which dis-
appeared under chloroform j these facts prove only how large ie
the posaibihty of error, how vigilant mu^t be our care if we will
avoid a danger which the wisest have not always been so
fortunate as to escape.
In 10 cuBeai thoni the tumour waji ce^ted on tlie right side, in 2 on the left, uid
in I on both Me^ iU |>o8itiou bariug in 11 out of the 13 been di«tiiictly in the
hypochondrium, twice ouly m the upper purt of the ilinc region, and in those two
inatftncet aUowing of diiipkeemeiit upwards, but tiut at all in a downward dtrec-
tioiL The connexion of dyspeptic aytnptoms with the tumour in the right hypo-
chondritun on two occaaiuna may auggeat the probability of ita being iiometimes
formed by the scirrhooa pylorus, an hypotheaia which, in tlie caae of a patient
under the care of Sir Q. Burrows, was conlirmed by post-mortem examination.
Some movable tumours may posaibly be connected with the mesentery, and
tome may admit of the exphitiatiou which 1 have been informed that the lute Dr
Aherurombie of Edinburgli, proposed. He thought that a eort of spasmodic con-
striction of Bome of the tibrea of the colon enclosed a amaU collection of flatus
Bufficient to form a swelling distinctly perceptible by the hand of the physician,
but diatinguiflhable by its resonance on percussion from all tiolid Inmoura, I
cannot say, however, that I have met with any condition clearly answering to this
description, and have no doubt but that movable abdominal tumours presenting
the cbaractera above described are almost, or quite invariably, pix>diac«d by dia-
placement of the kidney. On this hypothesis^ toOj one can understand the occa-
sional sudden appearance of the a welling after a violent exertion or strain, as in
the case of one of my patients, m whom it followed concusaion in a railway car-
riage, or ol A gentleman in whom it was produced by a fall from horseback, M«
Cruveilhiert baa noticed these swellings, and has observed that it la almost
always the right kidney which is thus displaced, and that the accident, while
very rare in the mole subject, is far from being uncommon in the female. He
attributes it to the pressure of tightly-lacod stays UfK>n the liver, ** The kidney,"
says he, '^ is then compressed between the liver, which is in front, tbe lower ribe
and the Tertebral column, which are behind ; and is squeezeil, as it were, out of
the sort of bed in which it lies without being adherent to it, just as a plum'Stone
would alip from between the fingers. '*
1 do not know that any furtber light has been thrown on this accident^ or on
its mode of production, but a com^iarison of the numerous cases now on record sub-
stantiates the correctneA'i of Craveilhier*s opinion. In the Archivea de Midecine for
1859, voL ii. pp. 158 and 301, M^. Fritz has collected from various sources 35 cases
of ioating kidney. Of theae 5 only occurred in the male, 30 in the female. In.
19 case^ the right kidney waa movable, in 4 the left ; and whOe in 7 both orgaui
were somewhat miaplaced, the mobility of the right kidney was in 5 of tliese in-
stances mnch greater than that of the left.
• See the three admirable pbotognphs of a esse of ]>hantom tumonr, and the
influence of cblorofonn npon it in S. Welk, op. cU. vol ii» pp. 143-45.
t Anat&mk Pathohgiquc Oinirale, vol ii. p. 723.
LECTUEE XXVIL
OVARIAN TUMOURS AND DROPSY.
TuEATarENT; difficulty of estimating , its results. Duration of life in ovviiii
dropsy. Case^} diyisible into three cloases ; Bome must be let alonet ac/am maf
be, aome require interfereiice.
PROPirrLACTir mkabures, and Tnedicinal agents.
Operative PHoriiiEiKNas, Taitinu, when abaolutely naoeaiMy, OpinioniiAt li
danger of itn i>erfQrmiuice, statistica of the subject, bad result* po«uUj ovtf-
estituAtedf circumstances in whieh e&rly tapping may b« idminibU. Modt ol
performing the operation ; danger of exhaustion and of cyst inflammatiM ;
their sympt4:ims and treatment.
There is some fallacy as well as mnch truth iti abnoat ill
popular sayings. Even tlie adage tliat a "doubtful remedy is
better than none " is not of luiiversal application, for doubtful
reme<lies are often dangerous, and if they fail to cure tbey fre-
quently aggravate the disease. The danger of the disease itself is
an element never to be lost sight of in our estimate of the expedi-
ency of interfering with its progress ; and if the present suffering
it occasions is but small, if its advance is likely to be slow, if it
may be interrupted by occasional pauses, we should hesitate to
advise any proceeding by which, through perfect cure may possibly
be %\T0ught, yet on the other hand life may be cut short suddenly.
Tlie chances of complete recovery will by few persons be felt to
overbalance the risk of immediate death, and I do not think
it becomes ua to throw the weight of our influence into the scala
Considerations of this kind are nowhere more in place than In
an inquiry into the inaiment of omrian ttimours and (hvpmf — a
class of diseases which indeed ttind progressively from bad to
worse, which often bring with them much suffering, but in which,
nevertheless, the suffering is not invariable, nor the downwajd
tendency constantly progressive, so that we cannot limit their
I
neir h
PROGNOSIS IK OVARIAN DROPSY,
561
possible duration, or, from the date of their oommencement, calcu-
late with any approach to certainty the time whit:h will elapse
before they reach their close.
The reasons for this uncertainty are so obvious as scarcely to
need that I should insist upon them here. I may, however, re-
mind you that in many instances we are unable to tix the time at
which ovarian disease began; so imperceptible are often its
advances, so few the symptoms that accompany its earlier stages ;
that not infrequently the growth has attained a considerable size
l>efore the attention of the patient, or of her medical attendant, is
drawn to its presence. Even after it has been discovered, it is
often as difficult to foretell the future progress of the disease as to
determine its past duration. The cyst may long remain stationary,
its flaccid walls announcing that absorption goe^ on more rapidly
than secretion, or it may possibly disappear altogether. On the
other hand, just the opposite course may be run ; the barren cyst
may become proliferous, or the compound cyst may suddenly, and
apparently causelessly, pass into a state of active development, or
evidences of malignancy may manifest themselves in a growth
presumed for a long time previously to be innocent ; while to all
these contingencies must be added those inseparable from the
various kinds of interference which the mere palliation of the evil
in most instances requires. Advocates of the most opposite viewi*
with reference to the dangers attendant on ovarian disease are not
without ample support for their opinions : cases are to be found
of life continuing for years in very tolerable comfort, and even of
the sexual functions being duly performed, and pregnancy and
labour oc^jurrtng in spite of it, the patient dying at length of some
other perfectly diiTerent ailment. Illustrations of just an opposite
kind are still more numerous, telling of the rapid development of
the growth, of speedy impairment of the general health, of death
occurring in one, two, or tliree years from the commencement of
the evil, or of life being cut short even sooner in consequence of
some attempt atgi\ing temporary relief, which it was not possible
any longer to delay.
The endeavour hag been made, indeed, to arrive at more definite
results, and the late Mr Saftbrd Lee* collected with characteristic
diligence the particulaiB of 123 cases : —
• Do TumouTt oftke Uterm, p. 177*
2ir
N
Now from this table it appears that 90 out of 123 <
out of 4, or 73*9 per cenL^ terminated fatally within five
more than a third of this number witliiu one year
obsen^ed cnmmencement of the disease. But, on the o!
between the observed and the real commencement of ti
there is, as has already been stated, a wide difference, \
the numbers doubtlesa understate the duration of the evi
cases where the disease appeared to be most rapid, they
by no means truly represent the degree to which life
prolonged in spite of it Even as they stand, how
numbers show that in 16 out of 123 cases, or nearly 1
continued for a period of from ten to fifty yeai-s ; and it
be forgotten, tliat when a disease has been long quiei
patient learns to think but little of it ; she speaks of«
even her medical attendant is perhaps scarcely aware f
sence ; and when she dies either of that or of some other
it is doubtful whether he who sees the end had also
beginning of the malady. One other point there is, a
which there can be no duubt, and which invalidates all t
tics on the subject wherewith Idtherto we have been fi
and that is, tlie wide disparity between the results that
cases yield. One year and fifty years cannot both truly
the time occupied by the same disease in mnning its con
can fix the duration of uterine cancer with tolerable accu
find the disetisc, when seated in the w^omb, to obey the s
as govern it in other parts. We know, too, that the sloiH
fibrous tumours of the uterus have in themselvea no tex
ITS PROGNOSIS tTNCEBTAIN.
m
dfislroy life, thougli in their course some accideBt may occur to
compromise it^ and mauy others to render it painful The dis-
crepancy between the results of different cases of ovarian <lropsy,
on the other hand, plainly shows, what indeed the study of its
morbid anatomy has taught us, that under this name several
dillerent diseases have been included, having dift^rent tendencies,
warranting a different prognosis, and calling for different modes of
treatment.
In any inquiry into the treatment of the disease these facts must
not be lost sight of, but we most consider it with reference to the
special form of the affection with which in each separate case we
have to do. The question cannot be propounded as to whether
this or that plan of treatment is suitable for ovarian dropsy ; but,
given a certain form of ovarian disease, is this or that proc<3<?.diDg
. expedient or allowable; or is it wiser to* do nothing or to palliate;
or is the attempt to do more, justifiable; and when at length the
necessity for interference of sotm kind becomes absolutely unques-
tionable, are the risks even of palliative proceedings so consider-
able as to waiTant a greater hazard being run for the chances of a
perfect cure ?
All eases of ovarian dropsy and tumour may for the pui-poses
of therapeutics be considered as belonging to one or other of three
classes, according as they are, either —
Istj Cases which timt/ be let alone.
2d, Cases which mmt be let alone.
3tf, Cams just if i/hig or ahsoltUdi/ requiring iiUerference.
AU cases of ovarian dropsy, or of tumour undistinguisbable from
it, may be let alone in which the growth does not exceed the size
of two fists, in which its position does not seriously disturb the
lunctions of the pelvic viscera, in which it is unaccompanied by
severe suffering, and, as far as can be ascertained, is not in course
of rapid increase. Further, in proportion to the small size of the
tumour, to the smoothness of its surface, to its elasticity when
pressed upon, and to its mobility, wOl be the amount of encourag-
ment wiiich we shall be able to afford to the patient, since there
whII be the more reason for hoping either that the tumour is one
of those cysts of the Wolffian bodies, which never exceed certain
comparatively small dimensions, or that it may possibly be a mere
dropsy of the Fallopian tube, which, though not equally limited in
564
OVARIAN DRopsr:
the size to wliich it attains, has ia it nothing of the seri
character that belongs to ovarian dropsy, gven in cases, too
which neither of these hypotheses is correct, it may still
remembered, that an ovarian cyst, while small, is far more lik
to remain stationary than when it has attained a considerable 8
The mere size of the tnmoiir; however, provided it does not by
bulk disturb the general health, cannot be taken as an indicit
for interference. The old maxim, ** Quieta non movere," is at Ii
as applicable in medicine as in politics, and yon will remem
the iastance which I mentioned to you,* where a tumour consic
ably iBTger than the adult head, remained for many f
stationary ; and when it did increase, was yet long l>efoi?
operation of tapping became necessary.
Still, when it is said that such tumours are to be let alone, 1
not wish to imply that no precautions should be observed, or (
nothing can be done to retard their growth- These preoai^
however, are comparatively few, and abundantly simple. ■
may be summed up as consisting in the endeavour to mam!
the general health, and to prevent congestion of the pelvic viw
The first indication, I conceive, implies the avoidance of all s
proceedings as courses of mercury, of iodine, of iodide of pot
or of liquor potaasie, agents of whose power in retarding
development of ovarian cysts there is scarcely any evidence, w
of their injurious influence on the constitution, when loi^ c
tinned, there is the most abundant proof. To carry out
second object, we should certamly dissuade a person afifec
witli this disease from contracting any matrimonial engagemi
though between that and the non-fulfilment of an engagen
already fonned, or tlie separation of a married woman from
husband's bed, there is a wide difference, and moral considerat
enter into the question which more than counterbalance n
medical rules. Besides this, too, it is, I think, very doub
whether in the mysterious influence of the mind over the bi
disappointed affection, or the removal of a wife from her husbtt
bed, would not act more injuriously even on the sexual sya
iUclf, than the physical causes which alone oar restrictions
control Sexual intercourse, however, should be moderate ;
inasmuch as the influence of pregnancy and labour is often, '
• liccture XXV. p. 519.
ITS PALLUnVE TBEATMENT.
565
by no means always unfavourable, giiiug rise in many cases to
irritation of the cyst, to a more rapid increase of its growth, to
iutiammation of its peritoneal surface, and the formation of
adhesions ; or of its interior^ and to consequent outpouring of pug,
it is desirable that intercourse should not take place at those
seasons, just before or just after a menstrual period, when concept
tion is most likely to occur.
The condition of the bowels must always be most carefully
watched, and every attention must be paid to ensure the perfectly
regular performance of the menstrual function. If the menstrual
period is attended by any febrile disturbance, or by any increase
of pain in the tumour, the patient must be kept strictly in bed,
and four or six leeches must be applied over the painful spot, and
repeated every second or third day so long as the pain continues ;
a warm poultice, or fomentations with spongiopiliDe being con-
stantly employed in the intervals. As soon as the tumour has
risen completely into the abdomen, a well-adapted bandage should
be %vorn, partly for the comfort whicli it seldom fails to afford to
the patient, partly because a cyst fills far less rapidly wheu
moderate compression is made upon it than when no counter-
pressure is employed to resist the accumulation of the fluid*
It has, I know, been alleged that the power of medicine over
this disease is much more considerable than 1 have represented.
So greats too, is the influence of a name in determining the
conduct of most of us, that almost all the remedies of known
efficacy in ascites have been assumed to be beneficial in ovarian
dropsy. There can be no doubt, too, but that under the influence
of Buch remedies very appreciable diminution in the size of the
abdomen has taken place — a diminution, however, which I believe
to be due to the absorption of the fluid, which in many cases of
abdominal tumour is poured out into the peritoneal cavity, and
not to any modification of the contents of the cyst.
Some ovarian tumours, it was said, mi{^M, others miisi, be let
alone. The latter are all those cases, for the most part of rather
rapid growth, whose irregular nodulated surface, and whose solid
non*fluctuating mass suggests the idea that they are not mere
compound cysts, but productions of a malignant character. In
most of such cases, too, we find in the patient's history other
grounds still more cogent than the anatomical peculiarities of the
566
OVAEIAIT DROPST !
tumour for avoiding all interference. Such are the existence of
malignant disease in the uterus or in other organs^ or the facts ihni
the general health has failed simultaneously with the developmejit
of the tumour, and that loss of flesh and loss of strength have been
early attendants on its progress, and have not first appeared when
the different functions of the body had been disordered by ila
bulk, or when nutrition might be supposed to he impaired by the
tax levied on tlie system for the supply of t!ie mass. Unhappfly.
the cases which seem most to call for help are those in which it
is least possihle to afford it, while it is in precisely those wliich
may most safely he let alone that interference has the heat chanot
of success.
Between these two classes, however, there is a third in which
present relief is called for, and in which it is in our power to afford
it. It is just in these cages that we encounter the inquiry as to
the comparative risks and comparative merits of different proceed*
ings, whether it is much more hazardous to attempt to remove the
evil than to palliate it for a time with the almost absolute
certainty that a^^^ain and again it \^ill return, and that on each
occasion our power to palliate it will diminish ? Nor ia the
question altogeiher confined to these CJises, The uncertain tenure
of health and life, even in instances where the e\dl seejus qui^-
cent, suggests the importance of discovering some prcMseeding
wliich entails no greater hazard than we can conscientiously advise
our patient to encounter for a reasonable prospect of obtaining eo
great a good, and of freeing herself from danger ever impending,
like the fabled sword which hung over the guest at the banquet.
Very numerous, indeed, are the solutions which have been pro-
posed to these inquiries. It is our duty carefully to examine fixmz
merit, and carefully to scrutinize the different surgical proceedingi
that have been recommended for the reUef or the cure of ovariaii
dropsy.
The first of these proceedings which we must notice^ Uie mm*
plest, the least hazardous, and at the same time the most generaUj
applicable, is the opercUion of tapping. Simple as it is, however,
opinion is much divided with reference to the circumstances th«l
warnint its performance ; for while some practitionera look upon
it as too dangerous to be justified by anything short of most
absolute necessity, others consider it to be attended by little risk,
I
I
ITS FALLlATrrE TREATMENT : TAPPING.
567
and to be a palliative all the more valuable since it is sometimes
followed by a perfect cura
Two questioos then come before ug. The first of these concerns
the circumstances which by unanimous consent justify the perform-
ance of tapping as a palliative in casea of ovarian dropsy. The
second refers to the amount of hazard attendant on the operation,
and tlie consequent expediency or inexpediency of ha\dng recourse
to it when not actually compelled by the urgency of the patient's
symptoms.
The operation is absolutely indicated in all cases where the bulk
of the tumour is so considerable as seriously to interfere with the
patient's health, or to occasion her very severe suffering; and tliis,
be the supposed nature of the tumour what it may. In proportion
as the contents of the tumour are fluid will the relief <^ained by
the operation be considerable; but even though its great bulk
should be solid, still the diminution obtained by letting out even
some ounces may afford considerable temporary rehef to the
patieiit, and will fully justify the experiment
The state of tilings which calls thus imperatively for inter-
ference varies considerably in different patients, and is far from
being absolutely connected either with a cert^iin duration of the
disease, or with a certain size of the abdomen. A slowly-increas-
ing growth will often attain to a very large size indeed before it
causes serious disorder, and a tumour whose contents are entirely
fluid, commonly produces less distress than one even of smaller
size, into the composition of which solid matter enters in lai'ge pro-
portion. One reason of this probably is, that solid tumours more
frequently press upon the abdominal vessels, interfering^ with the
circulation tlm>ugh them, producing effusion into tlie peritoneal
cavity, and disturbing the kidneys in the performance of their
function, Orthopmca, habitual shortness of breath, even when
no exertion is made, complete loss of appetite, or sickness, owing
in part to the stomach being mechanically prevented from retain-
ing food, pain referred to the liver, and obstinate constipation,
with frequent colicky pain^ independent of the action of the bowels,
a very scanty secretion of urine, and a very feeble and thready
pulse, with, perhaps, irregularity of the heart's action, — such are
the symptoms which, when they begin to occur, indicate the im-
mediate necessity for tapping. Mere unwiehlinesa in moving
H
TEEATMENT OF OTABUN DROPSY I
about, or discomfort from the teDsion of the abdominal in!
though perhaf»a very painful to bear, cannot be regarded i
indications for the operation ; and time not infrequently
a person to a state of things which at first seemed almc
able. Even the circumstance that a tumour is steadily
crease cannot be taken as necessarily calling for the
since ovarii cysts, though large, sometimes come to a
and to decide in favour of interference when it is pofll
short time lon*^er to delay it, implies that we have an
oar own satisfaction the second question as to the amoi
attendant upon simple tapping, U
In the cases hitherto referred to, the dangers of tl^
scarcely enter as an element into our consideration, b&i
takes its place in the same category with various otlin
dQVm
1
tm
of necessity, such as amputation performed in conseqti
juries, which, how serious soever might be the risk aU«
them, would stiU be most legitimate, because tlie onlj
our command.
It woidd however be unreasonable to expect that \
performed in these circumstances should be free from da
this danger arises chiefly from two sources. Great as
often is to the patient, a certain amount of shock fa
evacuation of a largo quantity of fluid, and patients p
much exhausted sometimes sink in two or three days aft©
In spite of the warning given to the patient that tappii]
this way probably shorten her days, the choice is not inf
made to sul>mit to a proceeding which brings at least pre
nor have I thought myself failing in my duty if, whe
was almost powerless, I tried to secure the last boon ou:
ask of us — an euthanasia. The other danger is one of i
tion of the cyst-walls, issuing in the effusion of IjTnph
into it^ interior, and not infrequently associated with p
which often proves fatal in the course of two or thn
* [The following cjue of faU] tapping is worthy of special meDtioD m
tbe rarity of stinio of it» conditions. An otherwise healthy young '
adiMtliud into St Bartholomew*! Hospital with a Tcry large and tei
tximour, A« a preliiuinary to propo«e<l ovariotomy it was tapped. Tl
cauik'd intense agony, which was not confined to the moment of tlie tn
bat i^ontinned til! the <^hief projecting cyst was emptied* The paiiif in
entirely ceased, but was soon changed to the soirerings prodoioed
TAPPISQ ; ITS DANGERS,
569
N
This latter occurrence, too, seems to be of greater frequency after
first tappiDgs than in those cases where the operation has been
frequently perforuied, while death from mere collapse is, as might
be supposed, more likely to occur where recourse has often been
had to tapping. Besides these two risks, which not unnaturally
have led practitioners to shriiik from this operation, another objec-
tion has been urged to it on the ground of the increased rapidity
with which, after each time of its performance, the fluid reaccumu-
lates within the cyst Expressed in various ways, the opinion is
almost unanimous that tapping is bat the beginning ot the end,
and patients are commonly advised, even at the expense of great
inconvenience and discomfort, to put up with the praseut ill, and
not to purcliase prematurely a brief respite from sutfering at so
high a price.
The result of the general impression as to the danger of tapping
has been not only to postpone its performance in all cases to as
late a period as possible, but also to lead to the endeavour to devise
some other proceedings, which, if not in themselves less hazardous,
should at least aflbrd the chances of a greater good, and ofter by
the high prize which they hold out to the fortunate few, some
amends for the hazards that all must nm, and in the encounter
with which many, perhaps most, must faLL Such endeavours are
but the expression of a feeling deeply rooted in the breasts of all ;
and I see notliing to reprobate either in the surgeon who ad^dses,
or in the patient who encounters some great present risk, when
in the one scale is placed the expectation of perfect health, — death,
indeed, in the other; but still a death which does but antici-
pate, by a few months, the certain issue of her present suffering
existence.
To judge at all fairly, however, on such a question we must not
overcharge either side of the picture : and that which it now con-
cerns us to determine is whether the colours in wliich the i-esults
of tapping have been drawn are faithful, or whether they are not
somewhat darker than the facts of the case altogether w^an-ant
pamleiit perito»itifl ntid supiiuration of the tumour. She died within thrM days
from this Uipping. BeaideA ordinary »|ipeiiraiice8, it waa founds and it probably
accounted for th« }>ttin of tapping, that the great omentiini, having its ordinary
strueturi?, covered the whole anterior surface of the tumour, lying between it and the
abdominal wall. In thin situation it had been retained by old adhmons whkb
pinned iU lower margin tirmly to the peritoneum behind the pube&]
670 TBEA.TMENT OF OVAfilAN DPOPSY !
The chief, indeed almost the only numerical data of which we
are possessed bearing on this subject, are derived from a table of
46 cases collected by the late Mr S. Lee,* and of 64, the results
of which are given by Professor Kiwisch.-f-
Of these 110 cases, 18 terminated fatally within a few hours or
days after tapping, and 21 more in the following six months, or
in other words, 35*4 per cent, of the cases ended in the patient's
death in the course of half a year after the performance of tapping.
In 94 of the 110, death is stated to have taken place.
In 18 within a few hours, or in less than ten days after tapping.
„ 21 „ six months.
„ 16 „ one year.
„ 19 „ two years.
„ 11 „ three years.
„ 9 after a period exceeding three, and sometimes amounting
to several years.
94
In 89 of these cases we are further informed how often the
patients had been tapped.
It appears that 37 died after the first tapping.
„ 18 „ second tapping.
19. „ firom three to six tappings.
„ 13 „ „ seven to twelve tappings.
„ 12 „ more than twelve tappings.
89
The greater absolute mortality attendant upon first tappings of
course does not represent an equal amount of greater relative danger.
Still, when it appears that only 37 of the total 110 cases were in-
stances of the first performance of tapping, and further, that all
the 18 patients who died within a period of ten days from the
operation had undergone it for the first time, we are, I think,
compelled to admit that the first paracentesis is accompanied by
perils which are greatly lessened on its repetition. Of 38 patients
of mine who underwent the operation of paracentesis abdominis
on account of ovarian dropsy, two died of inflanmiation of the cyst
within a few days after its first performance, one sank exhausted
thirty-six hours after the second tapping, and a fourth died of
* OpcU. y, 176. \0p. cU. voL iL p. 116.
TAPPING : ITS DANGERS.
571
fexhaustion on the sixtt day after the tenth tapping. The othei-s
all survived the operation, which in one instance was ^lot repeated
on account of the large amount of solid matter that entered into
the compoBition of the tumour, and the serious symptoms which
had followed its first fierforniance. In one patient the lluid has
never re-collected, and when I last saw her after the lapse of three
years, during which time she had given birth to her lifth child, all
traces of the tumour had disappeared, and recoveiy might he
looked on as complete* In a second the cyst, having refilled,
spontaneously subsided, and to the best of my knowledge the
patient continues free from disease, Tliree died suljsequently
after attempts at the extirpation of the cyst, four sank under the
progress of the disease, in the course of which tapping was had
recourse to more than once, one died of apoplexy, and the remain-
ing patients were still living when I last heard of them, tapping
in many having been subsequently repeated on several occasions,
and the injection of a solution of iodine having in eight instances
been resorted to with results concerning which I shall have more
to say hereafter.
Unfavourable, however, as are the conclusions to which we are
irresistibly led by facts sucli as those which have just been men-
tioned with reference to the ultimat-e issue of tapping, it m yet
very questionable w*hether they represent the whole of the truth
concerning this matter. Some of the data from which the tables
were constructed wtjre not collected originally with the view of
fllustrating the ojteration of tapping, w^hile the majority of tlie
others are deduced from observations in hospitals, and must
therefore, for reasons obvious to all, yield a very high aver-
age of unsuccessful results. The cases that seek admission to
those institutions are almost always the least hopeful, generally
the most far advanced, not infrequently those of persons who
have sought out a place where death may come to them w^ith less
suffering than if they awaited it in their own homes. If relieved,
such patients quit the hospital, and are often lost sight of; so
that while the failures are known, the instances are frequently
nndiscovered in which life has been prolonged or rendered com-
paratively comfortable. Almost in proportion as experience con-
cerning this operation is derived from hospital practice, or from
observation in private, does the estimate of its danger appear to
572 TREATMENT OF OVABIAN DBOPST :
be increased or lessened, a circumstance which seems to showtiiat
the hazards of the operation depend at least as much on the con-
ditions that surround the patient, as on anything inherent in the
proceeding itself.*
It is, moreover, a question quite open to debate, whether the
period at which the operation is generally performed has not con-
tributed largely to its fatal issue ? The delay, commonly continued
until the different functions are seriously disordered, and the
patient's sufferings from mere mechanical causes have become
urgent, may on the whole be expedient ; but it can scarcely be
doubted that it must lessen the prospects of recovery when at
length the operation is resorted to. Besides, the favourable results
which are said to have followed the early performance of tapping
in some of those instances where tight bandaging was associated
with it, render it probable (due allowance being made for the ex-
aggeration by which many of the published reports of cases where
this proceeding was resorted to are vitiated) that the mere act of
tapping in certain selected cases of ovarian dropsy is imattended
•by any considerable hazard.
The whole of this subject needs a much more searching investi-
gation than it hitherto has received ; but in default of this, I
will venture to give my own impressions, and I do so as mere
impressions, which further experience may modify or completely
change. My present belief, however, is, that the dangers of the
operation of tapping have on the whole been over-estimated ; and
further, that while in cases where the amount of solid matter in
• In the A7nerican JownuU of Medical Sciences, vol. xix. New Series, April 1860,
p. 834, are some observations on the mortality attendant on tapping, by Dr W.
Atlee, showing that, even tried by such evidence as that adduced by Mr S. Lee,
the tendency of the operation is, on the whole, to prolong life, not to shorten
it. M. Velpeau, too, in a discussion at the Jcad&mie de Midecine (Jmimal ffeb-
domadaire, Nov. 28, 1856), demurs to the accuracy of the generally received opinion
of the great mortality arising from simple tapping. He admits that in one year
he lost four patients after tapping ; but these were exceptional cases of large com*
pound cysts, which it was found possible to empty only very partially. With
these exceptions he has performed the operation 312 times, on about 98 patients,
without any serious results either immediate or remote, and many of the patient!
(an unfortunately vague expression, which much detracts from the value of his
statement), survived its first performance ten, fifteen, or twenty years. Southaam's
cases were exceptional and are therefore omitted in this edition ; and I do not know
of any statistics more numerous than these in the text, from which aU sooroes of
error have been excluded.
I
TAPPING : ITS DAKGERa
the growth is conMderable, the rule which prescribes the postpone-
ment of the operatioa to the latest p«Dssible period is a sound one,
it will probably be more expedient in the case of simple ovarian
cysts to tap early, before the growth has acquired a large si^e, and
before the constitutional powers of the patient have seriously
suflered. We are, too, the more encouraged to employ simple
tappinj:^ once, moderately early in the case of simple ovarian cysts,
since while it does occasionally prove curative, it scarcely if at all
increases the risk of the subsequent performance of ovariotomy,
while it not infrequently yields information of great practical
value to the surgeon who may subsequently be called on to
operate on the patient.
The operation of tapping itself is simple enough.* Nothing
more is necessary than to bring the patient to the edge of the bed,
so as to allow of her abdomen projecting somewhat beyond it.
The bladder should then be emptied by the catheter (a precaution
for which the voluntary efforts of the patient are but a very
imperfect substitute), and it having been clearly ascertained that
fluctuation is distinct, and that no great thickness of solid matter
is situated at the point selected for puncture, the skin may be
divided for a quarter of an inch or less with a lancet, and the
trocar introduced. It has in some rare instances happened that
a large venous trunk ramifying on the surface of the cyst has
been wounded by the trocar, and that the haemorrhage has had
fatal i3sue.f Such an accident, however, is scarcely to be guarded
against by any foresight, while the risk of wounding the epigastric
artery is pretty certainly avoided by the selection of the linea alba
instead of the linea semilunaris as the situation of the pimcture.
If there were obviously considerable thickness of soHd matter in
the former situation, it would no doubt be our duty to puncture in
the linea semilunaris, or at some other part where there seemed to
be a less thickness of intervening substanca It is. however, quite
as easy to empty the cyst through a puncture made in the former
situation as in the latter, if the patient inclines a little more over
* Tlie Intc Sir "W, FcrffusHou was 1 believe the firat to do away with the old mode
of tapfiing the patient out of bed and in the sitting posture. It has now becoiue a mere
trtditiou of hygouG harhajotia days. Seu his PreuUical Surgtrtf ; and also a paper
on the subject by the bte Sir J. SimpaoiL
t A remftrkablo iuetuice of jEitd hsmorrhjige from the wottnd of a veuael of the
omentum which ftdhered to t krgeoTuiftii cyst lanlitad by Scuizoiii, 01^. ciL p. 45^
574
TREATMENT OF OVABIAN DROPSY Z
towftrda her face, and its greater safety renders it therefoK
generally preferable.
The two- fold danger of escape of cyst-fluid into the perit<ineaDi
and of admission of nk into the cyst is completely avoided by tin?
use of Spencer Welia' modification of Thompson's trocar and caniUa;
and the importance of gentleness in manipulation is now w
tlLOTOUglily appreciated, that it is needless to caution you againet
pressure of the ahdomen in order to get rid of the fluid m com-
pletely as possible, I think, however, that I have formerly aeon
inflammation of the cyst excited by such manipulations when
rather roughly i^erformed. The application of a flannel bandigo
afterwards, though not in general necessary, is usually a comfort
to the patient; and in eases where any considerable portion of the
growth is aoUd, can scarcely be dispensed with, since, unless sup-
ported by external pressure, the mass is apt to fall from side to
aide with eveiy movement of the body in a manner to oocsbbob
much distress.
I have always been accustomed to keep my patient in bed tot
a day before tapping, and for three or four days afterwards, and
to select for the opcraiion a time as distant as possible from a
menstrual period. Thase precautions, indeed, may not in every
case be necessary ; but, in spite of histories such as that of tbe
patient who every three weeks used to come by omnibus a dis*
tance of some five or six miles to Paris, and having been tapped,
immediately returned by the same conveyance, I believe them to
be always expedient In every instance of first tapping, wheie
we can have no data to guide us as to the probable results of the
operation, it is scarcely possible to err on the side of caution.
The dangers attendant on the operation of tapping are twofold ;
that of exhaustion on the one hand, of cyst-inflammation on the
other. The previous state of the patient's health has, as might be
expected, much to do with the former occurrence, but nothing
seems to furnish a guarantee against the latter. It sometime
happens that cyst-inflammation runs its course with scarcely any
symptoms other than those of exhaustion ; or lather I imagine
that in patients previously much debilitated a diseased state of
the blood is apt to supervene, and death takes place from pj^wmia^
of which the cyst-inflammation is the consequence, not the cause.
In other instances, however, the sinking of the patient is indepen-
i
4
TAPPING : ITS DAKGERS.
573
dent of any recent morbid process, but tbe slight shock of the
operation suffices to disiin-ange tbe frail macbinery, and to bring
it to a standstilL It is well to bear this risk in mind in all cases
where the patient is very weak, and to dissuade from tapping,
nnloss most iirgontly called for by the difficnlty of respiration, or
the inability to retain food on tbe stomach, which the mere
mechanical distension of the abdomen sometimes produces. The
precaution of letting the fluid out very slowly, of loweriEg the
head and sbouldera as it escapes, and of only partially t^mptying
the cyst, are the means by which the danger from exhaustion is
beat guaixled against, while, after tbe operation is over, careful
watching and judicious nursing are more needed than what is
fitrictly called medical treatment.
The cyst-intiammation is a still more serious accident, and all
the more from its occurring when least expected, though it is
certainly much leas likely to attack simple serous cysts than
growths of a more compound character and those especially which
partake of the nature of alveolar carcinoma. Its symptoms are
seldom very marked at the outset, and the piiin which attends it
is by no means proportionate to the danger of tbe attack. Tender-
ness on pressure over the tumour is indeed always endent, and
sometimes, when the inflammation has extended to the peritoneum,
there is likewise severe pain independent of pressure; but a
quickened pulse, a general febrile condition, unpreceded, however,
by shivering and sickness, are the signs which should at once
excite onr appreliensioa Of all the symptoms, indeed, vomiting
and an irritability of stomach, which rejects all medicine, all food,
al! drink, though the thirst is usually considerable, are of the
great-est moment, since they are almost pathognomonic of this
afifection. It seldom comes on within the first thirty-six hours,
often not until the third day after tapping ; while the rate of its
progress in fatal cases is variable ; death sometimes taking place
in three days from its commencement, in other instances not till
after the lapse of a week. Whether €].uick or slow, however, in
its advance, symptoms of an acute character are at no time weU
marked; the pulse seldom has much power, the intense pain often
attendant on peritonitis is absent, the bowels, though constipated,
answer tolerably readily to medicine, and death usually takes place
under the symptoms of depression which accompany pyaexaia.
TAPPING m OVARIAN DROPSY.
When allowed to go on unchecked for twenty-four or thirty-sii
houi-9, the cyst-inflammation is I believe an almost hopeless
affection, thaugh if treated quite at the outset, and in women not
exhausted by tlie previous ovarian disease, it jdelds toletsbl?
readily to treatment Depletion is the great remedy on which I
rely, and local depletion usually answers every end ; thoogfa^ on
one occasion, when the symptoms set in with much severity, and
indeed more nearly resembled those of acute peritonitis than of
inflammation of the cyst, I abstracted twelve ounces of
mere
blood from the arm with great benefit Twelve or eighteen
leeches, however, applied over the tender part, and followed by •
warm poultice frequently renewed, or by perpetual focnentatioil
by means of the spon^aopilino, often remove the pain, abi^ tba
fever, and stop the sickness. So long as the last-naniad Bymptom
continues, no amount of improvement in other respocte can b^
considered satisfactory, and whether the tenderneaa seemed to
call for it or not, I should repeat the depletion if the sickness hid
not ceased, or, at least, wivs not greatly mitigated. A single
large dose of calomel, as ten grains given in powder, aometimed
arrests the irritability of the stomach, and obtains the action of
the bowels with the smallest amount of general disturbanca The
le-ss, however, that the irritable stomach is teased with medicines
the better, and iced water in small quantities, or little pieoee of
ice given to the patient to suck, are by far the best means of reliev-
ing the sickness and of quenching the thirst When the moie
serious symptoms are passing off, a few spoonfuls of cold beef^ea
or of cold chicken broth will be found to be the most appiopriate
food, and that which the stomach will hest support
To see the patient early, to watch her carefully so as to be ready
with a tiraely repetition of the depletion if the sjiuptoma do
not yield to its first performance, such are the essentials for saving
the patient from this disease, in the management of which no
time is afforded for elaborate treatment nor any chance given for
retrieving lost opportunities.
i
LECTURE XXVIIL
OVARIAN TUMOUKS AND DROPSY.
TAAiTjCKNT contmaed. MeasuT«8 proposed for tlie mdical ctire of oramn dropsy.
Tapping tod prmenrsL Subcutaneous puncture of the cyst. Tap}>ing per
▼■gin&m, Tftpping followed by some contrivance for keeping the wound per-
manently open : incision and partial excision of the cyst. Tapping, with in-
jection of iodine ; — estimate of Its advantfigea.
OvARtOTOMT— dilfetence of its results now, and thirty yeara ago — canses to wMch
this is chieliy due — ^general acceptance of operation — ita indicatiotia.
ALTHoiTGti in the last Lecture I asdigned eome reasons for
ilrmhtmo whether tlie perils attendant on tapping in ovarian dropgy
had not been somewhat overrated, it must yet he aUowed that the
operation very rarely indeed proves curative, that the fluid
generally re*collect8, and that a reprieve, and commonly hut a
very brief reprieve^ is all tlmt it affords to the patient*
Hence have arisen suggestions of various proceedings, most of
which were modifications of the operation of tapping through the
abdominal walls, and which all had for their object the favouring
the contraction or atrophy of the cyst, and the retarding, if not
the preventing, the re-accumulation of the fluid.
Formerly when practitioners shrank, and with good reason, in
the then state of our knowledge, from the hazards of ovariotomy^
many of their proceedings demanded careful consideration » and a
judicial weighing, if I may so aay, of their good and evil sides.
Those days have passed, and instead of ovariotomy being now
fitly compared with the CEesarean section, it takes its stand, and
not disadvantageonsly, side by side with the other great operations
of surgery, while most if not all of the proposed substitutes for it
are on all hands acknowledged to he either futile ur hazardous.
The idea of preventing the accumulation of fluid after tapping
by tighthandaging rested on a crass mechanical view of the process
by which the obliteration of an ovarian cyst is brought about \ a
result which we know never takes place by the simple cohesion
2o
578
TREATMENT OF OYARIAN DROPSY:
of its opposite walls. A bandage, indeed, prevents enlargemeat
from taking place aa rapidly as it would do if no pressure wwt
exerted on the cyst, and so far is useful ; but it does no nioie.
while very tight bandaging is not altogether free from tbe risk o(
excitinfj that Biuch dreaded evil, cyst iDflammation. This proceed-
ing has therefore rightly been discontimied, first as useless^ oexi
as not altogether free from danger
Tlie suhctttammM pitficture of the sac, and thus allowiiig ita
contents to flow into the peritoneal cavity wa^ recommended on
purely theoretical pounds, according to which it was sought pur-
posely to imitate that most dangerous accident, cyst rupture, and
for the sake of a possible chance of recovery, to expose tbe patiest
to the risk of probable death. It stands self -condemned, and soon
will be forgotten.*
The same judgment must be passed on a somewhat similar pKh
ceeding, which consisted in the rej/wval of a pyrtion of I fir ofsi ioaff
after emptying it of its contents, and so permitting it to dndn into
the abdomen, on the assumption tliat the fluid, unchanged by the
grave injury inflicted on the cyst, will be absorbed by the
peritoneum, that the remains of the cyst itself will continue far
but a short time to secrete, and will then become alt-ered ia
character, and probably calcified. We nmd, however, soiie
guarantee of the probability of this occurrence usually taking pliice*
some evidence that the excision of a large portion of the cyst is
not likely to be followed by very acute inflammation of that which
is left behind, that the secretion from it will not become sanioos
or purulent, and consequently will not be likely to excite violent
l>eritomtis. Almost all experience, however, discredits these as-
sumptions; and the proceeding has fallen into merited disuse,
though the rare occasions in which the patient has survived it
serve to give a ray of hope to the operator who from some cause
or other is foiled in his attempt coraplet^^ly to extirpate an ovarian
tumour. Even in such cases, however, the wiser course ia not to
let the mutilated sac pour out its contents into the }x^ritoneum,
1
1
* A full account of all these vnried proceedrngs now abandoned, with an Jieooont
of the aiithor*s erpfiricoce of ench, an appr^intion of their varions merits *n«i dit-
a»l vantage's, and rtbiinilnnt references to dilTiTent writers will be found in Lectnm
xxijc of the former edition of this work. They are omitted here as having
Ittlle more thim a hiHtoriual value
VARIOUS PRO€EEDIKGS FOB ITS RADICAL CURE.
579
but to fasten its edges to the abdominal wall, and keeping the
opening patent, to treat the sac like an abscess by drainage, and
with all antiseptic precautions.
It is mainly with a view to the greater facilities thereby afforded
for drainage that it has been proposed tAypuTicimr an ovarian cyst
jMr vaf^hmm instead of through the abdominal walls. It happens
every now and tlien that the tumour is bound down by adhesions
90 firmly that it cannot rise out of the pel\ac cavity, or that one
cyst of a nmltilocular or compound outgrowtli Ls prevented from
leaving that position by the pressure of other cysts al»ove it. In
these circumstances puncture per vaginam is urgently called for,
since, as I have already mentioned, cysts thus situated have been
known to give way under the combined influence of pressure
from above, and of attrition against the promontory of the
sacnim.
In other conditions I do not recommend the proceeding.
Is/, Because the cyst, when large, sometimes prevents the bladder
from rising out of the pelvic cavity. The organ consequently be-
comes much altered in shape, and is spread out laterally in such
a way as to expose it, with no very great unskilfulness on the part
of the operator, to the risk of injury by the trocar*
2d, In the case of all compound and multil ocular cysts, the larger
are commonly those which are distinguishable in the abdominal
ca^^ty; the smaller cysts, and the greater proportion of solid
matter, are to be found near the pedicle. Hence a puncture
per vaginam is likely in those circumstances to be less efficacious
than tapping through the abdominal walls.
3^^, The risk of litemorrhage from wounding some large vessel is
greater when the puncture is made near the pedicle of the tumour.
^th. The greater difficulty of excluding the entrance of air when
the cyst is punctured per vaginam ; and the consequently increased
risk of cyst inflammation. Except in the case above mentioned
of a cyst impacted in the pelvic cavity, it does not then appear to
me desirable to deviate from the ordinary mode of tapping through
the abdominal walls,
I said that one of the objects proposed by vaginal tapping was
the readier drainage of the sac, and the cure thus indirectly
brought about by the production of cyst inflammation. The idea
of effecting the cure of a dropsy by providing for the perpetual
580
TREATMENT OF OTAHIAN DBOPSY:
outflow of the fluid, dates back to the time of Celsos f i
application to crises of ovarian dropsy was made nearly a centoiy
and a half ago by the French surgeon, Le Dran^f The observalioii
of instances in which the puncture wound remaining fistiilooa m
as to give constant issue to the secretion, the disease ended iS
last in the shrinking of the sac, the closure of the wound, and tie
recovery of the patient, kept the idea constantly present to the
mind of the surgeon. The grand objection to this proceeding; io
whatever way it is carried out, is that it counts for its sucoiM
upon the production of that most unmanngealile, one may say kh
calculable, factor, cyst inflammation. The cyst is to be con\*efted
into a large abscess ; and we are to count on the infliimnmtiiiD doC
being so severe as to extend to the peritonenm, and on the polmt's
strength being sufficient to enable her to withstand perpetual and
enormous purulent discharge ; a risk whit:h a little experienise
in the surgical wards of an hospital, or the obser\'ation d
children with fistulous empjemata, would teach us to lie a
most uncertain issue. The dangers are no doubt lessened by tfai
practice now adopted of stitching the edges of the wound to the
abdominal walls instead of introducing a tul>e or canula into Ike
sac ; but my own small experience of it in two eases, where it HM
adopted as a matter of necessity, not of choice, owing to the pre- h
sence of adhesions which prevented the extirpation of the tui&Dtii ^
ifl unfavourable, as both patients died. Noeggerath*sJ statistics o!
56 cases in which the operation was performed yield a mortalitj
of 29 fjer cent. ; cases of drainage by the vagina as well as by tilt
abdomen being included in the calculation. The gross results of
Mr Spencer \Vells'§ 800 ovariotomies yield a mortahty of about
25*4 per cent. ; of Dr Keith*s|| 280 cases, 145 per cent
Noeggerath's cases include, as I stated, those in which draimg^
was carried out per vaginam, as well as others; and henoe
* De MididnA^ lib. vii cap. xv. See pag« 362 of Milli^;&ii*s edition, Edialnit^
1 83 1 . My attention wm otlled to this pasaage by Fock's extremdy able [mper oo tki
'* Operative Treatment of OTftrianC)'i!t8/Mn4V«wai«<^i^^ OtlmtiahMwi^^ Tot m
p. 332, v^liieh coQtidiiH a good critique on the compnrative m^ts of Tarimu pro-
ceedinga,
t MmwiTU d4 VAeadimik Stryah d$ Chirwrgiet tome tL » 12]iio, Faiis^ 13
61 and 73.
t Quoted by OUbamien, op, c»l, p. 201,
i Op*cU, ToL ii. p. 922 ; and Med. Chin Trant., vol Ix. p. 209.
r h^on amd afU/r Aniieeplkt, Bto, Edinbtirgh, 187&
ITS RADICAL CURE ; DRAINAGE : IODINE INJECTIONS.
581
probably its comparatively favourable though still tinsatiafactory
resulU. There is no doubt but that inflamiuatiDn attacking parts
within the pelvic ca\ity is less apt to extend to the peritoneum
than when it attacks an abdomimJ organ ; of which rule pelvic
cellulitis, and inHamuiation of parts within the folds of the broad
ligament, are ai»t illustrations. It m also equally incontestible
that pelvic peritonitis is less apt to become generalised than is
similar mischief originating in the abdomen. It l-^ also partly
perhaps owing to the greater facility of keeping the cyst empty
w^hen tlie puncture is dependent that the better success is due of
drainage per vaginam than through the abdominal walls. But
when this has been granted, this proceeding, which Steiu adopted
with success, which Kiwisch strongly advocated, and from w^hicli
Scan^oni obtained at one time encouraging results, though he
seems of late to have abandoned it, cnnuot stand Its groimd
against ovariotomy. It most he remembered that in none but
simple cysts is cure by this method possible. In the case of a
simple cyst, however, it appears to nie more than doubtful whether
we are justified in exposing a patient to a danger so very formid-
able as that of the cyst- inflammation which this operation almost
invariably provokes. At any rate, we cannot^ I think, rest satisfied
with a proceeding, the indications for which must be furnished by
some purely exceptional conditions, but must carry our inquiries
further after some measure more certain, or more safe.
Such a proceeding, it is alleged, exists in the use of iodivs
injectioTis into ihe cavittf of the cyst, with the \iew of preventing
the re-accumidation of the fluid. There is no question as to the
occasional utihty of this measure in cases where for some reason
or other the drainage of a cyst after tapping is deemed expedient,
aod where iodine injections are employed for the purpose of
washing out the cavity, deodorizing its contents, and preventing
as far as may be the occurrence of septicaemia. But it has also
been strongly advocated as a curative proceeding on the very
reasonable assumption that the iodine injection into an ovarian
cyat will act in the same manner as w^ben thrown into the sac of
a hydrocele, and so modify the secreting power of its lining
membrane as to arrest the pouring out of the Huid, and bring
about thereby the obliteration of the cavity. The tirst reportwl
cases of the employment of injections of iodine for this purpose
682
TREATMENT OF OVABIAN DROPSY :
were published by M. Thomas in 1851 * though M. Boinet, who is
iti great advocate, put it in practice in 1847.+ Thirty yeara tgu,
when the results of ovariotomy were still unfortunate in a Ui^
proportion of cases, any measure which held out a prospect oi
permanent cure with far smaller risk to life, was eagerly embmoeA
The earlier results of the operation, however, were far from en*
couragiii^r, and the statistics down to tlie year 1859, collected from
various sources in Giiiither's elaborate work^ yielded out of 15S
eases a mortality of 59, or 38*8 per cent M. Boinet s cases, how-
ever, gave results far more favourable owing either to a mon*
careful selection of patients, or to greater precaution in the per-
formance of the operation^ for his fii'st 100 cases yielded 61
recoveries, 23 instances in which the fluid recollected, and only
lt> deaths; and in only 4 of these did death take place suffi-
ciently soon after the injection to bt* fairly tmceable to it W
his second 100 cases, 81 were cui*es, and in 45 of the 81 cas^
cure followed a single tapping — a result far better than that
which even follows simple tapping. In no case did death ensue
from the operation,
M. Boinet selects as far as possible single cysts [which may, at
least in a certain pTOportion, have been parovarian] ; he operates
while they are yet small, provided always that they are obviously
not stationary, and when their contents ai-e simple seniin* He
endeavoiii-s to puncture on the side whence tlie cyst springs, and
as low down as possible, just above the crural arch. Before the
whole of the Huid is evacuated, he passes through the canula a
long Indian-rubber tube, through which the remainder of the
fluid is allowed to How, and over whicli he carefully withdraws
the canula. Through this he next injects the iodised s»dution, or
if the contents of the cyst should, contrary to expectiition, be
either sanguineous or purulent, he washes out the cyst sevend
times with tepid water, or with water with a small addition of
ether for the more thorough dissolving of any fatty matter, and
then iajeets tlie solutif*n of iodine, which is not allowed to remain
in more than ten minutes. He does not consider that in the caae
4
• Jtimt MM, ChxT. Feb. 1851, and Scbmidt's Jahrb. 1861. No, rL p. a37.
t MoiMmpU, he, Svo, Tans 1855, p. I^'d, and Tt aiU dts Maiadm dka Owtt&rt$^
Sieme ed. Svo, Paris 1877, p. 449,
t Lehrtder UtUiffen Operatwnenf folio, 8S liefvnmg, IMpngf 1S59, u 156.
ITS RADICAL CUBE : IODINE INJECTIONS.
583
of lai^e cysts it is necessary to inject a proportionately larger
quantity of solution^ but contents himself with from 120 to 150
grammes, about 3^ to 4^ ounces; his object being not to till the cyst,
but to bring the whole of its linin*,' membrane into contact with tlie
solution, an end easOy accomplished by gently kueading the
abdomen. The solution which he employs consists of equal parts
of tincture of iodine and water, with the addition of 5j of iotiide
of potass, or 15 to 30 grains of tannic acid, in order to insure the
perfect solution of the iodine. It may be well to add that the
French tincture of iodine is more than double the strength of that
of the British Pharmacopeia, the proportion being 1 to 12f in the
former, 1 to 29 in the latter.
M. Boinet is very particular always to withdraw the solution
at the end of ten minutes, not merely allowing it to flow out^ but
emptying the cyst completely by means of the s^Tinge through
which the injection had been introduced. It is perhaps due to
this precaution that he has never met with those symptoms of
iodism or of cyst inflammation, which in common with others I,
in my Hmited experience, have observed. The accidents which he
met wnth in his last hundred cases w^ere all most trivial ; and as I
stated none were fattd, while in the only instance in my practice
in which the patient died, this sad residt was due tcj the partial
escape of the fluid into the peritoneal cavity.
Were I still so circumstanced as to be able to give a further
trial to iodine injections, I confess that I should be desirous to
avail myself of the opportunity. The success of ovariotomy is to
a large extent due to the exceptional skill of a few singularly gifted
sui^eons ; the injection with iodine is a proceeding within reach
of all Neither can there be any doubt hut that the risk of the
injection which by no means precludes the subsequent perform-
ance of ovariotomy is incalculably less than that of any other
measure which has the slightest pretension to eftect a radical cure,
'* Unfortunately for our patients " says M. Boinet,* and in this
opinion I am much disposed to agree, " no one now-a-days gives
himself the trouble to ascertain whether a cyst is unilocular,
whether its contents are serous, and w^hether it presents a condi-
tion favourable to the injection of iodine. It is considered quite
enough to know that there is a cyst, and whether it is unilocular
♦ Op. cU. p, 475.
684
TREATMENT OF OYAJaAN DROPSY:
or multilobular makes no difference — ovariotomy is done at oooe.
TliU3 it has come to pass that as ovariotcimy succeeds betlsr i&
simple unilocular cysts, than in those which are compcmtid m
multilocular, and as, moreover, much more Mat attends that cipem*
tion than the tapping and injection of a cyst, so some
entirely reject iodine injections, and condemn a mode of
which they do not know, which they have in many instancaB not
even tried."
It still remains for us, in the last place, to examine tlie grmi
radkttl cure of ovarmn drop^g, the extirpaii(m of the dismmd ^ifjf&iL
Unfortunately, I am old enough to have watched and to have
shared in the various fluctuations of opinion which have xnariced
the history of this operation. Twenty years ago, when the mor-
tality of those who submitted to it amounted to nearly 50 per oeaL.
while no progress seemed to he making in diminution of Ihii
fatahty, I dissuaded from it. Nine years later I re*8tated my
former opinions^ but followed them by a recantation, for which I
assigned my reasons ; and they who take interest in the story of
medical opinions may, if it please them, refer to w^hat once were
mine, and those too of many others. To repeat them now would
be an idle waste of time for ioto cmimo I accept the operatioD, and
in so doing tend my respectful congratulations to three pemooi
who in connexion with it have won themselves a name^ and better
still, have made the whole human race their debtors, and those
three are— T. Spencer Wells, Joseph Lister, and Xhomafi Kaidu
I have no intention of narrating the history of the operatioil,
interesting though it w^ould be, but what I need say can be said
very briefly; for on this occasion figures are more emphatic tluii
words. Fii-st performed in the year 1809 by Dr MacdowaU of
Kentucky, it was repeated betw^een then and 1840, 26 times. In 8
cases the patients died, 17 survived ; but in 11 instances, Z of whidi
were fatal, the opemtiou was not completed^ either from adliessions
which rendered the removal of the tumour impossible, or in con-
sequence of some error of dingnoaia Some sixteen years lals
Fock, whose able papers has already been referred to, ooUected the
particulars of 292 cases in which ovariotomy was either attempted
or performed. In 200 cases the ovary was removed, and in 111
instances the patients recovered, in 89, or in 445 per cent they
died, while in 31 of 92, or in 33'C per oent of those in whom tbe
I
h^
OTISIOTOHY.
585
operation was not completed death also took place. Putting all
the caaes recorded up to that time together, it appeared that there
was nearly oue chance in three against the operation turning out
feasible ; while, if completed, the risk of death and the prospect of
survival were oearly equaL Nor did it at that time appear that
the results of the later cases were more fortunate than those
of the earlier, and my unfavourable verdict was recorded in
1858, when Mr Spenc-er Wells had performed six only of those
operations by which he has revolutionized abdominal surgery. In
1864 there seemed to be reason for expressing, m 1 then did, a
more hopeful view of thQ probable future of the operation, for a
greater accui-acy of diagnosis had been attained, from wliich there
followed a more judicious selection of cases, while improvement
had been made in the mode of performing the operation, as well
as in the after ti-eatmeut of the patients^ and I did not hesitate to
say, " I think we are bound to admit ovariotomy as one of the
legitimate operations of surgery ; as holding out a prospect, and
a daily brightening prospect, of escape from a painful and inevit-
able death, whicli at last indeed becomes welcome, only because
the road that leads to it conducts the patient through such utter
misery."
Even then, however, the results, which yielded a mortality of
30 per cent, were far less encouraging than those which we have
attained to since then. The morttility in Mr Spencer Wells' 800
cases was only 25"5 per cent ; but still more cheering are the re-
ports of Dr Keith, Of 144 operations performed by him between
1862 and 1872 there were but 27 instances, or 18*9 per cent in
which the patient died ; and in his last paper on the subject, he
says ** withmd anlisq}iw8, my results over fourteen years, give a
mortality of almost 1 in 7 (14%5). Of the five years preceding the
use of the spray, nearly 1 in 10^ ; of the last of these five years,
1 in 21 ;" and iis he says, with pardonable exultation, " This long
daspised operation is now the safest of all the great surgical
operations, at least judging from these results ; twelve deaths of
the last 158, 3 of the last 77, and no deaths of the last 43 opera-
tione."
It does not come witliin my pro\^nce to go into details concern-
ing the operation, nor indeed am I competent to do it, but still it
is not without interest to hear Dr Keith's explanation of results^
tm
TttE^VTMENT OF OVARIAK DROPSY :
60 different from those of twenty years ago, when it seemed not tm*
reasonable to compare ovariotomy with the Ca^sarean section » and
this not gi^eatly to the disadvantage of the latter, Dr Ki^
attributes his succesa, and a similar explanation holdd good to t
great degree with reference to the successes of , other ovariotomista
— 1st, to the drainage of the abdominal cavity by means of a laige
gkss tobe going to the bottom of the pelvis ; 2d, to the use of the
cautery in dividing the pedicle; 3d, to the employment of
Koeberle's compression forceps, to prevent loss of blood j 4tli, to
the substitution of ether in the place of clJoroform as ixi
anaesthetic, by which after- vomiting is avoided, and the risk of
haemorrhage when the wound is closed, diminished ; and lastly, U*
the performance of the operation in the last 50 cases under the
carbolic acid spray ; thus carrying in the most effective manafx
Mr Listers antiseptic surgeiy into practice.
It remains for me now only to sum up the indications and
contra-indications for the operation —
Ist^ It is 7wt' to be performed in any case of single cyst which
is not increasing, or is increasing but slowly, wldle it has not as
yet interfered with the patient's general health. In other wonk,
life is not to be jeopardized for a mere discomfort,
2^?, It is }iol as a genend rule to be performed until aft^r the
cyst has been tapped once. The reasons for this caution am
threefold. In some rare cases the fluid does not re-collect ; the
amount of constitutional distuj-banee which follows tapping would
be some index to the amount that might be apprehended from
the more serious operation of extirpating the tumour; and
lastly, when the cyst is emptied, and during the proceaa of
its retilling, its relations, and the presence or absence of adhe^
fiions, especially to parts within the pelvis, can be more readily
ascertained.
I doubt whether, in the case of simple cysts, ovariotomy
ought not to be further limited to cases in which trial has
been made of iodine injections sufficient to ascertain them to be
ineflicacious.
3^, It is noi to be performed in any case in which a tumour is
felt in the pelvis, retaining the same situation but little changed
after tappiug, and fmm which, by means of the sound, the uterus
cannot be distinctly isokted, nor in any case iu w*hich the ovarian
ovARioTo^rr.
587
disease is believed on good grounds to be cancerous, or in which
it is associated witli cancer in other oi^ns,
4ih, It is fortiier contra- indicated, though not absolutely^ by
the presence of albumen in the urine, or at any rate by the per-
sistence of any trace of it after tapping, and also by the early
occurrence of swelling of the legs, and by the presence of any con-
siderable quantity of ascitic tiuid in the abdominal ca\it}% or by
the existence of grave organic disease of any of the important
viscera,
5th, And lastly, iU success is rendered extremely doubtful by
the previous occurrence of cyst inflammation, and general peri-
tonitis as evidenced by attacks of sickness, shivering, fever, and
abdominal pain, and by the presence of pus in the fliud evacuated
by puncture. The fact of a patient ha\dng had occasional attacks
of iibdominal pain of short duration, unattended by fever, or by
abiding tenderness, does not contra-indic4ite the operation, since
such attacks occur independently of inflanmiation. [Moreover,
true though it may be, that cyst inliaDimation lessens the chances
of recovery after ovariotomy, the recent remarkable experience
of Dr Keith in dealing with suppurating ovarian cysts* has led
him to think that, other circumstances being not unpropitious,
ovariotomy ouglit to be the rule of practice in cases of acute sup-
purating cysts, or when typhoid symptoms come on after tapping,
in some cases also of burst cyst. Our own experience does not
enable us to give any addition to, or to subtract from, the weight
of his valued opinion.]
On the other hand it is not contra-indicated,
1*/, By the patient's youth or Bge, though the young and the
old app^-ar to have a better chance than women in middle life,
nor by the fact of her having previously undergone several tap-
pings, nor by the iixegulaiity or suppression of the menses, since
complete menstrual suppression doe^ not prove both ovaries to be
implicated On the other hand, the co-existence of pregnancy, as
Mr S. Welh?' experience proves, does not of itself form an absolute
contra-indication to the performance of the operation, nor render
impossible its fortunate issue,
2d, It is justifiable aud to be recommenrled in all cases of
ovaiian tumour, provided it is not cancerous, and whether its
* Edinlfurgh Medkai JoumeU^ Feb. I@75 ; and L&twei, Mftrch 10, 1S77.
588
rARioTO^nr.
existence has been of long or short duration^ and whether tappiog
lifts or has not >>een frequently resoited to, where the liiseaae u
steadily and progressively increasing, and where the imdeat's
health is beginning to suffer from this increase, but as far as cm
be ascertained from no other cause independent of the local mt»*
cliief*
Something, indeed, I think much of our conduct nrnst bt
governed by the state of the patient's own mind and wishes; Isy
the calmness with which she can regard the possible failure of Ibt
operation, and the sudden entering on the " unknown land ; ** by
the strength of the ties which bind her to the world, and make her
desirous to continue in it^ and by the spirit of hopefulne^ that
may enable her to look beyond the risk of the few days^ to the
perfect health in future years which will be the reward of a
successful venture. Dread of the issue is a bad state of mind in
which to undergo an operation of this magnitude ; I am not sure
but that indifference is even worse: I am quite certain that
mural considerations must be weighed as carefully as tboee
furnished by the character of the tumom*, or the liistory of its
growth.
[Solul tumours of the ovary are comparatively rare, Leopold,
whose paper* on the subject is our best account of them, has col-
lected, after a wide search in medical literature, 56 exclusive of a
few not suiBciently fully described. Of these, 20 were what he
calls double-sided ; that is, both sides were affected — a higher pro*
portion than ia found in ovarian dropsy. Besides tubercle of the
ovary, of wliich I have only seen one specimen, I have met in'ith
several cases of soft cancer, and with one of sarcoma or hard
libroufl cancer. It occurred in an old woman, and was one-aided
It was sent to me as ovarian dropsy, the large ascitic coUectioii
giving rise to this belief* Extraordinary improvement followed
tapping ; but the abdomen soon refilled, and the case proved fatal
about three months from the tapping. Along with the ovariAO
disease was malignant degeneration of the cervix uteri The
woman had borne children from a uterus which was of that double
kind, called subseptus.
The solid tumours of the ovary are of various kinds — fibrous,
sarcomatous, carcinomatous and en chondroma tons. They do not
• ArehhfUr Oynade,, B. vi S. 189.
4
I
I
80UD TUMOUBS OP THB OVABY. 589
present clinical characters of a strikingly characteristic kind so as
to demand description, which in that case would be easy and in-
stractive ; and as this is not a suitable place for the mere accumula-
tion of cases, it is better, in the present state of our experience, to
be satisfied with referring to the paper of Leopold and the work
of Olshausen, Die Krankheiten der Ovarien].
LECTURE XXIX.
AFFECTIONS OF THE FEilALE BLADDER.
Ikflaxmatiox of the BL4IIDR1L, Its ftcttte and jnib-ftoaie form ; the l«ttcr tin
morip fn»juent — some times connected with tuberoolar disuaie of the ]ddii8j',<
with chronic nephritis, Chmnie cyBtitis,
Treatment of the diiferent forma of the dbease.
Ysaico-yAoiNAL Fistula. Eomarks on its prdTcntion, and on tlie tzi»taieat fnv^
liminary to an operatfon for ita cure.
I NTRSXr NO- VESICAL FlHTUl^A. _
Mamosant DiMEAfiE of the Maddrr.
Additional rouiarks on recent advimeea in the stndy of these affoetioita
It may at first 8ight appear that tlie affections of the uri
organs do not Jeserv^e a place in a course of lectures on the diseases
of women* To a certain extent, too, the objection is well-founded ;
and I will therefore state at once tbat it is not my intention to
enter on the consideration of the whole of so extensive a subject,
or to occupy your time with the minute study of diseases which
are common to both sexes, which run in both a similar counBep
and manifest themselves by the same symptoms.
There are, however, some disorders of the urinary apparatus
almost peculiar to the female sex. and others whose cati^ses and
whose course are ditTereot in women and in men, and it is to
these, and these tmly, that I propose to call your attention,
Eeference lias Imen frequently made to the manner in which
the bladder participates in tlie disorder even of the functions of
the womb, and instances have been adduced of the ad^imce of
serious organic disease of the uterus, unannounced by other
symptoms than those which an irritable stjite of the bladder, or a
somewhat altered character of the urinary secretion presented.
Nor ts this all» but nut infrequently the subsidence of uterine dis-
ease leaves behind some impairment of the functions of the blad-
der ; and constant irritability of tlie oi^n, pain in micturition, or
occasional difficulty in voiding the urine, remain as the after efiecta
INFLAMMATION OF THE BLADDER,
of gome not very severe attack of inflammation of the womb, or of
its appendages.
Injlanwmiimi, indeed, beginning in adjacent parts, and by its
extension involving the bladder, plays a very important part
among the causes of disorder of the urinary organs in woman.
It is thus that irritability of the bladder is not infrequently left
behind after an attack of vaginitis, or follows on a miscarriage or
a tedious labour. The recovery in such cases seems at 6Tst almost
complete ; but the slightest cause, such as the natural congestion
of the pelvic viscera which accompanies menstmation. accidental
exposure to cold, or the occurrence of pregnancy, suffices to repro-
duce the frequent, and difficult, and jminful micturition, and to
render the urine once more turbid, charged with the phosphates,
and abounding in deposits of pus or mucus* Such symptoms, too,
continue for months or years, varying in degree, now worse now
better, a life-long source of discomfort, tending rather to increase
than to diminish.
Acute Cf/sfitis has never come under my notice except after
delivery when its symptoms have been almost lost in those of the
graver inflammation of the utenia, or of the peritoneum with
which it was associated. These complications, when sevei-e, often
terminate in death, and tben the interior of the bladder is not
infrequently found denuded to a great extent of its mucous mera-
lirane, which hangs in dark sloughy slireds and patches from an
intensely congested surface ; its state closely resembling that
presented by the interior of the womb itself.
For the most part, however, the injury inflicted on the bladder is
less grave, or at least more circumscribed, and, not being attended
by serious affection of the womb itself, does not prove dangerous
to life. At some one point where during labour the pressure of
the fetal head was most considerable, the tissue dies, and the
patient's distress and dysuria find a melancholy alleviation in the
unconscious outflow of the urine. The inflammation has ended in
destruction of tissue and in the formation of a vesico-vaginal
fistula, but it has ended ; and suffering of a new kind now takes
the place of that which the patient had before endured But this
accident is happily not the most usual result of inflammation of
the bladder, the. long-continued pressure on the organ, or the
neglect to employ the catheter, or the inflammation of the uterus
592
INFLAMMATION OF THE BLABBER :
leading to a sort of mih-amUe cystitis very painful and very difficnft
of cone, but neither destroying life nor condemning the patient to
permanent incontinence of urine.
The history of such cases is generally something of this soit
Labour, or perhaps abortion, was followed by an attack of pain in
the lower part of the abdomen, with much tenderness on preasone,
and with difficulty and pain in voiding the urine, or sometinies
with actual inability to pass it. Leeches and other appropriate
treatment had probably removed the other symptoms and miti-
gated those referred to the bladder ; but still the patient iiiidi
herself distressed by a constant desire to pass water, which she b
unable to retain alx^ve twenty minutes or half an hour, the wish
to void it liein*:; uncontrollable, though the pain in the act itself is
liable to considerable variations. The urine is alkaline, often in*
tensely so, loaded vnlh the phosphates, and containing also a laigo
quantity of pus or mucus, the amount of which, however, frequently
seems to the naked eye more considerable than it really is from
the abundant deposit of phosphates with which it is mingled.
The constant direction of the mind to the urinary function no
doubt increases the frequency of the desire to empty the bladder,
and the incessant calls to pass water by night as well as by day
break down the patient's health and grievously embitter her exist-
ence. Every circumstance, too, which adds to the congestion of
the pelvic viscera exaggerates the irritability of the bladder.
Hence tlie menstrual period h always a time of increased diacom-
fort ; hence, too, the symptoms are sure to be aggravated by the
patient's return to her husband's bed, and the occurrence of preg-
nancy is invariably accompanied by an exacerbation of all her
sufferings, and by a real advance of her diseasa
Examinatian of the ])atient seldom faib to confirm the diagnosis
to which a mere detail of the symptoms would lead us, though it
must be borne in mind that, according to their own preconceived
notions, patients w^ill sometimes give greater prominence to the
indications of disease either of the womb or of the bladder, and
will, till closely questioned, say little concerning those oilier
symptoms which, though perhaps not less distressing, had yet im*
pressed them less because they were supposed to be subordinate
in importance or secondary in the order of their occurrenoe.
Tenderne^ on pressure over the pubes is a common attendant on
rrs sYMPTOMa
593
inflammation of the bladder, though, owing to the coutractad Btsto
of the organ this symptom is not always appreciable unless the
pressure is made directly downwards into the pelvic cavity. The
finger in the vagina generally ascertains all the parts to be unduly
sensitive, tliough often there is no perceptible alteration in their
condition. The mere increase of sensibility, too, is not always
manifest unless pressure is made forwards against the antericr
vaginal wall ; hut then the suffering which is at once experienced
points to the real seat of mischief, while the introduction of the
catheter excites pain almost intolerable from its severity, and
wliich often abides for many hours,
[Acute cystitis occasionally accompanies gonoiThrea vinilenta,
and I have seen examples in young prostitutes. Tenderness of
the parts was extreme, especially, and this for long after the
acutest symptoms had been relieved, when the bladder was pressed
by the finger in the vagina. In such cases the strangury is per-
sistent till the acutest stage is past* During it, examination,
especially bimanually, discovers the bladder contracted, into a
Bohd tumour of the shape and size of a hen's egg, Ij^ing between
the uterus and symphysis pubis. The vesical sound sometimes
cannot be passed ; or, if it enters, does so only to the extent of
two or two and a half inches, measuring from the external orifice
of the urethra. As the case gets better, it is interesting to observe
the gradual relaxation and enlargement of the bladder, the best
evidence of substantial cure, when it is thoroughly effected. I
Lave watched, in such a case, the bladder soften and enlarge
within a fortnight from 21 inches to 6.]
In the higher classes of society the ailment scarcely reaches
such a degree of severity as is here described* Approiiriate treat-
ment in the first instance, and prolonged care afterwards, if they
do not completely remove the disease, in general so gTeatly
mitigate it as to reduce it to, at the worst, a painful infirmity.
Among the poor, however, the case is very diflerent; for the
disease, at first neglected, is often but little heeded afterwards, and
when the patient has recovered from the more urgent consequences
of the delivery or the miscarriage in w^hich her suflerings origin-
ated, she is compelled to return at once to her ortiinary duties.
Causes, in themselves trifling, a slight exposure to cold, inability
to rest during a menstrual period, the oixlinary incidents of
594
INFLAMMATION OF THE BLADDER {
married life, sexual intercourse, pregnancy, abortion, or deHirery,
atld to the coDgeation of the bladder, aod increase its irritabilitr.
At length the patient seeks admission into a hospital, but sUys
there only long enough to gain some slight relief, not long enougk
to make any real advance towanis cure. The mucous membram
of the blad<ler becomes ulcerated, and blood in small qnantitiei
appears iu the urine, in addition to the deposits of pus and of tfe
phosphates which it before contained. The bladder is so can-
tract ed that it can no longer hold half an ounce of urine; and aotse-
timea the ureters themselves become dilated, as if the urim
sojourned there with less distress to the patient, nor do the kidnefi
remain exempt from a participation in the mischief. Their saV-
atanee wastes, while the distinction between the cortical and
medullary portion becomes less ob\"ious than natural; they beooroe
sacculated, and turbid urine is generally found witliin them, whik
their lining membrane is highly vascular, and the urine is some-
times actually purulent, or. in other words, pyelitis foUowB the
disease of the bladder, and with it atrophy of the proper tissue d
the kidneys. The mode of death in these cases is very vario«a&
Sometimes the patient sinks exhausted, and, having long beeu
feeble, passes away quietly and unexpectedly ; at other times the
irritability of the stomach becomes so extreme that all food and
all medicine are alike rejected. Sometimes much suticring pre-
cedes death, and I remember one poor woman who all day and all
night long sat crouched on a chamber utensil, so incessant wis
the call to empty her bladder, while she complained of the nrisa
as it passed scalding her like molten lead She remained thtis,
swaying herself to and fro in her agony, unrelieved by even the
largest doses of opium, till as life waned her jmins lessened too,
and at length she lay down, for the first time for many weeks,
worn nut and wearj% to die. In other cases the kidneys cease by
degrees to perform their functions, and at last no urine at all is
secreted, and tj^jhoid symptoms come on, under which the patieni
sinks rapidly.
There can be no doubt but that some of these cases ore ocni<
nected with tubercular disease of the kidney,* the affection of
• Sir B. C. Brodie^a works on IhaeaMs ofihf Vrinary Orsfans^ ooataini *t p. 18)
a short but TAiQuble ehuptor on symptoms affecting the bladder in cxuMbqoflOCv of
diseiio In iKe kidney, luid Mimo of the cad«s whtcli lio reUtea sppcAT to b*
<
1
k
^i^M
ITS RELATION TO KIDNEY DISEASE,
695
IJadder being secondary and subordinate, and tbis even tbough the
Bjmptoms dnrmg life have pointed almost exclusively to the blad-
der as the seat of mischiet It is probaUei too, tbat in other in-
stances the irritation of the bladder consequent on the miscarriage
or the labour from which the patient dates the commencement of
her illness, may have been the exciting cause of the subsequent
mischief, and that the tubercular deposit in the kidney has really
been occasioned by the previous cystitis. I have no means of
judging of the comparative frequency of tubercular disease of the
kidney in the two sexes ; it certainly is not common in the female ;
or, perhaps, it may be that one comparatively seldom sees the
termination of a disease so chronic as this would appear often to
be, causeless irritability of bladder sometimes occasioning distress
and proving rebellious to treatment for years before the more
serious symptoms set in. Possibly the more acute symptoms
coincide with the extension of mischief to the bladder though it^s
amount varies greatly j for while I have sometimes found nothing
more than intense congestion of its lining membrane, I have also
in other instances seen it ulcerated, with patches of lymph on its
surface, or have even found it completely destroyed, the muscular
coat being everywhere exposed, and the broad bands of muscular
fibre of a vivid red crossing the interior of the organ in all direc-
tions. Once, too, the mischief had passed even this point ; the
stances of tuberculoua disease of tbat org&u. RoldtAiis^i op. cit, voi it. p. 443^
does but just refer to tubercular dt'posit in tlie kidney ub a siicondary occmrence
and on© more commoii in the male than in the femalw ; while Louis, Rcchrrchf-s
Mir la PhihisiSf p, 129^ refein to the existence of conBidemMe tuberculous disease
of tlie kidney m a. rare occnrrencc. Rayer, Maiadifs d€s J?«rw, vol. iii. p, 61S,
tTMts very fuUy of the nffection, hut he also s^ieaks of it as being se^joodary to
tnbercolons disease elsewhere, and for the most imrt aim to such dis«aae in a
rather advanced form- Dr Prout, On Siomach and IhHnary Dtseasti^ 3d edition,
pp. 3&S"400v notices another clasa of c««Ba not Cfjnii0ctc<l with tnljende, t'oneem-
ing which he confi-Hsea his own knowlwlgie to be but incomplete. Sui?h cases are
not very rare in women ; they well dcsen'e a careful investigation. In my hands
I mnat tonfeas that tbey have been the opprobria of the wanl,
[The subject of genito-nrinary tuberculosis or renal phthisis, or nephro-phthiBis as
It if called in Ziemssen's Ci/cloprcditty is not su He iently described. I have seen only
one caae in the fetnale. It was in every reaped a characteristic one, as tlie post-
mortem showed, for during life only the chronic C3rstitis waa recogniied* Besides
Hokltansky^ Cruvdlhier, Kayerf Kosenstein, and Roberts make statements regarding
it in their clasaical works. 8e« also Mare hand and Scbiicking iji Archiv ftkr
Oyneekoloffk B, xii. 8. 433, where are many references].
IHHiAMMATION OF THE BLADDER ;
bladder was perfomted at one spot near its upper and
part, where the adhesion of a portion of omentum to it had akfii
prevented the escape of its contents, and in other parts the pen*
toneum alone remained entire. In this case, too, the diaeaM Ind
extended even to the nrethra, the walls of wliich were exceedingly
thickened, while its lining membrane was destroyed by ulc
ation, and numerous warty growths or granulations beset
surface.
In this, and in other cases, it is no doubt not to the tubercnb
deposit alone, but rather to the consequent pyelitis and cy^t
that tlie patient's intense aufferiDgs are due. What it concenu in
most to bear in miod is, that inflammation of the kidneys and of
the bladder may occur as secondary to tubercular deposit, when
yet no other symptom of tuberculosis is present, and further, Uiit
such a disease may run its course to a fatal issue without phthisis
3uper%^ening, even without any deposit of tubercle in the lungs
or elsewhere than in the diseased organs and the absorbent glaDdi
in their immediate vicinity.
One other class of cases there is, characterised like the ppwwl^j
ing by great irritability of the bladder, but more clironic in the
course, and tending less certainly to a fatal issue, though as htt
amenable to treatment. Their symptoms come on in early adu
age, and occur independently of pregnancy, marriage, or of
disorder of the uterine functions, while the change-a which
urine itself jiresents are not very remarkable. It is neither 1
with pus, nor does it abound in phosphatic deposits ; its qoantiiy
usually falls a little below the average, but its specific gmvttf
seldom much exceeds 1020, occasionally falls below it ; it o
usually nearly neutral, slightly turbid, containing a little exoees
of phosphates ; fiometimes also crystals of the oxalate of litne may
be discovered in it, and now and then a little albumen* tli0Bg^
its presence is by no means constant.
The history of these cases is usually very obscure, and ofteo
presents nothing more definite than the causeless occurrenoe of
fi'equent desire to pass water, attended by dull pains in the loina,
extending to the hypogastrium. These symptoms come on so
graduolly that the patient can scarcely tell the date of their
commencement, but knows only that for some two or three yeata
or more a source of discomfort, frum wliich she used to be bot.
ITS TREATMENT,
59T
lias been by degrees growing upon her. The general health often
continues comparatively undisturbed, even after the irritability of
the bladder has become very troublesome, while the symptoms of
constitutional disorder which do at length appear, are commonly
of a very vague and ilbdefined character, such as loss of appetite,
loss of strength, and general gastro-intestinal disorder, with a
tongue thinly coated with yellow fur, and not cleaning under any
modification of treatment My impression is, that these are cases
of a chronic form of nephritis, and that when they eodanger life,
it is by the extension of the mischief to the lining membrane of
the kidneys, and by the supervention of pyelitis, with that chronic
inflammation of the bladder itself with which it is usually associ-
ated. So long as this complication is absent, the disease shows
little disposition to increase, while there are long pauses in ita
course, though never a complete subsidence of all the symptoms,
the backache disappearing sooner than the irritable bladder, while
even when things are at the best, a trivial cause, and especially a
slight exposure to cold, will suffice to reproduce all the ailments
with undiminished intensity.
Of all these aflections, that in which the bladder is the primary-
seat of the mischief is, as might be expected, the most amenable
to treatment, though even then the course of the disease is always
slow, aud recovery often but imperfect Many of the instances
of cystitis after delivery are traceable to neglect of the very
ob\ious precaution of introducing the catheter when labour is at
all protracted, or whenever the pressure on the neck of the
bladder has been so considerable as to render micturition for a
day or two painful or difficult Another error which often lays
the foundation of this very troublesome complaint, is the omitting
to treat those slighter forms of cystitis which frequently succeed
to a tedious labour, and which, though they in nmny instances
subside spontaneously, yet rarely disappear so speedily or so com-
pletely if let alone as if a few leeches are applied over the
hypogastrium, and the uva urai, combined with some sedative, is
administered, while the catheter is employed regularly to prevent
any retention of urine. These precautions, too, are perhaps still
more frequently overlooked, though scarcely less neceasary in cases
where peritonitis has occtirred, or where inflammation of the
uterine appendages has taken place after delivery or abortion, or
598
INFLAMMATION OF THE BLADDER 1
even in the unimpregnated state, since subacute cjstitia ii fti
from being a rare sequela of any of the more active foims <rf
abdominal inflamumtion in women of all ages and in all djica]o-
stances.
If the disease, on whatever cause it depends, has not beea
checked at its very outset, recovery will at best be tedious. Our
prognosis as to this point may in general be deduced with tolei-
able accuracy from the condition of the urine, the presence in it
of a large deposit of the phosphates being a more unfavounhk
sign than an abundance of pus or of mucus. With reference lo
this, too, it may not be out of place to observe that in djnwiag
our conclusions fi*om the gelatinization of the urine witli Uf\nnt
potasstc, or from the abundance of mucus in the Huid, we ought to
make sure that there is no considerable leucorriio^al or purulent
discharge from the vagina, since ite unsuspected admixtiire with tie
urine h^is sometimes led to the expression of a far more uiifavoumhle
opinion as to the state of the patient than was really caUed for*
So lung as the disease retLiins anything of an acute character
Icjcal depletion will still lie useful, and the application of six or
eight leeches to the hypogastrium, two or three times repettted,
will be of more service than the employment once of a laipt
number* So soon, too, as tlie tenderness of the vagina admits ot
the introduction of the specnlum or of a leech tube, the reBd
afforded l>y drawing blood from the anterior vaginal wall will
genemlly be found to be very remarkable. The patient sbonU
be kept in bed ; her diet should consist of beef -tea, fannaceons
substances, and milk, with barley-water and the Vichy water is
her common drinks. In this stage, too, I know of no better
medicine than the extract and decoction of uva ursi.* On the
subsidence of the more acute symptoms the diet may be im-
proved, and the hydrochloric acid with pareira,t or half-dnichia
doses of the diluted phosphoric acid, may be substituted for the
pre\iou8 preiicription, while anything which amends the patient's
+ (No. 10.>
Extmcti Purcine . . gr. xlnU
Acid, Hydrochlor, diL T\ %l
Morphiie Hydroohlor. gr. m
Decoot Pamno . . Jtj
ft. mint, A fotuth {wrt U> W
t
B
• (No. 9,)
Extmcti Uvie Urei .
Tinct HjoBciumi ,
Tinct. ADmittii . .
Decoct. Uvir Ursi, ad
M. H mkt. Two ubloiflpoonfuls to be
Ukan erery fouj- hoars.
5J
I
taken oveiy liz hoiiri.
M
ITS TREATMENT. 599
general health wiU probably be of service in lessening the
irritability of her bladder. Wine and tonics are often of service
when the acute stage of the ailment is passed, and the urine,
though unhealthy in character, is secreted in sufficient quantity ;
and sometimes quinine, at other times chalybeate preparations,
will be found to be most usefuL
The irritability of the bladder not infrequently continues as the
result of mere habit after the disease to which it was originally
due has subsided. Large doses of the tincture of the j>erchloride
of iron, as fifteen or twenty minims three or four times a day>
frequently relieve this infirmity ; while it is also desirable to give
a sixth or a fourth of a grain of morphia every night in order to
lessen the incessant desire to pass water, which otherwise would
deprive the patient of sleep. Sometliing, however, will still
always remain to be accomplished by the voluntary efforts of the
patient to overcome a habit which, if unchecked, will so much
interfere with the comfort of her future life. During convales-
cence, the patient cannot too sedulously guard against catching
cold, or against any disorder of her menstrual function, each return
of which will long bring with it some revival of her former dis-
oomfort and a threatening, at least, of the rekindling of former
disease. Lastly, I may add, it is inexpedient that a married
woman should return to her husband's bed, to the local excitement
of sexual intercourse, and to the risks of pregnancy, until her re-
covery is well estabhshed.
Cystitis is unfortunately less often met with, at least among the
poorer class of patients, in the sub-acute form than in one
decidedly chronic, in which, in addition to pus and the phosphates,
the urine contains a large quantity of extremely tenacious mucus,
is intensely alkaline, and of a highly ammoniacal odour. In this
condition, in spite of a very extreme degree of local tenderness,
and of very frequent desire to pass water, the abstraction of blood
must not be resorted to; for it weakens the patient's general
powers without aUeviating her aUraent. A first step towards
relieving her sufferings is to place her in bed ; the uniform
t-amperature of the surface being thus maintained, pre^^ents any
sudden demand being made on the function of the kidneys, while
the disposition to congestion of the pelvic viscera is much lessened
by the maintenance of the horizontal posture. Throughout the
nOO TREATMENT OF TNPLAMMATION OP THE BLADDKB.
wbole course of one of these cases, opium in some form or oUur
is the F&medy on which our greatest dependence must be placed,
and its value far exceeds that of any medicine suppoeed to ejwrt
a specific infloence on the hladder. Of these medicines, two of
the most iiseful, the uva ursi and the pareira, have already been
alluded to. When these remedies fail in the forms which I hare
already suggested, I have seen benefit result from the conihinatioti
of the pareira either with small doses of copaiba or with die
benzoic aciA Sometimes, too, especially where the n of
urine is scanty, the benzoin alone has proved serviceti i . igh
a not infrequent drawhack from any of these medicines is tfait
they nauseate the stomach ; and the alleviation of local suffering
is then too dearly purchased at the expense of the patient's
general health.
I have on several occasions made trial of injectiotifl into the
bladder in cases where the condition of the urine was very ua-
healthy, and where it contained a large quantity of ropy mucos.
For this purpose I have, in accordance with Sir B. Brodie^s sug-
gestion^ employed the decoction of poppies, to which I have but
very rarely added a few drops of dilute nitric acid. The instances,
however, in wliich this proceeding was at all tolerated were quite
exceptional, and ahiiost always such severe and such abiding {laJti
was excited as to compel me to desist from a repetition of the ax»
periment. Even when home for two or three times, and giving
an earnest of effecting some lasting good by the improvemeiil
which it wrought in the state of the urine, pain has seldom failed
to come on, and to preclude the continued employment of the
measure. One reason of this failure (for I am not aware of any
want of care either in the selection of the cases or in the applica-
tion of the remedy) may perhaps have been that the persistence
of chronic cystitis in the female subject for any considerable time
generally, if not invariably, occasions iixitation of the kidneye^
and a sort of sub-acute pyelitis. There seems also to be a great
tenderness for the mischief in these cases to terminate in uloera-
tion of the mucous membrane of the bladder, and not to stop
short with tlie induction of tliat thickening which is so common
in the male subject.
One other proceeding which I have now and then resorted to in
cases of chronic cystitis with much irritability of the bladder, has
TESICO-VAGINAL FISTULA.
601
I
I
the introductioE of a seton just above the sympliysia pubis.
'iave observed decided benefit from it, especially io those cases
where the irritability of the bladder was out of proportion to the
amount of obvious disease ; though from its nature this remedy is
one to which we cannot very often have recourse,
[It has frequently been proposed in the severest chronic cases,
to make an artificial veaico-vaginal fistula ; and it has been tried
repeatedly by Emmet and others. But this opemtion, although
well worth considering, is not as yet established in the coniidenoe
of the profession. The theory of it is too plain to require stating;
yet it is not perfect, for I have known strangury persist in a case
of uterine cancer after a vesico- vaginal fistula w^as spontaneously
formed, from which relief had been anxiously anticipated. It is
worth while also to mention another method in which nature
rarely gives relief * As in the artificial formation of a vesico-
vaginal fistula, the relief is imperfect, because success is neces-
eariiy counterpoised by the discomforts of constant distillation of
urine from the vulva. It consists in contraction of the bladder
80 as to destrcy it as a reservoir, and thus produce complete
incontinence of urine.]
It would perhaps scarcely be right to take leave of the subject
of inflammation of the bladder without a word or two concerning
those sad cases in which vaginitis following delivery terminates in
the death of the tissues, and in the formation of ajistuimis com-
munication biiween the bladder mid vagiim. There can be no
doubt but that in the great majority of instances this accident is
due to the delay of instrumental interference in tedious labour,
coupled with the omission to use the catheter. It is extra-
ordinary how often this latter simple precaution is neglected,
how often the statement of the patient or of her nurse is accepted
as conclusive of her having emptied her bladder ; wliile the
practitioner, conscious perhaps of his own inexpertness in perform-
ing this little operation, is only too ready to frame an excuse to
his own mind for not attempting to do that which he knows he
should do but awkwardly, and fears that he might possibly fail
to do at aU. To this neglect of the catheter, and to the omission
to interfere instrumentally as early as is necessary, is the occurrence
of vesico- vaginal fistula to be attributed far oftener than to any
* [For a Bhort account of a case aee Medical Times and G<aeUe^ D«!a 13, 187B.]
602
TESICO-VAGmAL FISTULA Z
direct injury inflicted by the instrumeEts themaelTeft AlUt
labour is over, too, the same neglect to keep the bladder eoipcjr
not only adds to the patient's distress, hut greatly aggravateii tim
perhaps inevitable cystitis^ and renders the casa to a great degree
uafit for any attempt at cure by means of a plastic operatiotL
Wherever fi-om the protraction of labour, and from the long
stay of the head in the pelvic cavity, there is any reason to feer
the occurrence of inflammation of the var^iiia, its possible issue in
sloughing and in the formation of a fistula must always be borne
in mind, and attention must be closely directed to the local con-
dition of the patient as well as to her general symptoms, Tlie
bladder must be regularly emptied by the elastic catheter every
six hom^, a warm poultice must be constantly applied to the
hypogastrimn, and poppy fomentations to the vulva ; while the
vagina must be carefully s^Tingcd twice a day with lukewarm
water, and local leeching must be at once employed on the first
onset of symptoms of cystitis. The state of the parts must not
be judged of from hearsay, but must be inspected every day ; a
precaution which though especially necessary when any laceration
of the perineum has taken place, is yet in these cados alwaje
worth taking, since the appearance of the vuh^ furnishes no bed
index to the general stiite of the vagina. If the secretion from
vagina assumes an unhealthy character, and if shreds of m
membrane appear in it, we may be sure that sloughing has
place, and though the sloughing may be superficial, yet of this
cannot be certain, whUe contraction of the canal, and the forma-
tion of cicatrices are its almost inevitable results. The soothing
Injection previously used must now be changed for others of a
more stimulating kind, w^hile, when the parts begin to heal, it will
be expedient to introduce a large gum-elastic bougie into tlio
vagina, and to allow it to remain for some hours every day» in
order to prevent adhesions forming between the opposite sutfaoee
of the vagina by which the orifice of the uterus is sometimes
almost completely closed, or the vaginal canal itself is divided into
two chambers, into the upper of which the uterus opens. Nor
indeed are tliese the only possible consequences of sloughing of
the vagina, but in proportion to the extent of the mischief the
vagina is shortened ; the edges of any fistula are permanently kept
asunder, the space between the opening and the neck of the womb
to bed
mth^
ITS TREATMENT BEFORE OPERATIOlf.
603
is diminished, while the cicatrix tissue on which the operator haa
to depend for the closure of the apierture is endowed with far
feebler vitality than the unaltered structures of which, if the
mischief has been circumscribed, he may hope to avail himself.
H Supposing all these points to have received due attention, the
^ next question that suggests itself concerns the period after labour
at which any operation for the cure of the fistula should be at-
tempted. Now I believe that nothing should be done within the
first three months after delivery at the soonest, for the susceptibility
to inflammation is greater in the woman who has i-ecently mis-
carried or given birth to a child than in another, while not only
are all plastic operations about the sexual organs attended by some
hazard, but a degi^ee of local inflammation quite inadequate to
cause danger to the patient, may yet more than suffice to destroy
the promise of the most dexterous operation. Another reason,
■ too, for some delay is that within certain limits a fistulous open-
ing is likely to contract ; and it is well to obtain the full amount
of improvement which nature can effect before having recourse to
any surgical proceediug.* Besides this, too, it is of the greatest
importance that a person should be in the beat possible health
before the operation is undertaken, and no delay can be regretted
which atlords the opportunity for the amendment of her general
condition, and the improvement of the state of her urine. The
two generally keep pace with each other, and my own impression
is, that to operate at a time when the health is feeble, and the
urine aliounds in phosphatic deposits, is completely to throw away
all chance of benefiting our patient. If the aperture in the blad-
I
* [Contraction may go on to complete ei^outaneouB heaUng» As might be ex-
pected, til is is most likely to happen when the fiatnk haa be«n the result^ oot of
fofliunmation and stouglungp but of injury by instmmento. This ib well illuHtrated
Jdj the oceoaioDol s^KiDtaneoua healing of inteutionnUy made wounds in the bladder
as in lithotomy. I rememlxT thret* cases of spootaneous healing. Two occuriwl
not very long ago in my own exp^ience. In both the injury wm known to he
done hefore my being called to the cases. Both were cos^s of contracted pelrig.
In one the injury waa by the anterior edge of the long forceps cutting down on the
brim of the pelvis. It was healed before the woman left her bed* In the other, it
was not known how the injury was eflSected, whether by forceps or perforator.
When the patient was going about again , I was consulted as to the opnitlon for
TQiico-Taginal fistula. A little deluy^ which I recommended as desirable with a view
to the sacce^ of the operation, saw the healing of the fistula without any operation
it all.]
INTBSTrNO-VESICAX FISTULA-
der is comparflitively small, m that mine can be retained for
hour or so, in certain positions of the body, delay may be allowvd
a month or two longer, provided that the bladder tolarate thi
frequent introduction of the catheter ; an operation which tllft
patient wiU soon learn to perform for hersell I am not, however,
disposed to recommend that a catheter be kept constantly in the
bladder ; for a few days are generally the utmost limit dmiDg
which the patient can bear it ; the bladder then becoming irritated
by its presence, so as to compel the removal of the instnimeiit
Still less would I advocate the use of the plug, or of any mechasi-
cal device for restraining the outflow of the urine. All such con-
trivances irritate, and are likely to interfere with that heftltliy
condition of the parts which it is so essential to maintain. In i^
instances, therefore, where the aperture is large, and where no
urine is retained, delay continued after the eftects of the puerperal
processes have subsided, answers no useful end ; while when wait-
ing for this we must content ourselves with the daily use of the
tepid hip-bath, with the injection of waiin water into the vagina,
and with most sedulous ablution and scrupulous cleanlinees^ iS
means of preventing the irritation of the parts by the perpetual
escape of the urine.
It would be as much out of my province to go into detail coO"
cerning the operation for the closure of vesico-vaginal tistula as it
would be out of that of the physician who, lecturing on aneurism,
should affect to lay down rules fur tying the subclavian artery.
When successful, it has always appeared to me to be one of the
triumphs of surgerj^ and so close is the connexion between scienoe
and the surgeon's art, that the galvano-cautery has done away
with some of the difficulties which too often rendered manual akfll
unavailing.
It is not necessary to say much aliout that rare accident
intestinO'VesicaLJUiula ; for the circumstances in wliich it occorB
have no necessary connexion with the sexual ailments of women.
I have met with it but thrice. In the first case, it was associated
with malignant disease of the uterus ; had dysuria and painful
defii?cation and existed for between two and three years, theiTj
occurrence being coincident with the appeamnce of an indurated
tumour in the left iliac and inguinal regions ; and the escape of
fiecal matter with the urine had taken place for four months pre-
1
I
TONGOID DISEASE OP THE BLADDEH.
605
I
I
vious to the patient's admission into the hospitah In the second
case, the mischief succeeded to ulceration of the intestines during
fever nine weeks before, which had issued in the formation of a
pouch communicating above with the sigmoid flexure of the colon,
and below with both rectum and bkdder. This patient died in
the course of a few weeks, but less in consequence of the local
disease than of the progressive increase of the exhaustion which
the fever had occasioned. The tMrd case was that of a yonng
lady in wliom suppression of the menses from cold was succeeded
by inflammation, which involved among other parts the uterine
Uppendages on tlie right side, where a distinct tumour formed.
Hiis tumour, at first quite solid, afterwards grew softer, and then
diminished in size. Its diminution was not attended by any very
mai'ked dischai^e of pus, but about the same time purulent and
fa-cal matter began to appear in the urine, and continued to be
intermixed wit]i it for three weeks when she first came under my
notice* In tliis case, as in the other two, the sensitiveness of the
bladder was so great that all attempts at syringing it with tepid
water were of necessity discontinued ; but great relief followed
the use of very simple means, such as the employment of the uva
ursi, of hydrochloric acid and the pareira, and the administration
of opium or morphia, to mitigate suffering and to relieve the
irritability of tho bladder. In the case of the young lady, too,
concerning whom alone w^as there much room for hopefulness, the
fistulous communication became closed in the course of two
months, and after the lapse of a year I saw her [n perfect health :
slightly diminished mobiLity of the uterus being the only remain-
ing evidence of the serious bygone mischief.
I am not aware of having ever met with those sofi fimz/om
tuMours, or polypoid excrescences from the bladder, whose true
relation to malignant disease seems to be still undetermined. It
is, indeed, possible tliat in some of the cases of dysuria which have
come under my notice the symptoms may have arisen from this
cause ; but there is no sign actually pathognomic of their ex-
istence, and though in all obscure cases I am accustomed to have
recourse to the microscope for help, I have never yet succeeded
by its means in the diagnosis of any outgrowtli from the bladder.*
* The genenil c^iniao, md that adopted by RokitatiBky, op, eil, toL liL p. 460,
U that thete outgrowthfl lU belong to the dasa of maligQiuit diseaaea* Aji oppo-
606
MALIGNANT DISEASE OF THE BLADDER :
In the only ease of priviary Tmilignant diMase of the bl
tliafc has ever come under my notice, the patient was a
woman, sixty-two years of age, who had stiiiered for a
previonBly from pain in the region of the bhidder, aggra7at6d
after passing water, the caE^ to which became more frequent thaa
natural, while at the same time her urine grew turbid, and
deposited a thick sediment Blood now frequently appeared m
her urine, sometimes in small quantities, sometimes in clots, and
ahoufc three months before I saw her she lost a large quantity at
once. She had of late suffered from pain in the back, and for two
months the urine had been always thick with a ropj*- sedime
No treatment had been adopted till three weeks before her \
sion into the hospital, when the patient applied to a surgeon who
introduced a catheter, an opemtion followed by cansideiabla
hiemorrhage, which lasted for several days, though it was eveatn-
ally suppressed by gallic acid.
On being received into the hospital the patient's appearaa
was healthy, her pnlse was 80, and soft, her tongue slightly coati
her bowels were regular. No tumour was perceptible in the
abdomen, but firm pressure immediately over the pubes caused
3ome pain. The uterus was high up, small, its tissue soft and
perfectly healthy. In front of the uterus, pushing it into the
posterior bdf of the pelvis, ivas a firm, somewhat irregular growtll
reaching from the anterior half of the pelvis in the situation of
the bladder, apparently extending round that organ on either side,
but much more on the right This growth was perfectly immov-
able, it seemed to he connected with the pelvic walls, was aomd-
what tender on pressure. It was of such size as to occupy tha
wliole anterior half of the pelvic brim, though not dipping down
considerably into the pelvic cavity.
The urine was pale, alkaline, depositing ropy mucus, and under
the microscope crj^stals of the triple phosphate and cells of
nucleated epithelium were perceptible.
The patient derived considerable comfort, from treatment during
ten days' stay in the hospital ; but, returning home at the end of
aite view ifl, however, maintamed by Mr Sibley, in Traimadumi of P\aih* SbcM^i
vol ii, pp» 250 and 214, based on very careful microecopic obeenratioiifl. Groe^
On th€ Urinary Ovijans, 2(1 cd., Fhiladetphid, 1855, p. 32ij in his notioQ of thtm
outgrowths, itftBUTwefl their non-mAlignaDt €hamcter«
ITS SYMPTOMS.
607
that time, and indnlgmg in the intemperate habits to which she
waa addicted, she fell and injured her face^ — ^an accident that waa
foPowed by fatal erysipelas on the twelfth day after she left the
bospitaL The uterus and vagina were found on examination
after death to be perfectly healthy ; but the whole posterior half
of the bladder waa occupied by a medullary growth, with an
irregnl&r surface, which projected into the cavity of the organ, its
substance being in part firm, in part almost semi-fluid. The
anterior half of the bladder was quite healthy, as also waa the
substance of both kidneys, except that the right ureter being
involved in the diseased mass was dilated to three or four times
its natural size, and the inf nndibulum of the right kidney was
enormously enlarged.
As far as it went, this patient s history was exactly that of
malignant disease of the bladder, and had not her life been pre-
maturely cut short, the affection would no doubt have run its
usual couri*e, Hiemorrhage would have returned again and again,
and would have weakened the patient more and more ; the
increased growth would have produced increased difficulty in
micturition, while the advance of the malignant disease would
have been associated with the further development of the
cancerous cachexia; till, under these combined causes, death
would at length have taken place in circumstances far more pain-
ful than those by which it was actually attended.
As in this case, so I believe in moat instances of primary
malignant disease of the bladder, there is but little tendency to
the perforation of its walls and the extension of the disease into
the vagina The constant dribbling away of the urine which
sometimes attends the more advanced stages of this disease by no
means necessarily indicates the existence of any communication
between the bladder and vagina ; but is due in many instances
partly to the encmachnient of the evil on the cavity of the
bladder, partly to its walls having been rendered un3delding by
disease, and especially to the infiltration of the tissue of the neck
of the bladder with carcinomatous deposit. The observation of
Kiwisch* is also worth repeating here, " that the occurrence of
incontinence of urine in the course of cancer of the uterus is not
to be regarded as a certain evidence of the occurrence of per-
* Op, cU, vol iii. p. 308.
608
MALIGNANT DISEASE OF THE BLADDEB.
fnmtion of the bladder, for this symptom is frequently only
conaequence of carcinomatous mfiltration of the Deck of the bl
dei\ and especiaUy Jf that part corresponding to the sphincter, l^
which it is Mndered in the performance of its f unetions^ and tfam.
no longer closing the ostium veaicee* admits of the constant e^cttpa
of the urine."
Thongh the diagnosis of fnngoid outgrowths from the bladder
may be obseurc^ yet the ordinary form of malignant diseaae of tlie
organ appears to he too well marked to le&?e much room for un-
certainty. The causeless pain and difficulty in micturitioii,
coupled with the frequent desire to pass water, the occasional ap-
pearance of blood in the urine, sometimes in considerable quimitty,
and in the fonn of clots, while the secretion is habitually alkaltM;
unheal tliy, and deposits a sediment, are of themselveB sa^oqg
evidences of the nature of the case, though scarcely conclusive
unless associated with a firm, immovable tumour in front of the
uterus. In the absence of tlie evidence obtained by vaginal ex-
amination, tbe extreme rarity of primar}' cancerous disease of the
bladder always renders it the more probable supposition that the
kidneys are the seat of the mischief.
Tliere is no treatment specially applicable to malignant diseiii
of the bhidder, The indications to be followed are very ob%iotlfl^
and within certain limits and for a certain time their fulfilment
would not appear to l>e difficult To relieve pain by opiatc*s, to
render the urine less irritating by the mineral acids, the pareira
and those other remedies to which reference has been made in tha
earlier part of this lecture, to keep the patient in bed, and thus lo
equaUze as far as possible through the whole twenty-four hours
the demands upon the functions of the kidneys, and to maintaiii
the geneniJ health by good diet, and by the moderate use of
stimulants, are the objects to aim at. When once the nature of
the disease has been ascertained, the introduction of instrumenta
into the bladder must be caref ally avoided ; while, if it should
become necessary to draw off the urine, an elastic catheter without
its stilet must be employed with all possible gentleness. It is*
however, I beheve, but seldom in the female subject that this
disease produces actual retention of urine, though I remember a
patient many years ago in the Middlesex Hospital in whom the
urethra became implicated in the extension of the growth^ so that
I
MODES OF EXAMINING THE BLADDER.
C09
it became eventually necessary to tap the bladder above the pubes,
an operation which she survived only a very few days.
[Although the subject of diseases of the bladder is avowedly
treated here only in a fmgraentary manner, mention may be made
of the admirably ingenious and persistent attempts which are being
made to advance the subject on both its scientihc and its practical
sides. Eesearches such as those of Schatz, DiiboLs, and James ♦
and of which Winckel has given a sketch in his recent work-f-
on diseases of the female urethra and bladder, cannot but contribute
greatly to the intelligence and wisdom of the pmctitioner.
On the other hand, the surgeon has been accumulating ex-
perience in dilating the urethra rapidly, with a view to the more
thorough examination of the interior of the bladder ; and the late
bold and dexterous SimonJ actually proceeded so far as success-
ftdly to sound the pelvis of the kidney for stone, passing his in-
strument along the ureter. Whether or not anything of gieat
value will be the fruit of all these inquiries is doulitful, yet there
is much more reason for hope than for despair.
I have repeatedly examined the inside of the bladder with the
finger and acquired information of value. Winckel has, in this
way, reached and removed a vesical tumour. After such dilata*
lion, incontinence of urine has occurred, but not in my own ex-
perience. I have heard of this untoward result of the operation
of dilatation ensuing when the dilatation was made to an impru-
dent extent, but it may follow where the dilatation has not been
extreme. In my cases dilatation was resorted to during the per-
sistence of severe chronic cystitis. It was always done under
anoesthetic influence ; and the patients have always declared that
their symptoms were to a certain small degree relieved by it.
Various methods of rapid dilatation have been resorted to. Some-
times the finger is sufficient CJenerally a series of bougies or specula
is used ; and by these last light may be admitted so as to render
the bladder accessible to visnal inspection. To improve this latter
proceeding various endoscopes or retlectors have been tie vised But
I have seen enough to satisfy me of the great difficulties to be over-
come in perfecting these methods, not of the great success of any.]
• Bdinburgh Medical Jmimal, 1878.
t Dif Ktmikfi^Uen der wtihlithen BamHihrt nnd Bfasff Stut^trt, 1877.
X Volkmaim's Klini^he VoHrUijf, No. 88, Leqtstig, 1876,
1^
LECTURE XXX.
DISEASES OF THE URETHRA AND VAGINA.
Diseases of the Urethra. Congestion of the nrethra, most troublesome ai a
chronic ailment ; its symptoms and treatment
Vascular tumours of urethral orifice, their seat, nature, symptoms, and treatment
Ulceration of urethra ; doubts as to its syphilitic nature.
Diseases of the Vagina. Acute vaginitis ; character of the discharge whid
attends it, as distinguished from uterine leucorrhcea ; its treatment
Chronic vaginitis. Granular vaginitis, its real nature. Similar condition pecoliir
to pregnancy ; other varieties of vaginitis.
Cysts of vagina.
Fibrous and fibro-cellular tumours of vagina.
Cancer of vagina.
From the study of the affections of the bladder, we pass next
by a natural transition to the examination of those incidental to
the female urethra, a class of ailments which, though comparatively
trivial, are often attended by very serious discomfort, and are by
no means easy of cure.
Of these ailments, one of by no means unusual occurrence is a
state of undue congestion of the urethra, which sometimes presents
itself in an acute form, at other times has a chronic character.
In the former case, it very generally accompanies a similar con-
dition of the pelvic viscera, and hence is chiefly observed either in
newly-married women, or at the commencement of a menstrual
period, or is experienced during the first few weeks of pregnancy.
It is then attended by a sense of itching and irritation about tlie
urethral orifice, which is redder than natural, slightly swollen, and
tender to the touch, while micturition is accompanied by a scald-
ing or cutting sensation, the discomfort of which induces the
patient to retain her urine longer than usual
This, however, is a temporary discomfort, lasting for the most
part no longer than the cause which produced it, though its
frequent recurrence may no doubt issue in the chronic form of fhe
ODStiBES OF THE UIIETHRA : ITS CONGESTION.
Oil
I
ailtnent which constitutes ao abiding source of anEoyance difficult
to remove and very apt to recur. This chronic congestion of the
urethra cornea on with no apparent exciting cause in women who
have given biith to many children, the interruption to the free
circulation in the pelvic vessels having no doubt produced it, for
which reason it also sometimes follows on attacks of uterine
inflanimation, or of pelvic abscess, or cornea on during the growth
of an uterine or ovarian tumour. It adds also in other instances
to the distress produced by affections of the bladder, or is
asaociated with disease of the kidney, and with morbid states of
the urinary secretion. In this form of the disease there is very
confliderable thickening of the whole canal, which may be traced
as a firm cord as thick as the finger, or even thicker, running
under the symphysis pubis, somewhat tender upon pressure; while
if the nymphsB are separated, it may be seen as a large swelling
at the up^>er part of the entrance of the vulva, looking almost like
a distinct tumour growing from the anterior vaginal wall;* The
long-sUmding congestion lias here been followed, as it is elsewhere*
by overgrowth of the part, by hypertrophy of the cellular tissae
of the urethra, and hence, though the swelling may vary in size,
and the symptoms which it produces may admit of very great
alleviation, yet they never entirely disappear, and very slight
causes suffice to reproduce them.
Tliese symptoms consist in a sense of fulness and aching,
accompanied by frequent desire to pass water, which is scarcely
at all reheved by the act of micturition* The erect posture
aggravates these discomforts, as do sexual intercourse and the
approach of the menstrual period, while relief is obtained by rest
and the recumbent posture. The natural tendency of the allec-
tion is, aa can be readily understood, to grow more and more
troublesome under the infiuence of those causes which first
produced it ; attacks of an acute kind coming on every now and
then, during which the urethra becomes more swollen and more
tender, and the pain in micturition extremely severe. In one
instance I saw an attack of this kind issue in the occurrence of
suppuration in tlie cellular tissue around the urethra, and on
puncturing the abscess quite an ounce of pus escaped ; but on all
• This cocditioa wna first described by Sir V. Clarke, JHseaaes of JFomat, toL i.
612 DISEASES OF THE URETHBA :
other occasions these attacks have subsided almost spontaneonslj
and without leading to any such result.
There is no other condition with which, as far as I know, this
state of the tfrethra can be confounded. The only caution, there-
fore, which seems to me necessary as to this point concerns the
occasional dependence of this thickened state of the urethra upon
the presence of one of those small vascular excrescences of its
mucous membrane, which though usually seated at its orifice, are
yet sometimes so far within the lips of the canal as to escape a
superficial examination.
The acute form of urethral congestion is generally so brief in its
duration as scarcely to call for treatment. A tepid hip-bath, the
temporary discontinuance of sexual intercourse, if the symptoms
have succeeded to marriage, the avoidance of all stimulants, mild
diluent drinks, and slightly alkaline waters, such as the potass, or
the Vichy water, generally answer every purpose. In the chronic
form of the evil, attended by more or less hypertrophy of the
tissue of the urethra, complete rest is an essential, and the avoid-
ance of any cause, such as sexual intercourse, by which congestion
about the pelvic viscera can be excited or maintained. Generally,
indeed, if the urethral hypertrophy is at all considerable, the act
c'f intercourse is attended by so much discomfort as to lead to its
discontinuance. One or two leeches applied by means of a small
glass leech-tube to the urethra itself, and repeated weekly, or
twice a week for a short time, generally afford very great relief.
Frecjuent cold sponging, and the use of cold astringent lotions, or of
cold hip baths, confirm the improvement which depletion and care-
fid dietetic measures had obtained. I have found, however, that
any attempt at the employment of pressure, as suggested by Sir
C. Clarke, was attended by more annoyance than advantage, and
therefore content myself, as the removal of the hypertrophied tissue
cannot be expected, with explaining to the patient the nature of
her ailment, and the simple means by which, though she cannot
expect a cure, she may always obtain for herself great alleviation.
Under the name of Vascular Tumours of the orifice of the Meatus
Urinarius, Sir C. Clarke described a very painful affection, which,
though it had not altogether escaped the observation of previous
writers, had yet received comparatively little notice. These
tumours are hypertrophied papillse made up of elementary fibre-
VASCULAR TUMOUBS OF ITS ORIFICE.
613
cellular tissue, covered by a layer of teaselated epithelium, the
tliiekness of which varies much iu diiterent instances, aud very
richly supplied with vessels** They grow from the tower, and
often also from the lateral margin of the orifice of the urethra,
but they scarcely ever involve the whole of its eb'cumference, or
spring from its upper border. Sometimes they are furnished with
a pedicle, the hulk of the growth in that case projecting lH.*yond
the uretlual orifice, but often they are sessile, and then distend its
aperture, leaving a narrow passage at the upper part of the
urethra, through which the urine dows, though not readily j the
obstacle to its outliow oocasioning considerable ddatation of the
canal behind the excrescence* These gi'owths vary much both in
size, in vascularity, and in sensitiveness; but they do not in
genei-al exceed the bigness of a currant, are frequently smaller ;
aud I have never seen one larger than a hazel-nut, though instances
are alleged of their attaining the size of a pi^jeon s egg, or even a
still greater magnitude. Their vascularity and their sensitiveness
are generally proportionate to each other ; those whose colour is
most vivid, bleeding the most easily, having apparently tlie mosl
dehcate epithehal covering, and the most exquisite tenderness.
The most vascular of these growths are of a bright cherry-red,
while those which are least so are of the same colour with the sur-
rounding mucous membrane. Though frequently solitary, yet, in
many instances, two or three separate growths are situated at the
edge of the urethra, or just within its orihce ; and it is by no
means unusual to observe several small excrescences of a sindlar
character, but generally of a much smaller size, springing from
different points of the vestibulnm. Sometimes, indeed, they are
scarcely larger than the head of a blanket pin, but of a vivid red
colour, and most exquisitely tender. Those growths, which occupy
the urethra, seldom extend above a sixth, or a fourth of an inch
along its canal, but now and then tliey reach furtlier, and cases
are related in which almost the whole length of the urethra has
been the seat of these excrescences, a condition the more unfor-
tunate since it is almost impossible of cure.
* Sir C. Clarke, Dimane^ of IFmnen, Part L 303. P»g«t, op. cU. vol ii. p. 282,
not* ; Bttrfortl Norman, Lmulmi and Ed, Muf^iUy JottnuU^ June 1849, which con-
taina an iiccouiit of their raicroscofac htructure by Mr Qnekett j and ngain in
I^l^km Journal of MMkin^t Feb* 186*2, p* Ua.
mSKASKS OF THB UBETHKA !
m
"1
The symptoms to which these outgrowths give i
micturition, sometimes of extreme severity, though
in which the sensibility of the tumour is lowest, th^
one of discomfort rather than of severe sutfering. fl
this, there is in many instances pain on any attemp
intercourse, and tliia pain is often aggravated by the ]
the small ontgi^owths to which reference has been madi
vestibulum. The presence of these growths does not a
dnce a frequent desire to pass water, but, on the contr
infrequently happens that, on account of the pain whi
the effort at micturition, patients acquire the habit o
their urine for a longer time than natural. When, ho
long continuance of the irritation has produced that thi
tlie urethra which was spoken of a short time ago, its
istic symptoms manifest themselves in a constant 8eiM|
and aching, and frequent desire to pass water. |
It is not possible to say on what these oatgrowtl
though they have, in my experience, been much less c
the single than in the married, and in the young th
middle-aged. Thus of 21 cases of which I preserved a
occurred in married women, only 3 id those who vn
Five of the patients were upwards of 50 years old, 4 b
and 50, 6 between 30 and 40, 5 between 20 and 30, ami
was under 20 years of age. All but three of the marrii
had given birth to children, and in the case of son
patients there was a history of previous vaginitis or gom
circumstance which favours the suggestion of ScanjEoni
some instances these outgrow tlis depend on previj
urethritis.
There is a condition in some respects allied to this,
ductive of some of the same symptoms, in which i
occupies and obstructs the orifice of the urethra, f onned a]
only by a h>^rtrophied condition of the otherwise
mucous membrane, a fold of which nearly blocks up i
causing it to dilate behind the point of obstmction,
renders the act of micturition difficult and painful
unattended by the acute sensibility which accompanies th
vascular tumour. In many instances this hypertro|
^yam
VASCtTLAB TUMOURS OF ITS ORIFICE.
61!
urethrftl mucotis membrane is associated with the presence of a
numl>er of small outgrowths of mucous membrane, fringing thcj
orifice of the vulva or growing from the outer edge of the lips of
the urethra, and productive of some degree of irritation, and even
of inconvenience in sexual intercourse.
The ireatnieni of these excrescences, of whatever kind, is
abundantly simple, and consists in their complete removal, and in
the apphcation to the surface whence they sprang of some strong
caustic, or of the actual cautery, in order to prevent their i-epro-
duction, which is otherwise very apt to occur, I am accustomed
always to apply the actual cautery for this purpose, both because
it most effectually arrests that flow of blood, which I have known
in one or two instances where it was not employed to be so con-
siderable as to excite alarm, and also because it has seemed to me
to be more efficient than any form of eaustic in preventing the
reproduction of the growtk* The operation, though of very short
duration, is so painful, that very few patients can dispense with
the use of chloroform, and its administration is the more needed
since it is essential that the patient shoidd remain absolutely
quiet lest the urethra should be injured. Care to avoid this
accident is, indeed, the only precaution specially called for during
the excision of these growths; this, however, is all the more
necessary, since injury to the orifice of the urethra has sometimes
been followed by incontinence of urine, or by difficulty in its re-
^tention.
■p If after the excision of these growths there should remain any
one spot where their removal has not been quite complete, or if,
though no excrescence be present, a state of morbid vascularity
of the urethra should continue, such as sometimes precedes or
accompanies the formation of these little excrescences, either con-
dition is generally capable of removal by the application twice a
day, for two or three weeks, of the undiluted liquor plumbi.
There is a condition of ehrmiictdceratio7i of the urdkra of which
I have met with a few instances, and which it may be w*orth while
* Dr Medoro, of Padua, recommended some years ago m an Ilalian journal,
whence it was cxtrflct«d in Schmidt's Jahrbiicher, vol. xxxviL p. 186, the use ol the
actual cautery, withcmt previous i^xcisioUj for the removal of these growths, 1 have
not triecf it in thia manner, but ua ati adjunct to eiclslon 1 believe it to be most
detimble.
616
^ISBASES OF THE UKETTTEA :
to refer to here, since, though I believe it to be of syphilitic aiigta.
and therefore to lie, strictly speaking, beyond my province, I jtL
have found no meution of it in treatises on the venerea diseiaa
The affection has come six times under my observation : twin
in mai-ried women, who acknowledged to having sufiered bom
venereal disease ; and four times in women of unchaste life, ODi
of whom was at the same time suffering from a secondary syjihililic
eruption. In every instance the patienU alleged either thuK thfijr
bad been aware of the ulceration of the urethra, or that they hid
experienced diMcnlt and painful micturitioo for periods VBiyin|
from nine months to five years. Twice the disease was ftaooctfllBd
with an excrescence from the mucous membrane of the nreikia
having the chamcters of the less vascular form of those outgrowtfaft
which have just been described. The ulceration appears to oom-
mence at the orifice of the urethra, and to extend thence invank
towards the bladder, producing as it extends a great wideniog td
the canal, and a patulous state of its orifice, so that the ttnger
tip can enter it with ease, while the surface is the seat of lai^
firm, indolent granulations, which seci'ete a small qufmtity of a
muco-purulent fluid, are nob in general very tender to the toodi,
but highly sensitive to the passage of urine. I have mei with
this ulceration of the urethra independent ot any other disaitteol
the sexual organs, but have also observed it in eases vhdie
previous ulceration had destroyed the clitoris and the nympbft,
and have seen it associated with unhealthy ulceration about the
posterior conmussure of the labia and the entrance of the volri ;
as also with tliose small condylomatous growths about the vuh^
which one often meets wiih in cases of vascular tumour of the
urethra, and these latter, indeed, are more commonly present thaa
absent. When the disease has advanced far, or has been of long
standing, the cellular tissue beneath the ui-ethra nsmilly beGoiaes
considerably thickened, and I have seen the lower wall of tht
urethra represented liy a dense, cartilaginous substance, nol Qaliki
one of the hps of a hy].iertrophied, and partially procident cerm
uteri; while on two occasions 1 have been able to carry my finger
along the whole length of the canal into the bladder.
Even when not very far advanced this disease causes diffienUy
in the retention, or actual incontinence of urine, while, wheji it
has extended along the whole canal, and left its aperture perxnan-
CHBOMC ULCERATION OF ITS CANAL. 617
intly patulous, the patient becomes almost completely unable to
'x^tain her urine at alL One such case I saw in a young woman,
aged 22, in whom there was not the least power to hold the urine :
an iniirmity that she said had existed many months. I gave her
an elastic pessary to wear, w^hich, by pressing agaiuBt and mechani-
cally closing the urethra, rendered her more comfortable. Once
also, I saw a prostitute whose ulcerated urethra was ao widely
open that two lingers could be passed into the bladder with ease.
She was constantly soaked with urine ; but in spite of her loath-
some condition still plied her trade, and no argument could induce
her to abandon it
Whether these cases are truly syphilitic, or whether they deser\^e
more properly to he classed with the rodent ulcer, or lupus exedens,
1 am at present unprepared to say. On the one hand their directly
syphilitic origin may appear to be Tendered doubtful by the
circumstance that in only one instance was there any evidence of
then existing venereal taint ; wdiile on the other hand the altection
of the urethra differs from the other forms of rodent ulcer, lupus,
or eathiomt^ne, in being unattended by the same disposition to great
thickening of the adjacent tissues^ which, in the case of lupus of
the vulva, approximates the aflection at a first glance very closely
to elephantiasis.
In its less severe forms 1 have seen this condition greatly im-
prove, the pain in passing water diminish, and the ulcerations
cicatrize under the use, twice a-day» of a lotion composed of 3j of
oxide of zinc suspended by means of half an ounce of mucilage
in an ounce of water, and injected into the urethra, while tlie sur-
face was shielded from the irritation of the urine by the abundant
application to it of the zinc ointment. At the same time the con-
tinued employment of the iodide of potass and syrup of iodide of
iron have seemed to exercise a beneficial influence ou the patient's
general health, wliich in every instanc43 has appeared to be in-
diflereni. For the most part, however, these measures seldom
prove more than palliatives ; but in one case of verj^ long stand-
ing, when other means had completely failed, the repetition three
or four times of the actual cautery was of the most signal benefit
It was of course applied but lightly, so as not to destroy t!ie
tissues to any depth; and under its use the large granulations by
degrees disappeared, leaving a healthy surface behind ; the
r>18 DISEASES OF THE VAOOTA :
pain in micturition subsided ; the wide urethra eontractad
dimensions j and the patient regained the power of holduig 1
urina I am not prepared, however, to say bow &r in
instance the amendment was laatiog, or how far the moel <
cases would be amenable to the same treatment.
As we approach the end of these lectures, the interest wbich I
woidd fain persuade myself attached in some degree to the mV
jects that were broufrht before your notice diminishes, I fear, ct
almost every step. We have come now to the study of ailtniffnli
purely local in their character, often, indeed, painful, alwmjt
annoying, sometimes dangerous, but which yet afford small tnftttCf
for investigation, and seem to yield little scope for the exerctae of
the higher qualities of the practitioner of medicine. But an
observation which I made some years ago, when addressing tbe
seniors of our profession, may perhaps be repeated witbool
apology to those who are but beginning the exerdse of medioiii^
and OD whom it cannot be too deeply impressed that "tfct
thousand smaller ills to which mankind is subject* l>riDg. in tbtir
frequent repetition, as much suffering, cause as much sorn>W| and
therefore are as worthy of our heartiest labour to understand, and
of our best eftbrts to relieve, as those perilous visitants — inflam*
mations, fevers, apoplexies, which threaten life only at long inter-
vals, or on rare occasions/'*
With this preface let us now pass to the study of the distm^ af
the vagina, and of the external organs of generation. And first
among the ailments of the vagina we may notice, as we have done
in the case of other organs, those affections which are the reealt
of inilammation either in an acute or iu a chronic form.
The acute form of inflammation of the vagina^ apart from those
cases in which it occurs in the puerperal state, is probably oftenest
due to impure sexual intercourse. Between gonurrhc^a, however,
and acute vaginitis dependent on any other cause, there does not
seem to be any certain distinction furnished either by the
character of the symptoms or by their severity, while a similar
treatment is applicable to botk When dependent on the oo©-
tagion of gonorrhcea the symptoms generally commence witliin
three days after the suspected intercourse ; but vaginitis may be
equally excited by exposure to cold or wet, and espedallj bjr
• Croonmn Lectures, 8vo, London, 1854, p. 04.
ja
ACUTE INFLAMMATION.
619
getting wet-footed ; by local irritation of the aexnal organs, by
intemperate or imacctistomed sexual intercourse, and to this latte r
cause attacks of moderately severe vaginitis are not very rai'ely
due in newly-married women,
A disagreeable sense of fulness, heat and tenderness about the
vulva, with frequent desire to pass water, and pain and scalding
in the act of mictBrition, are the symptoms with which it set« in.
Sometimes there is associated with these discomforts great swell-
ing of the labia, wbich are so tender that the sitting posture can
scarcely be borne, wliile a feeling of aching and weight extends
along the perineum, and considerable tenderness of the hypogas-
trium announces that the bladder has become involved by the
advance of the inflammation. For the first twenty-four iiours the
customary secretion is suppressed ; but a discharge then begins to
be poured out in great abundance ; yellow, acrid, purulent,
occasionally streaked with blood, always of an ollensive smelL
This discharge is chiefly furnished from the lower extrenuty of
the vagina, though the inner siirfac* of the nymphfc, and the parts
about the vestibulum also contribute to it, and sumetimes the
inflammation extends along the vaginal canal, the whole of which
may then pour out the discharge. In a few instances the mischief
extends even further ; I have seen internal metritis supervene
upon inflammation of the vagina, and tAvo successive attacks of
vaginitis after an interval of eighteen months, were followed in
the same patient by such severe peritonitis as to call on each
occasion for the abstraction of blood. These, however, are
purely exceptional occurrences ; and in most instances the affec-
tion remains limited to the vulva and the lower part of the
vagina,*
If the parts are examined during the acute stage of the affection,
they appear of a bright red colour, shining, and swollen, while if
the finger is introduced into the vagina, the heat of the parts will
be found to be greatly increased. The introduction of the finger
even is almost always excessively painful, and the tenderness is
so great as to render the employment of the speculum quite im-
possible. During the severity of the onset of the disease, an
abscess sometimes forms in one or other labium, usually, if not
• [For aome Account of gonorrhcea with ovaritis and perimetritia, aee Matthews
Duncati on PerimdrUit and FaramdrUi», pp. 85 and 184.]
620
DISEASES OF THE VAGINA
invariably, having its seat in Cowper's gland ; but, supp^ieiflg 1
not to be the case, the swelling and tenderness generally aliste i
four or five days, the discharge loses its acrid character and oikmr
sive odour, and except that its quantity is excessive, differs litlk
form tlic muco-pnrulent secretion which constitutes ordiimry Imp
corrho.^a.
These changes in the character of the dischai^ge appear to
depend on the more or less abundant presence of pus globoleiii anl
of the tessekted epithelium of the vagina; desquamatioQ of
which takes place so very abundantly in va^nal leucorrb<Ba that
it furnishes us, as Dr Tyler Smith* has shown, with a very vala*
able means of deteruiiuing the source of the discharge from wbii*b
a patient suffers. To a very great extent also similar infarmalioa
may be gathered from the discovery in the discharge of a amiQ
infusorial animalcule first described by M, Donne, and oooi
supposed by him to be pathognomonic of gonorrhceal as diitia- I
gutshed from simple vaginitis. He soon, however, found cause to
renounce this opinion, though he still alleges that the Trichommmi
is never observed in healthy vaginal mucus, but only in the sedi-
tion when containing a large admixture of pus globules. This
latter statement, too, is confirmed by the researches of Kolliker
andScanzoni,f who further add the remark, that while never predi^Bt
in the cer\ical mucus, and by that circumstance plainly demoa-
strated to be something more than a mere cell of ciliary epith^linnv
as has been sometimes imagined, the Trichomonas J is on the OOt
hand not constantly present in vaginal leucorrhcea, and on tba
other the existence of the disease in a grave form is by no meam
* 0% Leueorrhfro^ &c., chap. iv. pp. 51-7&.
t Seo, with rdereaco to these pomta, i\\e veiy elabomte iiiTettig^tioiii of KtiUilD^ _
and ScaDzom, on the Mcnition of the mumu^ membTatie of the viigiu« uid cifva fl
uteri, in S<»U35onfa Beiird^^ &c., vol. iL, Wiirtzbui^, 1855» pp. 12S-14d. ™
t [For A full history of this aod alliwi matte ri, the read<?r U rrf«Twl to the work ol
HauBBTDnnri, Die Parasitm der toeibliehen Gegdddditaorganu^ 6«rliu, 1870. I hmrw aj*
self ill very nuniemus exaniiiiiitiouH of vaginAl diachaigoft diiooverrd the TricliomiiQji
otily a few tinios (not abovo five). In these iitfltiinces I oould conatfci tbo diacovvij
with Ko jwrnilinrity of the cn^ea. The niofft remarkable waa one of healthy {iregaiMy.
In it the THchomonAdif were innumerable, and in a state of activity both a«loiiiaiiiig
and amiiiiing. The field of the niicn)»coi:w might be likened to a football irriniimpt
every momul lu^sliiDg about with LU long whip- like hdir or haJrSt producing wild
motiona of the mooods themvcWea and of thtiir QeighbourSf aod of the poa oalk
othem lying ttbont.]
4
ACUTE INFIAMMATIoy.
€21
essential to its development, since it la found in some persona in
apparent health, and in whom the admixture of pus globules with
the discharge though evident, is yet not very considerable.
I It may perhaps be added, that as the microscope fails to furnish
' us with a means of distinguishing between gonorriupal and simple
vaginitis, so no symptom or combination of symptoms is absolutely
conclusive on this point The amount of affection of the urethra
certainly strengthens the suspicion of the gonorrho^al origin of the
disease ; but urethral inflammation and discharge are sometimes
present in cases w^hei^e bo suspicion of gonorrhcea can for a moment
be ent*;rtained, and according to M. Kicord, are likewise absent in
cases avowedly due to impure intercourse, about once in every
three times.
It is comparatively seldom, at any rate in private practice, that
vaginitis or vaginal leucorrho^a comes under om* notice in its
acute stage. If it does, the employment of tepid hip-baths, of
tepid vaginal injections, rest and mild laxatives, usually suffices
to afford relief, while as the inflammatory symptoms subside injec-
tions of cold water, of the diluted liquor plumbi, of solutions of
sulphate of zinc, or of alum, will restmin, and in a week or two
put a stop to the profuse discharge which for a season remains
behind.* Now and then, however, if the pain is very severe, the
tenderness great, and the swelling of the labia considerable, it is
expedient to apply eight or a dozen leeches to the vulva, to en-
courage the bleeding by a warm hip-bath, and a warm bread -and-
water poultice, and afterwards to keep warm fomentations of two
parts of the decoction of poppy and one part of the diluted
lead lotion constantly applied to the vulva. These measures will,
in most cases, w^ithin less than twenty-four hours, reduce a state
of previously intense suffering to one of very bearable discomfort.
Sometimes, however, the difficulty and pain in passing water con-
tinue very distressing, and in that case the extract and decoction
of iiva ursi with small doses of liquor potasse and of the tincture
• [In chronic vajcnui^is, whicli m far from a rare disease, wlitther eoiiiiiig on as a
conBequenee of icut^s v»giiiitia or arising otherwise, 1 have found fine powders, and
Mpocklly white biamutlip ii&^ful, iirobaldy in the same way &s auch medicines are
Uicfnl in catarrhal conditions of other organs It may bo dusted in aa a powder
tliroiigh the ^p^ciilum ; or it may be injected in a state of suspension in tepid or oold
water. For this last purpose a teaspoon ful may be stirred up in eight ounces of
water Immediately before uae.]
622
DISIASES OF THE VAGIKA !
of henbane seldom fail to afford very speedy and very miuked !*►
lief. I am disposed to think, iodeed, from my hospital expetieaei^
that the complication of vaginitis with some degree of it
tion of the bladder often fails to receive that degree of
wliich it merits ; for it has happened to me not infrequently to
meet with patients in whom very distressing dysuria, the evidail
result of chronic cystitis, was referred back to some acute attack
of leucoixhcca or gonorrhci^a which had occurred months befora
But it is, as I have stated, a more chronic form ofailmejU wA
which we oftener have to do, and this not only in cases when i
leucorrhccal dischai-ge has been left behind after the sufisidaMI
of the acute attack, bnt in a large number of instances where Urn
ailment has been chronic from the outlet Such are many of tbt
cases of leucorrhcea that occur in women exJiausted by beqoiM
child-bearing, or by prolonged lactation, or by menorrhagia. Studio
too, are the instances in which leucorrhtea accompanies chlonMtt,
and of the same kind are those abundant discbarges from the
sexual organs which take place in strumous children, and which*
sometimes assummg a subacute character, and being associated
with much swelling of the external parts, have been erroneomtf
supposed to be due to criminal attempts at intercourse. I nuj
just add, however, that the discharge in the case of the child takes
place almost entirely from the parts in front of the hymen, and o
the result, therefore, rather of vulvitis than of vaginitis. Anffl
condition wliich maintains or is dependent on habitual venotit^
congestion of the abdominal viscera is apt to be associated with
vaginal leucorrhoea. Hence the discharge is often observed m
only in women who suffer from ovarian or other abdominal'
tumours, but also in patients liable to disorders of the liver, or
hfemorrhoidal affections, or who suffer from habitual constipatioii.
Uterine tumours, and uterine misj jhicements are, as it is almost
needless to observe, apt to be associated with vaginal leucorrliOA;
while even in those cases in which the greater proportion of thi
discharge is poured out from the interior of the uterus, tliere ii
almost invariably a large admixture of secretion furnished
the walls of the vagina.
It is obvious that the chances of cure of this chronic v
leucorrho^a depend entirely on the uncomplicated character of tbi
ailment, or on the diseases with which it is associated being eft
ta
CHBONTC IKFLAMMATION, AND LEUCORBHCEA.
623
kind to admit of removaL Thus, the leucoirhcea attendant on
uterine tumours, while in itself it need not excite any solicitude,
yet scarcely admita of cure, its restraint by astringent lotions
being all that can be attempted. For the same reason, too, those
vagina! discharges which are associated with abdominal tumours
do not admit of cure; while in those instances in which they
aceompany hepatic disorder or abdominal congestion, as is not
infrequently the caae in women after the middle period of life, and
in whom menstruation haa ceased, the cure of the local ailment
depends on the removal of the constitutional disorder. The
leucorrhcra of the feeble and chlorotic obviously needs a tonic
plan of treatment, and the administration of chalybeate^, in addi-
tion to the emplo}^ient of local remedies ; while in the case of
children, it ia always necessary to ascertain that the discharge
from the vulva is not produced by the irritation of ascaridea in
the rectum.
But, not to dwell upon points which are almost seK-evident, I
must just notice some of the more useful astringent applications ;
for to these local means we must cliiefly trust, since there are no
internal remedies that exercise a direct influence on vaginal dis-
charges in the same way as cubebs and copaiba restrain uterine
leucorrhcea. First among these means stands the abundant use
of cold water, either for ablution, for vaginal injection, or in the
form of the hip-bath ; for simple though it is, and therefore often
too little had recourse to, it is not only very efficacious, but in
many instances suffices of itself to arrest the discharge, and, if
continued, to prevent its return. The water may be rendered
more astringent by the addition of about a quarter of an ounce of
alum to each pint of water used for injection, or by mixing a
quarter of a pound of alum with the water used for the hip-bath,
and which should be employed either on rising from bed, or, at
any mte, during the morning hours, not just before going to rest
at night The alum hath has the advantage of being one of the
best astringents, and also of being one of those remedies witJi
which a patient can always supply herself without the interven-
tion of the chemist If, however, it should fail, as all local
applications if long continued are in turn apt to do, a more
powerful injection may be obtained by the addition of a drachm
of tannin to each two drachms of the alum, or by dissolving the
624
UISEASES OF THE VAGINA ;
alum in decoction of oak-bark instead of in water. Both of
lotions, however, have the disadvantage of staining tlm Imn"
almost as indelibly as the nitrate of silver, though not of m> daik
a colour. The lead lotion of various strengths, and lotioiil rf
sulphate of zinc, either alone, or in combination with alum, mAf
also be employed, if other means fail ; but failures very oftiai
depend on the inefficient use of the injection, rather than on my
fault in the remedy itself j and it is therefore always of impoit^
ance to ascertain that the patient employs a syringe of sulficiail
size, and that she uses the injection when in a recumbent and soft
in a sitting posture. It is also always desirable that cold witer
should he injected into the vagina so as to remove the dischiije
as much as possible l>efore tlie medicated injection is emploTed
I have no personal experience of the use of nitrate of silrcr ia
solution or in substance in cases of chronic leucorrho^n, Tbm
can be no douht, however, but tliat in instances of Vk^ry obslixiile
discharge after acute gonorrhccal vaginitis, the remedy has proved
of great ser\nce * For very obstinate cases of vaginal leucorrfacn
a plan of Scanzoni's will probahly be found successful.t He in-
troduces into the vagina a plug of cotton wool, the outer surface
of which has been bestrewn with alum in powder ; or if then? be
much sensitiveness of the parts, with a mixture of one part of alnin
and one or two parts of loaf-sugar. This plug should not be
allowed to remain longer than twelve hours at a time, nor should
its introduction be repeated oftcner than every second or Uitid
day, injections of tepid water being employed in the intervtk
The chief drawback from the adoption of this plan seems to be
that unless carefully watched a very troublesome vaginitis WMj
be induced by the remedy, which in that case may aggniTate
instead of arresting the discharge. M, Guerin,t whose experienoa
in the management of this class of ailments is so extensive, speab
alau in the highest terms of tlie result of introducing a plug of
cotton wool, of the size of a walnut, and containing about a tea^
spoonful of powdered alum, through the speculum, and quite up
to the fundus of the vagina, where he allows it to remain five or
six days. He does not seem to have experienced any gravi^r in-
convenience from its use than a little irritation of the mucous
• Acton, On Uus Qew^rativt Orfjtirut, kc, p. 287. f Op.ni. p. 287*
X Maladi^da Orgatus OituUt^uc EsOemet ds laFmime, Svo, Puriik, 1864, p. J
1
ORAKULAB VAGINITIS.
625
membrane, near the fourchette, as the dissolved aJam comes in
contact with it, and which is reatUIy removed by washing with
tepid waten For the majority of cases even of very chronit:
leucorrlicea, however, a very efficacious and probably a safer mode
of keeping the astringent in constant contact with the vajO^nal
walk is furnished by the use of the alum or tanuin pessaries of
Sir J, Simpson.^
Attention was specially tlrawn some few years ago by M.
DeviUe of Paris"f", to what he believed to be a previously unnoticed
form of inflammation of the vagina, and to which from its
anatomical peculiarities, he applied the u^meot f/ranular ra/flnitiii.
These peculiarities consist in the presence of numerous round
shot-like bodies, of a more vivid red colour than the adjacent
tissues, in the depressions between the rugoe of the vagina, and
especially abundant towards the upper part of the canal These
bodies were imagined to be the hypertmphied follicles of the
mucous membrane, and were supposed to bear a large share in
secreting the abundant thick yellow discharge which was poured
out from the vagina. The affection was fiuther observetl to be
connecteil very closely ^vith the pregnant state, while it scarcely
ever oceuiTed in women who hatl not at some comparatively recent
period given birth to children.
The researches of minute anatomists, and especially those of M,
Ljfaodti.have show*n. however,that the vagina is singularly destitute
; Df mucous follicles, and that these brnlies are nothing else than
hypertrophied papiDte. This discovery, while it explains the as*
sociation of granular vaginitis w^ith the pregnant condition, at once
deprives it of all claim to be regartled as a peculiar disease. It is
nothing else than vaginitis associated with h^^pertrophy of the
vaginal papilke — a physiological condition in pregnancy; one
which, independent of that state, may follow or accompany long-
continued intlammation, irritation, or discharge.
I [Several descriptions have lately been published of a disease
I * JBcL Mmihly Jmrfuil, June 1848, ami Ohstetrk Works, [k 98. Formal* are
gfren there for Tarimus kinik of pessaries. The a him and taniuii nm mibde as fol-
lows :— ft. Tanninic 3ij, Ccrae albee Bv, AxuugitK Jvi, misce, et divide in Pcmob
qmntaor. ft. Alum. wil|>h. Jj, pulv. Catcclm Sjt ^^^^' *1»vib Jj, Aiimgrnj 3v«s»
miaoej et divide In pi^ssos quatuor.
t ArdUva de MStUeim, Qnatrikne Setie, tome v. pp. 305, 417.
t ZtUtchrift/. roHomdU Medixinj 1849, vol tiL p. 1.
2 R
628
BISIASES OF TEE VAGINA :
almost exclusively observed in pTej2rnaiicj% and which may hei
modification of the granular vaginitis just referred to. AldiiM^
cases had been previously described, yet it is to Winckel tlill Ht
are indebted for attracting special attention to it. It hftS beea
called vaginitis emphysematosa, and Winckel described it* uiidcr
the name of colpo-hypeiplasia cystica. In subsequent TolitBiei
of the journal in which WinckeFs papers appeared, are to be fomil
other cases and observations by Zweifel, Niicke, and Ch<^neviiR^
It is characterized by the presence of numerouB air-blebd, aiitfiaf
the mucous surface of the vagina to project. They BXt mcfd
numerous in the higher parts of the vagina, and vary from tin
minutest size to that even of a hazel nut When touched Ibij
give the feeling and sound of emphysema. and when seen areola
steely brown colour. Their patbolofry is as yet mysterious, tad
their connexion with vaginitis doubtful, for in some cases the dis-
charge supposed to indicate vaginitis was not present. The difleoie
generally disappears after confinement, and is not known to hxm
at any time great importance. Emphysema seems a moie Bp-
propriate designation than vaginitis, and Spiegelbeig believer that
air is contained in lymph channels.
Both acute and chronic vaginitis occur in a variety of fo
which are not aufhctently described, and of which I sbiiU infiidT
mention illustrations. Lately, in St Bartholomew's Hospital Ilr
Herman showed me a case of well marked pustular vaginitis, '
affecting only the upper part* The pustules were numerous, some I
of them confluent, some not burst, some alreaily opened and pre-
senting the appearance of the little foul ulcers of the stomatitis of
children. The case was, 1 nnderstand, soon cured by oidinair
treatment About the same time I had in the hospital a case of 1
acute vaginitis, easily cured, wiiere the inflammation wm not
diffused, but curiously mapped like the spot^ of measles. In an- ^
other case, which could scarcely be called vaginitis, for there was
no purulent discharge nor symptoms of inflammation, and which j
proved incurable, at least for several years wdiile uuder my obser* '
vation, the whole vagina was spotted, the points being mow
numerous at the upper part Such spots I have often seen in small
number ; hut here they were in such number and regularity as to
recall to mind the Dalmatian dog, or the skin of some cases of ;
* Arehiv/Str Gpimkolo^U, E. ii S. aS8,
7AEI0US FORMS OF VAGINITIS : VAGINAL CYSTS,
627
pura. The spots were as laige as pin heads, and Dr Arthur FiuTe,
who saw the case, regarded them as inflamed follicles. Acute
vagmitis mth extremely copious purulent discliarge, but w ithout
much redness or tenderness, is often observed in old women as a
, result of wearing a pessary. Its cure soon followa withdrawal of
the offending instrument. A case of acute vaginitis was recently
recommended to my care in hospital by Dr Godson. It was in
a very old woman ; the redness of the upper part of the vagina
"was intense, the tenderness was great, and the discharge of pus
was copious. There could be discovered no reason to suspect
gonorrha^al infection. It was easily cured. Its great peculiarity
w^as its recurrence with some regularity, every month or six weeks.
Since her dismissal from the hospital, it has, I understand froui
/the Sister of Martha, again relapsed.
Acute infiamniation, sometimes wth sloughing of the vulva,
Vagina, and bladder after deli very,* noma or cancrum of the vulva,
and paravaginitis or inflammation of the cellular tissue around
the vagina, which has been called by Schrcederf perivaginitis
phlegmonosa dissecans, are rare affections, which, however, deserve
mention.]
»0n two occasions I have met with cysts projeding into the
vaghm^ In one instance tlieir presence gave rise to no incon-
veaience, and the patient, who died of faecal abscess, was not aware
of tlieir existence, though they were so low do%vn as partially to
protrude througli the vulva. Two, which were of the size of a
chestnut, were connected with the posterior vaginal wall, and were
so firm as to convey the impression of being solid fibrous grouths.
The anterior cyst, was smaller, softer, and felt like a small vaginal
cystocele. The surface of all three was of the same colour witli
that of the adjacent vagimil wall. After death, these cysts were
_ found to have firm, tliick, tibrous walls, to be lined by a polished
f membrane, and to contain a perfectly clear, glairy, yellowish, and
rather viscid lluid, not unlike synovia; the anterior cyst differing
from the others only in its walla being rather thinner. Similar
• [See Edinburgh Mrdiml and Stiiyical Jmtmal for April 1, 185fi, p. 25, of case-
book. See hIso Hardy atid M^Clintoek, I^actical ObservaiioM in Midfci/ery, p. 46 ;
alBO Humbert, Arckivca dc Tocohgk Aoit, 1876. For otlier references, see
Churchill^ Disms^qf Women, sixth eilitiiin, p. 62.
t Handlmch der Krankh^Un dtr wcihlkJieit Geschleehls-organej Lcipjcig, 1875^
a 45e.]
G28 DISEASES OF THE VAGINA :
in kind to this was a cjst described by Scanxoni,*
had slowly developed itself till it had attained the
pigeon's egg. It had probably been many years in coarae of de>
velopment, for the patient had long experienced pain in sejmd
intercoursei referred to the situation of the cyst, and this pain u
last became so severe as to render the act impracticable. Hit
tumour was seated at the right side and anterior part of the vagina;
it was very sensitive, tense, but yet yielded a sense af flactaalUML
The nmcoua membrane covering it and in its munediate oeigbKottF
hood was very red, and there was abundant secretion from tl»
vagina. The cyst was opened, and an ounce of transparent isOQi
fluid was let out from its interior which was felt to be lined bj •
smooth membrane. Injections of a solution of nitrate of «ilfi!r
were made into the cyst for fourteen days, in order to prevent aiiir
re-coUectiou of the fluid, and apparently with good effect ; fgf six
months afterwards no trace of the tumour could be deteetad
Almost identical with this was the history of the patient in my
aecond case. She was a manied woman, aged thirty-three, who
for some seven years had been aware of the presence of a swellingl
about the size of an egg, which» though not painful, was yK the
cause of inconvenience in sexual intercourse, while besides sbo
had more or less aching about the vnlva, and for six months had
suffered from frequent desire to pass water and from {lain in
micturition. The situation and appearance of the swelling wem
such OB immediiitely to suggest the suapicion that it was l pr^
cidenfc bladder, and it was only after the introduction of a cathi
that this was ascertained not to be the case. It was of the
of an egg, projecting between the labia, and its surface^ boni
exposure, had assumed much of the character of ordinary intfgo*
ment. It was elastic, evidently containing fluid, was situated «t tht
upper part and rather to the right side of the vulva, springing bott
the under surface of the right njonpha, and sufficiently movftUs
to aUow of its being pushed back entirely within the vagina. On
puncture, nearly an ounce of glairj^ fluid was evacuated, and iImt
cavity was afterwards injected witli equal parts of tincture of iodiiv
and water. The previous uncomfortable sensations were grettty
relieved by the proceeding, and for a time at least the tfuocnir
was got rid of ; but I do not know whether the fluid re^oollectod.
1
ecarfl
stasfl
VAGIKAL CYSTS : FIBROUS TDMODHa,
629
i
I
(IVlien va^nal cysta are evacuated of their glairy contents they
seldom require any further treatment* But, as in cysU of the
ducts of Cowper'a glands, the incision or puncture may heal ; and it
is necessary, as in a ranula, to excise a portion of the cyst Then
the cyst is kept permanently open and shrinks, but often remains
easily discoverable for the i^st of life ; and this is not the case
with the cysts of the ducts of Co\vj>er's glands.]
The only point of epecial moment connected with these cysta
regards the distinction between them and those cases in which the
vaginal wall itself is prolapsed, constituting a rectocete or a
cystocele ; either of which conditions, when of long standing, is
associated with thickening of the vaginal wall, and may on a
superficial examination be mistaken for a cyst in these situations.
The complete disappearance of the tumour formed by the pro-
lapsed vagina under pressure, and its increase upon any effort at
straining, coupled with the results of the introduction of the
catheter, are simple and conclusive means of distinguishing
between a swelling produced by mere vaginal prolapse and one
dependent on the pi-esence of a cyst in its \ralls.
There is still much obscurity with reference to the mode of
development of these cysts, though Yirchow* is inclined to the
opinion that they originate in obstructed mucous follicles. Such,
no doubt, is tlie origin of those small superficial submucous cysts,
seated quite low in the vagina, especially around the urethra, or
at the lower part of the anterior vaginal wall, of which M. Hoguier^f
to whom we owe an elaborate essay on the subject, also makes
mention. These cysts, which seldom exceed the size of a large
pea, and are often smaller, appear to be merely obstructed mucous
follicles, since tlieii' w^alls are always thin, and so transparent that
their contents are visible through them. These cysts, with which
I confess that I am not familiar, though Huguier speaka of them
as being more frequent than the others, seem to produce no
symptoms, but to buiBt spontaneously, or to give way during
sexual intercourse, and are therefore of less importance even than
the others.
My knowledge of fhrous tumours of the vagina is equally frag-
mentary, and indeed I believe them to be still rarer than cysts
• Die Krankhaflen OetchwOlsU, yoL i. p. 247.
t Mimmrea dc la SocHU d§ ChwurgU dc Paris, yoI I 4to, 1847, pix 326-39i.
DISEASES OF THE VAGIKA:
connected witli its walls. In the only instance that I have mit
with, the tuniotir, which was spherical in form, tlid not exceed lilt
size of a cob-nut, gave rise to no symptoms, and remained (jiute
stationary for more than two years, during which period the
patient was under my observation. Sometimes, however, tumoms
having this origin actjuire a very considemble size ; and the lafti
Professor Kiwisch* quotes from a German journal the history of
a case in which a tumour weighing more than ten pounds spnmf
by a pedicle of two fingers* breadth from the posterior vagiml
wall, two inches from the orifice of the canal Tumours ol thit
large size, however, are possibly fibro-ceUnlar, rather tiuxn strict!?
speaking fibrous growiba, and spring originally, not from the sub-
stance of the vaginal wall so much as from the celltiltr tna»
around it, hut naturally grow as they increase in size, in that
ilirection where they encounter the least resistance, and thus oomcr
at last to assume the appearance of pedunculated tumonre of tb«
vagina. Such is probably the natiue, and will most likely lnj ihf
progress, of a tumour in a patient who was under my care in June
1857> in St Bartholomew 'S Hospital She was thirty-three years
old, had been married eight years, and a year after marriage bad
given birth to her only chihl She professed to have eufferal
habitually from some ilegree of dyauria, which Jiad been aggravitoi
after her marriage ; but in August 1856, had suddenly beoome m
much worse, after suppression of the catamenia» from catchiiig
cold, that the use of the catheter became necessary, and bad tl
intervals been required since. Her mine, on admission^ waa
turbid and mixed with blood, hut her geneml health was goodt
and the dysuria almost dianppeared under the intiuence ol roil
and very simple treatment in the hospital The cause of her
symptoms seemed to be a tumour, about three lingers broad, soiae*
what oval in form but with its larger end towards the uterus, and
which lay in the direction of the uitjtlmu This tumour was firm,
but with some degree of elasticity : its surface was smooth, and it
was not tender on pressure. Behind it, and driven quite iuto Uie
posterior part of the pelvis, was the heiilthy uterus, whicJi had no
oonnexion with it wliatever. The inin>duction of tlie catheter
was attended by some difficult>% and the instrument, in entering
the bladder, passed much to the left side. Now, supposing this
• Op, cit, ToL il p. 560,
I
FIBEOUS TUMOURS : CANCER.
631
tumour to increase, as it doubtless will, it is in the direction of
the vagina tliat it will encounter the least resistance ; thither it
will therefore grow, and there it will probably, in course of time,
I present itself as a polypoid tumour. Such, doubtless, was the
history of the growth of a tumour which Sir James Paget* has
described, and which I hatl the opportunity of seeing with him.
It sprang originally, from the right side of the vagina, and the
patient had been aware of its existence for between three and four
years, though she had sought for medical advice on account of it
only within the previous twelvemonth. One physician whom she
consulted took it for an abscess, and punctured it ; another recom-
mended the employment of some support. It had not pnjtruded
beyond the external parts till some ten days before its removal, at
which time it hung beyond the vulva as a mass five inches in
diameter, of a somewhat pyriform shape, connected by a pedicle
an inch and a half long and of the same thickness, with tlie right
wall of the vagina, and the tissues beneath, just behind the right
nymph a, which was as it were arclied over the upper part and
right side of the neck or pedicle of the tumour. Its removal was
accomplished with very little loss of blood ; and the pedicle was
found to pass by the outer wall of the vagina, in the loose tissue
■ between it and the ramus of the pubes, and reached nearly two-
thirds of the way to the uterus. The characters of the tumourj as
minutely described in Sir James Paget 's own notes, with a copy
_ of which he favoured me, were just those of the fibro-cellulai^ out^
H growth, which is apt in all situations to attain a size such as the
tirm fibrous tumour less often reaches, and is always much slower
— in acquiring^-f"
P The subject of malig^fiarU disease of the vagina has been ali'eady
in a measure anticipated in the remarks made upon uterine cancer.
I am, however, inclined to think that the rarity of primitive cancer
of the vagina has been to some degree exaggerated : and although
the main features of the disease are the same m when it takes its
point of departure from the womb itself, there are yet some reasons
on account of which it deserves a separate notice. Caticerous
disease of the vagina, consequent on similiar aft'ection of the
I * Op. eii. vol. IL p. 115.
f [For an account of an interesting case, with numerous litemiy refcrencos, see
iiapur by Prof lihsor Simpaon in the Edinburgh Medical Jourruil for Jqhc, 1B7B.}
632
DISEASES OF THE VAGDfA :
uterus, begins for obvious reasons at the upper part of tha
canal, and travels thence downwards, involving in general tiieni'
tenor more than the posterior wall l*rimitive cancer of the vagnu
does not show the same predilection for the anterior waU; iMf
does it in general seem to be;^n at one spot, and thence extend ;
but, for the most part, cancerous indltration takes place into lim
whole of one, or more often of both walla of the ▼!§»!
simultaneously, and b at least aa obvious near the vulva oi tti tW
neighbourhood of the uterus. To this rule, which obtattw inaQ
instances of fungoid cancer of the vagina (ami they are by far tl»
more numerous, since to that class may be referred 15 oat of W
cases of which I have a record), the epithelial variety of llie dis-
ease forms an exception ; for in that the mischief seems to btgia
at one circumscribed spot, not in the vicinity of the utema, and,
as far m my experience goes, in the posterior wall ; and to exteni
to the subjacent tissues and to pass into the state of nken-
tion wbUe as yet the womb is quite unaffected^ and appaieolly
healthy tissue is to be found both above and below the seal of
mischief.
The following statements embody the chief results thai «i
dedncihle from the cases to which I have referred : —
In 15 instances the disease was fungoid ; in 4 epitheliaL la
1 case only the disease, which was fungoid, was limited to IIk
anterior wall ; and in 1 of fungoid cancer, the right side of tht
vagina only was allected when I saw the patient, though the dis-
ease, doubtless, extended afterwards.
In 6 cases, of which 2 were fungoid and 4 were epithelial, the
disease was limited to the posterior wall. In the fungoid cases
the posterior uterine lip also was afVected ; in the epithelial, the
uterus was free, though in one instance tlie os uteri began to be
red, spong}^, abraded, and bleeding, yet I think not cancerous.
In 11 causes, all of which were instances of fungoid disease, both
vaginal walls were involved In 2, however, the anterior wall
was chieily affected.
In 2 of these cases the contraction of the vagina v^reviuted
uteius from being reached.
In 1 case there was an outgrowth fmrn the intt^riur of
uterus, and in 1 a granular state of the anteriur lip, the nature
which was doubtful
I
CANCER : ITS SYMPTOMS.
633
Or, ia otiier words, in 6 cases the uterus was perfectly healthy ;
in 2 it could not he reached ; in 2 the afiecfcion of the uterus was
sHifbtj and its nature not quite certain ; in 9 it was the seat of
decided cancerous tli^ease.
With reference to the circuraJ^tances wliich favour its occurrence,
cancer of the vagina seems to conform to the same rules as in-
fluence the development of uterine cancer ; except, perhaps, that
it appears to come on at a later period of life than cancer of the
womh ; for only 7 of the 19 cases were olmerved between the ages
of 35 and 50 ; and the remaining 12 between the ages of 50 and
66. As with cancer of the womb, so also with that of the vagina,
marriage and child-bearing apparently favour its production ; for
only 1 of the 19 patients was unmarried ; while tlie remainiug 18
had been pregnant 95 times^ and had given birth to 86 children ;
or, in other words, there were 5*3 pregnancies and 4*7 labours at
the full period to each marriage.
■ Beyond the evidence furnished by these data of the general
conformity of vaginal cancer to the same laws as govern the
development of cancer of the uterus itself, I do not know that the
conclusions are of much moment The same similarity, however,
between the two forms of disease, obtains also between its
symptome, whichever be the situation that it occupies, and the
duration of the atlection appears to be about the same in both
instiinces.
The early symptoms very closely resemble, as this table shows,
those which attend the commencement of uterine cancer.
The first symptom was pain in 4 cases.
„ „ htemon^hage without pain „ 6 „
n f» *j witn „ „ b ,1
„ ^ pain and discharge . . „ 1
„ „ dischaige without pain . „ 2 „
19
Pain seems to be rather more frequent as an early symptom
than when the disease begins in the uterus ; and pain referred to
the back, increased by defaecation or micturition, is also of very
common occurrence throughout the disease. The pain seems of a
more abiding kind than that of uterine cancer, though in a large
proportion of instances the severe paroxysms of suflering, due no
634
DISEJISES OF THE VAGINA:
doubt in great measure to uterine action being excited
advance of disease in the womb, are absents The reason for this ,
IB furnished by tlie fact that vaginal cancer may rua its oooise |
to its fatal issue without the womb being at all implicated*
though there is unquestionably a general disposition both to
the extension of mischief by contiguity to the uterus, and al--*<» to
the occurrence of secondary though independent affection of that
organ.
Perforation of the rectum or of the bladder is not of such tre^
quent occuiTence in this disease as might beforehand be anticipiitod,
though the action both of the bowels and of the 11 ' ' is com-
monly more or less ditticult and painful ; and the i t of the
urethra, which sometimes takes place in fungoid cancer of the
anterior vaginal wall, may render tlie evacuation of the bladder
not only difficult but impossible.
The prELCtical conclusions to be drawn with reference to this
form of disease are somewhat of the following kind. That it
occurs, though less often, yet in the same circumstances as uterine
cancer, showing the same predUectian for the married over the
unnmrricd, and for those who have been fre*|uently pre^ant ovi*r
the sterile. Its general symptoms seem also to be similar, except
that mere painless ht^moiThage is somewhat rarer than in uterine
cancer— a circumstance for which the seat of the disease in vaginal
cancer probably affords a sufficient explanation. The progress of
the disease appears in both instances to Lie analogous ; the cancer-
ous cachexia is developed in the one case as in the other, the
advance of the evil is equally rapid, and the disposition to second-
ary deposits at least as decided in fungoid disease of the vagina {
in fungoid disease of the womb.
There is but little to observe with reference to treatme
except that the topical palliatives which are of use in uteriofi
cancer are obviously of more difficult application when the diseaiie
is seated in the vagina. The only gleam of hope that brightens
the case of a patient with malignant disease of the vagina is
aiibrded in those instances w here the affection is of the epithelial
kind. The similarity of structure between the vagina, vulva, and
external parts show^ itself, as has been so well pointed out by JL
Hiiguier,* in the similarity of tlie diseases by which they am
* Mimoirt9 tU VAcadimU di Midedne, voL xiv. 1849, p^ 600.
J
CANCER : ITS TEEATMENT.
635
attacked. There is, therefore, some hope that ulcerated growths
of the epithelial kind about the vagina may he found to belong to
the class of lupus, or rodeut ulcer, rather than to the more utterly
hopeless categorj' of diseases which are intimately allied with
ncer, and that local treatment may not be so thoroughly fruitless
experience has too amply proved it to be in the case of malig-
lant disease of the womb. But hope even derived from this
lurce is, I fear, but too often doomed to be iDusive ; for, on the
oae hand, the position of the disease not only renders surgical
interfereuce extremely difficult, but iu all the cases which have
come under my notice, the mischief has extended too deep into
the submucous tissue for it to be possible to tiissect off the diseased
structure from the subjacent tissues. On the other hand, tlie pain
attendant on the introductiou of the speculum generally rendei"S
any attempt at the continuance of the loc^l treatment abortive.
Some Lime since a case was under my care that seemed favourable
for local treatment. A long strip of raised, red, large granulations
extended for nearly an inch in breadtli and two in leogth along
the left and posterior wall of the vagina up to its roof, but leav-
ing some quarter of an inch of healthy tissue between it and the
neck of the womb. Sir James Paget, who was good enough to
see the patient with me, was in hopes, from the absence of
thickening alxiut the parts, that the disease might be classed
rather with rodent ulcer than with true carcinoma ; and accord*
iugly we det^^rmined to apply the nitmte of mercury to the
affected surface. The results of this proceeding were for a time
most encouraging ; and though the introduction of the speculum
caused pain which lasted for many hours, yet the patient gkully
submitted to a plan of treatment, the benefits of which she ex-
perienced in the diminution of the previously profuse, offensive,
blood-stained discharge, in the mitigation of the backache, and the
improvement of her general heidth. Three or four applications
of the acid produced the complete cicatrization of all but just that
part of the disease which affected the roof of the vagina. Jn that
situation, however, the application of the caustic was extremely
difficult, and there the mischief spread. Deposits took place,
thickening the vaginal wall, the granulations grew lai^er, bled
more readily, and extended close up to the side of the cer\ix uteri,
between which and the diseased structures an interval no longer
636 CANCEKOUS DISEASE OF THE VAGINA.
existed ; and thus treatment was baffled, hope was lost, and we
were driven once more to recognise the very narrow limits that
circumscribe our power to heal The patient left the hospital,
and died painfully a few months afterwards ; and I do not know
that her life could be said to have been prolonged by the local
treatment, though unquestionably it was for a short time bright-
ened by a hope which, though illusive, yet cheated her only of
some suffering and some sorrow.
LECTURE XXXI.
DISEASES OF THE EXTERNAL ORGANS OF OENEUATION.
IjfTLAuMMATQRT AFFE€TtONS. Iiif!iunm&tion of the labia, its conuexioE with uh-
literation of duct of Cowjier*8 gktid ; deacription of the ghiDd ; mode in wMcli
inflammfttitm occura in it,
Fu nine alar inflammation.
Eczema. Prungo^ itii Tftxlty* Pmntiia generally^ independent of it ; cftusea and
treatment of priiritus,
tuflnramiition of Folliclea of VuIto,
llYi'EiiiESTHEfciiA OF EXTERNAL oKQAJfs. Vo^niil SpBJim, Of Vaginigmus. Cor-
cygodynia, or pain about coccyx. Remarka on Masturbntion, and ezdsion of
clitoris for its cure.
Ulcerative affehtions, Tertiiiry Syphilis ; difficulties of its diagoosis. Lu*
pus ; its characters, its relation to epithelkl cancer. Caae ia illustration.
Treatment
liALtGKAKT DISEASE, generally nssnmes form of Epithelial Cancer^ its symptomn
and course. Importance of early removal
The arbitrary line of demarcation which in this country separates
the prov^ince of the physician from that of the surgeon has limited
my experience both in private and in hospital practice with refer-
ence to the diseases of the exienml arf/mis of generation. If,
indeed, we lea%^e out of consideration such as are the result of
syphilitic infection, the remainder of these ailments are by no
means of frequent occurrence, nor in general of very great import-
ance.
Of inflammfJimn of the lahia, nyDiphm, aiul cMcrnal iyrgans,
except as an accompaniment of vaginitis, I have seen ahnost
nothing, and of the unhealthy erysipddlous iiijktmmation of those
parts, which, occurring in the child, is apt to pass into a state
of sloughing, I have seen very little. Intleed, notwithstanding
that for more than five and tliirty years I was connected with
large institutions for the diseases of chiidren, I have met with
but three or four instances of its occurrence, and only one of
diphtlieritic inflammation of the labia and nymphac. The circum-
638
DISEASES OF THE VDLVA I
b
stances in which either of these afTectiona occurs <
as comiiiouly met with in this country as in some ]
Continent ; while tliey both appear to belong to the ol
diseases rather than to be purely local ailments such as
strictly within the scope of these lectures.
The intitimmation of the labia attendant on vaginitis
ticuiarly on that form of it which is dependent on
sometimes extends to the cellular tissue on one or othf
ends in the formation of abscess. For the most part
abscesses in the labia are not the result of diffuse inf
but of inflmnvmtwn seated in one of those glantls which
l)y the name of Duvemey's, Bartliolin's, or Cowpei
They are situated one on either side of the entrance of
in that triangular space bounded by the orifice of the
the one side, the ascending ramus of the ischium on the
the transversalis perintei muscle on the third, and are i
the superificial perineal fascia, and by some fibres of the
vaginae. They are small conglomerate glands, of about
a pea or small bean^ and open by a narrow duct sona
eight lines in length just in front of the hymen,
carunculae myrtiformes, and secret that albuminous ;
poured out abundantly in sexual intercourse.
It happens sometimes that the duct of this gland on
other side becomes obliterated, and that the secre
accumulates within it causing it to form a small swel
size of a marble, a cob-nut, or somewhat larger, which ]
the lower part, and towards the inner surface of the la
may remain for some time in this condition producing lii
venience, but in general it becomes irritated in walking,
iu sexual intercourse, and thus the case first presents it
* Like 8oine oM diBCo?eriej3, so that of the Gxistcnco of theae glftod
by Dijvenity in the C43W, and aflpi-warjs by Bartholin in tlie humnn f«
forgotten after HaUcr bad »oug]it for them in vain. Mr Guthrie in
ZHatases of tht BladtUr, refcra to them, though without ^ving any «
tion of their form or relationB ; but it is to the venerable TicMtemann, oj
that we ow« DOr {irca<jnt accurate acquaintance with them. His eoft
Davemeyxhtu DriUtm^ kc, was published at HeidlebeTg in 1840, bis h
having been begun the year previously, and M, Hngoier, in ignoniii/oe I
Tiedemauii*s ob8(.*rvai]onH, re<ii^cov(<rud them in the jeiir 1841, w b«ite(
describing their structure, which he pubUsbed in the Mhnoiru d$ jj
M4dmn€, jk. 1850.
iM
IKFLAMMATION OF COWPEE's GIJlKD,
639
If now it is opened before inflaiomation has attacked it>
^ couple of drachms of a fluid like the white of egg will be let
but, the swelling will disappear, aud may perhaps never be repm-
puced, since in many instances the cyst, after a free incision has
peen made into it, becomes obUterated. Sometimes though no
iDonsiderable annoyance has been produced by the swelh*ng^
inflammation has taken place in its interior sufficient to render its
contents purulent, while in other cases the inflammation is not
limited to the gland itself, but extends also to the adjacent tissue.
The labium then becomes hot, swollen, and intensely tender and
painful at its lower part, so that the patient is unable to move
about, or even to leave the recumbent position without great
suffering, while on its inner surface the gland forms an exquisitely
painful prominence, and matter escapes on a punctnre being made,
with great and usually permanent relief to the patient It does,
however, now and then happen that much suffering is produced
by the successive re -formation of these tumours of Cowper's gland
at intervals of two or three months, an annoyance w^hich can only
be prevented by laying the cyst freely open, and removing a
portion of its wall, or probably by the injection of a solution of
iodine into iU cavity.
[Abscess of Cowper's gland, formed between the labium and the
ascemiing ischial ramus, may burst in this situation, or it may be
discharged through the duct. Of this latter condition I have seen
two examples in young virgins ; and in both it was necessarj'' to
lay open the duct by incision from the orifice at the hymen to
the sac of the abscess. I have observed, and easily felt, inflamed
and indurated Cowper^s gland, causing painful sitting. Two cases
of gonorrhcea of the ducts have come under my notice, in young
prostitutes who came to me at the Royal Infirmary of Edinbui^gh.*
Both had had ordinary gonorrha^al vaginitis and were declared
cured ; but they insisted thay were not, as they still had slight
purulent discharge. In one, cure was affected by simple means,
including dilatation of the orifice of the duct by a probe, so as to
allow free discharge of its contents. In the other, cure was not
effected till the duct had been twice treated by injection of a solu-
tion of nitrate of silver. This was done by the oculist's instru-
ment for injecting through the pnnctum lachrj^male. But tlie
* See Edinburgh Obsklrical Tmm/actionSt yoL iii p, 89.
|H
640
most interesting case I have seen of intlammaf
Cowper's gland was one which puzzled and vexed \
of which the secret was discovered by the mother
who was the patient. This careful lady brought her
me with recurring attacks of the vulvar inflammi
gonorrha^a infantum* My anticipations of pertnani
easily attained improvement were repeatedly disapfi
last the mother showed rae a pin-head red spot whic
and frum Miiich the iuHammation spread out agBin.
treatment by Goulard water was given up. The red a
donbtedly the opening of the inflamed ducL Th
ultimately cured by persistent use of the Goulard wat
The above condition has never come under my notd<
comparatively young women, and who either were ud
least were accustomed to sexual intercourse. TLere an
affections, however, which have no such relation, bol
perhaps more frequent in the middle-aged than in the
are at least as apt to occur in the single as in the mEE
troublesome hoUst slow in their advance to suppuratfc
by much discomfort, occumng two or three at a time,
succession after each other, fresh crops of them frequei
ing at intervals of two or three weeks sometimes show
on the outer surface of the labia. The patient's attentic
first called to them by a disagreeable itching and smart]
then perceives a small pimple or two with a hardened
pimple by degrees enlarges, and the hardness around
both superficially and into the substance of the labium
a mass as big as a small hazel-nut. It is not attende
geueml swelUng of the labium, and does not form
like an ecthjnnatous pustule, but its surface con tint
the time when suppuration having taken place
quantity of matter is discharged after which the !
gradually disappears.
The only local treatment which has seemed of mud
this troublesome ailment consists in the tree applical
nitrate of silver while the boils are still in the papula
done effectually, this often prevents the further prog
pimple, and spares the patient much of that suffiai
fomentations, poultices, and all other surgical appliance
ende
1
4
BOILS: ECZEMA.
641
period do but very imperfectly mitigate. There is no general
treatment which will prevent their formation any more than that
of boib elsewhere ; bnt as their occurrence seems sometimes con-
nected with that irritation of the sexual system wMch oft^n ac-
companies the final cessation of the menses, we are in such cases
furnished with an indication to guide us worth bearing in reiuem-
brance.
[This remarkable disease is well worthy of more careful study
than lias been given it, for it is not rare ; and I have seen it in a
very aggravated case prove not only destructive of health, but
almost dangerous to life. In this case tlie severity arose from the
great size and quick repetition of the cold abscesses. Nothing was
found to be of decided service ; but in one case in an elderly female,
whom I treated a few yeai*s ago, the disease very distinctly appeared
to be arrested by inunction with mercurial ointment, not carried
so far as to produce evidence of hydrarg^Tismus,]
One of the most troublesome affections of the external organs
is eeze-^na of ih£ ridva which is apt to run a very chronic course,
and to prove extremely intractable. For the most part the ail-
ment appears in the flexures between the thighs and the labia,
whence it extends to the labia themselves, and afterwards, as it
becomes chronic, to the nymphie, while it is not infrequently as-
sociated with eczema about the margin of the anus» and extending
along the perineum. In its acute stage it presents no diOerence
from ec7.ema in other parts of the body, but it seldom remains
long in that condition, passing rapidly into a chronic state. In
this state the labia are apt to lose the hair which naturally besets
them, and they waste from removal of the fat which gives them
their rotundity, while they and the nymphte become covered with
a tliick, hard^ w^hite epithelium, and the mucous membrane on
their inner surface becomes dry, unlubricated, liarsh and unyield-
ing. It is not usual for this disease to afiect the vulva generally,
but instances in which it has done so have come under my notice,
the mucous membrane entirely losing its natural appearance, the
diy, harsh, and thickened condition of the orifice of the vagina
being associated with a marked narrowing of its calibre. In the
worst cases, too, the disease involves the pneputium cUtoridis to
such a degree, that its thickened indurated tissue projects between
the labia, while where the opposing surfaces are in contact they
2 s
642
DISEASES OF THi: VTJLYA :
coQtinue red, abi-aded, and just in the condition of pi
by acute eczema. It is noteworthy, also, that in two
severe chronic eczema, a vascular tumour of consideml
from within the orifice of the urethra, but I do not km
the two was of the longer standing.
Those slight attacks of eczema to which some wom€
at the return of a menstrual period, from over-walk
similar causes, are often much relieved by the frequent
of a glycerine lotion or of one with carbolic acid and
while the parts where the eruption ha3 been wont to ^
be afterwards rendered less irritable by the emplo]ni
glycerine or of zinc ointment. If the inflammation is
the discharge from the surface abundant, the patient n
in bed, and the continued application of an oxide of i
will both restrain the secretion and abate the soreness,
wards the ablution of the parts with thin starch, and
them constantly covered with the henzoated zinc c
compound wliich has the advantage of not readil]
rancid), seldom fails to bring about very speedy relief.
It is» however, the chronic form of eczema, attend
desquamation of dry scales of epidermis that is most 1
to cure, or even to relieve. I have observed it in its ae^
only in hospital patients, and these it was almost ii
induce to remain long enough for more than some
alleviation of their ailment to be obtained. The disti
ing was in most instances relieved for a time by si
parts with cod-liver oil. The relief wliich this affordi
was but temporary, and other unctuous applications m
same end, also only for a time, and in general less
Indeed nothing short of completely modifying the state
by caustic applications seemed in these cases to he
prospect of cure. I have for this purpose employe
nitrate of silver, substituting for it, as fresh and m
epidermis was produced, a solution of twenty \
* {Formula No- 11.)
R Glyceriui Acidi Curbolici . , 3 "J
Aqiiam ad . . * . * » Jr
M. ft. Lotio.
a
t (Foniiit
Zinci Oxydi . . .
Calamioiv te?igatie
Miit. AciK^iiD
Aqtumiid jx.
ECZEMA: PRURrrcs.
ounce of distilled water. Professor Scanzoni* uses with the
same object a solution of half a drachm of caustic potass in an
ounce of distilled water, which is to be lightly applied by means
|of a camer€ hair pencil, and advises, besides, as the disease abates,
prery copious and frequent ablution with cx>ld water.
I Mere external applications, however, though essential for the
[patient's relief, and conducing much to her permaneiifc recovery,
seldom suffice in cases of much severity and long standing. In
them, as in chronic eczema seated elsewhere, a long continued
course of arsenical preparations appears to furnish the only means
of effecting a permanent cure.
Prurigo is often spoken of in connexion with that distressing
itching of the sexual organs from wliich women frequently suffer.
While pruritus, however, is a common ati'ection, prurigo is one of
very consiLlerable rarity ; and I have never met with an instance
in which the eruption was limited to those parts, though patients
suffering from general prurigo are sometimes much distressed by
the appearance of the eruption on the genitals, while others are
driven by tlie irritation to scratch themselves to such a degree as
to wound the skin, and thus produce little bloody points not un-
like those which one sees on the top of the papilhc of prurigo.
In spite of this absence of any necessary connexion between the
painful itching of the sexual organs and the appearance of any
eruption on their surface, this will periiapa stilt be the most con-
venient place for introducing what I have to say concerning it.
Though commonly spoken of as prtirUm of ths p^idmda or of the
milva, the sensation is by no means limited to one part, but is
sometimes referred to the external organs, to the surface of the
labia or to the mons veneris ; at other times it is experienced
about the nympha? and the vestibulum, while sometimes it affects
the vaginal canal, or even the os uterL The circumstances in
which it is met ^vith vary as much as the situations to which the
sensation is referred, and serve to show that in strict propriety
the ailment deserves to be classed, as it is by some Continental
writers, among the nervous affections of the sexual organs. It is
far from being an infrequent attendant on the earlier mctnths of
pregnancy, and likewise sometimes accompanies organic disease of
the womb, especially carcinoma in its earlier stages. It sometimea
♦ Op. ciL pw 662.
644
DISBABES OF THE VULVA I
hHf
atteads, and still oftener precedes, the menstruftl peno-
in women who menafcruate scaEtily, irregularly, oi
while again it frequently occurs at the approach of the
period, when menstruation lias either finally ceaaed,
to disappear. It accompanies hjemorrhoidB, and is ao:
of the discomforts produced by a varicose state of the
labia, it attends the onset and decline of most caaes i
tion of the vagina^ and. in short, is seldom altogether i
any cause whatever produces a state of unnatural c
the sexual organs. Now and then it is associated m
herpetic eruption on the inner surface of the labia, th
which are apt to assume, on bursting, something of t
of small aphthous sores ; but my own experience d
me to regard this condition as at all of common occn:
To describe a sensation is proverbially difficult ; b
observed, that as this pruritus varies in degree, so it
kind* It is sometimes an unpleasant sense of creepinj
tion, at other times a feeling of smarting, while ii
the positive itching is so distressing as to be almosl
Wannth always aggravates it, and with some perao
to coiMc into a warm room in order to experience an
while in the case of most patients theniglits are in j
sleepless, because to lie down in bed is at once \
commencement of the itching* Cold for a mome
tliis rehef is but momentary, and patients are driva
and rub themselves in order to obtain a sort of reliel
slats in the substitution of a burning, smarting senai
less toleralile itching. This, however, not only doe^
but the very rubbing of the parts both aggravate
condition, and also helps to produce and to keep i
morbid sexual excitement, which in some of then
Btitutes by no means the least of her sufferings. ■
The treatment obviously depends on the condition!
this distressing sjinptom is associated. The empiri*
tion of lotions, ointments, or other applications, with
inquiry as to the state of the uterine functions, is woi
One case I remember in which the application of tl
silver to a long-standing abrasion of the os uteri wis
the almost immediate cure of a previously very distreei
^eiV
d
PRURITUS.
645
"Wlien consequent ou vaginitis the cure of the inflammation and
the cessation of the itching take place almost simultaneously,
while in geneml nothing relieves the irritation which accompanies
the decline of the vaginitis more than the Goulard water and
hydrocyanic acid» in the proportion of two drachms of the latter
to eight ounces of the former* Whenever there is much evidence
of congestion uLout the external parts, as shown either by their
heat, swelling, or redness and tenderness, a few leeches to the
vulva, or to the margin of the anus, will generally give much
relief, and the same local leeching is, tis might be expected, of
much service when the pruritus is associated with hremoiThoids.
The herpetic eruption on which Dr De wees of Philadelphia laid so
much stress as a cause of this ailment, is relieved — as are other
cases where, without any disposition to the formation of vesicles
or of little aphthous ulcers, much heat and redness of the parts
exist — by a lotion of borax and morphia,* which indeed has proved
more generally serviceable in my hands than any single remedy
besides.
In those cases in which there is any local inflammation, or
considerable congestion present, unctuous applications do not in
general do much good. In others in w^bich this condition does
not exist, or has been completely removed, the employment of a
liniment of half a drachm of chloroform to an ounce of olive oil,
both externally and to the vaginal walls, which, I believe,
Scan^oni was the first to recommend,^" is oft<in of great service.
The pm'e cod-liver oil, also, often relieves the external irritation,
though I suspect chiefly in those cases in which there is an ap-
proach to a state of chronic eczema; while the late Dr Eigby
strongly advocated an ointment of equal parts of cod-liver oil and
red precipitate ointment aa successful in cases which have proved
rebellioug to other means.
Two other reraedies have sometimes done good service in cases
of obstinate pruritus ; one of these is quinine, which, given iu
• (FormolaNa 13.)
ft. Sodffi Snbbof^oU ....
MnrphiiE Hydrochlor. , .
Aquie Laiiroceruai . . ,
Aqum Ro«» ftd, . . .
M. ft. Lotio.
t Op* cU. p. 545.
3iv
gr. viy
5i
5^
646
DISEASES OF THE VtJLTA :
two-grain doses every sir houra, has in some, I fear
instances, appeared to me to relieve this as it does othi
affections. The other remedy ia beUadoniia, which botJ
employed and internally administered, has often provec
Hiieful. I generally give the helladonna in the form
combined with camphor, beginning with half a grain
tract to three grains of camphor, and increasing the
until dimness of vision, or sense of dryness in the th]
ducei At the same time, I direct an ointment of a ac]
extract of belladonna to half an ounce of spermaceti aii
half an ounce of glycerine, to be smeared twice a-da
surface, and the relief which these measures obtain has
outlasted their emplojrment and proved to be permane
There still remains the employment of the nitrat€
either externally or to the vaginal walls, according to
irritation ; but I have not myself had recourse to it ;
other remedies have relieved the ailment, or it has o
the removal of its cause, as in cases where it occurred di
nancy ; or the patient has no longer heeded it, as in
stances of cancer, where other and worse sulfering has
former annoyance seem less intolerable
[The connexion of pruritus with diabetes mellitui
often remarked, and it has also been denied* But I
too many examples of the combination to allow me
doubtful as to its being more than accidental. In &
cases the pruritus seems due to the irritation of the d
In such the disease succeeds to the diabetes and disap;
it, as in a case to which I was lately called, solely on
the pruritus. In the severer cases of diabetic pruritus
ings are in proportion to the severity. The parts are in
swollen, deep red in colour, and sometimes have oa t
numerous vesicles or small pustules, somewhat 1
In two cases of this severe disease, which I have recen
aged women, I regarded the disease as neurotic, be©
commencement it had no relation with the commencco
diabetes, and becjiuse in both there were other neuroee
it was intensely neuralgic herpes zoster. In tlie othei
tempoimy paralysis of the left side of the face and tongt
skin and mucous membrane of the aflected parts we
A
VAGIKISMUS.
covered with herpetic pustules. It was curious to observe the limit-
ation of the pustules in the face and mouth by the mesial line.]
This is perhaps the best place to notice two painful neuralgic
affections, the one of the vagina, the other of the rectum, which
I under the names of vaginismus and mccygod^tiia^ have of late
[attracted considerable attention, though both conditions must
I have long been known practically to all who have had much to
do with the treatment of the diseases of women.
The former condition is one of pain and spasm at the entrance
of the vagina, so severe as to be a complete bar to sexual inter-
course. The pain» however, is often by no means limited to the
act of sexual congress, but the patient experiences a sense of dis-
comfort about the vulva, which is raised to positive pain on walk-
ing, and sometimes even on assuming the sitting posture, though
the degree of suffering varies much in diHerent women, and in the
taame woman at ditlerent times. If any attempt is made to intro*
duce the finger, the pain at once becomes intolerable, and the
completion of the examination is prevented not merely by the
patient's inability quietly to submit to it, but by the violent con-
Striction of the sphincter vagime which is at once produced
This state is by no means invariably limited, as in the ca^ea
related by Dr Marion Sims,t who first proposed for it the name
of va^nismm, to newly married persons in whom intercoxirse hai
been imperfectly accomplished, and in whom the hymen has been
but partially obliterated I have seen it in its less extreme
degrees, left behind after chronic uterine inliammation, and have
observed that in some cases long after the introduction of the
finger or even of a speculum, could be borne without suffering,
the act of coitus, no doubt, owing to the peculiar excitement of
the nervous system which attends it, was so painful as to be
altogether impossible.
I have never seen it as an isolated symptom in patients other-
wise altogether healthy, but have always observed it to be
associated with other nervous and hysterical symptoms, with
dysmenorrhtea, often with pain in deftecation and micturition ;
and like aU ailments of this plass, its severity is liable to great
* [For iome remarlcs ott and cases of mginUtiDiu and roccygodyniA, nee Mcdica
Time* and GmiUe^ for October 1& and November 30, lfi78.]
t ObdctrkaL TraiuaicliQna, vol iil p. 356. .
648 DISEASES OF THE YULYA :
and apparently causeless variation. Allied to this condition, too,
is the intense pain in micturition which I have occasionally
observed in unmarried women, and which I have seen baffle all
kinds of treatment. Of this a most striking instance came under
my notice in a young unmarried lady about 24 years old, in whom
it had been gradually coming on almost from the very time of
puberty. She was pale, delicate, and thin, but had no other
positive ailment than the agony which attended every act of
micturition, and which continued for a quarter or half an hour
after she had emptied the bladder of urine, which was found in-
variably to be healthy. She was seen by numbers of doctors ;
she was sounded for stone on more occasions than one, was
treated by all imaginable remedies ; her bladder was injected with
sedatives, and with carbonic acid gas, tonics, large doses of
chalybeates, sea-air and bathing, and visits to the German water-
ing-places, were all had recourse to. Her general health at the
end of these experiments was no worse, and her local suffering no
better, than at their commencement, and she continued, after
years of treatment, a feeble, nervous, hysterical invalid, with little
power of body or of mind, and with this one distressing peculiarity
only to distinguish her from a hundred others.
I do not think that a state of vaginitis is» as Dr Churchill*
considers, usually the first step towards the production of this
vaginal pain and spasm; and as I have known the state to
supervene in women who had been married two or three years
before the commencement of the symptoms (though never in any
who had given birth to children), I believe the conditions in which
it originates may be very various.
The first essential in all cases towards the patient's improve-
ment is her separation from her husband's bed, and the complete
cessation of all attempts at intercourse. Tepid hip-baths, soothing
local treatment, and the removal of any inflammation of the
vagina or of its orifice, should any such condition exist, come
next The application, for this purpose, of a solution of nitrate of
silver by a speculum to the whole tract of vaginal mucous
membrane, as recommended by Dr Churchill, implies, however,
that already considerable progress, must have been made towards
* Diaaues of Women, 4th ed., Dablin, 1864, p. 123, where will be found a TWf
good aocount of this condition.
VAGINISMOa
649
[he patient's cure, since, in some of tlie cases wliich I have seen,
the finger even could not be introduced without intense suffering.
The removal of any obvious uterine ailment, and the improve-
f the patient's geoeml health, are of course to be attended to ;
but I may say that in do case have I found the bromide of potass,
notwithstanding its undeniable influence over epilepsy, exert any
special powers in those instances in which the exciting cause of
hysterical, epileptic, or other nervous ailments, appeared to be
disoDler or excitement of the sexual system. It was sometimes
useful ; it often failed, just as it does iu otlier cases ; its sedative
influence seeming to be exerted on the nervous system in geneitd,
not on the sexual system in particular.
The tepid douche to the sacrum and nates have in some instances
proved of much service in my hands ; and I should expect the
mud and ciirbonic acid gas baths of Meinberg and some other
places in Germany to be useful, though I have not had any
opportunity of trying them in these cases.
The gradual dilatation of the orifice of the vagina by means of
bougies is the last step in the treatment of these cases, and one
w^hich acls in two ways, both by mechanically widening the canal
and also by accustoming the vagina to the presence of the foreign
body. I have employed rectum bougies of different sizes, directing
the patient to introduce one for an hour daily, exchanging it as
she was able for one of a lai^er and still larger size. Dr Sims and
Dr Chorcliill employ glass dilators, which have the advantage of
being more cleanly,
I have seen one case in which I can conceive it possible that
;»ome surgical proceeding such as is practised by Dr Marion Sima
would be of advantage, though in this instance the intense vaginal
tenderness was but one of a set of symptoms of most aggravated
hysteria. Dr Sims's operation consists in the excision of the
remains of the hymen, the subsequent incision of the vaginal
orifice, and the further enlargement of the canal by means of a
dilator. This proceeding indeed is somewhat formidable, and is
attended sometimes by a good deal of haemorrhage ; but the con-
Hition of vaginal spasm tmd pain is so grievous as to justify almost
^r means being adopted for its relief,
tckache is so common an attendant ujKjn a large number of
r—
I
but little heed to it, and except in instances where it U
severe, make but few inquiries as to its exact situatic
tlie circumstances that aggravate or relieve it To thj
bably due, that untO the late Sir J. Simpson* dira
tion to pain in the coccyx, or coccygodijnia, it had nc
cogmsed as a distinct affection, though Dr Barnes ■(- rei
caaea published fifteen years previously in the JVi
Medical JouttuiI, by Dr J, C. Nott of New York.
Usually after child-birth, sometimes after a fall or b
lower part of the spine, occasionally after long contii
exercise, sometimes as one of a train of symptoms asso<
misplaceuient or some other ailment of the uterus ; aii<
then, independent of any obvious exciting cause, ,wome]
of pain which they refer to the coccyx and its point c
with the sacruoL This pain is experienced in sittinj
very severe during defeecation, is usually constant and di
aggravated at intervals without any apparent cause. It
by the recumbent posture, but, unlike the pain that ac
prolapsus, is not aggravated by walking or by the ere<
It is often worse at the menstrual period, is considen
vated by constipation, and is sometimes rendered veH
sexual intercourse. V
There is no special tenderness of the lumbar regioQi
upper part of the sacrum ; but the lower part of the
often sensitive, and the patient directs attention to t
it43elf as the poiut whence this sensitiveness proceeds ; as
on the bone is found to be acutely painful. The press
bone upwards causes much more suflering than its pres
wards by the finger in the vagina or rectum, and
coccygeal joint is especially painful
Professor Scanzoni,; who has given by far the f
best account wliieh we possess of this aflection, states
of 24 patients, of whose cases he has a record, first com
the pain during child-bed ; that 6 of these patients were ;
and 5 of tliem had been delivered by the forceps afte.
and difficult labour. Two other patients referred to fjM
rides on horseback as the occasion of their suflering* ™
♦ Mifdical Times, July 2, 1869. f Qp. «
V t 0^ cil, pik 589-602.
COCCYGODYNTA.
651
of the 24 cases, the ailment seemed due to causes calculated to
' produce local injury of the coccyx, and how frequent such injuries
must be receives a good illustration in the fact, that 32 out of
I 180 coccygeal bones which the anatomist Hyrtl collected in
j two years presented evidence of dislocation and subseq^uent
anchylosis.
In many cases, however, the pain in the bone is not due to any
traumatic cause, but is sympathetic with some uterine or ovarian
disease, and that by no means of a kind to affect the bone by
pressure, or in any mechanical manner.
In these instances the removal of the coexistent disease is
obvioiialy the firat duty of the practitioner, and how important
this may be is further shown by a fact which Scanzoni mentions,
that three women who had suffered much in their younger years
from this coccygodynia, became completely free from it as soon as
• menstruation had completely ceased.
I have not seen, or at least have not recognised this affection in
its severer and more intractable forms. One of the worst cases of
it which I have observed occurred in a young unmarried lady, in
connexion with haemorrhoidg and habitual constipation, and dis-
appeared completely when those conditions were relieved. Perfect
rest, mild aperients, the complete emptying the rectum of all
focal matter ; leeches to the coccyx, tepid hip-baths and w^arm
fomentations ; such are the means by which, in the majority of
instances, much relief is afforded. If these means fail, or if the
pain is obviously neuralgic, or if, though mitigated, it is not
removed by this treatment, Scanzoni resorts to the subcutaneous
injection of morphia over the painful spot He has found this a
far more efficient remedy than any kind of liniment, ointment, or
siippositor}^ and, unlike Sir J, Simpson, states that its results have
but rarely disappointed him.
The condition, though tedious, and apt in its severer forms
to relapse, appears to be tolerably amenable to treatment. Of
Scanzoni's 2i cases, 10 recovered perfectly, 9 were much relieved,
the result of three wkich he saw but once is unknown to him, and
in two the evil continued unrelieved by any treatment Even in
these, however, the suffering was not so severe as, in his judgment,
to warrant the subcutaneous division of the muscles, ligaments,
and fasciee connected with the lowest part of the coccyx, which.
1
Sir J. Simpson
success. The object of the o|Hjratbu is to set
free and perfectly at rest, and, if other meana
undoubtedy be had recourse to, though not as a first ^
independent of previous treatment.
Some years ago I felt it my duty to notice here
condemnation some statements wliich bad been mado 1
ence to the frequency of masturbation in the female ae
removal of the diiori^ for its cure. Them can be no
that self-abuse is not limited to the male sex, and tl
sometimes become addicted to it ; and it must have hi
all pi-actitioners of medicine to receive occasional paini
sions from women who were unable to overcome a \ice, i
in which polluted their thoughts, or who traced the
sexual feeling in married life to habits contmcted in
hood. Such cases, however, are by no means frequei
seems doubtful whether the practice of masturbation
such injurious physical ellects in the female as in thft
ject, though it is impossible to over-estimafce its bani^
on tfie moral feelings and the sense of self-respect.
If the habit could be overcome, if the mind could 1
to its purity by any mutilation of the person, one wool
no penalty could be too great to pay for such a boon,
of sexual feeling is, however, by no means confined to ti
habitual masturbation brings mth it no change in the oi
is not alone by irritating it that some women who have s'
lowest depths earn for themselves a nauseous living bj
ing to the passions of the most abandoned of their owi
by removing the clitoris would the habit be broken t
the means of indulging it removed *
The operation was therefore entirely nnphysiolog
there were circumstances connected with it which
• With reference to the absence of any cbango in tbe sexual or
acxion witli habitunl masturbation, the staU^ments of IHmmt Dadls
ciai¥o :— ** * Toun l«j jours on rc9oit dans In prison d«« proetlta^ q
dfl 008 filles d'une laacivetc effren<W, on de ces fetnmca, plus laa
adonniefl an vice houteux dont j*ai parU ; on examine caa femm«
AQtres^ et jamais elle^ n*ont pMaent^ daaa bsar organisation, U radn
lea diatin^&t dn restc dea proiititiiiSeey on da oommtm des femmeii''
datts la rUU de Parii, Paris, IS57, 3d cd. voL i p. 111.
ITS FOLLICULA.R DTFLAMMATION.
653
ail riglit-minded men to condemn alike the proposal and the pro-
poser. Happily we need not now dwell further on the subject,
for all practitioiiei-s am af,T*eed that the only indication for removal
of the clitoris is furnished by disease of the organ itself*
M, Huguier has described, with extreme minuteness, in the
Mejruyirs of the Amdemy of Medicine of Faris^ the diseases of the
sebaceous and piliferous follicles of the vulva. He speaks of a
condition of acne of the vulva, in which the contents of some of
the eebaceous follicles accumulate without any obvious cause.
The number of follicles so affected k not in general considemble,
thou^^li like acne of the face, which in all respects it closely re-
sembles, the atlbction is extremely chronic, and difterent folUcles
are apt to become diseased in successioiL The accumulation of
their contents, too, sometimes occasions inflammation of the fol-
licles, and then that disease is produced which M. Huguier terms
mdvar foiliciditis, and which has occasionally come under my
observation, though far less often than it and other ailments of
the external organs present themselves to one who has so peculiar
a field as is furnished by the Edpital de Lourehu, This affection,
which he states to be most frequent during pregnancy, may occur
also at other times, induced by local irritation of any kind, and
especially by habitual want of cleanliness. It is characterized by
the appearance in the fold of the thigh^ on the outer surface and
free edge of the labia, on the nympke, and on the base of the
pnepntium clitoridis, of little red rounded papillie, which at tirst
scarcely exceed the size of a pin's head ; some of them being
distinct, while others are collected together into irregular pat€he8.
By degrees these follicles, at first merely congested and enlarged
by the accumulation of their contents, become more inflamed, a
little drop of pus may be seen at their apex ; they then usually
burst and shrivel, though sometimes they wither without having
previously diacharged their contents*
The ailment, if left untreated, is chronic in its course, and the
follicles take as long as twenty or thirty days, or even longer, to
pass through the three stf^es of eruption, suppuration, and desicca-
tion, wliile successive crops will run the same course and protract
the disease for weeks or months. It is, however, amenable to
very simple treatment, such as rest, cleanliness, baths, the em-
• VoL rv. 527.
654
DISEASES OF THE TULTA :
U'
ployment of mild astringents, such as the lead lotion^
solutions of nitrate of silver.
From these eruptive diseases of the external oifl
now to the study of some other affections, not so siB
their character, though stUl seated exclusively in the i
and io the subjacent cellular tissue. The correct class
these diseases is very difficult, for while some are und
syphilitic character, others belong to the same category
and are quite independent of venereal taint, and of
pass by gradations difficult to seize into the same qS
doubted epithelial cancer. *
I do not pretend to say anything concerning the ;
varieties of sy^ihilitic disease of the external organs.
my familiarity with them is hut small I have, how
eionaUy met with what wotdd seem to have been form£
syphUu^ but which had been of such long 8tandiii|
proved so rebellious to treatment, that questions had
as to whether they were not really of a malignant d^
Such a case was that of a patient, aged forty-M
admitted under my eare witli ulceration of the extemi
a year's duration, which appeared to have caused no
siderable inconvenience than occasional difficulty in le
nrine» On the inner surface of her left labium, and es
to the nympha, was a sore of a semicircular form, sligl
lar in its outline, its edge^ somewhat indolent, its siirfi
by tolerably healthy granulations. The concavity of tl
directed upwards, its convex edge downwards, begii
natTow edge about a quarter of an inch below the c
extending down to within about three-quarters of an
lower part of the leffc wall of the vagina. The cic
similar sore occupied the inner surface of the right nj
the right side of the entrance of the vagina, and a sm
of its lower edge was still unhealed The orifice oi^
was red and ulcerated, but it was not umiaturall;^
uterus was healthy, and there was no enlargement of
in the groins.
In this patient there were no other venereal symptoi
she confessed to having had sores accompanied by bubc
sore throat, fourteen years previously. Recovery, anc
d
TERTIARY SYPHIUS : LUPUS.
655
incfttri;5ation of the Borea took place in three months, under the
continued employment of the iodide of potass, with the black wash
externally, and the occasional application of nitrate of silver. Other
doubtful cases which have come under my notice have neither pre-
sented any evidence of syphilm, nor has it been possible to obtain
from the patient'a statements any proof of its pre\"L0U8 existence.
The danger in such cases is scarcely of taking them for scinius,
but rather of confounding them with some forms of epithelial
carcinoma. The stony hardness of a scirrhous labium or nympha
has in it something very characteristic^ and the sore which forma
on the mucous surface at that early stage when alone mistake is
possible, is a mere superficial abrasion of epithelium, not a distinct
ulcer with raised edges. Genuine epithelial carcinoma, beginning
on the external parts, is less apt to extend up the vaginal canal^
and does not show the same exclusive preference for the mucous
surface of the labium ; while when ulcerated, its hardness usually
extends deeper, and its surface presents a more coarsely granular
appearance* From rodent ulcer, or lupus, the diagnosis is more
difficult In that, however, the base of the ulcer is usually more
indurated, and an indurated state of the integument extends
^ beyond the limits of the ulcer, producing in very many instances
^ a marked contraction of the orifice of the vulva ; while, further,
this disease is seldom limited to the inner surface of the labia, but,
in general affects their posterior part, the posterior vaginal wall
for a short distance, and also, in many instances, the vestibulion ;
a greater extent of surface than syphilitic disease commonly
involves, while lastly, in a large number of cases, there is associ-
ated with the ulceration a very remarkable disposition to hyper-
trophy of the labia and nymphae.
This last peculiarity led M* Huguier,* who was the first person
to give a minute description of this disease, to propose for one of
ita varieties the name of luptis hypertropkiciis, designating its
other forms lupiLs serpi/finoHus^ and lu^nis pcrfarans. In most in-
stances, however, the characters are so blended as to render it
doubtful whether there is any special advantage in these subdivi-
sions. The affection may be briefly described as a form of
»• Bee hmMiminre mr rEdkiom^ne fie la lUgi<fnvulm-anaU^ in Mhni, de VAmd
de Midedne, 1849, voL xiv. p. 507. The eograviiigs of Uie disease are mnarkftblj
chafractemtic of iU pecoliar featurcts.
ulceration, attended by little paio, which creeps
vulva, healing at one part while it advances at anotl
in its progress towards healing, but also exteading sloi
irregular^ usually rather overhanging edges, the tiflB
and of the parta immediately around, is hard and o
It is, moreover, attended by a disposition to hyperti
parts not destroyed by idceration^ as for instance, of H
nymphffi, and by the formation of condylomatous growt
entrance of the vagina, and the orifice of the anus, wl
themselves also become ulcerated. It is a further cl
of this affection, that the ulcerations in healing tend
gi-eat contraction of the orifice of the vulva, by th
of a firm cicatrix-Hke tissue, which also usually occupi
extent of surface than the ulceration had done which
M. Hoguier's essay contains an account of nine c
disease, and five have come under my own observati0
total of fourteen cases, all of which occurred in womfl
cither married or were known to have indulged in s
course, with the exception of one of M. HuguioEi
concerning whom no mention is made ou this point,
of M, Hoguiers patients, and only one of mine, had hi
a peculiarity which seems scarcely accounted for by
ment which, when the disease has reached an advani
may present to sexual intercourse,
[A case to which I was called some years ago is,
know, so unprecedented in the amount of destructic
worth describing. I only saw it once in consultation
ease was at one time regarded as cancerous. The p
about forty, had had the disease for at least five yei
lived many years after my \isit While the disease ^
extensive, she bore a cliili On the hips, just beyond
tuberosities, were long scars, thin and bluish, of ho
The entire anoperineal region was gone, there bein
space as big as a fetal heai The uretlu^ was entire
the mucous membrane between it and the cervix u
was healthy. Except the anterior portion of the vagii
of it or of the rectum or anus was discoverable. '.
cervix uteri the bowel opened by a tight aperture jui
to admit a finger. When the faeces were hard she <
d
LTPCa.
657
Diwue i^d to
hvn iMgnn.
Veara. MoDthi.
18 6
20
6
20
6
22
0
21
0
25
0
29
0
Patients came under
ootice at aga of
Years.
$2
DiBMse aitid to
haYe begUEi.
Years. Months.
elf clean, but only then. Although the extent of ulceration
^m eaormous, the patient was attending to her household duties.]
The influence of age in the production of this disease is shown
in the following table : —
Pfttieuta came aud^er
notice at age of
Yeara.
20
21
22
24
26
26
30
Or, in other words, the disease hegan.
Under 20 years in 1 case.
Between 20 and 25 „ 4 „
„ 25 „ oO „ 5 „
„ oO „ 00 „ 2 „
At 45 1 „
„ 66 1 „
T4 „
be duration of the ciiaea.se, including the time during which
the patients remained nnder observation is shown in the following
table:—
EeHnlts,
mb(
jr. J.
iOTttUoil,
Ciireil.
Relieved.
Not R«lieT€d,
Died.
1
under
1 year
1
..♦
^..
...
3
n
18 months
•2
1
.*.
3
i»
2 years
...
2
...
1*
1
^1
3 „
..*
1
...
■ • •
1
n
4 „
1
• . »
■ . >
...
4
between
8 and 9
, , ,
3
.**
1
1
If
10 „ n
» > •
. . »
...
1
I 14 4 6 13
It is quite evident that between this aSection, which runs a
i course so uniformly slow, which admits of cure after tlie lapse of
more than three years, and of great relief even after eight yeara,
and any kind of malignant disease there must be an essential
L^ This patient died under chloroforro, ttod not from the idTanee ot the dl^eaaft.
M
difference. Moreover, when it runs a fatal cou»«
destroy life as cancer does, either by attacking som^
or by involving;, as it extends, all the tissues
morbid change, but death takes place from peritoniti
on the formation of fistulous communications betwee
and rectum and the contraction of the bowel whose iw
come implicated in the disease. The microscope,
the distinctions which observation of the general fe
disease suggests*.
With reference to the distinction between these ul<
such as are really of syphilitic origin, it deserves r
one case only of M Huguier's did tliis disease a;
grafted on sypMlitic mischief ; while in the other tl
thougli one of the patients was a prostitute, and some
had undoubtedly exposed themselves to the risks <
not one presented the slightest symptom of any venei
The genemi character and progress of the disease
be best illustrated by the history of the case of a i
thirty, who was admitted under my care into St Bl
Hospital in June 1850. She had then been marrie
had given birth to one child at the full period, and
miscarried from fright at the fifth month, a year hef<
under my notica She always had good health, thou
stniation was irregidar, until after her labour, which i
natm-al She got about, however, too soon after her
and to this indiscretion she attributed a leucorrhcei
* The foUowing meiDoruidiiiii wm made by Sir J«niM Pigot of
mniic by bim zftoT the deatb, under clilorofonn, of a yoting woman
of thia kind hiid «3tiiit«d for eightefin months t — ** In tho xiuiteri*l m
free surface of tho upper ulcer there were «o many smnll apithd
TuriouA fihnpeB, witb well-marked nuclei and nuclcoH, and yarioiw g\
that epithelial i^n*?er mijjht have lK»€n ausiwetwi But aU thtm
nuclei were BtnAU, there were no Uniinittod epitheUal corjiOAclai^ t
most significant) when I eiamined theHubatance of its biwe, taking i
and (rum immediately bencatb its surfacf}, I found notHing but tlie
of the mucous membrane, with infiltntedi inflammatory, or rsptr
. . . « . On the whole, the result of the miDroscopic examiEAti
certainly that the chHracters of these iilcen» are like those of oommoi
no new-formed strueturw of peculiar or specific form. If the ouitef
the surface of the ulcer hod b^cn examined during life^ they wo^d pa
to a dia^noeis of epithelial caiioer. They were, however* I imagin«, dii
cells from adjacent parti of the mucous membrane, or perhapt fn
pert of the enrfaice o( tbffi tdcex**' ^
LUPUS.
659
ently streakef! with blood, from which she had suffered ever
since. This discharge had bec^Die more profuse since her mis-
carriage, hut, with the exception of slight pain iB the back, she had
not experienced any other incoevenienca until two montba pre-
viously. Since that time, however, she Iiad had a good deal of
pain, both in micturition, and in sexual intercourse, and the dis-
charge had beox)me yellow, tliick, offensive, and escaped in gushes.
The patient said that ^he had lost flesh, but she did not appear
either enunciated or seriously out of healtlh
■ The labia and nymphte were much swollen, but not diseased ;
a very abundant dirty puriform discharge escaped on separating
them. A red, granular, bleediii}^ ulceration, with a hard surface,
slightly painful to the touch, and bleeding readily, surrounded the
urethm, while the finger intfoduced into the vagina discovered a
continuation of a similar condition extending upwards for about
■an inch in breadtli, by an inch and a half in length. That part of
the disease, however, which extended within the vagina was not
entirely in a state of ulceration, but a thickening and uifiltratton
of the tissues reached for some <iistance on either side and the
actual ulcenition was of very limited extent On the posterior
vaginal wall, a little distance from the orifice of the canal, was a
small hard tubercle, the size of the top of the little finger, covered
by unchanged mucous membrane. Six months later, the external
parts were more tumid, and both they and the inside of the thighs
were excoriated by the profuse discharge. The tuljercle on the
posterior vaginal wall remained unaltered, but a strip of ulc43ra-
tion was creeping up on either side. Five months hiter, or in the
middle of May 1851, tbe patient became again pregnant, and on
■ Febniarj^ 19, 1852, she was delivered of a live female child, after
a labour of little more than Hve hours* duration. The tubercle
at the posterior wall of the vagina had somewhat increased during
Iter pregnancy, and the perineum felt hard and brawny. It
fgave way during the passage of the head, but, nevertheless, tlie
^patient passed through the puerperal state without any bad symp-
tom, and on the 18th of March was again received into the hospital.
The labia were then greatly swollen, but neither from anasarca,
Bor from intiammation. Their surface was pale and much
wrinkled, like the hand when long soaked in water, while the
whole of tbe integument felt thickened like that of a part aflected
elephantiasis. The n}T)iphtie were also greatly enlarged, and
6 GO
DISEASES OF THE YTTLVk :
i $xA*
projected between the labia, but otherwise their tissue iV\*\ not
appear to be much altered, except on their inner ulcerated surfiuxL
On separating the njrmphae an irregular ulceration was seen mi*
rounding the urethra, which it seemed to have partially detadied
from its superior connexions, and passing up under the sTtopfayss
pubis. The clitoris appeared to have been destroyed by Hm
ulceration, which extended up quite to the superior commtmao fl
of the labia, whence it passed on to the inner surface of tlie"
n)rmphae, while pale rose-coloured warty granulations, exactly
like those of the ulceration, suirounded the edges of the uretbre,
and formed a prominence about it almost of the size of a hazel-ani
The edges of the lacerated perineum were cicatrized to the exteOt
of about a third of an inch, but the rest of the ununited margins of j
the labia, and the walls of the vulva and vagina as far as conU i
be seen, were of harder texture than natural, semicartilaginons^ ol j
a pale rose red colour, destitute of epithelium, smooth and not j
granular-looking, but just like a section of a scirrhous mass, i
pouring forth a copious sei'o-purulent secretion* A gretralsti
ulceration extended for between half an inch and an inch alo
botli walla of the vagina, that on its posterior wall ceosing at the
base of the tubercle abeady mentioned as situated therei.
Tlie removal of tlie nynipha' was followed by great geo*
amendment, and by partial cicatrisiation of the sore that swrrou
the urethra. Tlie gmnuhir outgrowth immediately at its <
had by the end of Jlay lost nearly the whole of its pretematii
redness, and was covered, as were the condylomatous gron
mth pale mucous membrane. The inner surface of each labiv
wliich looked before like sections of carcinomatous growths
covered by healthy mucous membrane. On the 8th of July IBBi
just two years from the patient's first coming under my not
there no longer existed any jvositive ulceration, though in othe
respects matters continued much as before, except that a vtvidt^
red, thoiigli but slightly sensitive excrescence, as big as the tip i
the little finger^ now sprouted from the wall of the urethra \
quite filled up its canal, while the papiUie which l»eset its msxgin
continued as befora
From this time I never saw the patient again ; but tl
imfiuished history display's the peculiarities of the disease,
slow progress, and its partial amendment. I wish it ilhistmt
more favourably tbvi t^ults of tt^atnient, though indeed thf''
LUPUS : ITS THEATMEXT.
661
j left tlie hospital better in many respects than when she
it, and tLia in spite of its never having been possible to
I induce her to remain there fmm more than three months at a
time. To a certain extent good diet, rest, cleanliness, the use of
the hip-bath, and simple tmirritating lotions improve the state of
the ulcemtions; and I have sometimes liafctered myself that
cicatrization would speedily take place. In a few vreeks, hpwever,
the limit of this improvement has usually been attained, and the
- patient hiia passed from under my care benefited indeed, but by
f no means cured. In the only instance in vt^hich complete recovery
took place, the patient was kept steadily on a course of mild
mercurial medicine with small doses of the iodide of pottiasium for
nearly two mouths. In this instance, however, the ulceration ilid not
date from longer than seven months previously, and the amount of
thickening and hypertrophy of the nympht« was inconsiderable.
In other cases I have employed preparations of mercury, iodine,
■ and arsenic, without having been able to attribute to any one of
them a special influence over the disease, and the experience of
M. Iluguter does not in these respects differ from my own. One
point to which he refers is of great moment, namely, the expedi-
Iency of renioving the nyniphie, or any of the adjacent parts, -which
may readily admit of extirpation, provided the ulcerations upon
them appear indisposed to heal. I should indeed be inclined to
advocate in every case the removal both of the ulcerated nympha?,
and also of all those papillary or condylomatous excresceuces
which beset the orihce of the vulva, as a preliminary step to any
attempt at the cure of the disease. The opposing surfaces keep
up mutual irritation, while the hardened tissues prevent any
application being etlectually made to the ulceration about the
H vestibule. The outgrowths, too, around the vuha are apt to
■ become the seat of ulceration, and also to increase by their presence
the probabilities of the occurrence of a relapse. I am unable to
say to what extent the use of the stronger caustics, such as the
acid nitrate of mercury, may be of service in those instances in
which the ulcerations are most indolent, but I am inclined,
though from very slight experience on the subject, to think that
where its application is practicable, the influence of the actual
cautery is more beneficial in modifpug the state of the parts than
that of any kind of chemical escharotic.
Malignant disease of the external parts usually assumes, as
L
662 DISEASES OF THE VULVA :
might be expected, the form of epUTvelial cancer, though a case of
scirrhus of the labium, and one of fungoid disease of the vulva
have both come under my notice. Epithelial cancer generally
commences in the fonn of a little hard tubercle on the outer
surface, but near to the edge of the labium, and without being the
seat of positive pain, is yet, in most instances, a source of annoy-
ance by the smarting and itching which it occasions. It may
continue thus for an uncertain period — for several months,
perhaps for longer — ^till at length its surface becomes abraded, a
serous discharge exudes from it, and then, completely losing its
epithelium, it presents the appearance of a circular sore seated on
a hard, somewhat raised base. It now spreads by ulceration, the
ulcer always retaining somewhat of a circular form, while with its
extension the indurated base also reaches further and further
beyond the limits of the ulceration. It constantly displays an
indolent character, its edges being hard, and its surface depressed
a little below the level of the surrounding integument The
granulations so distinctive of the ulceration of epithelial cancer
are frequently kept in check by the constant attrition of the
opposing surfaces of the labia, for it is worth notice that, though
the disease usually commences at the edge of the labium, the
ulceration generally advances inwards towards its mucous surface,
and comparatively seldom spreads outwards on the integument.
From the inner surface of the labium it next involves the nympha,
the praeputium clitoridis, and the clitoris itself , which parts, before
they are attacked by actual ulceration, generally become red,
abraded, and finely granular on their surface. For some time even
after the ulceration has taken place, the inguinal glands continue
healthy and are not enlarged, and the general substance of the
labium is not afifected. Presently, however, the ulceration extends
in depth ; as it does so, it grows more irregular, and the granula-
tions that beset its surface become larger, while the whole labium
now looks red and swollen, feels hard, and slightly irregular, and
is very tender to the touch.
There is little difficulty in filling up the picture with the few
dark touches needed to complete it. The disease sometimes
destroys the labium, and then extends upon the integument of the
thigh as a deep excavated ragged ulcer, which yet does not in
general discharge much, nor invariably occasion severe pain. At
other times a gland ^NveW^, m^\^»aR» ^c«^\S\:^ ycl «a.^,\5B& ^Jes^ <s^^
lPn?HELIAL CANCEH,
663
it then dies, and a large cancerous ulcer is left behind, while, as
the disease advances, the patient loses health and flesh, and fades
away, not destroyed by hitiniorrha^^e, as in uterine cancer, nor by
any means constantly worn out by pain, for that is usually toler-
ably amenable to opiate remedies*
I should perhaps mention that I have seen one iuatance of the
commencement of epithelial carcinoma, not on the cutaneous sur*
face of the labium, but on the outer surface of the left nympha
in a young married woman thirty-one years old. The disease had
the form of a deep hole, with ragged edges, apparently about large
enough to contain a niit, but the edges were so close together that
it was impossible to see to the bottom of it, while any attempt
to separate them in order to obtain a good view gave so much
pain that it was forced to be abandoned. Its edges and surface
were made up of small red semi-tr;inspai'ent granulations of the
size of a pin's bead, aud rernaikaljly characteristic of epithelial
cancer. The commencement of the disease was referred to a fall
against the edge of a chair five months before, wlien the patient
hurt the external parts very much, and suflered from prt*fuse
haemorrhage in consequence. She would not submit to an opera-
tion theu, but returned to the hospital a year afterwards, when
all interference was out of the question, for the ulceration had
destroyed tlie labium, and extended to the thigh. The poor
w^oman had followed her occupation as a weaveress almost to the
time of her admission, had suffered much, had fared ill, and had
taken to opium-eating for rebel She was transferred to the work-
house, but I do not know when she died.**
Our data are hardly sufficient to deteiTuioe satisfactorily the
duration of this disease. I beheve, however, that the tubercle which
precedes the development of the carcinomatous sore may exist for
a long period, even for several years, though I do not imagine this
usually to be the case; but tliat when the process of ulcemtion
lias commenced it runs its course to a fatal issue within two years.
In the treatment of epithelial carcinoma the one great question
to decide concerns the possibility of its removal If let alone, at
any rate after ulceration has commenced, its progress is invariably
• I have alflo seen one insUnce.in a woman aged thirty-four, of the simul-
toneous oceummce of mulign&iit alctralion of thf interior of the Ixibm and jij^tnphpe,
and of epitheliftl carcinoma of the akin o?er the pul^s. Ik'ath took place in twenty
months. There was infiltration of cancerous matter into the body of the uterujs, but
iti oarrix was healthy, aud no ^econdury deposits exiated in any other organ*
664 TREATMENT OF CANCEB OF THE VULVA.
to a fatal issue ; and any of the local applications which may be
tried in ulcerations of a doubtful character on other parts can
never be efficiently employed in diseases of the external sexual
organs of women. I have not experience enough to say in what
proportion of cases the disease recurs, or how long a period of
immunity may be hoped for after its extirpation. Of this, how-
ever, I am sure, that present comfort is promoted, that life is
decidedly prolonged, and that a chance, if but a slender chance, at
any rate the only one, is thereby aflforded the patient of a per-
manent cure. The surgery of the operation lies beyond my
province ; the only suggestion that J would venture to give con-
cerning it is, that care should be taken to remove enough, and
that the operator should not, through fear of making too large a
wound, cany his incisions too near to diseased tissues.
[This remark is confirmed by the history of one of two cases,
out of many more of cancer of one labium, which came under my
care in the Eoyal Infirmary of Edinburgh, and which I mention
on account of their striking character. They were exactly like
one another, and had such physical characters as marked them
out as a distinct species to be described. Both were in otherwise
healthy women, who had borne children and had arrived at the
menopause or near it In one labium, which was not swollen or
oedematous, but merely distended, was a healthy-looking ulcer
with a circular margin. The base of the ulcer had a nearly
uniform thickness of about a quarter of an inch. This base was
so hard as to maintain the shape of the fiat circular ulcer, as if a
penny had been stitched into the skin. The ulcer could be easily
isolated from the apparently healthy neighbouring parts. In
both, the diseased mass was amputated by galvano-caustic. One
patient returned home apparently cured. The other returned home
in a much worse state than that in which she came ; the whole
labium being a mass of cancerous hardness with much ulceration.]
INDEX.
PAOB
Abdomkn, ezaminatioii of 11
encysted dropsy of 666
floating tomoan of note, 667
Abortion, share of, in prodaction of uterine ailments . Ill
cause of inflammation of uterine appendages .... 428
Adenoma of uterus 188,889
Amenoirhoea, from defective formation 29 .
mechanical causes 82
in opposite states of the system 87
suppression of menses 48
Ticarious hemorrhages in 46
treatment of 42, 61
Aniemia, a cause of amenorrhoea 87
Anteflexion of uterus, a natural condition 190
comparative frequency of it and of retroflexion . . 189
Anteversion of uterus 186
Ascent of the uterus, its causes and import 289
Ascites, diagnosis of, from ovarian dropsy 649
Atresia of vagina 82
operation for 84
Bladder, distended, diagnosis of, from ovarian dropsy .... 666
prolapsus of 146
its characters, and mode of production , 147
effect on the uterus and kidneys 148
symptoms 166
treatment 168
various modes of examining it 609
affections, often secondary to those of uterus .... 690
inflammation of 691
chronic 692
relation of, to disease of kidneys 694
treatment 697
fungous tumours of 606
malignant disease of 606
666 INDEX.
PACT
Blood, alterations of, as cause of amenorrhoea 89
menorrhagia 64
Boils, affecting the labia 640
Cancer of the bladder 606
of the vagina 681
oftheyolvB 662
of uterus 844
definition of it . ' 346
scirrhous cancer . 846
medullary cancer 848
ulceration of 849
attempts at healltig 850
general changes in uterus 852
on its exterior 858
affection of the bladder in 856
of body of uterus 857
cancerous polypi 858
alveolar 859
epithelial 859
cancroid ulcerations . . 863
secondary deposits in 865
relation of, to fibrous tumours 266
diagnosis of, from fibrous tumours . 284, 895
simple induration .... 893
frequency of . 867
influence of age on 869
uterine functions 871
influence of pregnancy and labour . . . 872
hereditary predisposition .... 875
symptoms of 876
pain 877
occasional absence of 879
hemorrhage 881
discharge 883
cancerous cachexia 885
sometimes latent 888
acute cancer 889
complicating labour 890
duration of 896
treatment 898
of the hsemorrhage 400
pain 402
discharges 405
cachexia 406
labour with 408
extirpation of uterus 410
excision of cervix uteri 412
employment of cold 417
caustics and of actual cautery . . 418
INDEX. 667
PAOB
Cancroid ulcerations of uterus 860
Catarrh of cervix uteri 123
use of zinc alum in 125
Cauliflower excrescence 860
Caustics, mode of applying to os uteri 122
use of in cancer of womb 418
Cautery, actual, use of in cancer of womb 419
Cellulitis, pelvic 421
Cervix uteri, comparative physiological importance of it and of body of
uterus 110, note 111
chronic catarrh of 128
sometimes chief source of dischaige 124
use of zinc-alum in 125
hypertrophy of 99, 127
in cases of prolapsus 140,144,147
excision, on account of 100
cyst-formation in note, 128, 241, 247
removal of, in cases of cancer 412
Chloroform, vapour of, as local ansesthetic 404
Chlorosis 89
Cirrhosis of the ovary 498
Clitoris, its excision in cases of masturbation 652
Coccyx, pain at, or coccygodynia 650
Corroding ulcer of uterus 864
Cowper's gland, inflammation of 688
Cretins, puberty late in 86
Cysts of cervix uteri note, 128, 241, 247
diagnosis of 250
treatment of 252
on exterior of uterus note, 492
in connection with cancer of uterus . 854
of ovaries, varieties of 497
their comparative frequency . . . 516
Wolffian bodies 498
vagina ........... 627
Diabetes, a cause of pruritus of vulva 4, 646
Diagnosis, errors in, illustrated 8
Digitalis, use of, in menorrhagia ^8
Diseases of women, study of^ important 1
errors committed in 8
disturbance of function in 5
I sensibility in, ' 7
exaggerated estimate of note, 9
Dysmenorrhoea 71
neuralgic 72
its treatment 81
congestive 78
membrane expelled in 75
its relation to gout and rheumatism ... 76
668 IXDEX.
PAOB
Dysmenorrhoea, congestive, its treatment 84
treatment of rlieomatic cases .... 87
mechanical 78
alleged inflaence of nterine flexions on . . 80
its treatment 88
extirpation of ovaries for 90
jScraaeur, for amputation of cervix uteri, dangers of . 100, 416
Eczema of vulva 641
Emansio Mensium 36
Emmenagogues, remarks ou 44
Emphysematous vaginitis 626
Endometritis 70, 127
occurrence in fever 128
purulent form of 129
possible rektion to malignant disease .... 129, 132
hemorrhagic form of 130
treatment of 132
Enlargement of uterus, from defective involution (see Hypertrophy) . 96
Enucleation of fibrous tumours 803
Examination in diseases of women, rules for 10
of abdomen 11
vaginal 13
by rectum 14
with sound ..... 15
speculum 21
Excision of portion of wall of ovarian cyst 578
External peritonitis 437
Extirpation of uterus, when procident 177
inverted 229, 234
in cases of cancer . 410
Fallopian tube, its unnatural patency note, 96
disclu^ge of ovarian cyst through it .... 622
Fat cysts of ovary 611
Fatty tumours of uterus 837
Fibrinous polypus (see Polypus) 253
Fibro-cystic tumours of uterus note, 261, 329
polypi note, 255
Fibroid (recurrent) tumours of uterus 830
Fibrous polypus (see Poljrpus) 320
tumours of uterus, general characters and microscopic structure . 257
relations of, to uterus 258
size and number 261
containing laige cysts . note, 261
spontaneous cure of 262
softening of 268
calcification of 266
relation of^ to malignant disease . 266
frequency of ....... 267
influence of age on 267
INDEX. 669
PAOB
Fibrous tomoan of nteniB, inflaence of marriage on 269
symptoms of 270
inflaence of, on fecundity .... 278
state of ntems in 276
diagnosis of 278
from ovarian tomoor . . 280, 646
abortion .... 281
flexions of ntems . . . 283
cancer of ntems . . 284, 895
associated with intense pain 285
from pregnancy .... 287
prognosis of 291
complicating pregnancy . . 298
treatment 296
nse of iodine 298
the Krenznach waters 299
chloride of calcium ... 802
surgical treatment of . . . 808
extirpation of . . . 308
of labour, complicated with 811
unusual varieties of 815
Fibrous tumours of vagina 629
Fistula, intestino-vesical 604
vesico-vaginal 601
Fleziona of uterus 181
how produced . 187
comparative frequency of ante and retro flexion . . 189
anatomical results of 191
congenital 190, 198
symptoms of 194, 201
alleged cause of dysmenorrhoea 80
their importance overrated 196
symptoms of, accounted for 200
diagnosis of . 206
treatment 208
employment of mechanical means . . 210
Follicular inflammation of vulva 668
Formulae, aperient, chalybeate 48
astriugent 65
antiphlogistic, sedative 68
mucilaginous 407
anodyne liniment 119
for cases of cystitis 698
sedative lotions 642, 646
Gangrenous inflammation of vulva 637
Gonorrhoea, its diagnosis not always possible 618, 620
a cause of acute metritis 102
Granular vaginitis 625
Hsematocele, uterine, its nature 462
670 INDEX.
PAQB
Hsematocele, uterine, 83rmptom8 and course 456
cases illustratiye of 459
diagnosis 440, 467
prognosis 471
treatment 473
indications for puncture .... 475
Hair in ovarian cysts 507, 512
Hodge pessary 164
Hymen, imperforate 82
Hypertrophy of uterus, from defective involution 95
from sterile marriage 97
of cervix only 99, 127
partial 24S
Hysteria, peritonitis stimulated by 4
Idiots, puberty late in 36
inflammation of uterus, difficulties in its study 101
acute, its causes and symptoms . 102
treatment 104
chronic 108, 112
treatment 116
uterine appendages (see Uterus, appendages of) . 421
Intestino-vesical fistula 604
Iodine, injection of, into ovarian cysts 581
its dangers and results 582
points on which information needed .... 583
Intra-uterine injections, in menorrhagia 67
Inversion of uterus 218
its causes 219
symptoms at time of its occurrence ... 221
in chronic state . 222
spontaneous replacement of 224
diagnosis of, when chronic 233
treatment — attempts at replacement .... 226
extirpation of uterus . 229, 234
from polypus 236
Involution of uterus, how effected 94
results of its interruption 93
Irritable uterus 77
Kidneys, atrophy of, from prolapse of bladder 148
in cancer of uterus 879
disease ol^ producing symptoms of cjrstitis .... 594
Kreuznach, waters of, in cases of fibrous tumour 299
Labia, cohesion of in infancy 83
inflammation of . . . 637
boils on 640
cancer of 662
Labour, share of, in production of uterine ailments Ill
cause of inflammation of uterine appendages .... 423
complicated with fibrous tumour 298, 811
INDEX. 671
PAOB
Labour, complicated with polypus . . 828
cancer 391, 408
induction of, prematurely, in fibrous tumour . 814
Leeches to uterus, how applied 85
caution with reference to their use 104, 117
Leucorrhoea, its sources 116
treatment of 119
ceryical 124
treatment of 125
vaginal, microscopic character of 620
treatment of 628
Lupus of Yulya 655
Malformation of sexual oigans, a cause of amenorrhoea .... 29
Masturbation, removal of clitoris for 652
Maturity, sexual ; menstruation no proof of 28
Menorrhagia, its causes twofold 52
constitutional causes of 54
from local causes 57
occasional death from 65
its treatment 60
of cases requiring antiphlogistics ... 61
use of astringents in 64
digitalis in 68
local measures in 66
scraping uterine mucous membrane in . 59, 69
intra-uterine injections in 68
Menstruation, its occurrence no proof of sexual maturity .... 28
various causes of its disorders 6, 25
disorders of, referred to three classes ..... 26
first, average date of 27
tardy, usually difScult 27
precocious note, 58
suppression of 48
its treatment 51
excessive (see Menorrhagia) 52
Metritis, acute 102
Molluscum of uterus 888
Kabothian bodies ; their nature 128
enlarged 247
Nubility, menstruation not proof of 28
Obliquity, congenital, of uterus 198
Ovaries, special function of 5
defective development of 29
extirpation of, for dysmenorrhcea condemned .... 90
displacement of 490
hernia of note, 492
Inflammation of 477
in cases of acute metritis 103
rare in an acute form 481
672 INDEX.
PA«B
Oyaries, inflammatioii of occasional occurrence of aTMoess .... 4^2
most frequently chronic 485
symptoms of chronic ovaritis 486, 489
treatment 488» 481
cirrhosis of 493
cysts o( simple cysts of, connected with Wolffian body . . 498
from enlai^ged Graafian vesicles 501
from other causes 504
sometimes stationaty .... 518
disappear .... 520
compound cysts 506
cystosarcomatous 509
colloid cysts 509
cancerous 511
fat cysts 511
cysts of, frequency of different kinds of 516
discharge of, by yarious chann^ 522
danger of rupture into peritoneum 526
twisting of pedicle of 528
inflammation of 529
solid tumours of 588
Ovarian dropsy, disorder of health from 580
predisposing causes of 582
exciting causes of 536
early s3rmptoms of 587
advanced symptoms of 540
diagnosis of 279, 469, 544
prognosis of 561
treatment 560
palliative 564
tapping in 566
radical 577
tight bandage after tapping . . 577
sub-cutaneous puncture ... 578
puncture per vaginam .... 579
maintenance of opening 579
excision of portion of wall 578
iodine injections 581
extirpation of ovary .... 584
Ovariotomy 584
often impracticable 584
its mortality 585
indications for and against it, stated 586
Parovarian cysts 499
Pelvic cellulitis 421
diagnosis from uterine hematocele 440
Pelvi-Peritonitis 427
Peritoneum, rupture of ovarian cyst into 626
Peritonitis, hysterical 4
INDEX.
673
Peritonitis, external ....
Pessaries, their different kinds
rules for their introduction
Plethora, a cause of amenorrhcea
Plug, in cases of mcnorrhagia .
Polypus of uterus. Mucous polypus
Glaudular
symptoms of
source of hiemorrhage in
diagnosis and removal of
Fibrinous
its nature, symptoms, and treatment
Fibro-cystic ; its nature doubtful
Fibrous ; structure of . . .
source of haemorrhage in
relations of, to uterus
inversion of womb, by
symptoms of . . .
diagnosis ....
and of inverted womb
management of labour with
removal of .
Malignant
Pregnancy, share of, in production of uterine ailments
obscured by fibrous tumours .
diagnosis of, from fibrous tumour .
ovarian dropsy .
rendered dangerous by fibrous tumours
cancer
Extra-uterine, diagnosis from uterine htematocele.
Procidentia of utenis
its symptoms
treatment . • .
cautions in returning it
operations for its cure .
failure of all operations .
danger of Huguier's operation
extirpation of uterus for
Prolapsus uteri, its different degrees
anatomical arrangements which prevent its occurrence,
its causes,
mode of production in the aged
alterations in the uterus itself from it
complete prolapse, or procidentia
secondary to prolapse of vagina
symptoms of its earlier stages
complete prolapse (see Procidentia)
associated with pregnancy
its treatment .
nnte^
2lT
I'AQB
487
159
166
37
66
244
246
248
249
251
253
254
255
320
321
323
236
824
825
236
328
326
358
93, 109
289
288
555
293
408
467
136, 141
152
168
169
171
173
175
177
135
134-136
137
138
140
141
142
149
152
154
156
674 INDEX.
PAOB
Prolapsus uteri, mechanical support, when to be used (see Pessaries and
Supports) 159
rare varieties of 177
of vagina 143
a cause of hypertrophy of cervix uteri . . . 144
partial, of anterior or posteridf wall (see Bladder, pro-
lapse of ) 146
symptoms of 155
Prurigo of vulva 648
Pruritus 648
attendant on diabetes ^ . . 4, 646
Puberty, precocious note, 53
tardy, from various causes 27, 36
Puncture, subcutaneous, of ovarian cyst (see Tapping) .... 564
Rectum, prolapsus of 148
its treatment 161, 168
Recurrent fibroid tumours of uterus 330
Retroflexion of uterus, comparative frequency of it, and of anteflexion 189
Retroversion of uterus 179
mode of its production 181
causes of 183
diagnosis from uterine hematocele .... 468
ovarian tumours .... 547
Rodent ulcer of uterus 364
Rupture, spontaneous, of ovarian cyst 522
Sarcoma of uterus 330
its relation to cancer 336
Scarification of uterus : its uses 86
Scirrhus of uterus 346
Secretions, from sexual organs ; their various sources . • . 7
Sensibility, disorders of, in diseases of women 7
Sexual maturity, menstruation not evidence of 28
Sound, uterine ; by whom suggested 15
Sir J. Simpson's described 16
mode of introduction 16
risks in its employment 17
Speculum uteri, invention of 18
varieties of 19
mode of introduction 21
its value estimated 22
Support, mechanical, in prolapsus uteri 159
internal 159
external 166
Supporter, the uterine 210
objections to its use 211
Sterility, influence of flexions of uterus in producing it ... . 204
polypi 250
fibrous tumours 278
Syphilis, tertiary, of vulva 654
INDEX. 675
PAOB
Tapping in ovarian dropey 566
attitude in 578
its dangers estimated 568
exhaustion after 574
cyst-inflammation from 575
followed by tight bandaging .... 577
sub-€utaneou8 578
per yaginam 579
and maintenance of opening .... 580
injection of iodine 581
Teeth in ovarian cysts 511
Trichomonas, in vaginal leucorrhoca 620
Tubercle of uterus 389
ulcerations said to be tuberculous .... 360
Tumours, floating, of abdomen noU, 557
Ulcer, rodent, of uterus 864
Ulceration of os uteri ; its characters 115
importance formerly overestimated noU, 111
local treatment of 121
cancroid 360
Urethra, congestion of 610
vascular tumours of 612
chronic ulceration of 615
Urine, albumen in, from presence 6f leucorrhoea 4
Uterine sound (see Sound) 15
Uterus, absence of 31
irritable 77
diseases of 92
peculiarities predisposing to 107
influence of pregnancy and its results in their produc-
tion 92, 107
inflammation of 98
acute 102, 104
chronic 108, 116
imperfect involution of 98
chronic catarrh of 124
serous cysts of noUf 492
application of leeches to 85
sciurification of 86
granulations of its lining membrane (see Endometritis) . . 59, 70
cancer of 844
cancerous, extirpation of 410
inverted 2-29, 284
procident 177
appendages of ; inflammation of 421
its causes 428
not identical with puerperal fever 424
its relation to peritonitis . 427
tendency to suppuration 425
674
INDV
l*rolapsus uteri, mechanical supiwrt, wl
Supports) .
rare varietiea of
of vagina . . • •
a cause of hypir*
]mrtial, of aiir'
laps** «)!')
symptoms •
Prurigo of vulva
Pruritus .
attendant on ili'V
Puberty, precocious .
tardy, from v.i;
Puncture, subcutuiH"'.' . i
Kectum, proln]»Mi/> «■
its treat J«:
Kecurrent fibmi'l f •' ■ atmfiit
lletrotlexion '{* .
Retrovcrsi.»ji ■• • :rf.itiuri)
pull^•tl^
Rodin'.
Ruj'tm
: » aiicfiious
: into .
.ut previous to ojMiMlioi
• M* of
•. \r::«ti«'n (»f .
»vr:i'U remain stalumjiry
lisoatjc i)f utiiu:
l'..r
London, New Burlington Street.
May, 1879.
SELECTION
MESSRS J. & A. CHURCHILL'S
COMFRISINQ
I
' ALL RECENT WORKS PUBLISHED BY THEM
ART AND SCIENCE
07
MEDICINE
676 INDEX.
FAOK
Uterus, appendages of ; infiamination of, post-mortem appefirances, and pro-
cess of cure of ... 430
nature and analogies of . 431
its symi)toms .... 432
chronic course . 435, 441
diagnosis . . 436, 545
occasionally independent of pu(-r-
peral causes .... 444
its treatment . . . 446
puncture, when indi-
cated ... 450
Vagina, atresia of 34
prolapsus of 143
its influence on cervix uteri 144
its symptoms 145
acute inflammation of . . . . • 618
its treatment 621
chronic inflammation of 622
its treatment 623
cysts of 627
fibrous tumours of 629
malignant disease of 631
extension of cancerous disease of uterus to . . 355
rupture of ovarian cyst into 524
spasm of, or vaginismus 647
Vaginal hernia 177
Vaginitis 618
granular 625
emphysematous 626
Vesico-vaginal fistula 601
treatment previous to operation for . . 603
Vulva, diseases of 637
boils on 640
eczema of 641
pnirigo and pruritus of 643
follicular inflammation of 653
gangrenous inflammation of 637
tertiary syphilis of 654
lupus of 655
cancer of 662
Wolffian bodies, cysts of 498
often remain stationary 518
Zwanck, his pessary described 163
PRINTED BT NRILL AND COMrAXY, EDINBURGH.
■ INDEX 8 ■
?AOl
rAoa
JordiQ^ Surgtcft] Inquiries . . 6
Steiner's Diseases of Children . . 13
Leber and Rottcustcm's Dental Carie< 23
Stills and Maisch's Disiieiisatory . 13
L«e (H.) 00 SjpliiliR . . . S
Stocken'fl Dcntol Mnterm Medica . 12
Leared on Imperfect Digestion . • IB
Stowe's Toiicological Chart , , 20
Liebreicli's Atlas of Opbtlmlmoscopy 22
Sullivan's Tropic^ Diseases • . 17
lAxmng on Megrim, &c. . . . 18
Swain's Snrgical Emergencies * * 5
MacdoDJAld'a (A .) Diftcautc of tfa e beart 1 6
S Wayne's O^tetric Aphorisms • . 14
Mflcdotiald's (J. D.) Ezaminution of
Taa*8 Operatire Dentistry . . 23
Water , , . . . .21
Tait's Hospital Mortality . . * 15
Mackenzie on Diphtheria . . .16
Taylor's Principles of Medical Jnris*
Marnamarn on Diseaaca of tbe Eye , 23
pmdence . . . 20 1
^- Manual of Medical Juris- ^
Mftdden*« Health Reiiorta, . . 17
Manden on ccrtam Forms of Cancer 19
prudence . . . .20
Mason on Harelip and Cleft Palate . 5
— Poisons in relation to Medical
Surgery of tlio Pace . . 5
Jurisprudeuce . . .20
Maimder'a Operative Snrg^ry . . 4
Teale's Dtmgers to Health . . 21
— Surgery of Arteries • * 4
Thomas on Ear and Throat Diseases 6 —
Mayne*ft Medi(!nl Vocabulary . . 2;2
Thompson's Stricture of Urethra * 7 1
Morris (H.) Anatomy of the Joints . 10
— Pnictieal Lithotomy and 1
Ogston^i Medical Jarinprudence . 20
Lithotrity . • ^ ■
Oabom on Hydrocele . . .7
— Diseases of Urinary Organs 7 fl
Parkes* Manual of Practical Hygiene 21
— Diseases of the Prostate . 7
Parkin's Epideraiolof^ . , .23
' — Calculous Disease . , 7
Favy on Food aod Dietetiea . . 18
Thornton on l>ac.heotomy , , 16
^~ on Diiibetoi . * . .18
Thorowgood qo Asthma . . .15
Peacock's ValvuUr Disease , , 16
— on Materia Medica . 12
Phillips* Materia Medica • . .12
Thudicbnm'B Pathology of Urine . 8
Pirrie'a Surgery . , ♦ , 4
Tibbits' Medical Electricity . . 22
Pollock's Ilbeumatism - • .19
— Map of Motor Points . . 22
Romsbotham's Obstetrics , * » 13
TUf 8 Uterine Therapeutics . . 18
HeTOolds' Uses of Electricity - . 22
Boberts' (C.) Maiitial of Anthro-
— ChftDge of Life . . .IS
— Health in India . . .If
pometry 9
Tomes* (C« S.) Dental Anatomy . 23
ntfbat^ (D. Lloyd) Practice of Mid-
— (J. and C. SO Dental Surijcry 23
wifcry ...... 13
Take on the Influence of the Mind «
upon the Body . . 21 ■
Van Burcn on Diseases of the Genito- ■
Bonssers Tranrf usion of Blood , . 6
^^Bouth's Infant Feeding . . .13
^BAov's Burctwan Fever .17
^^'ylo and H&rley's Materia Medica . 12
Urinan- Orgnua . , .8
Veitcb's Haiidlxwk for Nurses . . 16
Rutherford*! Practical Histology . 9
Virchow's Post-mortem Eswminations 10 M
Wagstaffe's Human Osteology , g ■
Walton's Di*ea*i»s of the Eye . .22
Salt's Medico* Electric Apparatus . 23
^ManMim'a Diseases of the Heart . 16
Ward on AITcctions of the Liver , 17
^^Bavage on the Female Pelvic Organs 4
Waring*» Practical Therapeutics . 12
^^Bavory's Domestic Medicine .15
— Baiaar Medicines of India . 17
^Hlayr^'s Orthopicdic Surgery 6
Welk(Soelberg) on Disea^s of the Eye 23
^^Pchrocder's Manual of Midwifery . 13
— Long, Short, and Weak Sight . 23
^HBcrople on the Heart .15
Wells (Spencer) on Diseasea of tbe
^Hfiewiirs Dental Anatomy . .23
Ovaries . . . .14
^Kiaptor's Diseases of the Heart . 16
West's DiseHses of Women . . 14
^^nSheppard on Madness . . .21
Whistler'^ Syphilis of Larynx . , 17
Sibson's Medical Anatomy . . .10
Wilks' Diseases of Nervous System . 18
^_^Sjeveking*» Life Assurance . . 21
— Pathological Anatomy , . 10
^Hniith(E.) Wasting DtieaseaofChildren 13
WlhKjn's{E,)A[iatomi8t'BVftdo-Mecum 11
^■^ — Clinical Studies . 13
— Diseases of the Skin . . 19
^Bfim i th ( Henry) Surgery of the Rectum d
Lecturea on Ekzema » . 19
^Hfimith (Hey wood) Gyntecology , . 14
— Lectures on Dermatology . lf$
^nBmitb (J.) 'Dental Anatomy , . 23
Wilson's (G.) Handbook of Hygiene. 21
HStnitli (W, R.) Nursing . . .15
Woodman *fc Tidy's Forensic Medicine 21
^Spender's Bath Waters . . .17
J
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HISTOLOGY AND HISTO-CHEMISTRY OF MAN:
A Treatise on the Ek-nients vl* Composition and Stnicture of the
Hnman Body, by Heineich Feey» Profesaor of Medicine in Zurich*
Translated from the Fouilh German Edition by Arthur E. J.
Baukek. Assistant- Surgeon to University College Hospital. And
Revised by the Author. 8?o, with 608 Engi-avings, 2l8. a87#3
HITMAN PHYSIOLOGY:
A Treatise designed for the Use of Stndenta and Praetitionera of
Metlicine, by John C. Dalton, M.D., Professor of Physiology and
Hygiene in the Ct>l!ege of Physicians and Surgeons^ New York. Sixth
Edition, royal 8vo^ with 31G En^ravings^ 20s. [1^5]
HANDBOOK FOR THE PHysIOLOGICAL LABORATORY.
by E. Klein, M.D.»F.R.S,, Assistant Professor in the PatbologicalLabo-
ratoij of the Brown Institution, London ; J. Buedon-Sandebson,
M.D., P,R.S., Professor of Practical Physiology in University College,
London; Michael Foster, M.D., F,R,S., Prsclector of Physiology
in Trinity College. Cambridge; and T, Laudee Bkunton» M,D.,
F.R.S.i Lecturer on Materia Medica at St. Bai-tholomew*s Hospital ;
edite*! by J. BuEDON-SANDEEaoif. 8vo, with 123 Plates. 24fi, HSTaj
PRACTICAL HISTOLOGY:
By William Rutheefoed, M.D., Profesaor of the Institiites of
Medicine in the University of Edinburgh. Second Edition, with
63 Engravings. Crown 8vo (with additional leaves ibr notes), 68,
ri87fl]
THE MARRIAGE OF NEAR KIN,
Considered with respect to the Laws of Nations, Eesnlta of Expeorienoa,
and the Teachings of Biology, by Alfred H. Huth. 8vo, I4a. ^8711
MANUAL OF ANTHROPOMETRY:
A Guide to the Meivsitrement of the Human Body, containing an
Anthropometrical Chart and RegiHter, a Systematic Table of Mea-
uremcnts, &c. By Cmaeles Bobeets, F,R»C.S.. late Aesisbmt
Surgeon to the Victoria Hospital for Children. With numerons
Illustrations and Tables. 8vo, Cs. 6d. 11^78]
STUDENTS* GUIDE TO HUMAN OSTEOLOGY.
By William Warwick Waqbtaffe, F.R.C.S., Assistant -Surgeon
and Lecturer on Anatomy, St. Thomas's Hospital. With 23 Platea
and 66 Engravings. Fcap. 8vo, lOs. Sd. l}9li}
s
I
10 CATALOGUE OP BEOBNT WORKS
PEINCIPLES OF HUMAN PHYSIOLOGY,
by W. B. Cabpknteb, C.B., M.D., F.R.S. Eighth Edition by Henbt
FowBB, 1(*B., F.B.O.S., Examiner in Natural Science, University of
Oxford, and in Natural Science and Medicine, University of Cambridge.
8yo, with 3 Steel Plates and 371 Engravings, 31s. 6d. [1876]
LANTDMARKS. MEDICAL AND SURGICAL,
By LuTHEB HoLDEN, F.R.C.S., Member of the Court of Examiners of
the Royal College of Surgeons. Second Edition, 8vo, 3s. 6d. CiSTT]
BY THB SAME AUTHOB.
HUMAN OSTEOLOGY:
Comprising a Description of the Bones, with Delineations of the
Attachments of the Muscles, the General and Microscopical Structure
of Bone, and its Development. Fifth Edition, with 61 Lithographic
Plates and 89 Engravings. 8vo, 16s. d^?^
PATHOLOGICAL ANATOMY :
Lectures by Samuel Wilks, M.D., F.R.S., Physician to, and Lec-
turer on Medicine at, Gu^s Hospital ; and Waxter Moxon, M.D.,
F.R.C.P., Physician to, and Lecturer on Materia Medica at, Guy's
Hospital. Second Edition, 8vo, with Plates, 18s. [1876]
PATHOLOGICAL ANATOMY:
A Manual by C. Handheld Jones, M.B., F.R.S., Physician to St.
Mary's Hospital, and Edwajid H. Sieyeking, M.D., F.R.C.P.,
Physician to St. Mary's Hospital. Edited by J. F. Payne, M.D.,
F.R.C.P., Assistant Physician and Lecturer on General Pathology
at St. Hiomas's Hospital. Second Edition, crown 8vo, with 195
Engravings, 16s. C1875]
POST-MORTEM EXAMINATIONS:
a Description and Explanation of the Method of Performing them,
with especial Reference to Medico-Legal Practice. By Professor
Rudolph Vibchow, of Bei;}in. Fcap 8vo, 2s. 6d. Ci87«3
STUDENT'S GUIDE TO SURGICAL ANATOMY:
a Text-book for the Pass Examination, by E. Bellamy, F.RC.S.,
Surgeon and Lecturer on Anatomy at Charing Cross Hospital. Fcap
8vo, with 50 Engravings, 6s. 6d. [^^73]
ANATOMY OF THB JOINTS OF MAN,
by Hensy Mobkis, F.R.C.S., Senior Assistant-Surgeon to, and Lec-
turer on Anatomy and Demonstrator of Operative Surgery at, the
Middlesex Hospital. With 44 Lithographic Plates (several being
coloured) and 13 Wood Engravings. 8vo, 16s. ri879]
MEDICAL ANATOMY,
by Fbancis Sibson, M.D., F.R.C.P., F.R.S. Imp. folio, with 21
coloured Plates, cloth, 42s., half -morocco, 60s. * [1869]
PRACTICAL ANATOMY:
a Manual of Dissections by Chbistopheb Heath, F.R.C.S., Surgeon
to University College Hospital, and Holme Professor of Surgery in
University College. Fourth Edition, crown 8vo, with 16 Coloured
Plates and 264 Engravings, 148. 0877]
I
I
I
AN ATLAS OP HUMAN ANATOMY:
illuetratinij aiubt of tb** orditiMvy Diaaectiona, tmd many not usoally
practised hj the Student To bo completed in 12 or 13 Bi-montlily
Parts, each contamiug 4 Ct*loured Plates, with Explanatory Text, By
Hickman J. Godlee, M,S., F.K.C.S., Assistant Surgeon to University
College Hospital, and Seniov Demonstrator of Anatomy in Univeraity
College, Palis I to YIL Imp. 4to, Vs. Sd, each Part. [1877'V]
THE ANATOMIST^S YADE-MECUM :
a System of Hiimiin Anatomy by Erasmus Wilson, F,R.C.S., F,E.S,
Ninth Edition, by G. Buchanan, M.A., M.D,, Professor of Clinical
Surgery in the University of Glasgow, and Henky E. Clakk, F,F,F.S.t
Lecturer on Ajiatomy at the Glasgow Royal Infirmary School of
Medicine. Crown 8vo. with 371 Engravings, 14s. 0^^} ■
ATLAS OF TOPOGRAPHICAL ANATOMY, f
^L after Plane Sections of Frozen Bodies. By Wilhelm Braitne,
^H Professor of Anatomy in the University of Leipzig. Translated by
^B Edward Bellamy, F.R.C.S,, Surgeon to, and Lecturer on Anatomy,
^B &c.f at, Charing Cross Hospital. With 34 Photo -lithographic Plates
^■^ aiad 46 Woodcuts. Large Imp. Svo. 4D9. L187T1
■the ANATOMICAL REMEMBRANCER;
H or, Complete Pocket Anatomist. Eighth Edition. 32mo, Ss. 6d, ^^^^
^THE STUDENT'S GUIDE TO THE PRACTICE OF MEDICINE,
by Matthew Chaeteris, M.D., Professor of Medicine in Anderson's
■ College^ and Lecturer on Clinical Medicine in the Royal Infiroiary,
Glasgow. Second Edition, with Engravings on Copper and Wood,
fcap. 8vo, 63. CM. t1«W
THE MICROSCOPE IN MEDICINE,
by Lionel S. B£ALE. M.B., F.R.S., Pbysician to King's College
Hospital F.mrth Edition, with 86 Plates, 8vo, 21s. ti»77J
HOOPERS PHYSICIANS VADE-MECUM;
ii or, Manual of the Principles and Practice of Physic, Ninth Edition
by W. A. Guy, M;B., FR.S., and John Harley, M.D., F.R.C.P.
Fcap 8vo, with Engravings, liis. 6d. C1874]
A NEW SYSTEM OF MEDICINE;
entitled Becognisant Medicine, or the State of the Sick, by
Bholakoth Bobe, M.D., Indian Medical Service. 8vo, lOs. 6d. nfl77)
UY TBH «AMK ATJTHOH.
PRINCIPLES OF RATIONAL THERAPEUTICS.
Commenced as an Inquiry into the Relative Talue of Qnmine and
Arsenic in Ague. 8vo, 4s. [1«T7] M
JCLINICAL MEDICINE : '
Lectures and Essays by Balxhazaji Fobtkr, M.D., F.R.C.P. Loud.,
Professor of Medicine in Qaeen^s College, Birmingham, 8vo, lOs. 6d.
[CLINICAL REMINISCENCES:
By Peyton Blaioston, M.D„ F.R.S. Post 8vo, 3s. 6d. t^s^S]
I
I
d
12 CATALOGUE OP RECENT WORKS
THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS,
by Samuel Fknwick, M.D., F.R.C.P., Physician to the London
Hospital. Fourth Edition, fcap. 8vo, with 106 Engravings, 68. 6d. PWS]
A MANUAL OF MEDICAL DIAGNOSIS,
by A. W. Barclay, M.D., F.R.C.P., Physician to, and Lecturer on
Medicine at, St. George's Hospital. Third Edition, fcap 8vo, lOs. 6d.
[1876C
CLINICAL STUDIES:
Illustrated by Cases observed in Hospital and Private Practice, by Sir
J. Rose Cobmace, M.D., F.R.S.E., Physician to the Hertford British
Hospital of Paris. 2 vols., post 8vo, 208. [187«]
ROYLE'S MANUAL OP MATERIA MEDIC A AND THERAPEUTICS.
Sixth Edition by John Harlet, M.D., F.RC.P., Assistant Physician
to, and Joint Lecturer on Physiology at, St. Thomas's Hospital. Crown
Svo, with 139 Engravings, 15s. [1876]
PRACTICAL THERAPEUTICS:
A Manual by E. J. Waring, M.D., F.R.C.P. Lond. Third Edition,
fcap Svo, 12s. 6d. [I87ij
THE ELEMENTS OF THERAPEUTICS.
A Clinical Guide to the Action of Drugs, by C. BiNZ, M.D., Professor
of Pharmacology in the University of Bonn. Translated and Edited
with Additions, in Conformity with the British and American Phar-
macopooias, by Edward I. Sparks, M.A., M.B. Oxon., formerly
Radcliffe Travelling Fellow. Crown Svo, Ss. 6d. [W7]
THE NATIONAL DISPENSATORY;
containing the Natural History, Chemistry, Pharmacy, Actions and
Uses of Medicines, including those recognised in the Pharmacopoeias of
the United States and Great Britain. By Alfred Still^, M.D., and
John M. Maisch, Ph. D. 1628 pp., with 201 Engravings, royal Svo,
348. a879J
THE STUDENT'S GUIDE TO MATERIA MEDICA,
by John C. Thorowqood, M.D., F.R.C.P. Lond., Physician to the
City of London Hospital for Diseases of the Chest. Fcap Svo, with
Engravings, 6s. 6d. [1874]
MATERIA MEDICA AND THERAPEUTICS:
(Vegetable Kingdom), by Charles D. F. Phillips, M.D., F.R.C.S.E.
Svo, 158. [1874]
DENTAL MATERIA MEDICA AND THERAPEUTICS,
Elements of, by James ^toceen, L.D.S.R.C.S., Leotorer on Dental
Materia Medica and Therapeutics to the National Dental Hospital.
Second Edition, Fcap Svo, 68. 6d. [1878]
THE DISEASES OF CHILDREN:
A Practical Manual, with a Formulary, by Edward Ellis, M.D.,
late Senior Physician to the Victoria Hospital for Children. Thiid
Edition, crown Svo, 7s. 6d. [187?]
PUBLISHED liY ,K AND A. CHtJKCHILL 18
I
THE WASTING DISEASES OP CHILBREN,
l.y Eustace Smith, M.D., P.R.C.P. Limd,, Physiciiui to the King of
the Boli^iana, Physician t*» the East London Hospital for Children.
Third Editioii, pt^st 8vo, Hb. Gd. i^^"*^}
HY TTfB SAME AFTnOK, I
CLINICAL STUDIES OP DISEASE IN CHILDREN.
Post yvo. 7s, Od. n87«]
INFANT FEEDING AND ITS INFLtJENCE ON LIFE ;
<n\ tho Causes and Provention of InBLat Mortality, by Ghablks H. F,
RouTH. M.D., Senior Physii'ian to the Samaritan Hospital for Women
and Cliililj-en. Third Ediiion. fcap Svo, Vs. i]d. n*»7ni
COMPENDIUH OF CHILDREN'S DISEASES:
A Handbook for Praetiiionfrs and Students, by Johann Steiker.
M.D., Prof^esatir in the University of Pnigiie. Translated from the
S*^c<nid German Edition by Lawson Tait. FR.C.S., Surgeon to the
Birminf^hani Hoapital for Wi»inen. 8vo, 12s. 6d. ns7*l
THE DISEASES OP CFIILDREN:
Essays by WnxiAM He net Day, M.D., Physician to the Samaritan
Hospital for Diseases of Women and Children, Second Edition* fc»p8vo.
ilnlbePrcat]
I PUERPERAL DISEASES;
Clinical Lectures hv Foedyce Babkeb, M.D., Obstetric Physician
to Bell«-vue Hospital, New York. 8vo, 15b. Dm)
THE STUDENT'S GUIDE TO THE PRACTICE OF MIDWIFERY,
by D, Lloyd Roberts, M.D., F.R.C.F., Fhymcian to St. Mary's Hos-
pital, Manchester. Second Edition, fcap. 8vo, with 111 Engravings, Ts.
OBSTETRIC MEDICINE AND SURGERY, ^^^'^^
^ Their Principles and Pmctice, by F. H. RAMSBOTHAlf , M.D., F.R.C»P.
Fifth Edition, Svo, with 120 Plates, 22a. Daa7]
OBSTETRIC SURGERY:
A Complote Handbook, giving Shoil Rules of Practice in every Emer-
gency, from the Simplest to the most Formidable Operations connectc^d
with the S<;ience of Obstetricy, by Chablbs Clay, Ext.L.R.C.R Lond.,
L.RXuS.E., late Senior Surgeon and Lecturer on Midwifery, St.
Mary*B Hospital, Manchester. Fcap 8vo, with 91 Engravings, 63. (id,
OEDERS MANUAL OP MIDWIFERY. ^^^'^^
including the Pathology of Pregnancy and the Pacrpcral State.
Translated by Charles H, Cabter. B.A,, M>D. 8vo, with Engmv-
inga. I2h. (jd. [1*75]
HANDBOOK OF UTERINE THERAPEUTICS.
and of DiHCiiaoa of Women, by E. J, Tilt, M.D., M.R.C.P. Fourth
Edition, post 8vo, 10s. [i&7ej
BY rns SAMB AtrraoB,
THE CHANGE OF lilFE
^^ in Health imd Diaease ; a Practical Treatise on the Nervous and other
^H Affections incidental to Women at the Decline of Life, Thii-d Edition
I
14 CATALOGUE OP EECENT WORKS
OBSTETRIC OPERATIONS,
including the Treatment of Hsemorrliage, and forming a Guide to the
Management of Difficult Labour; Lectures by Robebt Barnes, M.D.,
P.R.C.P., Obstetric Physician and Lecturer on Obstetrics and the Dis-
eases of Women and Children at St. Greorge's Hospital. Third Edition,
8yo, with 124 Engravings, 18s. [1875]
BT THE SAME AUTHOR,
MEDICAL Am> SURGICAL DISEASES OP WOMEN:
a Clinical History. Second Edition, 8yo, with 181 Engravings, 28s.
L1878]
THE DISEASES OF WOMEN.
By Charles West, M.D., F.R.C.P. Revised and in part Re-written
by the Author, with numerous Additions by J. Matthews Duncan,
M.D., Obstetric Physician to St. Bartholomew's Hospital. Fourth
Edition, 8vo, 16s. ^879]
OBSTETRIC APHORISMS:
for the Use of Students commencing Midwifery Practice by J. G.
SwATNE, M.D., Consulting Physician-Accoucheur to the Bristol
General Hospital, and Lecturer on Obstetric Medicine at the Bristol
Medical School. Sixth Edition, fcap 8vo, with Engravings, 3s. 6d. [i876]
DISEASES OF THE OVARIES :
their Diagnosis and Treatment, by T. Spencer Wells, F.R.C.S.,
Surgeon to the Queen's Household and to the Samaritan Hospital.
8vo, with about 150 Engravings, 21s. P^2]
PRACTICAL GYN-^COLOGY:
A Handbook of the Diseases of Women, by SLstwood Smith, M.D.
Oxon., Physician to the Hospital for Women and to the British Lying-
in Hospital. With Engravings, crown 8vo, 5s. 6d. [1877]
THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY.
By Thomas Addis Emmet, M.D., Surgeon to the Woman's Hospital
of the State of New York. With 130 Engravings, 8vo, 248. C187»]
RUPTURE OF THE FEMALE PERINEUM,
Its treatment, immediate and remote, by George G. Bantock, M.D.,
Surgeon (for In-patients) to the Samaritan Free Hospital for Women
and Children. With 2 plates, 8vo, 3s. 6d. [i878]
PAPERS ON THE FEMALE PERINEUM, &c.,
by James Matthews Duncan, M.D., Obstetric Bl^ysician to St. Bar-
tholomew's Hospital. 8vo, 68. [1878]
INFLUENCE OF POSTURE ON WOMEN
In Gynecic and Obstetric Practice, by J. H. Ayeling, M.D., Physi-
cian to the Chelsea Hospital for Women, Vice-President of the
Obstetrical Society of London. 8vo, 6s. P878j
THE NURSE'S COMPANION:
A Manual of General and Monthly Nursing, by Chables J. OuLLiKG-
«voBTH, Surgeon to St. Mary's Hospital, Manchester. Fcap. Svo,
28. 6d. (0876
PUBLISHED BY J. AND A. CHUKCRILL U
I
A MAOTTAL FOR HOSPrTAL NURSES
and others en^^ged in Attending on the Sick hj Edward J. Doic-
viLLE, L.R.C.P., M.R.C^S., Surgtfcm to the Exeter Lying-in Cbarity*
Third EditiL^n. erown 8vo. 2b, 6d. C187SJ
LECTURES ON NITRSING, ■
by William Robert Smith, M.B., Honorai^ Medical Officer,
Hospital for Sick CUildren, Sheffield. Second Edition, with 2G En-
gravings. Post Svo, t>s. [1878]
HANDBOOK FOE NTTRSES FOR THE SICK.
by ZsPHEKtNA p. Ye ITCH- Second Editiun, crowa 8vo, 3s. Cd. n^7«] m
A COMPEiroiUM OF DOMESTIC JMEDICIKE ■
and Compani«>n to the Medicine Chest; intended as a Sonitje of Easy
Reference for Clergymen, and for Families residing at a Distajice
5-om Professional Asaistoncei by John SayoeYp M.S.A. Kintb
Edition, VIuhk 5s. PWe]
HOSPITAL MORTALITY
being a Statistical Investigation of the Betnms of the Hospitals of
Great Britain and Ireland for fifteen years, by La WSON Tait,F.RC.S.,
F.S.a 8vo, Ss. «kL P877]
THE COTTAGE HOSPITAL:
Its Origin, Progress* Management, and Work, by Hen BY C. BuBDETT*
tbe Seaman's Hospital, Greenwich. With Engravings, crown &vo,
78. M, [l»^
WINTER COUGH :
(Catarrh, Bronchitis, Emphysema, Asthma), Lectures by HoBACS
DOBELL,M.D., Consulting Physician to the R<^)yal Hospital for Diaeaoes
of the Chest, Third Edition, with Coloured Plates, 8vo, 10s. 6d. O^*'^
UT Tlt£ SAMB A1TTH0R,
LOSS OF WEIGHT, BLOOD -SPITTING, AND LUNG DISEASE.
With Chromo- lithograph. Svo, 10s. Od. Om}
CONSUMPTION :
lt« Natnre, Symptoms, Causes, Prevention, Curability, and Treatment.
• By Peter Go wan, M.D,, B, Sc, late Physician and Surgeon in
Ordinary to the King of Siaia. Crown 8vo. Ss. C*S78
NOTES ON ASTHMA;
I its Forma and Treatment, by John C. Thorowoood, M,D, Lond.p
F.R.C.P.. Physician to the Hoapitid for Diseases of the Chest, Victoria
Park, Third Edition, crown Svo, 49. 6d. [WS]
ASTHMA
Its Pathology and Treatment, by J. B. Bebkart, M.D,, Assistant
Pbysician to the City of London Hospital for Diseases of the Chest.
Svo, 78. (M. n»7B]
^DISEASES OF THE HEART-
^fe Their Pathology, Diagnosis, Prognosis, and Treatment (a Manual),
^1 by EoBEET H. Semple, M.D., F.R.C.P., Physician to the Hospital for
H Diseases of the Throat Svo, 8s.6d. C^876]
I 1
I
I
16 CATALOGUE OP RECENT WORKS
PROGNOSIS IN CASES OF VALVULAR DISEASE OF THE
Heart, by Thomas B. Peacock, M.D., F.R.C.P., Honorary Consult,
ing Physician to St. Thomas's Hospital. 8vo, 3s. 6d. CW7]
CHRONIC DISEASE OF THE HEART :
Its Bearings upon Pregnancy, Parturition and Childbed. By Anoits
Macdonald, M.D., F.R.S.E., Physician to, and Clinical Lecturer on
the Diseases of Women at, the Edinburgh Royal Infirmary. With
Engravings, 8vo, 8s. 6d. HSTfa]
PHTHISIS :
In a series of Clinical Studies, by Austin Flint, M.D., Professor of
the Principles and Practice of Medicine and of Clinical Medicine in
the Bellevue Hospital Medical College. 8vo, 16s. [1^75]
BY THE SAME AUTHOR,
A MANUAL OF PERCUSSION AND AUSCULTATION,
of the Physical Diagnosis of Diseases of the Lungs and Heart, and of
Thoracic Aneurism. Post 8vo, 6s. 6d. C1876]
DIPHTHERIA:
its Nature and Treatment, Varieties, and Local Expressions, by
MoBELL Mackenzie, M.D., Physician to the Hospital for Diseases of
the Throat. Crown 8vo, 5s. C1878]
DISEASES OF THE HEART AND AORTA,
By Thomas Hayden, F.K.Q.C.P. Irel., Physician to the Mater
Misericordias Hospital, Dublin. With 80 Engi*avings. 8vo, 25s. 0876]
DISEASES OF THE HEART
and of the Lungs in Connexion therewith— Notes and Obserrations
by Thomas Shapteb, M.D., F.R.C.P. Lond., Senior Physician to the
Devon and Exeter Hospital. 8vo, 7s. 6d. C1874]
DISEASES OF THE HEART AND AORTA:
Clinical Lectures by Geobqb W. Balfoue, M.D., F.R.C.P., Physician
to, and Lecturer on Clinical Medicine in, the Royal Infirmary, Edin-
burgh. 8vo, with Engravings, 12s. 6d. ^876]
PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART.
Lectures by Arthur E. Sansom, M.D., F.R.C.P., Assistant Physician
to the London Hospital. Second Edition, with Engravings, fcap. 8yo,
4s. 6d. [1876]
TRACHEOTOMY,
especially in Relation to Diseases of the Larynx and Trachea, by
Pugin Thornton, M.R.C.S., late Surgeon to the Hospital for Diseases
of the Throat. With Photographic Plates and Woodcuts, 8vo, 58. 6d.
a8763
SORE THROAT:
Its Nature, Varieties, and Treatment, including the Connexion
between Affections of the Throat and other Diseases. By Prossbb
James, M.D., Lecturer on Materia Medica and Therapeutics at the
London Hospital, Physician to the Hospital for Diseases of the Throat.
Third Edition, with Coloured Plates, 5s. 6d. txm]
PUBLISHED 1;Y J. AND A. CHURCHILL
SYPHILIS OF THE LARYNX
(Lesions of tbi> Secondary and Tnteiincwlkty Stages). Lectures
delivered at the Hospital for DiROiisea <if tlio Throut uud Gbest»
London, by W- Macneill Whistler, M.D,. M.R0,R» Phyait^hm to
the Hospital; Honorary Physician to the National Trainiiit? School
for Music, With En^mvinga, crown 8vo, 4b. [1>»7V]
WINTER AND SPRING
on the Shores of the Mediterranean. By Henry Bennet, M.D.
Fifth Edition, post 8to, with numerous Plates, Maps, and Engravings,
128. 6d. [ibTiJ
BY THB SAME AUTHOR.
TREATMENT OP PULMONARY CONSUMPTION
by Hygiene, Ch*mat*». and Medieine* Third Edition, 8vo, 78. 6d.
PRINCIPAL HEALTH RESORTS
of Europe imd Afjica, and their Use in the Treatment of Chronic
Diseases. A Himdhook by Tif omas Moee Madden, M*D„ MR.I.A.,
Vice-President of the Dublin Obstetrical Society. 8vo, JOa. 0«7^}
THE BATH THERMAL WATERS:
Historical, Social, and Medieal, by John Kent Spender, M.D.,
Surgeon to the Mineral Water Hospital, Bath, With an Appendix
on the Climate of Bath by the Haw L. Blomefield, M,A., F.L,S.,
RG,S. 8vo, 7s. 6d. I1977J
ENDEMIC DISEASES OF TROPICAL CLIMATES,
with their Treatment, by John Sui*i*rVAN, M.D., M.R.C.P. Post 870,
68. n877]
DISEASES OF TROPICAL CLLMATES
and their Treatment ; with Hinla for the Preserration of Heitlth in the
Tropica, by Jameb A. HoRTON, M.D., Surgecm- Major, Ai-my Medical
Depiirtroent. Second Edition, post 8vo, 128. 6d. 0*79)
HEALTH IN INDIA FOR BRITISH WOMEN
and on the Pievintion of Diaeaso in Tropical Climates by Edwakd J»
TlLT^ M.D.* Con Bul ting Physician -Accoucheur to the Farringdon
General Dispensary. Fourth Edition, crown 8vo, Ss, 1*^*1
BURDWAN FEVER,
or the Epidemie Fever of Lower Bengal (Causes, Symptoms, and
Treatment), by Go PAUL CHtJNDER Roy. M.D., Surgeon Benfi^al
Establishment. New Edition, 8vo, 5s. t«W«]
BAZAAR MEDICINES OF INDIA
and Common Medical Plants : Remarks on their Uses» with FnU Index
of Diseases, indicating their Treatment by these and other Agents pro-
curable throughout India, &c., by Edward J. Waring, M.D.. F.R.O.P.
Lond., Retired Siu'geon H.M. Indian Army. Third Edition. Feap
8vo. 58, ri^sj
SOME AFFECTIONS OF THE LITER
and Intestinal Ciinal ,- with Remarks on Ague and its Sequela?, Scurvy,
k Purpura. *kc., by Stephen H. Ward, M.D. Lond,, F.R.C.r,, Physician
4
18 CATALOGUE OF RECENT WORKS
DISEASES OF THE LIVER:
Lettsomian Lectures for 1872 by S. O. Habebshon, M.D., F.R.C.P.,
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NUTRITION IN HEALTH AND DISEASE :
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ATLAS OF OPHTHALMOSCOPY,
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DISEASES OF THE EYE :
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pital. Third Edition, fcap. 8vo, with Coloured Plates and Engravings,
12s. 6d. P87e3
DISEASES OF THE EYE :
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Third Edition, 8vo, with 3 Plates and nearly 300 Engravings, 258.
HINTS ON OPHTHALMIC OUT-PATIENT PRACTICE,
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OPHTHALMIC MEDICINE A^D SURGERY:
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DISEASES OF THE EYE:
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Hospital. Tliii'd Edition, Sto, with Coloured Plates and Engravings,
258, as73]
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LONG, SHORT, AXD WEAK SIGHT,
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>
IKFLA^rMATlON OF THE BLADDEK.
591
some not very severe attack of inflammation of the womb, or of
I appenda^res,
Infiammaiion, indeed, beginning in adjacent parts, and by its
tendioB involvings the bladder, playa a very important part
aong the causes of disorder of the urinary organs in woman.
is thus that irritability of the bladder is not infrequently left
shind after an attack of vaginitis, or follows on a miscarriage or
tedious labour. The recovery in such cases seems at first almost
>mplete ; but the slightest cause, such as the natural congestion
' the pelvic viscera which accompanies menstruation, accidental
qK>aure to cold, or the occurrence of pregnancy, suffices to repro-
uee the frequent, and difficult, and painful micturition, and to
?nder the urine once more turbid, charged with tlie phosphates,
nd abounding in deposits of pus or mucus. Such symptoms, too,
ontinue for months or years, varying in degree, now woi'se now
etter, a life-long source of discomfort^ tending rather to increase
ban to diminlsk
Amite CifsfUu has never come under my notice except aft-er
lelivery when it^ symptoms have been almost lost in those of the
{raver inflammation of the uterus, or of the peritoneum with
vhich it was associated. These complications, when severe, often
terminate in death, and then the interior of the bladder is not
nfrequently found denuded to a great extent of its mucous mem-
brane, which hangs in dark sloughy shreds and patches from an
intensely congested surface ; its state closely resembling that
presented by the interior of the womb itself.
For the most part, however, the injury inflicted on the bladder is
less grave, or at least more circumscribed, and, not being attended
by serious ailection of the womb itself, does not prove tlangerous
fco life. At some one point where during labour tbe pressure of
the fetal head was most considerable, tbe tissue dies, and the
patient's distress anrl dysuria find a melancholy alleviation in the
unconscious outflow of the urine. The inflammation has ended in
jiestruction of tissue and in the formation of a vesico- vaginal
fctiala, but it has ended ; and sufl'ering of a new kind now takes
jthe place of that which the patient had before endured. But this
accident is happily not the most usual result of inflammation of
the bladder, tbe long-contmued pressure on tbe organ, or the
leglect to employ the catheter, or the inflammation of the uterus
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