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Full text of "A system of gynaecology"

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Dr. Graham Campbell 







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A SYSTEM OF GYNECOLOGY 



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SYSTEM OF GYNECOLOGY 



BY MANY WRITERS 



EDITED BY 



THOMAS CLIFFORD ALLBUTT 

M.A.. M.D., LL.D., F.R.C.P., F.E.S., F.L.S., F.S.A. 

REGICS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE, 

FELLOW OF GONVILLE AND CAIUS COLLEGE 



AND 

W. S. PLAYFAIR 

M.D., LL.D., F.R.C.P. 

PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE, AND 

OBSTETRIC PHYSICIAN TO KING'S COLLEGE HOSPITAL 




iLorttfOtt 
MACMILLAN AND CO., Ltd. 

NEW YORK: THE MACMILLAN CO. 
1896 

All rights reserved 






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PREFACE 

In the earlier treatises on medicine diseases of women were included, 
but were of necessity imperfectly described. 

Of late years this department of medicine has grown so largely 
that the Editor of the new System of Medicine found it would be 
better to deal with it, as a whole, in a volume especially devoted to 
the subject ; in the preparation of this volume I have assisted him 
as Joint Editor. 

The advances made within the last few years in Gynaecology are 
perhaps more remarkable than in any other branch of medicine. 

The whole subject is one of recent development. Even the 
work of its pioneers is within the recollection of the older amongst 
us : a treatise on gynaecology written twenty years ago is ab- 
solutely useless as a guide to the practice of to-day, and does not 
contain even a reference to many of the topics now known to be of 
primary importance in connection with diseases of the reproductive 
organs in women ; on the other hand, many opinions and methods 
of treatment, then largely taught and practised, have justly passed 
into oblivion. 

Much of this great progress is undoubtedly on the surgical 
aspect of the subject. The increasing frequency of abdominal 
sections has directed attention to the diseased states thus revealed, 
and to methods of treating them, previously quite unknown. 

Unbalanced zeal has had its inevitable result of injudicious 
practice, which is to be regretted ; against adventure of this 
kind protests have been made by the more conservative-minded 



vi SYSTEAf OF GYNECOLOGY 

memben <>t' our profession! often justly, sometimes unjustly. 
\ir is it in this country alone that this adventurousness is seen. 
Any one familiar with current gynaecological practice, both on the 
Continent and in tlic United States, must know that the same spirit 

fcive t litre Indeed, it is probable that gynaecologists abroad 

i]t to impute t<> their British colleagues a backwardness in 

adopting methods of treatment largely practised by themselves; 

m.iiiv of us think, too largely. Conservatism of this sort may have 

.alts. hut. <>n the whole, it is not to be regretted, and it is 

rarely better than to err in the opposite direction. 

It is obvious that a collection of independent essays, written by 
men on topics which they have specially studied, must' carry more 
weight, and be more useful than any work compiled by a single 
writer. An endeavour has been made to entrust the several subjects to 
thoroughly representative men ; and it is hoped that the results of 
their combined labours will give an accurate exposition of gynae- 
_cy as it is taught and practised amongst us. 

I am myself alone responsible for the selection of the contributors, 
which my co-editor has left to my judgment; but I am not in any 

way res] Bible for the opinions they have expressed, some of 

them, indeed, I do not share. 

In a work by various authors differences of opinion will 

necessarily be found; some condemn methods of practice which 

others approve and recommend. This does not appear to be 

ible; it is surely better that in vexed and disputed ques- 

l.oth Bides should be fairly considered. 

W. S. PLAYFAIE. 



CONTENTS 



PAGE 

The Development of Modern Gynecology. M. Handfield-Jones . . 1 



The Anatomy of the Female Pelvic Organs. D. Berry Hart 

Malformations of the Genital Organs in Woman. J. William Bal 
lantyne ........ 

The Etiology of the Diseases of the Female Genital Organs. W 
Balls-Headley ....... 

Diagnosis in Gynecology. Robert Boxall 

Inflammation of the Uterus. A. H. Freeland Barbour 

The Nervous System in Relation to Gynecology. W. S. Playfair 

Sterility. Henry Gervis ....... 

Gynecological Therapeutics. Amand Routh .... 

The Electrical Treatment of Diseases of Women. Robert Milne Murray 

Disorders of Menstruation. John Halliday Groom . 

Diseases of the External Genital Organs. William J. Smyly 

Displacements of the Uterus. Alexander Russell Simpson . 

Morbid Conditions of the Female Genital Organs resulting from 
Parturition. George Ernest Herman .... 

Extra-uterine Gestation. John Bland Sutton 

Pelvic Inflammation. Charles James Cullingworth 

Pelvic Hematocele. William Overend Priestley 

Benign Growths of the Uterus. F. W. N. Haultain 



31 

63 

112 
151 
187 
220 
231 
249 
300 
339 
372 
393 

425 
451 
485 
524 
561 



vni 



SYS'/ EM OF GYA '.-ECOLOGY 



my. .1. Knmvslcy ThorntoD . 

01 i in Uterus. W. J. Sinclair 
\i. Operations. John Phillips 
hob of i hi. F.u.ini'iAN Tubes, Alban Doran 

b i ovaky. W. 8. A. Griffith 
[OTOMT. .1. Greig Smith 

op Tin D hsrus. Edward Malina 
tsss F i m Female Bladder and Urethra. Henry Morris 



PAGE 

611 
643 

7!:i 
782 
836 
872 
911 
027 



[NDICES 



959 



ILLUSTRATIONS 



FIG. 
1. 

2. 
3. 

4. 

5. 



10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 



Brim of Bony Pelvis ...... 

Diagram of Bony Pelvis and of Pelvic Floor . 

Sagittal Mesial Section of Female Pelvic Floor 

Virgin External Genitals with the Labia Majora separated . 

Rectal and Vaginal Mucous Membrane 

Sphincter Ani in full-time Foetus .... 

Axial Transverse Section of right half of Female Pelvic Floor 
Axial Transverse Section of Female Pelvic Floor 
Axial Coronal Section of right half of Female Pelvis 
Blood-supply of Uterus ..... 

Lymphatics of Uterus ...... 

Lymphatics of Uterus and Pelvis .... 

Nerve Diagram ...... 

Relations of Uterus and Ovaries viewed through Brim 

Sagittal Lateral Section of Female Pelvis 

Uterine Mucous Membrane showing relation of Glands and Stroma 

Cervix and upper part of Vagina showing Rugse 

Seal's Ovary showing Cortical and Medullary Layers 

Sagittal Lateral Section of Genital Organs in 3^ months' Foetus 

Pelvis and Contents from above .... 

Perineal Region .'.... 

Sacral Section of Pelvic Floor ..... 

Diagram of Genu-Pectoral Posture showing Vaginal Distension 
Dissection from behind ..... 

T. S. of Wolffian Bodies in six weeks' Foetus 

T. S. Pelvis, six weeks' Foetus .... 



PAGE 

32 
32 
33 
34 
36 
38 
39 
40 
41 
42 
42 
43 
44 
45 
46 
47 
47 
49 
50 
52 
54 
55 
56 
58 
59 
59 



SYSTEM OF GYNECOLOGY 



.'. B. of six works' Foetus showing Genital Cord 

28. Section of Ovary and Wolffian Body, Human Embryo, third month 

29. L. B oaths' Foetus to show development of Hymen . 

30. Diagram of d-vi'loping and fully formed Genital Tract 

rior View of right Uterine Appendages . 
32. Congenital absence of outer two-thirds of right Fallopian Tube 
;.rus Didelphys 
- Bioornia 
35. 1* Septus . 

Unicornis, posterior view 
la Vulvae Superficialis 

38. Anus Vulvalis . 

39. Pseudo-Hermaphroditism, Perineo-Scrotal Hypospadias 

40. Female Generative Organs of Halmaturus 

Two completely separated Uteri of many Rodentia . 
Single Uterus continued into two separate Cornua of the Insectivora, Carni 
vora, Cetacea, and Ungulata .... 

43. The single Uterus of the Simiae and Man 

44. Section of a Catarrhal Patch on the Vaginal Aspect of the Cervix 

45. Healing of a Catarrhal Patch treated by Astringent or Antiseptic Injections 

46. 47. Schroeder's Operation for excision of the Cervical Mucous Membrane in 

Cervical Catarrh ....... 

48, 49. Section of Tissue removed by Curette from a case of Interstitial 

Endometritis ...... 

50. Section of the Glands from a case of Glandular Endometritis 

Bastion of the Uterine Tissue in a case of Chronic Metritis 
52. Leiter's Coils .... 

68. Application of Leiter's Coils . 
54. Bath Speculum 

65. Syphon Douche 

66. Bed-Bath ... 

: Matthews Duncan's 

58. Diverging Speculum (Neugebaur's) 

59. Playfair's Probe 

60. Uterine Tenaculum Forceps (Sims') . 

61. Intra-Uterine Canula (Atthill's); Platinum Canula, with Stilette 

62. Uterine Scarifier 

68. Steriliser for Instruments (Harrison Grippe) 
64. Glass Jar for Sponges, Wool-Pada, etc. 



ILLUSTRATIONS 



XI 



FIG. PAGE 


65. Steriliser for Ligatures ... ... 269 


6Q. Catgut or Silk sterilised in Alcohol . 




269 


67. Junker's Inhaler .... 




273 


68. Griffin's Speculum 






275 


69. Cusco's Speculum 






275 


70. Gauze Applicator (Whalebone) 






275 


71. Forceps to introduce Gauze . 






275 


72. Cervical Speculum (Bantock's) 






276 


73. Duckbill Speculum (Sims') . 






277 


74. Barnes' Tent Introducer 






277 


75. Chambers' Tent-introducing Forceps 






278 


76. Uterine Dilator (Hegar's improved) . 






282 


77. Uterine Dilators (Hayes') 






282 


78. Uterine Dilator (Matthews Duncan's) 






282 


79. Clover's Crutch 






283 


80. Teale's Forceps 






284 


81. Budin's Tube .... 






285 


82. Graily Hewitt's Uterine Tube 






286 


83. Goodell's Two Parallel-bladed Dilator 






. 287 


84. Uterine Dilator (Ellinger's) . 






288 


85. Sims' Three-bladed Dilator . 






288 


86. Palmer's Two-bladed Dilator 






289 


87. Dilator (Priestley's) . 






289 


88. Uterine Dilators (Reid's) 






289 


89. Scissors, Uterine (Kiichenmeister's) . 






291 


90. Sims' Metrotome 






292 


91. Simon's Uterine Scoop 






293 


92. Sims' Pliable Curette 






293 


93. Double Uterine Curette (Gervis') 






294 


94. Recamier's Curette .... 






294 


95. Uterine Scoop, or Spoon Saw (Thomas') 






295 


96. Dredging Curette (Bell's) 






295 


97. Uterine Flushing Curette (Auvard's) 






295 


98. Routh's Flushing Curette 






295 


99. Vertical Section three months after Curetting 




297 


100. Vertical Section of the Uterine Mucous Membrane fifty-fiv< 


} days after the 




application of a Caustic 




298 


101. Leclanche Cell ..... 




301 


102. Carbon Rheostat . . 






303 



XII 



SYSTEM OF GYX.KCOLOGY 



T 

103. Edebnann Galvanometer 

104. "Weston Ifilliampere meter 

105. Intra- I'teiine Kl.rtrode 

106. ApostoliV Carbon Electrode . 

107. Adjustable Platinum Electrode 

108. Electrode for l'tnn-turt' 

109. Vaginal Eleotrod( 

110. Portable Battery with Collector and Galvanometer 

111. Simmer's Induction Coil 
-edge Induction Coil 

113. Regulator Switch-Board for Continuous and Induced Currents 
1 11. Switch-Board for regulating Lighting Currents by means of Resistances 
11.'.. Diagram of Switch -Board for regulating Lighting Currents by means of 
Shunt ....... 

116. Switch-Board for Shunt Regulation . 

117. Descent of Perineal Hernia in front of the Broad Ligament 

118. Reposition of the Retro verted Uterus with the Sound 

119. Hodge Pessary in the Vagina retaining the Uterus in situ . 

120. Profile on Section of lacerated, but healthy, Cervix Uteri . 

121. Profile on Section of lacerated and inflamed Cervix Uteri . 

122. Lacerations of Cervix Uteri and Vagina 
Laceration of Vagina forming a " Pocket " . 

124. Central Rupture of Perineum .... 

125. Diagram showing different kinds of Fistula 

126. Annular sloughing of Cervix Uteri, upper surface . 
Annular ploughing of Cervix Uteri, lower surface . 

128. Slough in one mass of Cervix Uteri, upper part of Vagina, and base of 

Bladder 

129. Dilated Abdominal Ostium . 

130. Gravid Tube .... 

131. Tubal Mole in Section 

132. Microscopical Characters of Chorionic Villi in section, in Blood-Clot 
138. Diagram to show the early relations of the Amnion and Chorion and the 

Subchorionic Chamber ...... 

134. An early Tubal Embryo, showing the Polar Disposition of the Villi 
136. A Gravid Tube with patent Ostium ..... 

136. Fallopian Tube and Ovary, Mole and Corpus Lutenm from a case of com 

plete Tubal Abortion . 

137. Uterine Decidua ; from a case of Tubal Pregnancy 



ILLUSTRATIONS 



FIG. PAGE 

138. Transverse Section of the Pelvis of a Woman with an Embryo and 

Placenta of the fourth month of Gestation occupying the right 

Mesometrium ........ 466 

139. Sagittal Section of a Cadaver, with a Mesometric Pregnancy at Term . 467 

140. Tubo-Uterine Gestation ....... 470 

141. Injected Uterus with Fibroid . . . . . .566 

142. Microscopic Section of soft Fibromyoma ..... 567 

143. Microscopic Section of common Fibromyoma .... 568 

144. Section of Fibroid Uterus ....... 569 

145. Diagram of Growth of Uterine Fibroids ..... 570 

146. Encapsulated Submucous Fibroid becoming Polypoidal . . 571 

147. Submucous Polypus ........ 572 

148. Uterus, showing Subperitoneal Fibroids ..... 575 

149. Submucous Intravaginal Cervical Fibroid ..... 582 

150. Subserous Cervical Fibroid, tilting Uterus above Pubes and bulging 

Posterior Vaginal Wall . . . . . .582 

151. Advanced Fibrocystic Degeneration of Stalked Subperitoneal Fibroid, with 

partially Twisted Pedicle ...... 587 

152. Edematous Interstitial Cystic Fibromyoma ..... 588 

153. Microphotograph of (Edematous Fibroid, showing Endothelial-lined Spaces 589 

154. Complete Rupture of the Perineum and the lower Portion of the Recto- 

Vaginal Septum . . . . . . .746 

155. Relations of Levator Ani to the Rectum and Vaginal Walls ; normal 

Condition . . . . . . . . 746 

156. Relations of Levator Ani to the Rectum and Vaginal Walls ; injured 

Condition ........ 747 

157. Perineorrhaphy : Preliminary Incisions ..... 749 

158. ,, Denudation . . . . . .749 

159. Purse-string Suture . . . . . . . . 750 

160. Perineorrhaphy; Repair of the Recto-Vaginal Septum . . . 750 

161. Section of torn Sphincter ....... 750 

162. Perineorrhaphy : Recto-Vaginal Septum repaired .... 751 

163. ,, (Simon-Hegar Method of Suture) . . . .752 

164. ,, ,, ,, ,, 2nd Stage and Side View 753 

165. ,, Alexander Duke's Method .... 754 

166. Surface View of Posterior Vaginal Wall with Right and Left Lateral Sulci 755 

167. ,, ,, ,, ,, ,, with both Lateral Vaginal Sulci 

sutured ........ 755 

168. Elytrorrhaphy (Sims') ....... 757 



\1V 



KM OF GYX.hCOLOGY 



169. 
171. 

180. 

182. 
183. 
184. 
185. 
186. 
187. 
188. 
189. 

190. 
191. 
192. 
193. 
194. 
195. 
IM. 
197. 

198. 

199. 
200. 
201. 



Denudation and first Lay< 



of continuous Suture 



tinuous superimposed 
uperimposed Suture 



olporrhaph} 
oompleted 
Anterior Oolporrhaphy ; Passage of second cos 

Silt:. .... 

Anterior Oolporrhaphy : Passage <>t' third Layer <>f 
ration .... 
t I'liy. first stage 

ud stage . 
third stage 
ration for Cystooele 
. 
Vaginal Fixation .... 
angular) 
(angular and curved) 
- ihinvolutii'ii . 
Amputation of Oerriz: Hegar's Method 

,, Marckwald's Method . 
Vesico- Vaginal Fistula Knives (Sims') 

ok (Bmmet's) for making Counter-Pressure 
. 
Mode of freshening the Bdgei of a Fistula by Flap-splitting 
Mod* Sutures in Vesico- Vagina] Fistula . 

of applying Counter- Pressure to the Point of the Needle by means 
of a Blunt Hook Bmmet) . 
Mode of fixing and twisting the Sutures (Sims) 
il Fistula (superficial variety) . 

Section of rube from a young Subject 

"f the PUfid iii Fig. 193 as seen under a \ inch objective 
Section, near the Ostium. ..fan inflamed Tube 

Ing the earlier Changes seen in Salpingitis 
wing the free Surface of the Interior of a Tube whieh lias been 
obstructed and dilated for a long period 

"f an inflamed Tube, in Its Middle Third, showing active Inllam 
"" -..... 
The free Suiiaee of the Intcri<>i ..r a suppurating Tub(> 
Section of a suppurating Tube, showing advanced Di 
Orary and Tube, showing Obstruction of the Ostium by a Perimetritic 
which forms a Deep Pouch . . . . . 



ILLUSTRATIONS 



s Dome 



Blade 



Ligature on Pedicle 



792 



FIG. 

202. Tube showing Obstruction of the Ostium from inflammatory Swelling of 

its Coats ........ 

203. Tubes and Uterus from a Patient who died of Phthisis three years after 

Incision of Peritoneum infected with Tubercle 

204. Cystic Fibromyxoma of the Fimbriae .... 

205. Microscopical Section of a Papillomatous Outgrowth from the Left Tube 

206. Papilloma of the Fallopian Tube . . . . 

207. ,, ,, Sections of an Outgrowth under high and 

low Power 

208. Primary Cancer of Fallopian Tube 

209. ,, ,, in Section, with Tubule-like Structure 

210. Dr. Cullingworth's case of Primary Cancer of the Tube 

211. Dr. Essex Wynter's case of Cancer of the Tube 

212. Diagram to show placing of Table, Surgeon, Assistants, Nurse, and Instru 

ments in Ovariotomy . 

213. Tait's Modification of Wells' Catch-Forceps 

214. Catch-Forceps (J. Greig Smith's Model) 

215. Blades of J. Greig Smith's Forceps . 

216. J. Greig Smith's Peritoneal Catch-Forceps 

217. ,, Large Pressure Forceps 

218. Wells' Large Forceps, bent . 

219. ,, ,, straight . 

220. ,, ,, 'Pressure Forceps, Rectangular 

221. Thornton's T-shaped Pressure Forceps 

222. Wells' Clamp Forceps 

223. Nelaton's Cyst Forceps 

224. Sydney Jones' Cyst Forceps . 

225. J. Greig Smith's Scissors 

226. ,, ,, Reel-Holder 

227. Wells' Large Cyst-Trocar 

228. Wells' Small Cyst-Trocar with Fitch 

229. Tait's Cyst-Trocar . 

230. Sydney Jones' Pedicle Needle 

231. Wells' Pedicle Needle 

232. J. Greig Smith's Forceps for placing 

233. Keith's Glass Drainage Tube 

234. Glass Drainage Tube . 

235. Sponge-Holder 

236. J. Greig Smith's Suture Instrument 



XVI 



SYSTEM OF GYNECOLOGY 



- Fordsbire Knot ..... 
Triple interlocking Ligature, Thread* inserted, Loops divided 

Threads interlocked ready for tying 

Threads tied . 
211. Seivw for aiding in the Delivery of Solid Tumours . 
itor for producing Elastic Pressure . 



PAGE 

889 
890 
890 
890 
895 
923 



LIST OF AUTHORS 

Ballantyne, John Win., M.D., F.R.C.P., F.R.S. Edin., Lecturer on Midwifery and 
Diseases of Women, Medical College for Women, Edinburgh. 

Balls-Headley, W., M.A., M.D., F.R.C.P., Lecturer on Midwifery and Diseases of 
Women, University of Melbourne. 

Barbour, A. H. Freeland, M.A., B.Sc, M.D., F.R.C.P. Edin., Lecturer on Midwifery 
and Diseases of Women, Edinburgh Medical School. 

Boxall, Robert, M.D., M.R.C.P., Assistant - Obstetric Physician and Lecturer on 
Practical Midwifery and Gynaecology, Middlesex Hospital. 

Croom, John Halliday, M.D., F.R.C.P. Edin., Physician to the Royal Infirmary, 
Edinburgh, Clinical Lecturer on Diseases of Women, and Lecturer on Midwifery 
and Diseases of Women at the Medical School. 

Cullingworth, Chas. James, M.D., D.C.L., F.R.C.P., Obstetric Physician and 
Lecturer on Midwifery and Diseases of Women, St. Thomas's Hospital. 

Doran, Alban, F.R.C.S. Eng., Surgeon to the Samaritan Free Hospital for Women. 

Gervis, Henry, M.D., F.R.C.P., Consulting Obstetric Physician to St. Thomas's 
Hospital. 

Griffith, Walter S. A., M.D., F.R.C.P., Assistant - Physician Accoucheur to St. 
Bartholomew's Hospital. 

Handfield -Jones, Montagu, M.D., Obstetric Physician and Lecturer on Midwifery 
and Diseases of Women to St. Mary's Hospital. 

Hart, David Berry, M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases of 
Women, Edinburgh Medical School. 

Haul tain, F. W. K, M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases 
of Women, Edinburgh Medical School. 

Herman, Geo. Ernest, M.B., F.R.C.P., Senior Obstetric Physician and Lecturer on 
Midwifery to the London Hospital. 

Malins, Edward, M.D., M.R.C.P., Obstetric Physician to the Birmingham General 
Hospital, Professor of Midwifery at Mason College. 

Morris, Henry, M.A., M.B., F.R.C.S., Surgeon to the Middlesex Hospital. 



xvm SYSTEM OF GYNECOLOGY 

* 

bt Hilne, M.A.. M.r... F.R.C.P. Edin., F.R.S.E., Lecturer on Midwifery 
and I 1 Women, Edinburgh Medical School. 

Phillips, John, M.A.. M.I>.. F.R.C.P., Assistant Obstetric Physician to King's College 
Hospital 

- M.h.. I.I.. 1).. F.B.C.P., Professor of Obstetric Medicine in King's 
ric Physician to King's College Hospital. 

a. Ov.iviul, M.l'.. M.D., LL.D., F.R.C.P., Consulting Obstetric 
ng's College Hospital. 

Booth, Amand .!.. M.D., B.S., M.R.C.P., Obstetric- Physician to Out-patients to 
iring Cross Eospital, Physician to Samaritan Free Hospital for Women. 

Simpson, Alex Russell, M.D., F.R.C.P. Edin., Professor of Midwifery, University 

I linhurgh. 

: :. W. Japp, M.A.. M.D., M.R.C.P., Professor of Obstetrics and Gynecology, 
ns College, Victoria University. 

Smith, Jas. Greig, M.A.. M.B., F.R.S. Edin., Professor of Surgery, University 
Bristol. 
. Win. .1.. M.I)., F.R.C.P. Ireland, Master of the Rotunda Hospital, Dublin. 

. John Bland, F.R.C.S., Assistant Surgeon to the Middlesex Hospital, Surgeon 
to the Chelsea Hospital lor Women. 

Thornton. .1. Knowsley, M.B., CM., Consulting Surgeon to the Samaritan Free 
Hospital. 



order to avoid frequent interruption of the text, the Editors have only inserted 
the numbers indicative of items in the lists of " References " in cases of emphasis, 
ore references to one author are in the list, where an author is 
quoted from a work published under another name, or where an authoritative state- 
ment is made without mention of the author's name. In ordinary cases an author's 
name is a sufficient indication of the correspond in; i item in the list. 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 

Great as the progress has been during the last fifty years in every 
domain of medicine, in no department has it been so marked as in that 
which embraces the diseases peculiar to women. Indeed, in tracing the 
developments of modern gynaecology, it is difficult for the student of our 
times to estimate the value of each claim to progress, and to set a just 
price on each alleged advance ; for it must be allowed that among many 
brilliant achievements many false starts have been made, and the boasted 
triumph of yesterday has been ranked among the failures of to-day. 

Sir William Priestley, in his address before the section of Obstetric 
Medicine and Gynaecology, says : " Looking back on forty years of 
gynaecological practice, I can recollect what has been termed a craze for 
inflammation and ulceration of the os and cervix uteri. During its 
prevalence, it was said of some devotees that every woman of a household 
was apt to be regarded as suffering from these affections, and locally 
treated accordingly. Shortly afterwards came a brief and not very 
creditable period when clitoridectomy was strongly advocated as a 
remedy for numerous ills. This, fortunately, had a very limited currency 
and was speedily abandoned. Then followed a time in which displace- 
ment of the uterus held the field, and every backache, every pelvic dis- 
comfort, every general neurosis, was attributed to mechanical causes, and 
must needs be treated by uterine pessaries. Again we had an epoch 
when oophorectomy was not only recommended, and largely practised 
as a means of restraining haemorrhage in bleeding fibroids, but also as a 
remedy for certain forms of neurosis, even when the ovaries were healthy 
or not seriously diseased. Ere long it was discovered that removing the 
ovaries for neuroses, even if safely accomplished as far as life was 
concerned, was frequently followed by more serious nervous penalties 
than those for which it had been used as a remedy ; that, in fact, 
it often entailed a loss of mental equilibrium, and sometimes ended 
in insanity. Close upon this, again, came an ardour for stitching up 
rents in the cervix uteri following child-birth, rents which were described 
as producing many hitherto unknown evils, and frequently conducing to 
the establishment of malignant disease. Lastly, we have had what has 
been described as an epidemic of operations for the excision of the uterine 

B 



SYSTEM OF GYNECOLOGY 



appendages; and even now. though this operation has but recently come 
into vogue, there is a reaction against its too frequent performance, and 

a demand in its place for more conservative methods, Which shall leave 

jrstem ;i chance of still performing their 
important functions." 

Whatever may have hern the mistakes or the delays in true progress, 

it any rate, pleasant to know that the age of mere speculation and 

tit mysticism has passed ; and that the accurate knowledge and 

tidier certain! the present day have been won by anatomical 

and pathological research, and by patient clinical observation both in the 

OOm and the operating theatre. 

It will always be a pleasant task to acknowledge the deep debt of 
bude which gynecology owes to Sir Joseph Lister; for without his 
scientific discoveries and brilliant teaching, the successes of modern 
pelvic and abdominal surgery could never have been won. 

The groundwork of all true development in any branch of medical 

must lie iii the establishment of an accurate knowledge of 

anatomical detail, and a correct appreciation of pathological changes. 

It may be well to review the advance of our knowledge in these sub 

and first in anatomy. 

Anatomy. Tkt blood-supply of the uterus, by the uterine and ovarian 

een well known and described by anatomists for many 

: but the manner in which the blood is distributed to the organ 

had ben less minutely studied : until Sir John Williams wrote his 

now classical paper "On the Circulation in the Uterus, with some of its 

mica! and Pathological Hearings," our knowledge of this important 

subject was extremely imperfect. Sir John Williams pointed out that 

tin- provision tor the flow of blood into and out of the uterus is such, 

th.it thfl process COUld with difficulty be disturbed by mechanical causes. 

The entrance and the exit take place at the sides of the organ at 

and not at its extremities; while in the uterus the 

Of the current is transverse to its length and perpendicular to 

its em ligature might therefore be placed round the uterus at 

any point without affecting the circulation above and below. The only 

ire which could materially interfere with the flow of blood into the 

'. M one surrounding the broad ligaments (their upper 

BII being included within it), together with a portion of the uterus. 

In this case the inflows to the parte above or within the ligature, and the 

them, would be diminished or stopped. ( ondit ions similar 

to th : nd when the uterus forms a hernia, either in the inguinal 

oanal or pouch of Douglas. When the fundus of the 
found in the pouch of Douglas the condition is spoken of 

BOD : but it ifl really a great deal more than this : 
ihl Ik a- .,[ the condition found when the uterus 

is in the ingnmal anteflexion or anteversion. Both are true 

the symptoms are due h, great part to the constriction at 
the i: be sac in posterior hernia by the sacrouterine ligaments. 



THE DE VEL OPMENT OE MODERN G YN.ECOL OGY 3 

There is another condition which may interfere with the return of 
blood from the uterus, namely, procidentia. Here all the veins of the 
broad ligaments may be so stretched that their channels may be 
considerably diminished, and all the channels for the return of blood 
from the uterus may be so narrowed that the organ must consequently 
suffer from passive congestion. These two conditions, hernise of the 
uterus and great procidentia, appear to be the only displacements of the 
uterus which can give rise to congestion of the organ. 

To those who remember the period in the development of gynaecology 
when uterine displacements were made to explain endless ills, it will be 
clear that the publication of the above essay made an enormous difference 
in the value attributed to so-called mechanical causes. Nowadays a 
more rational view is taken of the importance of alterations or devia- 
tions from the ordinary position of the womb ; and it is recognised that 
very considerable changes in the position of the uterus are perfectly 
compatible with the enjoyment of excellent health. The outcome 
on the clinical aspect is easy to imagine ; pessaries are no longer recklessly 
inserted for every slight misplacement, but are retained for those more 
severe cases in which relief to an embarrassed circulation is clearly called 
for. 

The Pelvic Peritoneum. Good work has been done in the past years 
by those who have increased our knowledge of the anatomical and 
obstetric aspects of the pelvic peritoneum. Thus Polk and Barbour have 
shown that in the full-term pregnant uterus the peritoneum in front and 
behind has the same relations as in the non-gravid uterus ; whereas, at 
the sides, the peritoneum is so lifted up by the growing uterus that the 
base of the broad ligament is on the level with the pelvic brim. Stephen- 
son concludes that the ligamental portions of the pelvic peritoneum 
offer considerable and permanent resistance to stretching beyond the 
limits of their elasticity ; and that the tension thus thrown on them is 
sufficient to undo their attachment to the pelvic walls. The peritoneum 
covering the uterus, however, instead of borrowing from neighbouring 
parts, undergoes a gradual yielding to an unlimited extent growth 
supplying the additional material necessary to prevent thinning. The 
contrast is great between the unlimited expansion of the uterine peri- 
toneum, under the gradual increase in bulk of the ovum and its 
intolerance of a rapid dilating force a contrast aptly illustrated in the 
history of the induction of premature labour by the rupture of the 
uterus on the injection of but a few ounces of water. The peculiar 
property of the uterine peritoneum of gradually yielding under a small 
but persistent force, while breaking under a sudden one, confers upon it 
something of a plastic character. Dr. Stephenson remarks : " Such being 
the properties of the serous coat, it is evident that it must play a part 
in the dynamics of the uterus. It furnishes a part of the persistent 
pressure inside the organ. It is also capable of taking a share in the 
retraction of the uterus. Whatever be the state of the muscular fibres 
of the uterus when labour is over, they are surrounded and supported by 



SYSTEM OF GYNAECOLOGY 



an elastic Capsule, with which any force tending to produce dilatation lias 

kon. This idea is strongly supported by the anatomical fact that, 

in the portion of the uterine walls where reaction is manifested, the 

peritoneum u firmly attached ; whereas the parts where no active 

us have either no peritoneal covering, or that membrane 

is but Loosely attached thereto." 

The knowjedge of this behaviour of the pelvic peritoneum under the 
disturbing influence of pregnancy is of immense importance to the 
gical surgeon; for it enables him to estimate the probable 
changes in the anatomical arrangement of the membrane, when fibroid 
tumours or broad ligament cysts have developed in the pelvis, and have 
materially affected the relations of its parts. Again, in the rupture of 
tubal gestations, or in the formation of pelvic hsematoma from other 
bs, the effect of the peritoneal resistance on the development of these 
swellings is made clear. 

nf the Pelvis. We are greatly indebted to the 
good work done by Hart and Barbour for our accurate knowledge of the 
manner in which the connective tissue of the pelvis is distributed. This 
. lying subperitoneal!?, surrounding the cervix uteri, and spreading 
out between the layers of the broad ligament, is of the highest pathological 
importance, as in it, and in the pelvic peritoneum, occur those in- 
flammatory exudations so common in women. 

late years our knowledge of the disposition of this tissue has 
been rendered much more accurate ; and, accordingly, our discrimination 
Ivic inflammatory attacks made much more precise. The most 
valuable information is obtained by studying sections of fro/en pelves. 
This method gives the precise position of the tissue, its amount and dis- 
tribution. By injections of air, water, or plaster of Paris, we have learnt 
the varying attachments of the pelvic peritoneum to the subjacent tissue ; 
and the lines of cleavage, as it were, of the pelvic connective tissue 
along wliieli lines pus will burrow. The valuable experiments of Band], 
ihlesinger have given us the following results: 
1. Water injected between the layers of the broad ligament, high 
up in front of the ovary, passed first into the tissue lying at the 
it of the side-wall of the true pelvis. It then passed into 
the tissue of tin- iliac fossa, lifting up the peritoneum, and followed the 
course of the jMsoas, passing only slightly into the hollow of the iliac bone. 
Lastly, it separated the peritoneum from the anterior abdominal wall for 
little distance above Poupart's ligament, and from the true pelvis 

tlOfl beneath the broad ligament to the side and in front 
of the istiunus, the deep lateral tissue became filled first ; then the 
peritoneum became lifted up from the anterior part of the cervix uteri ; 
thence the separation passed first to the tissue near the bladder; 

ultimately the fluid passed along the round ligament to the inguinal 

There it * the peritoneum along the line of Poupart's 

ligament, and passed into the iliac fossa. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 5 

3. An injection at the posterior part of the base of the broad ligament 
filled the corresponding tissue round Douglas' pouch, and then passed 
on as described in the first section. 

Much might be written to show what extensive work has been done 
to perfect our knowledge of the sectional anatomy of the female pelvis, 
of the structural anatomy of the pelvic floor, and of the position of the 
uterus and its appendages ; but the work already quoted will illustrate 
how full a share anatomy has had in the development of gynaecological 
science. 

Turning from the anatomical to the pathological and clinical 
aspects, it is interesting to note that the enormous strides which the 
science has made, and which have raised it from a desultory collection 
of hypotheses to its present high position, have all been taken in the 
last half century. It is true that in the early part of the century 
Recamier was advocating the use of the speculum and sound, and by his 
writing and teachings was giving an impulse to the study of uterine 
pathology; but it was not until about the year 1840, when Simpson in 
England and Huguier in France took the field with so much warmth, 
vigour and originality, that interest was awakened and the future of 
gynaecology assured. Recamier, Lisfranc, Kiwisch, Huguier, Simpson, 
and others had already paved the way for further discoveries, when Dr. 
H. J. Bennet, in 1845, published the first edition of his work on Inflam- 
mation of the Uterus, and roused the attention of the profession in every 
country to the pathology which he there set forth. The chief points he 
insisted upon were the following : 

1 . That^inflammation is the chief factor in uterine affections, and that, 
as results, there follow from it displacements, ulcerations, and affections 
of the appendages. 

2. That menstrual troubles and leucorrhoea are merely symptoms of 
this morbid state. 

3. That in the vast majority of cases inflammatory action will be 
found to confine itself to the cervical canal, and not to affect the body 
of the uterus. 

4. That the disease is properly attacked by strong caustics. 

It is difficult for the modern student to apprehend the conflict of 
opinions which arose over these assertions of Bennet ; it is sufficient to 
say that his views were strongly controverted by such able writers as 
Tyler Smith, Robert Lee, West, and others ; and that in the present day 
few gynaecologists would be prepared to accept such statements without 
considerable modifications. 

Thanks to the study of microbic pathology, much evidence, that in 
those days seemed misty and conflicting, is read by us now in a totally 
different sense. The knowledge of septic organisms, the influence of 
specific microbes, the conditions of tissue-resistances, have opened out for 
us new ideas and new interpretations ; and it is probably not too much 
to assert that had Dr. Bennet possessed our advantages much of his 
pathology would have been rewritten. 



SYSTEM OF GYN. ECOLOGY 



Another landmark in the history of the development of modern 
gynecology was the publication by Dr. Tilt, in L850, of his book on the 
eubje Inflammation ; later the same writer put forward the 

following propositions : 

1. That tie- recognised frequency of inflammatory lesions in the 
ovaries and in the tissues which surround them is of much greater 
ical importance than is generally admitted. 

J. That of all inflammatory lesions of the ovary those involving 
iction of the whole organ are rarej while the most numerous, and 
the most important, may be ascribed to a disease that may lie 
called either chronic or subacute ovaritis. 

3. That, as a rule, pelvic diseases of women radiate from morbid 
ovulation. 

\. That morbid ovulation is a most frequent cause of ovaritis. 
That ovaritis frequently causes pelvic peritonitis. 

6. That blood is frequently poured out from the ovary and the 
oviducts into the peritoneum. 

7. That subacute ovaritis frequently initiates and prolongs metritis. 

8. Thai ovaritis generally leads to considerable and varied disturbance 
Of menstruation. 

9. That some chronic ovarian tumours may be considered as aber- 
rations from the normal structure of the Graafian cells. 

Much of the pathology involved in these propositions of Tilt was 

sound, and has stood the test of time and more extended research; and 

though, as in propositions three and four, his teaching is not nowadays 

vet by it a considerable stimulus was given to the study of 

n pathology, and in testing the truth of his assertions more and 

lighi was gained. Morbid conditions of the tubes had been but 

little studied in Tilt's time, and the relation of tubal disease to ovarian 

inflammation was hardly appreciated ; had tubal pathology been better 

understood, probably less weight would have been attached to morbid 

ovulation as a cause of pelvic dis< 

The year 1854 marked a fresh epoch in the evolution of gynaecology; 

then it irai that the great war of uterine displacements and pessary-manu- 

re began. Hodge in America, Velpeau in France, and Grailv 

l.md, Stood forth as champions of the immense importance 

Iposition of the uterus in the causation of pelvic disease. How 

..ly the theory was urged may be judged by Velpeau's statement : 

i'-clare, nevertheless, that the majority of the women treated for 

affections of the uterus have only displacements, and I affirm, that 

teen times out of twenty, patients suffering from disease of the 

iromb, or of some other part of this region, those, for instance, in whom 

they diagnose engorgements, are affected by displacements." 

again, showed in his writings and teachings the 
importance he attached to displacements of the womb; in his 
known woik on />,,,,, ,,/ //" 1,,. formulates the following 
ions : 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 7 

" 1. That patients suffering from symptoms of uterine inflammation 
are almost universally found to be affected with flexion or alteration in 
the shape of the uterus ; an alteration of easily recognised character 
though varying in degree. 

" 2. That the change in the form and shape of the uterus is frequently 
brought about in consequence of the uterus being previously in a state of 
unusual softness, or what may be often correctly designated as chronic 
inflammation. 

" 3. That the flexion once produced is not only liable to perpetuate 
itself, so to speak, but continues to act incessantly as the cause of the 
chronic inflammation present." 

For a long time the teaching and literature of this epoch caused a 
vastly undue importance to be laid on the presence of every flexion or 
deviation, however slight. Every gynaecologist or practitioner who 
claimed special gynaecological merit, felt himself called upon to invent a 
pessary or to modify some one else's instrument ; and if, to quote Dr. 
Clifford Allbutt, " the uterus could justly complain that it was always 
being impaled on a stem or perched on a twig," it certainly could not 
complain that there was want of variety in the stem or monotony in 
the contour of the twig. 

Thanks to a more complete study of the circulation of the uterus by 
Williams, and to the teaching and practice of Matthews Duncan, a more 
correct appreciation of the importance of uterine displacement has been 
arrived at ; and we can recognise that it is possible for the uterine axis, 
as for the nasal septum, to be somewhat deviated without the patient's 
health being materially affected thereby. The value of a pessary in 
suitable cases is fully allowed ; but the instrument is no longer thought 
to be a panacea for every pelvic ill, or even a justifiable placebo to soothe 
the patient when diagnosis is at fault. 

Surgery. The next great era in the progress of gyncecology dates from the 
establishment of ovariotomy as a recognised operation ; for abdominal 
surgery, and especially that branch of it which had reference to disease 
of the uterus and its appendages, received its greatest impulse when it 
was found that ovarian cysts of the most formidable nature could be dealt 
with successfully and safely. Much discussion has arisen from time to 
time as to whom the credit of the first successful ovariotomy belongs, but 
it is now fairly certain that this honour rightly belongs to Dr. M'Dowell 
of Kentucky. 

The record of this first operation is of interest ; it was performed on 
a Mrs. Crawford of Kentucky in December 1809. The tumour inclined 
more to one side than the other, and was so large as to induce her 
professional attendant to believe that she was in the last stage of 
pregnancy. She was affected with pains similar to those of labour pains, 
from which she could find no relief. The incision was made on the left 
side of the median line, some distance from the outer edge of the rectus 
muscle, and was nine inches in length. As soon as the incision was 
completed the intestines rushed out upon the table ; and so completely 



B SYSTEM OF GYNECOLOGY 

the abdomen filled by the tumour, that they could not be replaced 
during the operation, which was finished in twenty-five minutes. In 
it bulk Dr, Ri'Dowell was obliged to puncture it 
could be removed. Be then threw a ligature round the Fallo- 
pian tube near the uterus, and out through the attachments of the morbid 
ti. The sac weighed seven and a halt pounds, and contained fifteen 
i a turbid, gelatinous-looking substance. The edges of the wound 
being brought together by the interrupted suture and adhesive strips, the 
11 was placed in bed and put upon the antiphlogistic regimen. "In 
jays Dr, McDowell, " I visited her, and, much to my astonish- 
ment, found her engaged in making up her bed. I gave her particular 
caution for the future, and in twenty-five days she returned home in good 
i. which she continues to enjoy." Mrs. Crawford lived until March 
. and had DO return of her disease. She enjoyed excellent health 
Up tO the time of her death. 

It must not. however, for a moment be supposed that the idea of 
ovariotomy originated with M'Dowell : years before, the Hunters had 
shadowed forth the possibility of removing ovarian cysts; and John Bell, 
of Edinburgh, though he had never performed ovariotomy, yet in his 
Bfl dw.-lt with peculiar force and pathos upon the hopeless character 
of ovarian tumours when left alone, and upon the practicability of 
removing them by operation. From this time forward operating surgeons 
time to time undertook the operation : sometimes a solitary case, 
followed by success or failure, sometimes a small group of cases (as 
published by Dr. Clay of Manchester in 1842) with a fair percentage of 
succc- recorded; but still the operation had not secured the 

confidence of the profession, and the records were few and far 
betwi 

In L850 Mr. Duffin inaugurated a new era by raising the epiestion of 

the danger of Leaving the tied end of the pedicle within the peritoneal 

: and by insisting upon the importance of keeping the strangulated 

tamp OUteide. Of this step in the history of ovariotomy Spencer Wells 

ss: "Whatever may be our opinions and practice at the present 

time, and whatever nWS we may hold upon the question, whether this 

treatment of the pedicle has advanced or retarded the 

" of tin- . Mr. Dnthn's arguments led to great changes and 

results to the use of the clamp and to all the modifications of treatment 

Ian1 upon it. and ultimately to researches as to the physiological 
:1,,, 1 I sal phenomena of ligatured stumps within the peritoneal 

Cavity, ami to the study of the important subject of drainage by Koeberle 

n." 
Much might be the excellent work done by Baker Brown, and 

ii the cautery; also of Tyler Smith's revival of the 
practir- o< returni] dicle with the ligature: but the history of the 

ovariotomy dates from the publica- 

Snl book in 1864. From this time onward 

abdominal peli v bas bad ; continuous story <>f forward prog] 



THE DE VEL OP ME NT OF MODERN G YNJS COL OGY 9 

step by step difficulties have been overcome, and each advance has been 
established on a sound scientific basis. 

Among the many useful points made clear by Spencer Wells that 
regarding the union of divided peritoneum was of special interest. From 
experiments made upon dogs, rabbits, guinea-pigs, and other animals, he 
was able to give visible evidence that, in the union of the cut surfaces of 
an abdominal incision, however accurately other tissues might be brought 
together, if the cut edges of the peritoneum are left free within the cavity 
they retract, direct union does not take place, and secondary evil con- 
sequences result. On the other hand, in specimens where the divided 
edges or rather surfaces of peritoneum have been pressed together, the 
smooth, serous, inner coat of the abdominal wall is perfectly restored. 
The stitches cannot be seen on the inside, though plainly visible on the 
skin ; and there is no adhesion of intestine or omentum. But in other 
specimens, where the peritoneal edges were purposely excluded from the 
sutures, and the animal was not killed for a day or two, intestine or 
omentum adheres to the inner surface of the abdominal wall, thus com- 
pleting the peritoneal sac at the great risk of intestinal obstruction ; to say 
nothing of a want of firm parietal union and subsequent ventral hernia. 
It was clearly demonstrated that, when skin or mucous membrane is 
divided, the edges must be brought together to secure direct union. If 
they are inverted, union is prevented. The exact opposite holds good 
with serous membranes. Their edges should be inverted and two surfaces 
of membrane pressed together, so that the sutures are not seen. The 
effused lymph then makes so smooth a surface that even the line of union 
cannot be seen. 

To those of us who have been brought up in the atmosphere of modern 
surgery, when the details of ovariotomy are carried out with almost 
universal agreement, it is difficult to realise the fierceness of the fights 
which raged round the comparative merits of a long or a short abdominal 
incision ; how bitterly the advocates of the intraperitoneal treatment of 
the pedicle regarded those who treated the pedicle by the extraperitoneal 
method and the use of the clamp, or how great was the importance 
attributed by each operator to his own special method of closing the 
wound ! Bit by bit evidence has been accumulated as to the desirability 
of using opium freely or sparingly after the operation ; as to the best 
mode of feeding the patient and maintaining her strength ; as to the use 
of stimulants ; the modes of entry of septic poisoning, and the after con- 
sequences and complications of the operation. 

Ovariotomy in the course of its evolution taught us great things re- 
garding the tolerance of the peritoneum even of rough handling and injury, 
provided nothing septic be left for absorption. Many details of treat- 
ment employed at present in abdominal surgery were learnt in the school 
of ovariotomy. In his address on " Abdominal Surgery Past and Present," 
delivered before the Medical Society in October 1890, Mr. Knowsley 
Thornton attempted to sum up the causes of slow progress and too frequent 
failure in abdominal surgery up to the year 1876, and to place the various 



io SYSTEM OF GYNECOLOGY 

- in what seemed to him bo be their order of importance. He says: 
We haw first the genera] want of cleanliness and the lack of all apprecia- 
tion or knowledge of what constituted surgical cleanliness, then the long 
Ligature and the damp, both clumsy and unscientific, and both specially 
I to make the want of cleanliness more deadly, and then following 
with an appreciable but tar different influence, we have delay in operating, 
tapping and the Ion- incision. Then 1 must not forget drainage, for I 
think it is highly probable that a really good system of drainage, rach as 
we now have, thanks to Koeberle" and Keith, would have done much to 
counteract the evils I have named above, though the frequent use of the 
drainage tube, with the Ion- - ligature and tin; clamp, v^ould have intro- 
duced new dements of risk, which I shall have to refer to again when I 
k of the place which drainage occupies in the successes of to-day." 
Probably the long ligature and the clamp had less to do with failure 
than the want of knowledge of antiseptic precautions. At the 
it day we use a clamp round the pedicle of a fibroid tumour, we 
fix it in the lower angle of the abdominal wound, and yet we keep the 
wound and peritoneum perfectly free from septic mischief: moreover, in 
extirpation of tin 1 cancerous uterus per vaginam we tie broad ligaments 
with silk ligatures, and leave long ends hanging down into the vagina 
till they come away ; and yet we do not get septic peritonitis. 

Probably delay in operating plays a more important part in results 

than we have hitherto supposed. The early ovariotomists had to under- 

i it age of cases of long standing, cases in which the 

il length had been exhausted by years of suffering, and in whom 

[stance to the slighter or more severe forms of septic attack was 

y impaired ; cases, moreover, in which dense and difficult adhesions 

to bowel, bladder, liver, and neighbouring parts had become organised in 

the long delay. At the present time the majority of these difficult cases 

D cleared oil", and in most of the cases now undertaken the health 

is still unimpaired, and adhesions (if present) are soft and easily sepft- 

: moreover, long experience has taught us how to discriminate 

unsuitable eases of a malignant type, and these we have the wisdom to 

have severely alone. 

i will ever minimise our vast obligations to Sir 

but. in fairness to the early operators, we may notice that 

ells had taken steps at a very early period to prevent the 

exposure of his cases to noxious influences. He did not allow surgeons 

who had been in contact with leptlC cases to be present at his operations J 

he kept hi- ward- for abdominal cases separate from wards in which 

rine iloughing cancer or other betid diseases were 

present ; and he himself gave up all work in the post-mortem room. 

The dawi tter things in the way of surgical cleanliness had thus 

been shallowed forth before the full light of Lister's teaching had risen 

as It hi describing thus far the growth of ovariotomy the names 

Miinent pioneers, such as Clay of Manchester, Atlee of America, 

. and in;' bherworki received scanty recognition, it is 



THE DEVELOPMENT OF MODERN GYNAECOLOGY n 

because in the present article no attempt is being made to describe fully 
the evolution of ovariotomy, but only to show the place it took in the 
development of gynaecological science, and to emphasise some of the 
principal teaching and the elaboration of details which secured for it the 
present successful position. 

When once the removal of the ovaries in cases of cystic disease of 
these organs had become an established operation, it was to be expected 
that surgeons would consider the advisability of removing the uterine 
appendages for other morbid conditions : but no special move was made 
in this direction till about the year 1872, when we find that Hegar, 
Battey, and Lawson Tait all began to work in this special field. Battey's 
original idea was to remove ovaries, not in themselves diseased, for the 
cure of certain nervous diseases, which he believed to be caused or kept 
up by structural or functional derangements of the ovaries. Hegar must 
have the credit of introducing the removal of ovaries for the cure of fibro- 
myoma of the uterus ; while to Mr. Lawson Tait belongs the credit of 
introducing the operations for removal of diseased ovaries and tubes. 

It is now fairly well established that extirpation of the ovaries for 
various neuroses is practically a failure : the operation has been re- 
commended in cases of insanity occurring at times of ovulation, in cases 
of hystero-epilepsy, also in hystero-neuroses other than epilepsy of severe 
character, but in very few instances has a cure been reported \ in the 
majority no good has been gained, and in a certain proportion the patient 
has been left mentally and physically in a worse condition than before. 

When, on the other hand, we study the cases in which the ovaries 
have been removed for the cure of uterine fibromyoma we find that a 
great step has been gained, and that Professor Hegar has added a valuable 
resource to our treatment of these tumours. Knowsley Thornton con- 
siders that we owe an immense debt to Hegar for the introduction of 
this method of dealing with fibromyomas ; that the operation has, of 
course, its risks and its failures, but that, with care in the selection of 
proper cases, and with care in the removal of every particle of ovarian 
tissue, it is most satisfactory in its results, and is one of the most 
thoroughly scientific and valuable operations in the field of abdominal 
surgery. When we come to consider the removal of diseased ovaries 
and tubes, as recommended by Tait ; and try to gauge the degree in 
which this operation can be called an advance in gynaecology, we have a 
difficult question to deal with a difficulty mainly owing to the intemperate 
zeal of many advocates of the operation. In cases in which tubes are 
filled with putrid or specifically diseased pus, and are displaced and badly 
adherent ; or, again, when an ovary has become a mere bag of pus, dis- 
placed, and fixed by adhesions low in the pelvis, operation is urgently 
called for and should be undertaken. 

There are cases, also, in which the ovaries, for a long time the subject 
of chronic inflammation, may be displaced and adherent low in the pelvis ; 
cases in which the tubes may be slightly thickened by mucoid degenera- 
tion, or are in an early condition of hydrosalpinx : in such cases when 



12 V OF GYNAECOLOGY 

tlic patient is drifting into chronic invalidism, is incapacitated from work, 
and is unequal to the duties of life, extirpation is certainly called for. 
On the other hand, to remove ovaries and tubes for early stages of sub- 
ovaritis, for slight of pelvic peritonitis affecting the end of 

the tube and the ovary, for minor degrees of salpingitis, for ovarian pro- 
lapse apart from coarse disease, is to bring the operation into well-earned 
disrepute, and to retard rather than to advance the progress of the 
It i>. unfortunately, in the very cases in which the operation 
i- most necessary that the greatest danger arises; for it is impossible to 
extirpate tabes full <>f foul pus or suppurating ovaries without great 
danger of fouling the peritoneum : moreover, in these cases the intestines 
often BO adherent, or so softened by inflammation, that a great risk 
of rupture or of subsequent faecal fistula must necessarily be run. It 
has been well said that if the mortality could be obtained for all the cases 
of pyosalpinx operated upon in the United Kingdom since Tait intro- 
: the operation, it would run the natural mortality of the disease very 
indeed. There are, moreover, sundry objections to the operation 
which should be recognised, though they are frequently ignored. The 
i<>ii does not by any means always lead to a permanent cure: a 
large proportion of patients operated upon suffer from continuance of the 
which preceded the operation; sometimes inflammatory products 
>rmed which press on nerves and thus cause fresh troubles, or fix the 
- and thereby cause intense pain; or grave mental symptoms may 
; or the pedicle may suppurate and the healing of the wound be 
gravely drlay.d. 

Mr. Alban Doran summed up the position of the operation very 
ily when he remarked that it was very evident that removal of 
the appendages was an operation to be avoided whenever possible: and 
Professor Sinclair has wisely pointed OUt that operators are disposed to 
regard the woman's escaping with her life as constituting per se a 
nit : whereas more attention should be paid to the ultimate 
effects upon the general health. 

In c on nection with this operation, we may properly consider the work- 
done of late years both in Germany and in England, by which it has been 
11 that in many instances the mere breaking down of adhesions, 
amove! of cither tube or ovary, is quite sufficient to relieve the 
patient of all h.-r previous symptoms, and to restore her to an active, 

useful lite. 

The revival of ovariotomy between 1858 and 1865 Led, in the words 

'aget, to an extension of the whole domain of peritoneal surgery, 

i. naturally enough, began with the removal of the uterine 

Kra The removal of Bbromyomas of the uterus has always been a 

much more tenoni matter than the performance of ovariotomy: thus up 

to ,! ' the year 1883, or thereabouts, such eminent operators as 

d Bantoch had a mortality of 30 per cent. 

ii by improved methods and wider experience 

J) has shown that u i- possible to have a mortality not much greater 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 13 

than that of ovariotomy, still the operation in the hands of the majority 
of surgeons has not given such satisfactory results. The greatest gain so 
far has been brought about by Hegar's suggestion of the removal of tubes 
and ovaries as a method of procuring arrest of growth and subsequent 
atrophy of these growths. 

The rising generation of medical students is much more efficiently 
trained in obstetrics and gynaecology than was the case twenty years 
ago ; and, doubtless, as fibroids of the uterus are recognised earlier, 
and cases of rapid growth of them are better watched and understood, 
Hegar's method will be applied in suitable cases with less delay, and 
at a time when removal of the uterine appendages is more feasible. 
We may thus hope less frequently to see large fibroid masses filling 
the abdomen and calling for abdominal hysterectomy with its greater 
mortality. 

It is not within the scope of this article to enter upon the various 
methods of operating for uterine fibroids, nor upon the various modifica- 
tions of existing operations ; but it is noteworthy that the most eminent 
gynaecological surgeons of the present day are not the most ardent advo- 
cates of frequent operating, and show their skill rather by their judicious 
selection of cases suitable for interference. Again, there is a decided 
tendency to prefer removal by abdominal section to any form of 
vaginal operation ; save in cases where submucous fibroids have already 
been partially delivered. As to the treatment of the pedicle of the 
tumour, when the growth is removed by abdominal incision operators 
are still divided in their choice between the extraperitoneal method and 
the intraperitoneal as advocated by Schroeder. Probably it will be 
found that each method has its advantages, and that the choice of 
method must be decided rather by the nature of the growth than by the 
fancy of the operator. While on the subject of fibromyoma of the 
uterus, it is impossible not to refer to the electrical treatment of fibroids 
which has been brought forward by Dr. Apostoli during the last few 
years. Many years ago it was asked whether fibroid tumours could be 
dispersed by the use of the galvanic current, but no satisfactory reply 
could be obtained. Apostoli has come forward claiming that he has 
found a means of applying currents so strong that destruction and 
shrinkage of the tumour is obtained without any damage to the patient's 
healthy tissues. According to his method, the operator applies a large 
clay pad over the abdomen in which is embedded the positive pole of a 
galvanic battery ; then a sound, made of platinum with the lower part 
protected by some insulating covering, is passed through the cervix into 
the uterus ; or, where this is impossible, a sharp-pointed steel sound, with 
all but the terminal half inch insulated by a protective coating, is plunged 
through the vaginal wall into the substance of the tumour : the connec- 
tions are now made, and a current, varying from 50 to 100 milliamperes 
or more, is allowed to pass. With reasonable care currents of this 
strength can be used without any damage to the wall of the abdomen. 
Many cases were brought forward by Apostoli to show us that 



i 4 SYSTEM OF GYNAECOLOGY 

tinder this treatment fibroids commonly shrink down to half or a third of 
their original balk, and in many instances are practically destroyed with- 
out ,iiiv Blooghing <>r suppuration The method has been" fairly tested by 
numerous operators since its introduction, and it is to their results that 
we must look in deciding whether this electrical treatment of fibroids is 
i in advance in our knowledge and modes of treatment 
or nol an be decided at present, the result of the most recent 

inquiries has lea* as to the following conclusions: 

1. The majority of fibromyomas (especially those of slow growth) are 
nol reduced by the treatment 

j. Soft fibromyomas are somewhat reduced in size by the use of the 

ent 

3. [hemorrhage due to submucous fibroids, or perhaps to the 
fungous endometritis bo often associated with them, is greatly lessened. 
In tl l the positive pole is introduced into the uterine cavity, 

and the negative is connected with the abdominal pad. 

}. ( lonsiderabls damage may he done to tissues in using this treatment 

The opponents of Apostolus method have pointed out that fibroid 

tumours of the uterus (especially the soft cellular form) may be reduced 

quite as satisfactorily by the use of rest, hot douches, and ergot, as by 

tin- ose of electricity ; and with much greater safety. Also that the 

shrinkage obtained by the ose of the current is by no means permanent 

ids hemorrhage, the happiest results often follow the use 

of dilatation and curettage, so that there is no special advantage in 

employing the electrical treatment. Keith and other observers have 

spoken in terms of warm commendation of Apostolus work, but so 

not brought forward results which carry general conviction. 

tended observation is needed, but at present it can hardly 

be said that the electrical treatment of fibromyoma of the uterus ranks 

high among <>ur gains [vide art " The Electrical Treatment of Diseases of 

Worn 

One of the results of the recent advances 
in abdominal surgery has been to give as a wider acquaintance with the 
pathology and treatment of those interesting cases in which the foetus is 
I outside the uterine cavity. Much of our present knowledge is 
due to the investigation of Bar. Lawson Tait since Tait's first operation 
in iss.j for niptun-d ectopic gestation an operation which he performed 

esstully great attention has been directed to the subject, and much 
ice in our knowledge has been made. Before this epoch extra-uterine 
gestation was thought to be one of the rarest events in the pathology of 
pregnancy: now we know that the accident is one of common occurrence. 
The older text bo at much that was purely hypothetical on the 

object : thu- I'd .i variety in which conception was affirmed 

to occur U follicle, and development to take place entirely in 

Tait pointed out that no museum specimen or post-mortem 
recoroVgives any ground for inch a view. 

Again, regarding the so-called abdominal form of ectopic gestation, it 



THE DE VEL OPMENT OF MODERN G YNJE COL OGY 15 

was believed that an ovum might be fertilised, drop into the peritoneal 
cavity on its way to the tubal opening, and grow from its beginning 
free in the peritoneal cavity. Without saying that this is impossible, 
we may assert that in our present state of knowledge the notion is purely 
imaginary, and is not borne out by any evidence of dissections. More 
extensive research and observation has led us to view almost every case 
as primarily tubal, commencing either (i.) In the fimbriated end of the 
tube ; or (ii.) in the centre of the tube ; or (iii.) in the interstitial part 
of the tube. 

Much light has been thrown on the etiology of blood tumour in the 
pelvis by abdominal sections undertaken for ruptured tubal gestation ; and 
now it is clear that the majority of pelvic hematoceles and hematomas 
are due to blood poured out from the end of the tube after rupture of 
the gravid tube or separation of the sac wall : in a few cases only 
can it be traced to such other causes as reflex of menstrual blood, 
hemorrhagic peritonitis, rupture of A^eins in the broad ligament, and the 
like. No great advance has been made in our knowledge of the 
causes which lead to the production of an extra-uterine gestation ; but 
the hypothesis which has gained the widest hearing is that it is due to 
some lesion in the interior of the tube which obstructs the ovum in its 
passage to the uterus. This lesion is in some cases a desquamation of the 
epithelium of the tube, whereby the cilia are removed, and a pouching of 
the tube may be produced in which the ovum remains instead of con- 
tinuing its journey to the womb. In other cases a stenosis of the lumen 
of the tube is brought about by peritonitic adhesions which, in the course 
of their contraction, produce an angular bend in the tube, and so 
arrest of the ovum. The theory of lesion in the interior of the tube 
seems to cover a large number of cases ; and it is strengthened by 
the fact that a history of previous trouble on the same side of the pelvis 
can frequently be elicited. The event is often, though not always, pre- 
ceded by a period of sterility. The theory is also supported by the 
further supposition that the normal site of impregnation is in the uterus, 
and that if the ovum be delayed, and impregnated in the tube, ectopic 
gestation results. Cases of ruptured tubal gestation, when examined on 
the post-mortem room table or during an abdominal operation, have taught 
us to what an extreme degree the ruptured peritoneum may be lifted from 
the pelvic walls and viscera by the gradual development of the foetus, 
or by repeated hemorrhages beneath the membrane. This elevation may 
reach as high as the umbilicus or even further. 

In a paper read before the Royal Medical and Chirurgical Society of 
London, Mr. Bland Sutton drew attention to the fact that the ovum in a 
case of tubal pregnancy, like the ovum in uterine pregnancy, is liable to 
become converted into a mole (apoplectic ovum). In November 1892 
the same author brought a communication on " Tubal Moles and Tubal 
Abortion " before the Medical Society of London, and by his admirable 
drawings and accurate research added greatly to our knowledge of this 
important condition. 



16 SYSTEM OF GYNAECOLOGY 

On the subject of tubal moles Bland Sutton Bays: "The retention 
of an impregnated ovum in the Fallopian tube leads to occlusion of the 

abdominal ostium, an event usually complete by the sixth, but often 
delayed to the eighth week following impregnation. It is therefore 
comparatively a slow process. When the ovum is lodged in the ampulla 
of the tube the ostium cannot close. So long as the tubal ostium remains 
open the ovum is in constant jeopardy of being extruded through it into 
the peritonea] cavity, especially when the ovum lies near or in the ampulla 
of the tube. When an impregnated ovum is thus extruded from the 
tube into the general peritoneal cavity, it is invariably in the condition 
of a mole, and the accident is always accompanied by haemorrhage. The 
extrusion of a mole in this way is always indicated by the term 'tubal 
abortion.' Free haemorrhage may occur from a gravid tube and the mole 
be still retained in consequence of its attachment to the wall of the tube. 
Under such conditions the bleeding may be repeated. This is known as 
'incomplete tubal abortion."' 

Since the discovery of the tubal mole, specimens of occluded Fal- 
lopian tubes filled with blood, independent of tubal pregnancy, are now 
found to be infrequent. In the last report of the Museum of the Royal 
College of Surgeons (1892), a description is given of "An unequivocal 
example of Hematosalpinx." This is a fair indication of the revolution 
which has taken place in our knowledge of the early stages of tubal 
pregnancy. There is one point in the treatment of ectopic gestation, 
advanced to term and in which the foetus is still living, which requires 
further study, and this is the treatment of the placenta after incision of 
the sac and extraction of the child. To strip off the after-birth from the 
underlying tissues would usually involve a terrible haemorrhage and 
probably the death of the patient; yet to leave the placenta means, in 
too many instances, secondary septic changes and the death of the mother. 
Lawsofl Tail has recommended that the cord should be cut off close to 
the placenta, the sac washed out, and then sealed by stitching it over the 
placenta; the abdomen is then to be closed, and the after-birth left 
to be absorbed. 

The establishment of ovariotomy, leading as it did to the; great exten- 
sion of peritoneal Surgery, has led us to another great advance, namely. 
to the recognition of the benefits of abdominal drainage. Operators differ 

greatly in their estimate of the value of the drainage tube in abdominal 
surgery, but few in the present day will be found to deny its value in 

suitable cases. Whether in the treatment Of pelvic abscess, in the 

ippurative or tubercular peritonitis, or again after the removal 

of foetid, closely adherent pelvic cysts, the drainage tube becomes of 
primary importance, For tome time the question was debated whether 
an incision made into the vagina] roof t<> allow of a canula being 
drawn through from the peritonea] cavity into the vagina] canal were not 
the better method of drainage: but it has been fairly well proven by 
Krith, Alban Doran, and other authorities, thai the cavity of the jx-ci- 
toneum can '" more effectually emptied ami kept Ucc of exuded fluid by 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 17 

the glass drainage tube passed down from the abdominal wound into the 
floor of Douglas' pouch. Of course in some cases the use of the rubber 
tube or of iodoform gauze may possess a special advantage. No one who 
has witnessed the good effects of abdominal drainage will doubt that in 
the recognition of this surgical expedient we have made a distinct 
addition to our surgical knowledge. 

No account of the work done in the development of gynaecological 
science would be complete without a reference to the splendid achieve- 
ments of Marion Sims in the field of vesico-vaginal fistula. In numbers 
of women life was rendered one long period of suffering and distress 
until Sims brought his skill to bear on the subject of these lacerations. 
It is not difficult to picture the constant mental agony of a young woman, 
still in the prime of life, in whom the discomfort due to incontinence of 
urine and the foetor depending on clothes soaked with decomposing urine 
were horrors from which she could never escape. From the days of 
Ambrose Pare" attempts had been made by Lallemand, Roux, Gosset, 
Jobert de Lamballe, and many other surgeons, to find a satisfactory mode 
of closing these fistulas ; but with what amount of success may be judged 
by the words of Velpeau, who, writing in 1839, says: "To abrade the 
borders of an opening, when we do not know where to grasp them ; to 
shut it up by means of needles or thread, when we have no point 
apparently to secure them ; to act upon a movable partition placed 
between two cavities, hidden from our sight, and upon which we can 
scarcely find any purchase, seems to be calculated to have no other result 
than to cause unnecessary suffering to the patient." 

In 1852 Sims brought out his perfected method of healing these 
rents in the floor of the bladder ; and gained a series of successes which 
entirely altered the aspect of this special domain of surgery. He laid 
claim to three discoveries namely, that he had produced a speculum which 
enabled an operator to explore the vagina perfectly ; that he had found a 
suture which was not liable to set up inflammation or ulceration ; and 
that by the use of his catheter, the bladder could be kept empty during 
the healing of the fistula. 

Sims was shortly afterwards followed by Simon of Germany, and to 
the efforts of these two workers we owe our present satisfactory know- 
ledge of the subject. Simon himself laid great stress on the importance 
of the operation called by him kolpokleisis, or closure of the vagina an 
operation to be resorted to in cases in which the cure of a vesico-vaginal 
fistula could not be successfully accomplished. Doubtless such a surgical 
resource may be found valuable occasionally ; but the cases must be rare in 
which the fistula cannot be closed by patience and perseverance. Year by 
year, however, fewer cases of these fistulous openings occur. Better 
hygienic surroundings have told favourably on the young girls of the 
present day, and pelvic contractions are less frequent ; the frequent use 
of the midwifery forceps, and their earlier application, prevent the foetal 
head from resting so long on the mother's soft parts, and prevent the 
sloughing of her anterior pelvic tissues ; and an increased knowledge of 

c 



SYSTEM OF GYNECOLOGY 



the mechanism of delivery has led to a more successful management of 
difficult labours. 

Reference may be made here to certain plastic operations which have 
been devised in connection with the vagina for instance, plastic operations 

for lessening the calibre of the vagina, others for preventing prolapse of I he 
uterus, plastic operations on the cervix, and so forth, but none of them has 
taken a very firm hold on the surgical world. In the same category might 
be placed sundry operations which have been devised of late years for fixing 
the uterus; thus Alexander's operation of shortening the round ligaments 
in eases of uterine prolapse, hysteropexy or fixation of the womb to the 
posterior surface of the parietal peritoneum, detachment of the vagina 
from the anterior wall of the uterus with opening of the anterior peri- 
toneal eulrdesaCj and forward fixation of the uterus these and sundry 
other operations have all their earnest advocates, but I have not given 
them a recognised place in uterine surgery ; for it cannot be said as yet 
that they have secured the confidence of the gynaecological world ; they 
are rather on their trial than accepted as proven remedies 

Malignant Diseases. The ancient writers were doubtless acquainted 
with cancer of the uterus, but their knowledge was narrowly limited ; and 
we may certainly claim that in the last fifty years we have made great 
advances in our knowledge of the pathology and clinical course of 
malignant diseases of the female genital organs. It is a matter of extreme 
regret that we have hitherto made so little progress in our modes of 
treatment, and are still so far from an acquaintance with any curative 
method. 

Even in the earlier part of the present century the knowledge of 
uterine cancer was very shadowy ; for Church, writing in 1864, - 
" If we compare the writings of different persons, and those men of great 
experience, we shall find many points of interest undetermined, and others 
the subject of incessant controversy. Very frequently the description 
of the disease conveys only a lively picture of the uncertainty of the 
writti : and so vague, indeed, is the sense in which the term cancer is 
sometimes applied, especially by the French authors, that it would be 
quite impossible to recognise the complaint from their description." Den- 
man fully appreciated tie- uncertainty of the description generally given* 
He lays: " Of cancer it is to be lamented that we nave at present neither 
a tolerable definition nor a correct history, nor any accurate distinction 
of the several Varieties which are certainly known to exist. Nor is 
it yet proved whether cancer of any pari has any specific quality 
according to the structure of the part affected ; nor have we, in fact, any 

Other idea than that it is an incurable disease. Till within quite recent 
- Cancer W8J often confounded with fibroid tumour of the uterus, and 

the division into schirrus, encephadoid, epithelioma, and colloid was com 

monlv quoted in the text hooks of the day. Moreover, the term 

'corroding ulcer 3 was applied by Dr. John Clark, and subsequently Sir 
Charles Clark, t< n form <f ulcer of thecervia in which nothing but rapid 
destruction of tissue is noticed as a pathological lesion ; in which there is 



THE DE VEL OPMENT OF MODERN G YNM COL OGY 19 

no hardness of the part affected, no induration nor inflammation of sur- 
rounding organs nothing but molecular death in the cervix uteri, and 
disappearance of its structure as by liquefaction. It has been described 
under the names of rodent ulcer, diffuse ulcerative cancer, epithelial cancer, 
and cancroid of the uterus." Many other authors might be quoted to 
show how little certainty existed. 

A decided step in advance was taken when Thiersch and Waldeyer 
laid down that all cancerous disease in the uterus takes its origin from 
the epithelium lining glands which dip down into the parenchyma. 
" Only Thiersch, and recently Waldeyer," says Billroth, " maintain as I 
do the strict boundary between epithelial and connective tissue cells. I 
only call those tumours true carcinomata which have a formation similar 
to that of true epithelial glands (not the lymphatic glands), and whose 
cells are mostly actual derivatives from true epithelium." At one time 
surgeons were doubtful whether malignant disease arose more often in 
one part of the uterus than in another ; but another advance was made 
when Sir Charles Clark wrote that " carcinoma particularly affects 
glandular parts, and the cervix of the uterus being the most glandular 
part of it, is probably the reason why it becomes, more liable to this 
disease than any other part of the viscus." 

Before this time Dr. Burns had laid down in his work that "as 
opportunities are not frequent of examining the womb in the early stage 
of the disease, and as in course of time it involves parts not at first affected, 
we have not yet decided what the comparative liability of different parts 
of this viscus is to the disease." Yirchow advanced our knowledge still 
further by his investigations into the differences between malignant 
cauliflower excrescences and non-malignant papilloma. He stated his 
belief that some tumours, in every respect resembling vegetating 
epithelioma, are really non - malignant papilloma. The difference 
between the latter and real epithelioma is to be found by microscopic 
examination of the submucous tissue, which in the one case is healthy, in 
the other case diseased. In 1888 Williams published his well-known 
Harveian Lectures on uterine cancer, and summed up fairly the extent of 
our present knowledge. 

Three varieties of malignant disease affect the uterus sarcoma, 
carcinoma, and adenoma. In the uterus sarcoma and carcinoma are always 
malignant ; adenoma often, but perhaps not always. The uterus is divided 
into three parts, mainly according to the character of the epithelium and of 
the glands met with in each part. The first is the vaginal portion : this 
portio vaginalis is really a cup of stratified epithelium, resembling a tailor's 
thimble, which fits on the lower end of the cervix proper. The next 
part is the cervix, and the third is the part above which constitutes the 
body and fundus of the organ. These divisions are of importance because 
cancer may begin in any one of them, and the disease generally presents 
different characters, runs a different course, and is amenable to treatment 
in different degrees, according as it begins in one or other of them. 

In the first division the disease is almost always a squamous 



SYSTEM OF GYNAECOLOGY 



epithelioma. In this case the lines of growth arc not towards the cavity 

of the uterus, but outwards and downwards towards the vagina; it 

towards the vaginal vault, and then down along the surface of the 

Vagina] walls. There is no evidence that laceration of the cervix playtj 
any j>art in the etiology of this form of cancer ; hut most of the cases 
occur in women who have borne children. 

hi the second division we find disease occurring witli much greater 
frequency. The starting-point of the cancer of the cervix seems to he 
always in the glandfl of the cervix ; and if we study the lines of growth 
of the disease, we find that it usually spreads downwards and outwards 
into the Burrounding cellular tissue. The vaginal walls are usually 
spared 

In the third division we have cases of cancer of the body of the 
uterus. This pari of the uterus is much less commonly the seat of the 
disease than is the cervix ; at one time, indeed, it was doubted whether 
r ever originated primarily in the body, but numerous undoubted 
have been brought forward to prove the statement. All cancers of 
the body seem to be of the columnar epithelioma kind. They occui 
most oft. ai after the age of fifty : they give rise at an early period to 
much pain and flooding; they are more common in nulliparons patients, 
and. once begun, they involve the whole surface of the body, though they 
tend t0 respect the Cervix. In the later stages the disease passes through 

the internal os and attacks the cervix; it also spreads deeply, involve! 

the mUSCUlar wall, and may pass through it. 

No description of the evolution of this subject would be complete 
without reference t" the admirable work done by Ruge and Yeit in 
investigating the true nature of granular erosions of the cervix, and 
showing how these lesions differ from early manifestations of true cancer. 
An erosion differs from cancel- in that the epithelium on its surface 
and Lining it- glands consists of a single layer and assumes no aberrant 
forms; and from adenoma of the cervix, in that the glands are compara- 
tively superficial A simple erosion, again, bleeds less readily whei 

touched than docs the early ulceration of commencing malignant growth. 

As regards the treatment of uterine cancer but little can be said. 

ten or lift ecu years a considerable controversy ha> 

ed concerning tin- rival merits of supravaginal amputation an< 

total extirpation in cases of cervical carcinoma. Most authors art 

agreed that removal of the cervix is sufficient when the portid 

ilia alone is affected ; but there is not the same agreement when the 

- the upper part of the cervix. Martin of Berlin and 

i have published numerous cases of total extirpation 

of the uterus for cervical cancer; but their reports, and those of other 

Skilful Op Only demonstrated that the operation can be done 

by experienced SUrgeom frith a very low rate of mortality. Williams 

vical carcinoma supravaginal amputation doei 

all that is needful, and that no advantage in the prevention of recurrence 
growth is gained by the larger operation. His views, however) 



THE DEVELOPMENT OF MODERN GYNAECOLOGY 21 

have by no means met with general acceptance by the profession ; and 
the opinion seems to be gaining ground that if, in a case of cancer of the 
true cervix, an operation be recommended, total extirpation will prob- 
ably give the best result. Attempts at progress are being made at 
present principally in the direction of early diagnosis : and surgeons are 
endeavouring, by microscopical examination of scrapings removed with 
the curette, or of sections taken from the suspected cervix with knife or 
scissors, to gain early and certain knowledge while the disease is still 
narrowly limited and surrounding tissues not invaded. 

Sarcoma Uteri. Very little was known about this affection by the 
early authors of this century. Reference is found in gynaecological 
literature from time to time to certain forms of fibroid tumours which 
had a tendency to return after removal; and the term "recurrent fibroid " 
was often used. Sir James Paget put these tumours into three divisions, 
namely, (i.) malignant fibrous tumours, (ii.) recurrent fibroids, (iii.) myeloid 
tumours. Lebert described them as fibro-plastic tumours, and Rokitansky 
gave them the title of fasciculated cancer. Virchow was the first to give 
a clear and intelligent description of these growths, and to put them 
under the head of sarcoma. Gusserow and other observers in Ger- 
many, following on the steps of Virchow, have of late years given careful 
study to uterine sarcoma. Resembling, as it does, cancer of the uterus 
in many respects, there are certain well-established points of clinical dis- 
tinction between them. At one time it was thought that the disease 
always arose in the body of the uterus, and never began primarily in the 
cervix ; but this has now been shown by Veit and others to be a 
mistake, though of course the large majority of cases are of the former 
variety. Primary sarcoma of the uterus occurs anatomically and clinic- 
ally in two distinct forms, namely, (i.) Fibro-sarcoma, which forms a more 
or less firm, circumscribed, rounded tumour growing from the uterine 
parenchyma ; and (ii.) diffuse sarcomatous tumours growing from the 
connective tissue of the uterine mucous membrane, and composed mostly 
of small round cells. 

Between diffuse sarcoma and carcinoma of the fundus the diagnosis 
has to be made almost entirely by the microscope. While we have still 
much to learn regarding malignant affections of the genital organs, we 
may congratulate ourselves that our knowledge has become more definite, 
better founded, and more concise. We may here notice that much know- 
ledge has been gained by a more frequent use of cervical dilatation ; and 
in this respect much gratitude is due to Professor Hegar for his admirable 
mechanical dilators. It is true that dilatation and curettage were practised 
in the days of Recamier, but not to any considerable extent. So 
long as surgeons had to trust to slow dilatation of the cervix with tents, 
and had to consider the risks of septic inflammation consequent on the 
use of this mode of opening up the cervix, the operation was comparatively 
seldom resorted to ; but the present method of rapid dilatation has re- 
moved much of the difficulty, and has enabled us to explore the cavity 
of the uterus quickly and safely. In cases of haemorrhage occurring at 



SYSTEM OF GYNAECOLOGY 



or about the time of the climacteric, cases in which the uterus is found by 
bimanual examination to be distinctly enlarged, this method of explora- 
tion Lb of imm< for it enables us with the curette or the finger 
move small portions of the hypertrophied mucous membrane, and 
to determine promptly by the microscope whether the tissue be malignant 
Belie \ me forms of malignant growth have what 
may be termed a precancerous stage, it becomes of immense importance 
in the character of the disease at an early period. 
\ .. great advance has been made in our knowledge of malignant 
of the vagina and vulva : but the paper of Dr. Matthew^ 
Duncan on lupus of the vulva, published in the 27th vol. of the Trand 

London, has materially advanced our 
knowledge of this rare disease. In this communication Duncan 
pointed out that though vulvar lupus lacked many of the histological 
characters of lupus vulgaris, yet in its tendency to erode and destroy it 
closely imitated the latter disease. Lupus included ulceration, inflammaj 
tion, and hypertrophies, variously combined ; states which were not cancer 
not epitheliomatous, and not syphilitic. It may turn out that 
ies are included in this comprehensive term; but at present 
they are combined in one description on account of their apparent 
similarity. They are far from being so uncommon as is sometimes 
snppo 

Pelvic Inflammation. In endeavouring to trace the development of 

our know ! u ding acute inflammations occurring in the pelvis, we 

may date our researches from the year 1840 or thereabouts. Beforfl 

tlii- time, though ;d>scess of the womb had been mentioned by sucl 

early writers as Aetius and Paul of ^Egina, yet no systematic study of 

affection had been made. However, after the year INK) man; 

,\..ik. Thus in 1*11 Bourdon had written on "Fluctuat 

ing Tumour of the True Pelvis"; Doherty in 1843 had given us hi> 

views on chronic inflammation of the uterine appendages; Calvi in 18 l 

had described "Intrapelvic Phlegmonous Abscess " ; while in the said 

year Chun-hill and Lever had contributed to our knowledge of tin 

subject A little later, in L846, Nbnat was doing good work in tin 

same field Any one, however, who reads the medical history of these 

will see clearly thai the gynaecologists of those days were under 

:i that all the pelvic exudations or abscess sacs were solely 

duet . or maybe to suppuration, occurring in the cellular 

tissue of the true pelvis. Such terms as pelvic abscess, peri uterine 

parametritis, and pelvic cellulitis, all meant practically the 

same thing, namely, connective tissue inflammation. The first advance in 

our knowledge came through IVrnutz : in 1857 a case of BO-called perl 
ne phlegmon came under his care and the patient died. At the 

post! ination the pelvic tumour which had been supposed 

be formed by Inflammation of the pelvic cellular tissue was found 
1st of bladder, uterus, broad ligaments, and sigmoid flexure al 

matted together. The cellular tissue of the broad ligament and uterus 






THE DEVELOPMENT OE MODERN GYNAECOLOGY 



23 



was not involved, and no real peri-uterine phlegmon existed. The study 
of this and similar cases caused Bernutz and Goupil about the year 1862 
to publish their classical memoir, in which abundant clinical and post- 
mortem evidence was brought forward to prove the true nature of the 
swellings previously ascribed solely to the effect of pelvic cellulitis. 
Bernutz summed up his views as follows : 

1. That inflammation of the pelvic peritoneum is a disease very 
commonly met with. 2. That the tumour found after death in cases of 
pelvic peritonitis is formed by the matting together of various pelvic 
viscera as a consequence of this inflammation. 3. That inflammation of 
the pelvic serous membrane is always symptomatic, and that it is generally 
symptomatic of inflammation of the ovaries or of the Fallopian tubes. 

Old theories, however, die hard ; and, though Bernutz had brought 
forward such abundant proof in support of his assertions, yet for many 
years his views met with little general acceptance by the majority of 
gynaecologists, and the old views continued to be taught and held. Even 
such a keen observer as the late Matthews Duncan thought that 
Bernutz had been over-zealous in estimating the comparative frequency 
of pelvic peritonitis and the rarity of pelvic cellulitis. For some years 
opinions were strongly divided upon the comparative frequency of cellu- 
litis and peritonitis. With the narrowness and bitterness born of 
imperfect knowledge, some authors laid down strongly that in pelvic 
peritonitis cellulitis only exists as a complication ; while others were as 
ready to assert that cellulitis is in all instances the primary affection, and 
that the inflammation only spreads secondarily to the peritoneum. 
Writing in 1880 Dr. Gaillard Thomas, however, records his conclusions 
under four distinct propositions, namely : 

" 1. Peri-uterine cellulitis is rare in the nonparous woman, while 
pelvic peritonitis is exceedingly common. 2. A very large proportion of 
the cases now regarded as instances of cellulitis are really cases of pelvic 
peritonitis. 3. The two affections are entirely distinct from each other, 
and should not be confounded simply because they often complicate each 
other ; they may be compared to serous and parenchymatous inflamma- 
tion of the lungs pleurisy and pneumonia. Like them they are separate 
and distinct, like them they affect different kinds of structure, and like 
them they generally complicate each other. 4. They may usually be 
differentiated from each other, and a neglect of the effort at such thorough 
diagnosis is as reprehensible as a similar want of care in determining 
between pericarditis and endocarditis." 

Again, in 1886, Hart and Barbour state that there is now little 
doubt that Bernutz and Goupil pushed their views too far ; and that in 
America, Germany, and Britain gynaecologists now consider pelvic 
inflammation as both peritonitic and cellulitic. Moreover, they note 
that both diseases are always combined. Thus in a marked pelvic peri- 
tonitis there is always some pelvic cellulitis, and in a marked pelvic 
cellulitis there is always some pelvic peritonitis. This is quite analogous 
to what is found in pneumonia and pleurisy. Thus we may fairly con- 



24 SYSTEM OF GYNECOLOGY 

elude from the result of modern investigations that inflammation both of 
the cellular tissue and also of the serous membrane may arise, but that 
of the two the latter is certainly the more frequent. 

Much good work has been done of late years in developing our 
knowledge of the causation of pelvic cellulitis and peritonitis. In the 
case of the former disease recent investigations go far to show that the 
introduction of septic particles into the lymph circulation, by way of 
rents after operation, abortions, or full-term deliveries, is most commonly 
the cause of the mischief. Many good observers would go so far as to 
say that they know of no possibility of cellulitis unless some septic 
virus have been introduced into the vagina, and been absorbed through 
some abrasion or fissure in the mucous membrane of the vagina, cervix, 
or uterus. Certainly such indefinite causes as catching cold, exposure to 
chill, strains, and the like, are more and more regarded with suspicion ; 
and attention is concentrated on the possibility of the introduction of 
micro-organisms with its septic consequences. 

As regards the production of pelvic peritonitis, the point of most 
interest is to consider how frequently the disease is consequent on a 
pre-existing salpingitis. In 1893 Dr. Cullingworth published his re- 
searches into this question. Under the heading of "Pelvic In- 
flammation usually a Peritonitis originating in Salpingitis," he says: 
" The usual state of things disclosed on opening the abdomen in these 
cases is as follows : 

"The contents of the pelvis are generally concealed from view by 
the great omentum, which has been drawn down so as to cover them 
anteriorly, and has contracted adhesions to the peritoneum as it becomes 
reflected on to the anterior abdominal wall, as well as to the uterus and 
other pelvic viscera. Along with this screen, as it were, of omentum, it 
is not unusual to find coils of adherent small intestine. On separating 
and drawing aside the screen, one side, or it may be the whole of the 
posterior part of the true pelvis, is seen to be occupied by what seems 
to be an indistinguishable mass of matted viscera. The uterus itself is 
sometimes implicated in the mass, but in other cases its upper pari at 
is free. Tracing the Fallopian tube outwards from the uterine 
coiner on the side of the disease, it is often found to be normal in size 
for the first half-inch or so, and then to become involved in the adherent 
mass. This mass, on being Beparated and brought into view, is invariably 
found to consisl <f the uterine appendages more or less altered by 
inflammation. There is always salpingitis, and the inflamed and thickened 

tube commonly enfolds the ovary, which is frequently normal." 

With regard to the tubes the first point to be noted is that the 

evidences of peritoneal inflammation arc always mosl marked in the 

neighbourhood of the fimbriated end : this shows clearly that the pelvic 
Ditis has originated by direct extension fr<m the mouth of the 

inflamed tube, or by the escape of morbid .-eeivl ions therefrom. Where 
the secretion from the inflamed tube is chiefly mucous in character, with 
only a slight intermixture <f pus corpuscles, the intensity of the inflam- 






THE DEVELOPMENT OF MODERN GYNAECOLOGY 25 

mation round the abdominal ostium is shown by the extreme density of 
the adhesions at that spot and nothing more. Where the secretion, on 
the other hand, is wholly purulent, one of two things is found to have 
happened according to whether the fimbriated extremity remains patu- 
lous or has become closed. In the former case an intraperitoneal 
abscess is found, encysted among adhesions, and fed by the purulent 
discharge issuing from the open mouth of the suppurating tube ; in 
the latter case the pus by its accumulation distends the occluded tube 
and forms a pyosalpinx. Mr. Alban Doran, in his address before the 
East Anglian Branch of the British Medical Association in 1893, shows 
that tuberculous disease commencing in the ovaries and tubes may spread 
outward and involve the peritoneum, setting up tuberculous pelvic 
peritonitis. In one case under my own care this was very well shown. 
On opening the abdomen of a young woman the left ovary and tube 
were found matted together, and studded with small masses of tuber- 
culous material : the peritoneum as a whole was healthy ; but in the 
immediate neighbourhood of the diseased tube and ovary it was in- 
fected, and showed similar foci of tuberculous disease, in other words, a 
localised pelvic peritonitis had been set up. It is clear, then, that in 
a large number of cases the peritonitis is due to some mischief origi- 
nating in the ovary or tube ; but neither clinical nor post-mortem evidence 
has yet brought us to believe that the disease is always secondary to some 
pre-existing morbid condition of the uterine appendages. 

A form of pelvic peritonitis has been described by Matthews 
Duncan and others under the name of "encysted serous perimetritis." 
The peculiar feature is that one or several collections of serous or sero- 
purulent fluid are found pent up among coils of intestines. The collec- 
tion may occupy the pouch of Douglas, and press the floor of the 
pouch so forcibly downwards that the perineum is bulged. In many 
cases of pelvic peritonitis small collections of serous fluid are found 
pent up by adhesions between the coils of intestines ; but the disease is 
seldom specially described as serous perimetritis unless the amount of 
fluid pent up be very extensive. Before leaving this subject attention 
must be called to the extension of our knowledge regarding pelvic 
abscess ; from what has been already noted, it is clear that collections of 
pus in the pelvis are by no means always due, as had been supposed, to 
suppuration of the pelvic connective tissue. Operative surgery has done 
much to increase our pathological knowledge in this respect : and we 
now know that many so-called pelvic abscesses are really suppurating 
dermoid ovarian cysts adherent low in the pelvis, or perhaps tubes filled 
with pus ; or they may be suppurating hematoceles, or extra-uterine 
gestation sacs. This thought brings us to the subject of treatment in 
cases of pelvic inflammation. 

With a more exact knowledge of the morbid anatomy and clinical 
history of these cases of pelvic inflammation our treatment has under- 
gone considerable modifications; and to a large extent active surgical 
interference has taken the place of a treatment purely medical and pallia- 



26 SYSTEM OF GYNAECOLOGY 

tive. Indeed, as has been already pointed out, there has been a marked 
tendency to resort to the use of the knife in an undue percentage of 
: and often, too, in an early stage of the disease before time and 
observation have shown us what the natural powers of repair are capable 
of doing. The case is different when the presence of pus can be 
demonstrated with a fair amount of certainty : for. as an eminent surgeon 
has well said, a collection of pus calls for the same treatment, whether it 
occur in the mammary -land or in the pelvis, and opening of the abscess 
witli evacuation of the pus is urgently demanded in either case. 

Disorders of Menstruation. The division of these disorders into 
three -roups, namely, amenorrheas, monorrhagia, and dysmenorrheas, is a 
very old one and a very excellent one. In the last fifty years our know 
ledge of menstruation and its variations has undergone considerable 
development, not only through the revelation of new facts, but yet more 
by the exclusion of much that was purely imaginary and false. Several 
points of considerable discussion and doubt may be considered as finally 
settled. Thus that menstrual blood does not coagulate is known now to 
depend on a certain admixture of mucoid secretion from the cervix and 
uterus. Provided that the menstrual blood be not in excess, and, 
secondly, that a certain proportion of healthy mucus be secreted, we 
may be sure that the blood Mill remain fluid : but if an excess of blood 
be poured out from the uterine wall, and the mucus be therefore rela- 
tively deficient in amount: or if the mucus secreted be morbid in 
quality or positively deficient in amount, we are certain to find that the 
menstrual blood does clot. The coagulation which occurs in cases of 
bleeding submucous fibroids, or again in certain forms of endometritis. 
illustrates this point. 

Another point which has received considerable attention concerns 
the histology and alterations of the uterine mucous membrane during 
menstruation. Study of the infantile uterus by Williams and others has 
shown that to gpe&k of the layer of tissue superficial to the muscular 
fibres a- the mucous membrane is not correct; for the human foetal 
uterus shows a distinct submucous layer just beneath the peritoneum, 
so that the whole of the tissue i- internal to this mucous membrane. 
Nearly the whole of the muscular thickness of the human uterus is there- 
fore "muscularis mucosae," and the apparent absence of a submucous coat 
is thus accounted for. 

Another interesting question, which has been discussed lately, and on 

which much light has been thrown, is that of the rhythmical contractions 
of the litem- which OCCUT during nienst mat ion. Viewing menstruation 

miniature labour, one would expect that rhythmical contractions, 

akin to the reCURing pains of parturition, would be set up at the mem 

Btrual epoch ; and some years ago Braxton Hicks and others stated their 
belief that these contractions occur. Clear evidence of the fact is 
afforded by the behaviour of ;i uterus which contains a fibroid polypus ; 
for with the onset of the catamenia the Internal os is dilated, the cervical 
canal becomes patulous, and the external os la enlarged, bo that the 



THE DEVELOPMENT OF MODERN GYNECOLOGY 27 

finger can be introduced and the tumour felt. As the menstrual period 
passes the canal closes down again, and the internal os becomes closed. 
Again, if the cervical canal be tested by the passage of graduated 
bougies before and during the first few days of menstruation, the same 
opening of the cervical canal by the force of the uterine contractions can 
be observed. Sir John Williams has stated that the uterus contracts 
during menstruation, because the cavity after menstruation is smaller 
than it would be if the mucous membrane were gone without uterine 
contractions. The importance of the recognition of this fact will be 
seen when we come to study the causation of pain in connection with 
menstruation. In speaking of the changes which occur in the mucous 
membrane of the uterus at and about the menstrual epoch, it cannot be 
said that our knowledge has made much advance ; there are many 
opinions on the subject, but little definite knowledge. Modern research 
has made one point fairly certain, namely, that the whole of the mucous 
membrane of the uterus is not shed every month ; but rather that 
certain changes of a hypertrophic and fatty degeneration occur which 
lead to the exfoliation of the superficial part of this membrane. The 
papers bearing on this subject by Kundrat and Engelmann, Leopold, 
Williams, Wyder, and others, are too well known to call for farther 
comment. 

Amenorrhcea. No great advance has been made in our knowledge or 
treatment of amenorrhcea. In cases of imperforate hymen common sense 
has taught us that repeated aspirations are quite unnecessary, and that 
free incision of the hymen under antiseptic precautions, followed by rapid 
evacuation of the retained menstrual fluid, is a safe and scientific mode 
of treatment. If the opening made in the hymeneal membrane be free 
and patulous, there is little risk of fluid regurgitating down the Fallopian 
tubes, even though these latter be somewhat dilated. Under modern 
antiseptic precautions one never sees the rapidly fatal instances of septic 
peritonitis which used every now and again to terminate these cases. In 
the production of healthy menstruation, it is recognised that a healthy 
anatomical tract from the ovary to the hymen, a healthy condition of the 
blood, and a sound state of the nervous system are required ; so in con- 
sidering the causation of amenorrhcea (if we exclude pregnancy, lactation, 
delayed onset, and the menopause), it is clear that all cases must come 
under one of these headings. 

In his lecture on sterility, Matthews Duncan drew attention to 
an interesting condition of what he termed "one-child sterility." In 
these cases a healthy but delicate young woman, usually of the upper 
classes, marries and begets one child, and after this confinement men- 
struation never returns, the uterus passes into a senile state, and the 
woman's reproductive life is practically over. Here the absence of the 
menstrual function depends on a premature exhaustion of the genital 
system, and on an early exhaustion of the ovary with its Graafian follicle 
system. 

Menorrhagia. Improved methods of dilatation, and the safety which 



28 SYSTEM OF GYNAECOLOGY 

conies from the use of antiseptics, have done much to enlighten us on the 
causation and treatment of uterine haemorrhage. Thus twenty years ago 
comparatively nothing was known of the existence and frequency of 
fungous degeneration of the endometrium; whereas now the use of the 
curette and digital exploration of the uterine cavity have shown us its 
frequency in cases of endometritis and fibroid tumour. Of late years the 
pathological changes taking place in fibroid tumours have been worked 
(nt ; their methods of cure by natural processes have been clearly laid 
down, and many points in their treatment have been carefully studied. 
Reference has already been made to the so-called Apostoli treatment; 
and whatever the measure of its failure in the cure of fibromyoma, there 
can be no doubt that in the menorrhagia depending on the presence of 
a submucous fibroid, this method is a useful addition to our remedies. 

Attention has been paid in late years to the influence of an obstructed 
circulation in the production of uterine haemorrhage. Thus the late Dr. 
Wi h shire pointed out the effects of the early stages of hepatic cirrhosis, 
consequent upon the abuse of alcohol, in keeping up uterine blood loss ; 
here the effect of an impeded portal circulation in preventing easy escape of 
blood from the uterine circulation is well demonstrated, for by cutting off 
the supply of alcohol, and exhibiting remedies which act favourably on 
the portal circulation, the menorrhagia can soon be controlled. 

Again, in the case of an overloaded right heart, due to valvular or to 
pulmonary disease, another mode of production of menorrhagia has been 
shown ; for by the use of means calculated to assist the heart's action the 
uterine disorder is materially relieved and finally cured. In the know- 
ledge, moreover, of such drugs as hamamelis and the hydra st is 
Canadensis, we have made valuable additions to our store of uterine 
styptics. 

Dysmenorrhea. It is a cause for regret that we have made so little 
advance in our knowledge of this common disorder; still in some respects Ave 
may claim to have gained a more exact and scientific acquaintance with the 
phenomena of painful menstruation. Dr. Champneys has endeavoured 
to limit the use of the word pain as applied to dysmenorrhoea, and has 
suggested that it is only correctly used when the suffering is clearly due 
to the genital organs, and falls within the genital sphere. Pain due to 
the pelvic organs is limited above by a line level with the iliac crests in 
front and behind, and by the level of the knees below; by this definition 
various neuralgias, which are often present dining the menstrual epoch, 
are excluded. Tyler Smith and other authorities have compared the act 
of menstruation to a miniature pregnancy; and I myself, following 
out this simile, have shown that in a large proportion of cases the pain of 
dysmenorrhoea is due to some morbid condition at the os internum, and 
that the pain really depends mi dilatat ion of the internal os by uterine 

contractions under morbid conditions. 

Reference has already been made to the fact, that uterine contractions 
are present during menstruation, and that their effect in dilating the 

cervical canal is capable of clinical proof. 



THE DEVELOPMENT OF MODERN GYNECOLOGY 29 



One form of dysmenorrhoea, distinguished by the exfoliation of a 
membrane every month, has received special attention from gynaecologists 
indeed, the literature of the subject is so extensive, that were its value 
equalled by its bulk, our knowledge of the subject would indeed be com- 
plete. Much difference of opinion has been expressed on the etiology 
and pathology of these membranes ; but the researches of Wyder and 
others seem to point to inflammation as their cause. The thickness of 
the membrane, and the depth of the mucous membrane exfoliated, vary 
greatly ; and the microscopical examination shows a great variety of 
pathological conditions : all these conditions, however, are " endome- 
tritis' Wyder has remarked upon the presence of certain large oval 
cells, which have a length of from 0*012 to 0*02 mm., and nuclei, whose 
diameter is 0*006 ; or these cells, he says, may be two or three times as 
large. These large cells, he believes, are found only in the decidua of 
pregnancy, either intra or extra-uterine ; and they serve, therefore, to dis- 
tinguish real membranous dysmenorrhoea from early abortions. 

It has been pointed out that it is necessary to distinguish the true 
membrane of membranous dysmenorrhoea from those consisting of fibrin 
or blood -clot, coagulated mucus, casts of the vagina or the bladder, 
foreign bodies, or products of conception. It has been shown by many 
writers that mucosa membranes may be passed for some time without the 
presence of any pain ; and pain may be a marked symptom later. Thus 
it is suggested that, apart from some special sensitiveness of the canal of 
the uterus, pain need not result from the separation and passage of the 
membrane. How unsatisfactory is our treatment of membranous 
dysmenorrhoea may be inferred from a remark which Champneys makes 
use of in his Harveian Lectures : " The treatment of membranous 
dysmenorrhoea certainly is a most unhappy problem ; not even pregnancy 
going to full time cures it." 

There is another pathological condition in which gynaecology has 
made marked progress during the last fifty years, namely, inversio uteri. 
Until the year 1858, cases of inversion of the uterus after labour were 
only cured when the patient came under observation shortly after par- 
turition ; and in too many cases amputation of the inverted organ was 
considered the only available resource. About this date Tyler Smith in 
England, and White in America, recorded cases of slow reduction by taxis 
and elastic pressure. Of late years cures have been so numerous, even 
in cases which have come under treatment several years after the accident 
had happened, that the various instances are hardly thought worthy of 
record. The method of reduction which is in favour at present consists 
in the use of Aveling's repositor. The latter instrument was in no sense 
invented by Dr. Aveling, for Von Siebold employed a repositor which 
consisted of a curved stem surmounted by a fine sponge, the whole being 
held in position by a T bandage. Most of these earlier instruments, how- 
ever, having only one curve on their stem, were liable to slip ; whereas 
in Aveling's repositor there is a double curve (both sacral and perineal), 
pressure is transmitted in the curve of the pelvic axis, and slipping is 



30 SYSTEM OF G YN.ECOLOG \ ' 

thus rendered less probable, Of the many other plans devised for pro- 
curing slow reduction of a chronically inverted uterus, few have stood the 
i lime : and year by year the Aveling repositor becomes increasingly 

popular in the cure of these difficult and dangerous eases. In a few cases 
the accident does not follow labour, but depends on the presence of a 
fibroid or polypus growing from the fundus uteri ; it is in these latter 
that vaginal amputation of the mass, without any attempt at 
reduction, is indicated. 

In the short space available it has been impossible to trace at all 
adequately, or to do justice to much which may be reckoned as develop- 
ment of our science and practice; but enough has. been reviewed to show 
that in every department of gynecology in pathology, in bacteriology, in 
anatomy, clinical medicine, and surgery marked progress has been made ; 
and if at times advance has been retarded by over-zealous enthusiasts, 
still even to them we are perhaps indebted for the finger-posts which 
point out the roads on which we should not travel. It is clear that 
much of our increased knowledge is due to improved surgery, and to say 
this is again to declare the debt we owe to Sir Joseph Lister. 

Mr. Pearce Gould put the matter very eloquently when, in his recent 
address on the Evolution of Surgery, he said : " Although science knows 
nothing of nationality, and we rejoice in additions to our knowledge, and 
to our powers of combating disease and death, whether it comes to 
as from a French Pasteur, from a Teuton Koch, from our western 
cousins on the other side of the broad Atlantic, or from a son of that 
Eastern Empire now rising above the horizon, we cannot help feeling 
a special pride in the fact, that the name that shines with an unrivalled 
splendour on the page of surgical history is that of the Englishman 
Joseph Lister." 

Montagu Handfield-Jonks. 



REFERENCES 

1. ATLEE. Ovarian Tumours. 2. Battkv. Gynaecol. Trans. 1876.!. BENRT 
Hi.nnki. I nflammation of the Uterus, 1845. 4. Bernutz ami GoUPIL. Archiv G4n. 
1857. 5. Billroth. Surgical Pathology. 6. Bourdon. Fluctuating Tumour of True 

. 1841. 7. Burns. Midwifery. 8. Calvi. Tntrapelvic Phlegmonous Abscess, 
1844. 9. Churchill. Abscess of Uterine Appendages, 1844. 10. Clark. Diseases 

"des. 11. Clay. Obstetric Surgery, va. Cullingworth. Brit. Med. Jour. vol. 
ii. 1893. l-'i. Dbnman. Midwifery. 14. Doherty. Chronic Inflammation of &U 
Uterine Appendages, 1843. 15. Ai.m.w Doran. Address Brit. Med. Assoc. Brit. Med. 

Oct. 1898. 16. Ibid. Uterine Surgery. 17. Matthews Duncan. Land. Obstet. 

!. .wvii. 18. Ihid. I'arametrit is ai\d Perimetritis. 19. Ibid. Fecundity 
tiUty, and Sterility. 20. Bandfield-Jones. Brit. Med. Jour, 1898. 21. Bart and 
Barbour. Diseases of Women. 22. Begab and Kaltenbaoh. Op. Oyn, 28. 
Grail? Hiwitt. Di Women. 24. Hodge. Diseases Peculiar to Women. 

26. Keith. Tumours of Abdomen. ^\. Kunhrat and Engelmann. Strioker's 
Med. Jahrbuch. \^7'<. 'ii. Lebert. Traiti dts M</i. Cancereuses. 28. Leopold. 
Arch, fur Oynak. Band ri. i s 77. Band 29. Lever. Pelvic Abscess, 

Maladies de V Uterus. 31. Paget. Surgical Pathology. 32. 
Priestley. H.M.d. roL ii. 1895. 33. Sims. Uterine Surgery. 34. Stephenson. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



3- 



B.M.J. March 1892. 35. Sutton, Bland. Toy. Mcd.-Chir. Transact. 1889. 
36. Ibid. Load. Med. Soc. 1892. 37. Tait, LaVson. Diseases of Women. 38. 
Thomas. Diseases of Women. 39. Thornton, J. K. "Abdominal Surgery Past and 
Present," Loud. Med. Soe. Transact. 1890. 40. Tilt. Ovarian Inflammation, 1850. 
41. Ibid. Uterine Therapeutics. 42. Velpeau. Operettive Surgery. 43. Virchow. 
Cellular Pathology. 44. Spencer Wells. Abdominal Tumours. 45. Williams. 
Harveian Lectures, 1888. 46. IJbid. Obst. Soc. Lond. 47. Wyder, Arch. f. Gyn. 
Band xiii. 1878. 



M. H.-J. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 

A description of the anatomy of the genital organs, for gynaecological 
purposes, should have its own topographical basis ; that is, it should be 
described in relation to the bony pelvis. 

I shall therefore arrange this subject under the following heads : 
I. The main points in the anatomy of the adult female bony pelvis and of 

the pelvic floor filling in the pelvic outlet. 
II. The anatomy of part of the outer aspect of the floor that is, of the 
vulva or external genitals. 

III. The anatomy of the organs and tissues in the substance of the pelvic 

floor that is, of the vagina, urethra and bladder; rectum and 
anus; connective tissue, blood-vessels, lymphatics and nerves. 

IV. The anatomy of the organs on the upper aspect of the pelvic flow 

that is, of the uterus, Fallopian tubes, broad ligaments and ovaries; 
the pelvic peritoneum. 

V. The position of the organs : their dissection and structural anatomy. 

VI. The surgical anatomy. 

VII. The development of the organs. 

This convenient method of considering our subject is open to some 
objections. It might be argued, for instance, that the anus and urethra 
could be considered in other divisions than those in which I have placed 
them. The present arrangement, however, will be found suitable for 
our purpose. 

I. The main points in the anatomy of the Female Bony Pelvis and 
of the Pelvic Floor filling in the outlet. The brim of the pelvis (Fig. 1) 
has, as its boundaries, from left to right, the promontory, left sacro-iliac 
joint, left ilio-pectineal eminence, symphysis pubis, right ilio-pectineal 
eminence, right sacro-iliac joint, and thus back to the promontory. 

The part of the pelvis above the brim is termed the " false " pelvis ; 
that below the brim is spoken of as the " true " pelvis. It is in the 
true pelvis and in relation to the outlet that the unimpregnated female 
genital organs are placed. 

If the bony pelvis be regarded in sagittal mesial section (Fig. 2), 
we can see the conjugate ; the cavity of the true pelvis, with its inlet, 



32 



SYSTEM OF GYNAECOLOGY 



cavity and outlet ; the inclination of the conjugate to the horizon 
(average of 60 ). as well as the outline of the pelvic floor. What of the 




Fig. 1. Brim of bony pelvis. 



pelvic floor projects beyond the outlet-conjugate is termed the pelvic 
floor projection, and averages, at its utmost, about 3*2 cm. 




j. Diagram of bony pelvlii uid of pelvic tin.,,, i. Conjugate ; '-', ana] axis ; 8, , vaginal 
and nrethral axes; '-. horizontal line; 6, outlet-conjugate. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



33 



On the outer aspect of the pelvic floor lie the external genitals, and 
these in the upright posture have a direction nearly parallel to the 
horizon. 

In the substance of the pelvic floor lie the vagina and urethra, parallel 
to the conjugate, and about 2^ to 3 inches below its level ; the anus with 



PROMONTORY 



OVARY 

OVARIAN FIMBRIA 



FALLOPIAN TUBE 



POUCH OF DOUGLAS 



LOOSE TISSUE 



LOOSE TISSUE 




PERINEAL BODY 



Fig. 3. Sagittal mesial section of fe 
and the tube 



its long axis at right angles t< 
the peritoneum and the uterus a 
gives the following table of clini 

Projection of pelvic floor 
Coccyx to anus 
Fotirchette to pubic arch (n 



II. The anatomy of the Ex 
outer aspect of the pelvic floor 
extending from the front of the 



34 SYSTEM OF GYNAECOLOGY 

wards between the thighs, their posterior boundary, the fourchette, being 

about \-\\ inch in front of the anus. They comprise the following 
structures; namely, the labia majora, labia minora, fourchette, clitoris 
and prepuce, vestibule, urethra] orifice, hymen, fossa aavicularis. 
The genera] arrangement of these parts is seen in Pigs. 2 and I. 

It must be noted that in order to see these parts in the living woman 
their mutual relations arc necessarily disturbed. It is therefore of 
importance to note that, in the undisturbed condition, the labia majora 
and minora, being in contact by their inner surfaces, conceal the deeper' 
structures, the minora only projecting slightly beyond the majora; that 
probably the lateral halves of the vestibule are in apposition; that the 
lateral edges of the fourchette touch, forming a Ion-- (j. as seen in Fig. 1 ; 
and that the lateral edges of the hymen are also in contact. 

The labia majora are two folds of skin, united above over the pubes in 
the mons veneris, which pass downwards and backwards between the 
thighs, gradually thinning off" at a point 1} inch in front of tin- anus. 
Short crisp hail- covers their outer aspect, and microscopically we find 
sweat glands, hair follicles, and the usual constituents of a sl< i i i structure. 
The labia minora are also formed of skin of a thin, tine quality j 
they lie obliquely on the inner aspect of the upper two-thirds of the labia 
majora, and by the bifurcation of their upper ends form the prepuce of 
the clitoris and its so-called 'suspensory ligament. 

The vestibule is a triangular 
surface of smooth mucous mem- 
brane covered with several layers 
of epithelium, lying between 
the labia minora, and having 
the hymen at its base ; the 
V urethral orifice is in the middle 
of the base line immediately 
above the hymen. In the 
middle line, in the virgin, is a 

| grooved ridge which represents 
the corpus spongiosum of the 
male Pozzi's male vestibular 
band. 

The posterior ends of the 
labia minora form a narrow 
U-shaped loop the fourchette ; 

|\ if these margins he separated 

I* we see the fossa aavicularis as 

;i shallow fossa, artificially made 

by the examination, and bounded 
by the inner aspects of the 
fourchette and outer and lower 
portions of the hymen. 1 1- 
vestibule lies the hymen, the 
i 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 35 

anatomical entrance to the vagina. It consists of a thin fold of mucous 
Baembrane, perforated, so that when viewed undisturbed, its opening 
forms a vertical slit with its edges in contact. According to Dr. 
Cullingworth, the hymen is a longitudinal fold of mucous membrane with 
its edge directed forwards, and divided along about three-fourths of 
its length by a slit which extends nearer its upper than its lower 
extremity. The alterations in it induced by coitus and labour belong to 
obstetrics. 

The anal opening lies about H inch posterior to the fourchette, 
and between the two is the skin over the base of the perineal body 
(Fig. i)- 

The glans of the clitoris covered by its prepuce lies at the apex of 
the vestibule. 

III. The anatomy of the organs and tissues in the substance 
of the pelvic floor that is, of the Vagina, Urethra, Bladder, Rectum, 
and Anus, Connective Tissue, Blood- Vessels, Lymphatics, and Nerves. 
The vagina is a transverse slit in the pelvic floor, extending from the 
hymen to the fornices, where it passes on to the outer aspect of the 
vaginal portion of the cervix uteri at the base of the latter ; the de- 
marcation between them being recognisable to the naked eye. 

The vagina lies parallel to the conjugate, and consists of two apposed 
walls, anterior and posterior. Each wall is broader above than below, 
and is therefore somewhat triangular in shape. The mucous membrane 
lining it is thrown into many transverse shallow folds the rugae of the 
vagina. At the lower end of the posterior wall is one short vertical fold, 
the posterior column of the vagina ; while there are usually two at the 
corresponding portion of the anterior wall the anterior columns of the 
vagina. They are said to represent the remains of the septa between 
the two ducts of Miiller, from part of which the vagina is formed 
(Fig. 3). 

Between the vaginal portions of the cervix and the reflexions of 
the vaginal walls lie the fornices of the vagina anterior, lateral, and 
posterior. The anterior is the guide to the loose tissue between the bladder 
and the cervix ; the lateral lie at the inner aspects of the bases of the broad 
ligaments, and form a guide to the uterine artery and ureter ; while the 
posterior is separated from the peritoneum of the pouch of Douglas by 
about i- inch of tissue. The walls of the fornices are in contact. 

On sagittal mesial section (Fig. 3) the anterior wall, 2 J inches long, 
is seen to be straight ; the posterior wall, 3 J inches long, bends forward 
at its upper part. 

On transverse section the vagina is crescentic at its upper part, 
H -shaped lower down, and vertical at the hymen. 

Microscopically the hymen has multiple epithelium on its outer and 
inner aspects, the latter being thicker. 

The vagina is lined on its free surface by many layers of squamous 
epithelium ; deeper down near the papillae the epithelium is more oval in 
shape. This epithelium lies on papillae of connective tissue, with elastic 



36 SYSTEM OF GYNECOLOGY 

tissue and unstriped muscular fibre. Outside this lie two layers of 
unstriped muscular fibre, an outer (circular) and inner (longitudinal). 

Only a few glands arc present in the vagina, which has a structure quite 
homologous to skin. 

It is of great importance to note that loose connective tissue separates 
the anterior rectal wall and the posterior vaginal wall, and lies also 
between the bladder wall and the anterior vaginal wall. The urethra and 
anterior vaginal wall are closely incorporated. 

The Urethra forms a slit in the pelvic floor, parallel to the vagina, and 
is in reality a tonically contracted sphincter If inch long with the urethral 
orifice below and the bladder-opening above. It is lined with many 
layers of epithelium, squamous below, and like that of the bladder above; 



,m 



Vagina : C2^ Rectum 




Pio. '-. Recta) and vaginal mucous membrane. 

It is well provided with clastic tissue and muscle; tor there are not only 
circular and longitudinal unstriped fibres, but the same arrangement of 

Striped muscle also. Finally, we should keep in mind that at the meatus 

mucous glands are present as well as villous tufts. Skene's tubules lie at 

the Lower end of the floor of the urethra, are I wo in number, about : , ; in. 
in length. A very important practical point about the urethra is its 

dilatability. By means of suitable dilator- an amount of dilatation can be 
obtained sufficient to admit the ordinary index finger. Over-dilatation, 
however, may cause permanent incontinence. 

With the empty bladder the urethra forms a Y, the anterior limb of 

the Y being the longer. Between the urethra, anterior surface of bladder, 

and the posterior aspect of the pubes is a space, triangular in shape* on 

n, containing loose tissue and fat the retro-pubic fat (Fig. 3). The 

bladder is sometimes seen in tic cadaver as a thick-walled, apparently 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 37 

contracted organ, with its anterior and posterior walls in contact. On 
Bagittal mesial section the cavity then forms a slit continuous with the 
urethra. 

The bladder walls consist of mucous membrane lined with multiple 
and multiform layers of epithelium, and of unstriped muscle in three 
layers ; its fundus alone is covered by peritoneum. The mucous and 
muscular coats are separated by loose tissue. The empty bladder is a 
pelvic organ in the non-pregnant woman. It is generally believed that 
its capacity is greater in women than in men ; and, as a matter of 
fact, many women pass water twice only in the twenty-four hours. 

The ureters, two in number, run between the kidneys and the bladder. 
I shall describe their course in the pelvis only. At the pelvic brim each 
crosses the external iliac artery, and passes down the side wall of the 
pelvis below the level of the fossa ovarii. Where the vesical and obturator 
vessels originate, it begins to describe a bow-shaped curve, the middle por- 
tion of which is crossed by the uterine artery at the level of the os uteri 
externum, from which it is about f inch distant. It here lies related to 
the side of the vagina (Figs. 8 and 19), and then runs between the anterior 
vaginal wall and posterior bladder wall. It finally runs in the substance of 
the bladder wall for about 0'6 inch, and opens into the bladder cavity. 

If the bladder cavity be laid open we shall see three openings into 
it ; namely, the internal orifice of the bladder in the middle, and a ureteric 
opening at each side. The latter are about 1J inch from the middle 
line. Between the ureteric ends lies the inter-ureteric ligament. 

The rectum begins at the pelvic brim, and ends at the anus. We 
recognise three portions; namely, the first part, provided with a meso- 
rectum, beginning at the left sacro-iliac joint, and ending at the third 
sacral vertebra ; the second part, where the peritoneum gradually passes 
off from behind towards the front ; and the third part lying behind the 
posterior vaginal wall. It is separated from the posterior vaginal wall 
by loose tissue. The microscopical structure of the rectum is peri- 
toneum outside ; unstriped muscular fibre in two layers the longitudinal 
inner, and the circular outer ; and a submucous coat with a mucous mem- 
brane provided with a muscularis mucosae. The mucous membrane is 
provided with abundant Lieberkuhnian follicles. 

There are two important crescentic folds in the rectum, which form 
the sphincter' tertius ; they lie, one on the anterior wall, the other on the 
posterior. Each is about 1J inch from the anus, the posterior being 
the higher. The fold is formed by a special thickening of the circular 
muscles. 

The anus is a closed slit in the pelvic floor with only a slight antero- 
posterior linear measurement. It measures about an inch in length, and 
runs parallel to the axis of the pelvic brim j that is, at right angles to 
the rectal, vaginal, and urethral axes (Fig. 2). It is provided with a 
strong musculature (Fig. 6) ; namely, the sphincter externus and sphincter 
interims, the latter in two layers, circular (outer) and longitudinal 
(Ruedinger), 






SYS TEM OF GYX. ECOLOGY 



In front of tlu' anus Lies the perineal body, its apex being about the 

level of the internal opening of the anus and external orifice of the 
urethra. It is a pyramid of elastic tissue and of striped and unstriped 
muscular fibre. It forms a bracing point, therefore, for much of the 

musculature of the pelvic ti : namely, for sphincter ani, transversua 

perinei, bulbo-cavemosus, and levator ani (Figs. 3, 7, 8, and 9). 



LEVATOR ANI 




Via. 6. Sphincter an! In tall-time foetus. 

The cannective timn of the female pelvis Is very abundant and of great 
importance. It packs all the interstices between the main organs, and is 
sal pathological interest, as in it inn the lymphatics, blood-vessels, 
and nerves. Although the pelvic connective tissue i> practically continuous, 
and passes up into the ili;ic fossae and abdominal cavity, it is convenient 
to recognise it as being present in the following situations : -. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



39 



(a) Round the cervix uteri : this is the parametric tissue proper of 
Virchow. (b) Between the broad ligaments, (c) Between the posterior 
bladder wall and cervix uteri, (d) Between the vagina and the anterior- 
rectal wall, (e) Between the bladder and the pubes. (/) In the ischio- 
rectal fossa and below the peritoneum. 

By some anatomists the term parametric tissue is made equivalent 
to pelvic connective tissue. 



BLADDER 
OBTURATOR INTERNUS 



VAGINA 
LEVATOR ANI 



ISCHIO RECTAL FOSSA 



GLUTEUS MAXIMUS 



PERINEAL BODY 




Fig. 7. Axial transverse section of right half of female pelvic floor. (Seen from behind.) 



We have also in the pelvic floor an arrangement of sheet fascia the 
pelvic fascia of the anatomist ; the main parts of which can be seen in the 
diagrams of frozen sections (Figs. 7, 8, and 9). 

The blood-vessels of the pelvis consist of arteries and veins. 

The arterial supply of the pelvis is derived from the ovarian and 
)Uerine arteries. 

The ovarian artery is a branch of the aorta, and passes along the upper 
oorcler of the broad ligament below the level of the Fallopian tube. It 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



4i 



branches to the tube, ovary, and round ligament ; and then at the 
junction of tube and uterus passes tortuously down the sides of the uterus 
to join the uterine artery. From the arch thus formed at the side of the 
uterus branches pass at right angles into the uterine substance. 

The uterine artery is a branch of the anterior division of the internal 



SMALL INTESTINE 




ISCHIORECTAL FOSSA 



Fig. 9. Axial coronal section of riglit half of female pelvis. (Seen from behind : dotted line=fascia.) 



iliac. It passes downwards and inwards towards the cervix uteri, 
giving a well-marked branch to the cervix the circular artery ; but some- 
times several smaller branches take its place. The relation of the uterine 
artery to the ureter must be kept in mind. The uterine artery also 
gives branches to the vagina ; and these, with branches from the circular 
artery, form the azygos artery of the vagina. The pudAc artery, a branch 
of the same anterior division of the internal iliac, is a well-marked vessel 
at the outer boundary of the ischio-rectal fossa ; and from it we get the 



\2 



SYSTEM OF GYNAECOLOGY 



superficial and transverse perineal arteries, the artery to the bulb, corpus 
spongiosum, and clitoris, and the inferior hemorrhoidal artery (Figs. 10 
and 21). 



Btooa svfip/y of t/tertfS (tyrfl) 



OVARIAN ARTERY 




UTERINE ARTERY 



The venous supply of the pelvis consists of many anastomosing plexuses. 
There are thus vesical, hemorrhoidal, labial, vaginal, uterine, ovarian and 




TO LUMBAR GLANDS 



ROUND LIGAMENT 



TO HYPOGASTRIC GLANDS 



i'j'.. ii. Lymphatics of atoms. (Fotrier.) 



pampiniform plexufes. The vesical, vaginal, hemorrhoidal and pudic 
veinc open into the interna] iliac, and this passes to the inferior vena cava. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



43 



An important point is that the superior hemorrhoidal vein passes to the 
portal system, and we thus get an anatomical explanation of the monor- 
rhagia of drunken women. The pelvic veins are unprovided with valves. 
The uterine plexus opens into the ovarian veins ; the right ovarian vein 
passing to the inferior vena cava, where it is provided with a valve ; the 
left to the renal vein. 

The lymphatics (Figs. 11 and 12) of the pelvis begin in connective 
tissue spaces, form plexuses, and are so arranged that those from definite 
areas pour into definite groups of glands. Thus the lymphatics of the 



SUP. LUM. GLANDS 



INF. LUM. GLANDS 




LYMPHATICS OF 
CORPUS UTERI 
LYMPHATICS OF OVARY 

ILIAC LYMPH. GLAND 
CERVICAL LYMPH. GLAND 



Lymphatics of uterus and pelvis. (Poirier.) 



| external genitals and lower fourth of the vagina pour into the oblique 
i inguinal glands ; those of the upper three-fourths of the vagina and cervix 
i uteri into the iliac glands. The lymphatics of the body of the uterus 
| pass along the broad ligaments, and, accompanied by those from the ovary 
[ and Fallopian tube, reach the lumbar glands. The lymphatics of the 
: round ligaments open into the inguinal glands, and a gland lying on the 
obturator membrane also establishes a communication between the pelvic 
connective tissue and the inguinal glands. The rectal lymphatics open 
i into the sacral glands ; those of the bladder pass to the iliac glands. 



44 



SYSTEM OF GYXJ COLOGY 



Th< a are of great pathological importance. In malignant 

disease of the vulva and lower fourth of the vagina, the oblique inguinal 
glands are affected ; but in cancer higher up, the pelvic and lumbar glands 
are first infiltrated Through the lymphatics of the round ligament, and 
'ally through the obturator gland, we may have, though rarely, late 
infection of the inguinal glands in uterine cancer. I have now several 
times seen the inguinal glands enlarged in pelvic sarcoma, and in one 
instance 1 found the obturator gland distinctly enlarged. 

The abundant lymphatic supply of the pelvis explains the inflammatory 
attacks arising from sepsis and gonorrhoea, and abundant evidence of 
their importance wfll come up afterwards. Here we can only emphasise 
the great importance of antiseptics in operative work, and the avoidance 




l'i'.. 18.. Nerve diagram. (Flower.) 

of all minor manipulations with the sound as a means of diagnosis in the 
ni. 
The nervei of the pelvis are Spinal and sympathetic. The levator 

and sphincter are innervated by the inferior hemorrhoidal branch of the 

pudic. and by the fourth and fifth sacral and coccygeal nerves; the 
lid fourth and fifth sacral also supply the COCCVg* 'Us. 
be pudic nerve pass to the muscles of the perineum and 
clitoi 

The sympathetic is arranged in many plexuses. The hypogastrfl 
plexus between the common iliac arteries gives branches which, with 

those from the lumbar and sacral ganglia and sacral nerves, make up the 

Bfl lying on each side of the vagina. Branches 

them pais to the vagina, uterus. Fallopian tubes and ovaries. 

*i-il *-\u\ bulbs are found in the clitoris and labia minora. In the 

end in the epithelium. In the uterus, nerve plexuses 

and nerve cells are present in the muscular coat, and the nerve-ending] 

1* traced I rods and epithelium. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



45 



In the tube the nerves are arranged in two concentric plexuses, 
ending in the epithelium and in the nerve cells of the submucosa. 
In the ovary the nerve-endings have been traced to the Graafian follicles 
and cells of the membrana granulosa. 

Pain is so common a gynaecological symptom that it is remarkable that 
gynaecologists have not brought more precision into their descriptions of it. 
In a recent paper in Brain, Dr. Head has attempted to give greater accuracy 
to the definition of these sympathetic painful areas ; he states that the 
area for ovarian pain is " limited above by a line running horizontally 
from the top of the first lumbar spine to the umbilicus ; below by a 
line running from the third lumbar spine to midway between the pubes 
and umbilicus, but having a little downward tag near the anterior 
superior iliac spine." For the body of the uterus and Fallopian tubes the 
area is bounded above by the preceding one ; and below by a line 
running from a little below the top of the sacrum to the symphysis, 
but having a dip down over the buttock, and another over the front of 
the thigh. For the cervix uteri the painful area is over the lower part 
of the sacrum. For the ovary, therefore, it is formed by the sensory fibres 
from the tenth dorsal nerve 
root ; for the body of the 
uterus and Fallopian tubes 
by the sensory fibres of the 
eleventh and twelfth dorsal 
nerve roots ; and for the 
cervix by the sensory fibres 
of the third and fourth sacral 
roots. 

IV. The anatomy of 
the organs on the upper 
aspect of the pelvic floor 
that is, of the Uterus 




Fig. 14. Relations of uterus and ovaries viewed through 
brim. (His.) 



Fallopian Tubes, Broad Ligaments and 
Ovaries; the Pelvic Peritoneum. (Figs. 14 and 15.) The Uterus. 
If the uterus be separated from its appendages, it will appear as a 
pear-shaped body with a constriction the isthmus slightly below its 
middle, dividing it into two great parts, the body and cervix. At its 
inferior extremity is the os uteri externum; at the upper right and 
left angles lie the openings of the Fallopian tubes. Its anterior surface 
is more flat than the posterior, and only the upper half of the former 
is covered by the peritoneum. If a vertical mesial section be made, 
we can then see that the uterus has a cavity or slit, that its walls 
are about half an inch thick, and that the cavity is lined by mucous 
membrane -^ inch (1 mm.) thick. In a section through the cavity, 
dividing the uterus into anterior and posterior portions, we can see 
the shape and relations of its cavity more clearly displayed. The cer- 
vical canal is somewhat spindle-shaped, and the so-called uterine 
cavity consists of anterior and posterior triangular surfaces which norm- 
ally, and in the unimpregnated condition, are in apposition. The os 



4 6 



.'.1/ OF C LOGY 



uteri externum is the lower boundary of the cervical canal ; the upper 
boundary is less definite, but for practical purposes we may place it 
opposite the isthmus. The os uteri internum is the lower opening of the 
uterine eavity proper, while to the right and left above are the internal 




. of female pelvis. L points to Ischio-rectal fossa, 

..priu! Fallopian tubes. These three points namely, the os uteri 

internum and tin- Fallopian tube openings map out the normal surface 
from which menstruation takes place, and where normal pregnancy occurs. 
It i- difficult t. divide the unimpregnated uterus accurately into its 
various p sake the anterior \\;ill of the uterus we may 

consider it ;i- made up of three portions: firstly, the cervix, where the 
bladder i- attached, and with the ... uteri internum as its upper boundary 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



47 



the average measurement of this is an inch : secondly, the loAver uterine 
segment, which is rudimentary, and is bounded below by the os uterine 

internum, and above by the 
firm attachment of the peri- 
toneum it measures about 
half an inch, and has not yet 
been accurately mapped out : 
thirdly, the body of the uterus 
J'O-'^C^^^ proper, which begins where 

the peritoneum is firmly 
attached, and extends up to 
the fundus. 

The cervix has been divided 
by some into a vaginal, middle, 
and supravaginal portion ; and 
g^j this division is of importance 
in relation to cervical hyper- 
trophies. The vaginal portion 
is the symmetrical, unattached 
K"# part of the cervix (Fig. 17); 
the middle portion is at- 
tached to the bladder in 
front, but is free behind ; 
and the supravaginal portion 
is attached to the bladder in 
front and to the vagina be- 
hind. 

Structure of the Uterus. 
outer aspect of the uterus 
covered by peritoneum, ex- 
cept where the bladder is 

Fk. If..- Uterine mucous membrane showing relation of attached. Its Wall is half ail 
glands and stroma. ^eh thick, and made lip of IU1- 

striped muscular fibre and connective tissue. The mucous membrane 
of the uterus is -^ T of an inch thick 
and merits special description. In 
the cervical canal the mucous mem- 
brane has a peculiar arrangement visible 
to the naked eye the well-known 
arbor vitse. This consists of a vertical 
ridge with lateral ones slanting up- 
wards and outwards. The cervical 
mucous membrane consists of columnar 
epithelium, ciliated and narrow, with 
the nucleus deep in the cell. Many 
glands of a racemose type are present, 
and penetrate deeply into the connective tissue. In the substance of 





Fig. 17. Cervix and upper part of vagina 
showing ruga'. 



4S SYSTEM OF GYNECOLOGY 

the cervix are dense connective tissue and unstriped muscular fibre. The 
vagina] portion of the cervix is covered with many layers of squamous 
epithelium continuous with and similar to that of the vagina, The mucoid 
membrane of the uterine cavity proper is .}. of an inch thick, and of I 

-ravish red colour : it consists of a surface covering of columnar epithelium 
and an embryonic connective tissue. Numerous so-called "glands" open 
on its surface, and ramify and intersect in all directions down to the 
muscular eo]at. There is no submucous connective tissue. The "glands'' 
are lined with columnar epithelium of the same nature as the surface 
epithelium, and continuous with it. So far as my observation goes, the 
epithelium does Dot rest on a membrana propria. There hasbeen much dis- 
cussion as to the nature of these so-called glands : it is best on the whole 
to regard them not as specially glandular, hut as mere pits of epithelium, 
honey-combing the mucous membrane. The mucous membrane is really 
a lymphatic tissue, reticulated with epithelial diverticula whose function 
in some points we understand. During menstruation there is a 
superficial denudation of the mucous membrane ; and it is from the 
epithelial pits and the connective tissue between them that regeneration 
a place. During pregnancy also, we have, persisting close to 
the muscular coat, the funduses of these pits in the form of the well- 
known spongy layer. This arrangement permits not only of the 
separation of the placenta and membranes during the third stage of 
labour, hut also gives again epithelium and connective tissue for the develop- 
ment of a new mucous membrane during the puerperium. The connective 
If con-ists of elongated cells with nuclei, and branching small 
round cells anastomosing with one another. Leucocytes when present are 
to be considered pathological; and the same is the case in regard to 
onstriped muscle in the stroma. According to Leopold, the bundles of 
connective tissue are surrounded by endothelial cells, which thus form 
lymph spaces. 

The F<il!>>j>i<ui tubes are two in number, and pass out from the right 
and left upper angles of the uterus towards the side of the pelvis in a way 
described more fully afterwards. Each is about 10 cm. in length, 
and lies below the upper margin of the broad ligament. They are covered 
by the peritoneum for about five sixths of their periphery, the remaining 
and Lower sixth resting on the connective tissue between the layers of the 

broad ligaments. The following divisions are recognised : a portion 

piercing tin- wall of the uterus, the interstitial part ; a straight portion, 

iiiu> ; ;i curved portion, the ampulla : and, finally, the fimbriated end, 

with the special ovarian fimbria, The tube consists of a peritoneal 

ingj .1 mUSCUlar COat in two layers, circular inner and longitudinal 

ad a remarkably folded mucous membrane. The mucous 
membrane lining the tube Is continuous with that of the uterus, and is 

tin-own into many longitudinal folds which pass out into tin- fimbriated 

end. Iii the fimbriated end can be Been the ostium abdominale or outer 

opening of the tub pedal fimbria, the ovarian fimbria, joins the 

and tuhe. We musl note here the remarkable fact that the 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 49 

genital tract of woman communicates by this ostium directly with the 
I peritoneal cavity (Figs. 14 and 15). 

The mucous membrane of the Fallopian tube consists of columnar 
epithelium and connective tissue. The foldings of the mucous membrane 
arc very much less marked in the isthmus, much more so in the ampulla. 
The question whether these foldings constitute glands is still disputed ; 
but I see no valid reason as yet for considering them as anything more 
than a honey-comb arrangement of the tubal lining, indicating, so far as 
: we know at present, its close developmental relation to the uterus. 
! The calibre of the isthmus is such as to admit a bristle, while the ampulla 
will admit the ordinary uterine sound. 

The tube in the foetus has windings in it of a pathological interest. 
The hydatid of Morgagni, derived from the duct of Miiller, is attached to 
the fimbria or tube, and has a mucous columnar lining with clear fluid. 
Muscle and peritoneum make up its head and stalk. It must not be 
confounded with cysts in the mesosalpinx arising from Wolffian relics. 

Ovaries. The ovaries, two in number, lie projecting from the posterior 
lamina of the broad ligament, and on the side walls of the pelvis. The 
diameter of each ovary is 1 J inch by f by of an inch. The posterior 
surface looks backwards, the anterior is attached to the broad ligament ; 
their long axis is either perpendicular or somewhat transverse. The 
part of the ovary joining the broad ligament is named the hilum. 

Structure of the Ovary. The ovary is covered on its outer aspect by 

columnar epithelium, the germ , - 

epithelium of AValdeyer, who ^___- ^jj^^ 3 * 1 "\\ 

first indicated its nature and .. ; , I] 

importance in development. At ^ ^Kk //'/ 

the hilum the germ epithelium ^; /./ ^Tm 

is continuous with the squamous _J*? ^F v >f. ''/' 

epithelium of the broad ligament, Z // u 'j 

the boundary being marked by ^3D-h?^2^ 
the well - known white line of ^^JIotR >' ft 
Farre. In fresh specimens the -^JJ -." r - -*.> ' 

ovary has a dull, pearly lustre, 

the broad ligaments being more FlG . is. Seal's ovary showing cortical and medullary 
grayish. While Farre drew la y ers > also peritoneal capsule with tube on section. 

attention to this line of demarcation, he unfortunately omitted to note 
the real nature of the covering of the ovary, a mistake readily made if 
he examined adult ovaries only. 

Below the germ epithelium lies the tunica albuginea, a condensed 
concentric arrangement of connective tissue. On section we see that 
the rest of the ovary is made up of two portions, a cortical or outer zone, 
and a medullary or vascular zone continuous with the tissue of the broad 
ligament. In the cortical portion, and surrounded by connective tissue, 
we have the remarkable structures known as the Graafian follicles. Each 
ovary contains a very large number of these follicles, but whether they 
amount to eighty or ninety thousand, as some authors allege, is not quite 

E 



5 



SYSTEM OF GYNAECOLOGY 



certain. The Graafian follicles near the surface of the ovary are small, 
the larger ones being deeper ; but a few of the largest lie at the periphery. 
Each Graafian follicle consists of a tunica fibrosa and a tunica propria) 
the BO-called membrana granulosa, lined with columnar cells and con- 
taining the liquor folliculi. Usually the membrana granulosa has a 
projection of cells, the discus proligerus, which contains the ovunj 
proper. The ovum is made up of zona pellucida, yelk', germinal vesicle] 
and germinal spot (nucleus and nucleolus). The columnar cells im- 
mediately surrounding the ovum form the corona radiata. The 




RECTUM 



I - ns in 8J months' foetus. Note proximity of rectal and 

broad ligament conned the relations of ureter, ovary, and uterine artery are the same in 

the adidt. 



nucleolus hai been noted to have amoeboid movements. The ovary lies 
ihallow depression of peritoneum, the fossa ovarii. In some of the 
lower animals, such as the ral and seal, the ovary is surrounded bi 
peritoneal capsule, and thus is shut oil' from the general peritoneal cavity. 
It is alleged that the same arrangement may occur in the human female, 
and be a source <>f tubo-ovarian cyst- (Bland Sutton). The connective 

tissue Consists of round cells, and at the hilnm are many Mood-vessels. 

/'< neum. The upper aspect of the pelvic Hoof, the uterus, 

and it- append red by peritoneum, the arrangement of wniclj 

must now be described 

On sagittal mesial section the arrangemenl is as follows, from before 
backwards: The peritoneum of the anterior abdominal wall i> reflected 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 51 

on the fundus of the bladder a little above the level of the pubes. It 
then passes on to the anterior surface of the uterus, about the level of the 
os internum, over the fundus, and down the posterior wall of the uterus, 
which it covers completely. It dips down on the uppermost half inch of 
the posterior vaginal wall, and finally becomes reflected upon the sacrum 
and rectum. The vesico-uterine pouch of peritoneum lies between the 
bladder and uterine Avail. The posterior dip of the peritoneum below the 
level of the isthmus is known as the pouch of Douglas ; it will be more 
fully described shortly. The vesico-uterine pouch has sometimes been 
erroneously termed the space of Retzius (Figs. 3 and 7). 

The broad ligaments are formed by two folds of peritoneum passing 
out from the sides of the uterus to the side wall of the pelvis. The 
anterior fold of the broad ligament is a continuation of the peritoneum on 
the anterior surface of the uterus. Beneath it lies the well-known round 
ligament, which passes from the junction of the Fallopian tube and 
uterus, forwards and outwards to the inguinal canal. These round 
ligaments contain striped and unstriped muscular fibre, blood-vessels, and 
nerves. The posterior lamina of the broad ligament is in the same way 
a prolongation outwards and backwards of the peritoneum on the posterior 
surface of the uterus. It is larger than the anterior lamina, and lies 
partly on the side wall of the pelvis. Thus the ovary comes to lie both 
on the posterior aspect of the broad ligament and on the side wall of 
the pelvis. Between the layers of the broad ligament lie connective 
tissue, blood-vessels, lymphatics and nerves ; the connective tissue passing 
up into that of the iliac fossa. The so-called ovarian ligament joins the 
lower end of the ovary and the angle between tube and uterus ; the 
uterine muscle passes into it. The Fallopian tube occupies the greater 
part of the top of the broad ligament. The infundibulo-pelvic ligament 
of the ovary is that part of the top of the broad ligament not occupied by 
Fallopian tube, and to a certain extent it suspends the ovary. The paro- 
varium also lies between the layers of the broad ligament near the ampulla, 
and consists of a single longitudinal tube with several vertical ones. It 
represents the remains of the Wolffian duct and body, and will be more 
particularly alluded to afterwards. The utero-sacral folds are two ridges 
of peritoneum enclosing muscular fibre and connective tissue; they pass one 
from each side of the isthmus uteri, outwards and backwards towards the 
second and third sacral vertebrae. The pouch of Douglas can now be more 
accurately defined. Its upper lateral limits are the utero-sacral folds : in 
front the isthmus forms the anterior boundary, behind is the peritoneum 
covering the sacrum and rectum. The fact that so many pathological 
products are found in the pouch of Douglas, or its neighbourhood, is 
to be explained not only by its affording an actual pouch for lodgment, 
but by the near presence of the ovary ; and above all by the fact 
that the openings of the Fallopian tubes lie posterior to the broad 
ligament. Between the utero-sacral fold and the broad ligament lie the 
lateral pouches of Douglas, while on each side of the bladder there is a 
para-vesical pouch. 



sa 



SYSTEM OF GYNAECOLOGY 



V. The Position of the Organs : their dissection and structural 
anatomy. The position of the organs is best ascertained and described 
in an adult pelvis which has been hardened and the superjacent intestine 




II v removed Oae of the best of these drawings has been recently 
])ulli>licd by Waldeyer (Fig. 20). The uterus lies below the level of the 
brim, usually to the one side, and i> anteverted and anteflexed. Viewer 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 53 

from above, therefore, one can only see its fundus and posterior surface. 
The anterior surface touches the bladder, so that the vesico-uterine pouch 
is usually empty. The normal uterus is perfectly mobile, and its shape 
and normal relation to the vagina is a developmental one. Those who 
advocate ventro-fixations seem to forget entirely that the uterus is a 
mobile pelvic organ, and that after such operations it lies for a time in a 
state of abnormal position and fixation. 

The Fallopian tubes pass, firstly, out towards the side of the pelvis ; 
they then turn up, and the fimbriated end becomes applied to the posterior 
aspect of the ovary. 

The ovary lies on the posterior lamina of the broad ligament, on the 
side Avail of the pelvis, below the level of the brim, and in front of the 
sacro-iliac joint. The ovary on the side of the pelvis to which the uterus 
is inclined has its long axis vertical (Fig. 14); the other ovary has its 
long axis more or less transverse. 

The vagina runs through the pelvic floor parallel to the conjugate. 
The part of the rectum in relation to the vagina and to the urethra is also 
parallel to the conjugate. The long axis of the anus is parallel to the 
axis of the pelvic brim. The external genitals in the upright posture 
make a small angle with the horizon. 

Dissection of the Pelvis. If a cadaver be placed in the lithotomy 
posture a dissection may be made over the rectal portion of the peri- 
neum, and also of the anterior urethral portion. When in the former 
case the skin is suitably removed, we come upon the superficial fascia 
with much fat, and the base of the ischio-rectal fossae. If the fat, superficial 
vessels, and nerves be removed from these we then see that each fossa 
is bounded on the inside by the levator ani, and on the outside by part 
of the obturator internus. The varying portion of these boundaries is 
best seen on section (Figs. 7, 8, 9). Between them, the sphincter externus 
can be dissected out. The pudic artery lies on the inner aspect of the 
ischial tuberosity. If the skin be now removed from the anterior urethral 
portion we come first upon the superficial fascia, and then on the deep 
layer of the superficial fascia. This latter is attached to the pubic arch, 
its base hooking round the transversi perinei to join the anterior layer of 
the triangular ligament. On its removal we now see a double triangular 
arrangement of muscles, one on each side of the middle line. The base 
of each triangle is formed by the transversus perinei, the outer side by the 
erector clitoridis, the inner by the bulbo-cavernosus or sphincter vaginae. 
Below the lower end of the bulbo-cavernosus lies the Bartholinian gland 
with its duct opening at the sides of the hymen. Higher than the 
Bartholinian glands, and still below the bulbo-cavernosus, lie the erectile 
structures known as the bulbi vaginae. The removal of these muscles 
now exposes the anterior layer of the triangular ligament. This layer 
having been dissected off, we come upon the terminal branches of the 
pudic vessels and nerves lying on the posterior layer, and then cut into 
the retro-pubic fat. The exact relations of the fascia here have not 
yet, however, been accurately worked out. The triangular ligament un- 



54 



SYSTEM OF GYNECOLOGY 



doubtedly acts as a supporting element to the urethra and vagina, which 
perforate it ; and in the fare rases where a nullipara suffers from prolapsus 
uteri the edge of the triangular ligament, where it is perforated by the 
vagina, ran lie felt like a ring (Fig. 21). 




Perinea] region. 



If a dissection l><' now mad.- from above, and the peritoneum, uterus, 
and appendages removed, the pelvic diaphragmatic muscles will be 
exposed. These are the coccygei and the levatores ani ; and viewed from 
;d.<ve they form ;i concave muscular arrangement. The levator am' has its 
origin from the posterior aspect of the pubes, from the white line of fascial 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



55 



and the ischial spine. The fibres pass down, almost vertically, to become 
attached to the vagina, the rectum, its fellow, and the tip of the coccyx. 

The coccygeus has its origin from the spine of the ischium and passes 
to the lower part of the sacrum and front and side of coccyx. 

The obturator internus is well seen in the sections (Figs. 7, 8, 9). 

Structural Anatomy. In sagittal mesial section the pelvic floor is an 
unbroken layer. The vagina and 
urethra do not impair its strength, 
as they are slits passing through 
it at right angles to the direction 
of intra-abdominal pressure. The 
floor, however, can be divided 
into two portions, an anterior 
pubic mobile segment, and a 
posterior more fixed or sacral seg- 
ment. The vagina thus forms a 
boundary between these two. The 
pubic segment consists of bladder, 
urethra, and anterior vaginal wall. 
Its mobility is due not only to the 
less firm nature of its tissue, but 
also to its loose attachment to the 
pubes. 

The sacral segment is firmly 
attached to the sacrum, and 
consists of the tissue behind the 
posterior vaginal wall, which is 
included in it. In the upright 
posture the sacral segment is the 
supporting one, intra-abdominal 
pressure pressing the pubic seg- 
ment against it. FlG - a s " acal section of P elvic floor - 

Changes in pelvic floor due to posture. In the position known as the 
genu-pectoral the abdominal bulge lessens at the pubes and increases 
near the diaphragm. The projection of the pelvic floor is also less 
marked ; but the pelvic floor is still unbroken. The following facts are now 
of great importance : If the edges of the hymen be separated, air passes 
in and the vaginal slit becomes a cavity. The uterus if anteverted 
previously becomes more so, and lies farther from the vaginal orifice. 
The retroverted unfixed uterus does not become anteverted when a 
patient assumes the genu-pectoral posture, and air is admitted into the 
vagina ; but the uterus lies farther from the vaginal orifice and becomes 
more retroverted. These facts as to the dilatation of the vagina by 
posture give the key to proper specular examination, as was first shown 
by Marion Sims. The same dilatation of the vagina can be attained in 
the position known as Sims' semiprone posture, and also in the lithotomy 
posture, especially if the hips be raised. These postural methods are also 




5 6 



SYSTEM OF G YX. ECOLOGY 



invaluable in rectal and vesical examination. In the same way the 
rectum can be ballooned, and also, as Kelly has shown, the Madder. 1 
In this way. and by simple specula, thorough visual, and, in certain 
. digital examination of the bladder, vagina, and rectum can be made ; 
as will be fully explained in the appropriate section. In examination of 
Madder cases the genu-pectora] posture is advantageous, as well as in 
reposition of the gravid retroverted uterus. 

VI. Surgical Anatomy. In operative pelvic surgery by the vaginal 
route the following points must specially be kept in mind: 

i. Th' posturi of the patient and the mobility of the uterus. There 
is no doubt that the lithotomy posture is the most convenient 
for all operative work. By means of a broad, short, modified Sims' 
speculum the vagina becomes dilated in this posture ; and then with the 




-3. Diagram of genu-pectoral posture showing vaginal distension. (Based on frozen section.) 
VOlsella the uterus can ill most instances be safely drawn near the vagina] 

orifice, and an accessible field of operation thus obtained. By most 
operator! the use of the Bemiprone posture has been abandoned for the 
more convenient lithotomy one. 

ii. Blood-supply: tines of loose connective tissue in th pelvis allowing 
the separability , In the flap operations on the perineum, 

now so generally adopted, the Loss of blood Is trifling. The bleeding 
mainly venous, and is readily checked by pressure. In making 
the usual perinea] incision with scissors it is advantageous to have the 
thighs well flexed on the abdomen, so as to render the parts tense. In 
suturing, the flexion should be Less marked 

The line- of loose tissue in the pelvis are of the greatest importance 

from ;ui Operative point of View. Thus if a transverse incision he made 
of the perinea] body, SO as to split it into anterior and 

. the finger can then pass into the loose tissue between the 
wall and posterior vaginal wall: and these can he easily 
laims priority in this. 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 57 

separated till the peritoneum of the pouch of Douglas is reached. In 
this way dermoids of the recto-vaginal septum have been enucleated, and 
also certain forms of deeply burrowing extraperitoneal gestation attacked. 
This route is one seldom followed, but it is worthy of being kept in mind. 
The loose union between rectum and vagina allows of posterior col- 
porraphy operations. The operator can make a vertical mesial incision 
on the posterior vaginal wall until the loose tissue is reached ; he can 
then separate laterally, with the handle of his knife, the posterior 
vaginal wall, remove what seems necessary, and suture. I must also 
point out that this loose union between anterior rectal and posterior 
vaginal Avail is an important factor in allowing prolapse of the uterus. In 
the same way the loose tissue between the bladder wall and the upper 
portion of the anterior vaginal wall allows of anterior colporraphy. 

In vaginal hysterectomy the operator readily cuts by a transverse 
incision through the posterior fornix into the pouch of Douglas, as 
the thickness of tissue here is only \ inch. Anteriorly a transverse 
incision in the vaginal fornix exposes the loose tissue between the 
bladder and cervix, and the vesico-uterine pouch can soon be opened. 
Here as a rule little bleeding arises, but it is quite otherwise with the 
lateral attachments of the cervix ; there the tissue is dense and 
abundantly vascularised by the uterine artery. Before cutting the 
lateral attachments, therefore, it is imperative for the operator either 
to ligature or to apply pressure forceps : the anatomy of the ureter 
must also be kept in mind, as there is less than 4 inch between it 
and the cervix uteri. AYhen once the firm lateral attachments of the 
cervix have been thus separated the uterus can be more thoroughly 
drawn down, and the broad ligaments secured in the same way as in the 
case of the lower lateral attachments. 

Operations on the upper part of the vulva are usually superficial, as 
in clipping away irritable skin in pruritus vulvae. The bleeding is 
usually insignificant, even if the glans clitoridis be cut off. The 
operator must beware of cutting below the apex or sides of the pudic arch. 

In abdominal surgery the anatomy of the incision in the linea alba 
needs no remark. In pelvic adhesions the operator must be specially careful 
in the neighbourhood of the sacro-iliac joint and side of the pelvis owing to 
the position of the ureter here, and to the proximity of the large iliac vessels. 

Recently Diihrssen and Martin have recommended in certain cases, 
instead of abdominal section, incision by way of the loose tissue between 
the bladder and the uterus. 

VII. Development of the Organs. The subject of the development 
of the female genital organs is too complex to admit of full consideration 
here, and I shall therefore only take up some points of practical import- 
ance. In a human foetus of about the sixth week an important stage is 
displayed. This can be well seen in the diagrams obtained in a foetus 
carefully prepared in transverse serial section by my former assistant, Dr. 
Gulland. The foetus was obtained from a case of extirpation of a six 
weeks' pregnancy, where cancer of the cervix was present ; it was thus 



5S 



SYSTEM OF GYNECOLOGY 



perfectly fresh and in all respect* normal. In the diagram of the 
transverse Bection of tin* abdominal cavity are seen tin* two Wolffian 




bodies, markedly developed (Ki,u r - 25). Lower down (Fig. 26) they have 
diminished in rise, and are represented only by a few tubules; while th< i 
ovary, pedunculated and with well-marked germ-epithelium covering it, 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



59 



can be noted (Figs. 26 and 28). The broad ligaments with the duct of 
Miiller can also be seen. 

Lower down in the pelvis the genital cord is displayed (Fig. 27) ; 

VERTEBRA 



WOLFFIAN BODY 




WOLFFIAN BODY 



Fig. 25. T. S. of Wolffian bodies in six weeks' foetus. 



and at this stage one can note three canals in it ; the centre one being 
formed by the coalesced ducts of Miiller, while each lateral one is the 
Wolffian duct. This agrees, therefore, with the usual statement that in 



WOLFFIAN BODY 




' '. w 








Fig. 26. T. S. pelvis, six weeks' foetus. Note wide transverse of pelvis. 

the early foetus there are two sets of organs the Wolffian bodies with 
their ducts, and the ducts of Miiller. The former atrophy in the female 
sex but leave their traces in the broad ligaments, where are normally found 
the parovarium, or epoophoron (Fig. 28), and also certain additional but 



6o 



SYSTEM OF GYNECOLOGY 



donal relics in the form of tubules at the hilum, or of a speciaj 
tube in the broad ligament, uterus, or vagina, rarely continuous in all 



SPINAL CORD 



DUCTS OF MULLER 

AND AT SIDE 
WOLFFIAN DUCTS 




cm showing Lanital conl. A points to tissue in front of urino-genital 
sinus. On tin- posterior wall of tin' sinus is tin- eminence wrhere tin' ducts of Muller enct 



of them, 



\ 



W 



known as Gartner's canal. It represents the "Wolffian duct, 
and may be a source of retention cyst 
in the localities already named ; it is 
normally present in the cow and sow 

g The ovary develops as an epithelial 

%h thickening on the Wolffian body. The 

|| outer cells of 








)::'* 



the ovary form the germ 
epithelium of Waldeyer, which, by 
sending prolongations into the substance 
of the ovary, forms the ova. 

The duds of Mailer give rise to 
the Fallopian tubes, uterus and vagina 
/I!*;;! &ft y beeparatetoformthetub* 

ton; and coalesce to form tin- uterus am 

fpo, eiXH>plioron (tliat is, i^iro\.iiiiiiii). . , . . . , . 

vagina. Disturbance m this norma 
coalescence gives rise to malformations. According to some anato 
mitts, the Wolffian duets enter into the formation of the vagina, and 
give rise to the H shape on transverse section. As the diagram shows 
the ducts of Miilh'i- forming the vagina at first have a lumen ; but 
by epithelial proliferation from the Wolffian bulbs they become solid. At 



THE ANATOMY OF THE FEMALE PELVIC ORGANS 



61 



the lower part of the vagina there develop about the third and a half 
month two special oval epithelial proliferations, which break down cen- 
trally and thus form the hymen (Fig. 29). These bulbs I have recently 
found to be developed from the Wolffian ducts, and I have termed them 



UTERINE CAVITY 




VAGINA (NO LUMEN ) 



-BLADDER 



Fig. 29. L. S. of 'i\ months' foetus to show development of hymen. This shows formation of hymen 
by development of two bulbs from Wolffian ducts : these join and break down in the centre, and 
are met by an involution of hypoblast below. 

the Wolffian bulbs. This figure also shows the involution of the deeper 
layers of the vestibule to meet the hymen. About the fourth or fifth 
month the solid vaginal proliferation flattens out, and then forms a 
lumen. I believe, however, that it may do so earlier (Figs. 27 and 29). 

In the early foetus (fifth to sixth week) a cloaca is present; the Wolffian 
ducts open into the urino-genital sinus (Fig. 27) up till the third month, 
when they are closed by the development of the hymen. The subsequent 
stages are the formation of a septum and the development of the clitoris 
in front, and labia at the sides. 

The relation of the pelvic organs to the germinal layers is of interest. 



62 



SYSTEM OF GYNAECOLOGY 



The uterus, tubes, and ovary are mesoblastic; the adult vagina has its 
lining derived from the epiblast, the lower involution from the local 
outer covering, but the lining above the outer aspect of the hymen is 
furnished, as an examination of my specimens seems to me to demonstrate! 

through the Wolffian duct. The Wolffian duct is really epiblastic in its 
origin. The anus is also epiblastic, while the bladder and rectum are 
hypoblastic. The vestibule is derived from the urino-genital sinus, and 
is hypoblastic. 

The main practical points resulting from this development ar< 
follows : 




i -Diagram of developing and folly formed genital tract Ota, ostium tub* abdominale ; Jm. 

hydal I; /o, ovarian fimbria; o, ovary; lo, ovarian Ugamenl ; po, parovarium; lr, round 

ligament; iv, vagina; uw, upper waU of vestibule ;cc, corpus cavernosum clitoridis; u, ureter; L 
labium minus; fm, labium majus: wb, Wolffian i>< ><iv. On the right side are seen the norma] 
organ*. 00 tbs left the Wnltlian-body relics ami duct in addition. (CoDlenx.) 

1. Normally in the adult woman we find traces of the Wolffian 
body and dud in the parovarium (Fig. 30). This is the source of the 
ordinary parovarian tumour. 

_'. Skene's tubules in the urethra are probably not Wolffian relics, 
but represent the glanda of the male prostate. 

Abnormal relics of the Wolffian body at the hilum of the ovary, 
and in the broad Ligaments, may give rise to papillomatous developments. 
Some authors, however, consider the germ-epithelium as more probably 
irce of these when they are present in the ovary. 

L Gartner's canal may give rise to broad ligament, uterine, and 
vaginal <;. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 63 

5. Malformations are really due to persistent stages of arrested de- 
velopment. 

D. Berry Hart. 

REFERENCES 

The following references do not represent Gynecological Anatomy, but merely the 
main sources used in this sketch. Fuller sources are indicated, and should be con- 
sulted when necessary. 

1. Cullingworth. "A Note on the Anatomy of the Hymen and that of the 
Posterior Commissure of the Vulva," Jour, of Anat. and Phys. vol. xxvii. p. 343. 2. 
Fakre. "Uterus and its Appendages," Encyc. of Anat. and Phys. vol. v. Suppt. 
3. Flower. Nerves of the Human Body. London, 1872. 4. Frankenhaeuser. Die 
Nerven der Gebaermutter. Jena, 1867. 5. Gawronsky, Y. " Ueber Yerbreitung und 
fjndigung der Nerven in den weiblichen Genitalien," Arch, fur Gyn. Bd. xlvii. S. 271. 
6. Hart. Atlas of Female Pelvic Anatomy. Eclin. 1884. 7. Ibid. Contributions 
to the Sectional Anatomy of the Female Pelvis. Edin. 1885. 8. Head. "On Dis- 
turbance of Sensation with special Reference to the Pain of Yisceral Disease," Brain, 
1893. 9. Herman. "A Contribution to the Anatomy of the Pelvic Floor," Trans. 
Lond. Obst. Soc. vol. xxxi. 10. Henke. Topograpkische Anatomic des Menschen. 
Berlin, 1S79. 11. Hyrtl. Die Corrosions Anatomic und Hire Ergcbnisse. Wien, 
1873. 12. Kleix. " Entstelmng des Hymen," Festschrift der Gescllschaft fur Geb. 
und Gyn. in Berlin. "Wien, 1894. 13. Minot. Human Embryology. New York, 
1892. 14. Sutton, J. B. Surgical Diseases of Ovary. London and New York. 15. 
Waldeyer. Beitrdge zur Kenntniss der Lage der weiblichen Bcckcnorganc. Bonn, 
1892. For a fuller record of literature see Hart's Atlas and Index Mcclicus. 

D. B. H. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 

Introduction. The malformations of the female genital organs form a 
natural and sharply denned group of deformities whose special interest, 
from the gynaecological standpoint, lies in the effects which they produce 
upon the menstrual phenomena, and upon the sexual and reproductive 
life of the woman in whom they exist. These effects vary greatly in 
importance with the nature, position, and extent of the malformation ; 
and also, doubtless, with the constitution of the patient and her condition 
as regards marriage. Manifestly the absence of the uterus is a more 
serious matter than the imperfect development of an ovary or a tube ; 
and malformations which are of grave import in a married woman may 
exist without inconvenience in a spinster. 

It will be convenient to consider, first, the malformations of individual 
organs, beginning with those of the ovaries, and dealing in turn with the 
Fallopian tubes, uterus, vagina, and vulva j I shall then discuss the 
abnormalities which affect more than one of the reproductive organs, 
including cases of " hermaphroditism." 

In studying these genital anomalies, it must not be forgotten that we 
are concerned with organs which are derived from at least three distinct 
sets of embryonic structures. As embryology is the true key to the 
understanding of the nature of malformations, it will be well to state 
shortly what these organs and structures are. 



64 SYSTEM OF GYNECOLOGY 

Development of the Female Genital Organs. 1. The Ovaries. 
In the early, sexually indifferent embryo a development of certain 
cells of the genital fold or ridge takes place on each side of the 
bral column in the lumbar region. These cells of the germinal 
epithelium, for that is the name given to the epithelium of the peri- 
toneum in this region, form the genital or sexual glands which develop 
at a later stage into the ovaries in the female and the testicles in the 
male. Only a part, however, of the genital gland is thus produced) 
In the female this part of the ovary contains the ova, and is called the 
oophoron ; the other portion, the paroophoron or tubuliferous portion, has 
a different origin. In the early embryo there is seen, lying to the outer 
side of the genital fold, a glandular mass the mesonephros or Wolffian 
body, with a duct the segmental or Wolffian duct. In the male, some of 
the tubules of the Wolffian body extend into the genital gland, and 
form the rete testis, others remain as the vasa efterentia, whilst the 
Wolffian duct becomes the epididymis and vas deferens. In the female 
the Wolffian body largely atrophies; still, just as in the male, 
some of its tubules enter into the genital gland, and form the par] 
oophoron, whilst others, along with the Wolffian duct, persist in a rudi- 
mentary state as the parovarium or epoophoron, and occasionally as 
Gartner 8 duct. 1 At a later stage in development the sexual glands 
descend from their primitive position, the testicles passing to the scrotum, 
and the ovaries to the brim of the true pelvis. Such is the composition 
and development of the ovary ; and the anomalies which maybe expected 
are, therefore, malposition or non-descent of the whole organ, and 
abnormalities by excess or defect of either or both its constituent parts, 
oophoron and paroophoron. 

2. The Fallopian Tubes, Uterus, and Vagina are the representatives 
of the two Miilleiian ducts of the embryo. Lying near the Wolffian 
body, and on the outer side of the Wolffian duct, the Miilleiian 
duct, which is at first a solid cord, passes downwards to open into the 
allantoic portion of the cloaca. At a later stage the duet acquires a 
Lumen, and later still it fuses, in its lower portion, with its fellow of the 
opposite side to form the uterus and vagina, whilst its upper part remains 
separate as tin- Fallopian tube. In the male foetus the Mullerian ducts 
atrophy almost entirely, and are represented only by the uterus mascu- 
linus or prostatic vesicle, and possibly by the true hydatid of Morgagni 
The anomalies that may be expected in connection with these organs in 
the female are irregularities in the fusion of the lower parts of the 
Miilltiian ducts, in their mode of termination, their partial or complete 
absence and th. -it- imperforate condition. As will be seen later, all these 
malformations (that is, double Uterus and vagina, uterus unicornis, atresia 
ami defeetOI uteri et vaginas, and so forth), and Others whicb are not so 
easily explained by the help of embryology, are comparatively common. 

3. The Vulva. The mode of development of the external organs of 
generation is more complicated than, and not so well understood as that 

1 For further information "ii tlie homologies of these structure*, see (1 . 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 65 

of the vagina and uterus with its annexa. At the posterior or lower end 
of the embryo an invagination of the ectoderm occurs, by which the 
cloaca is brought into communication with the exterior, and thus is 
formed the cloacal opening or primitive anus. This is followed by an 
indifferent stage, during which it is impossible to foretell the sex of the 
embryo. The anterior part of the anal plate becomes thickened, and 
gives rise to a projection known as the genital tubercle, which is the 
anlage of the penis in the male, and of the clitoris and nymphae in the 
female. In its indifferent stage it may be termed the phallus. On the 
under surface of the genital tubercle appears a groove the genital groove 
which passes backwards into the cloaca. In the female the lips of this 
furrow become the labia minora, and the integument outside them 
develops into the labia majora. Soon the cloaca is seen to be divided by 
a partition the future perineum into an anterior cavity, or uro-genital 
sinus, into which open the urinary and sexual ducts, and a posterior 
which opens at the permanent anus. In the female the genital tubercle 
remains small and imperforate, and the sinus urogenitalis persists as the 
vestibule into which opens the urethra (the drawn-out lower end of the 
allantois), and the vagina with its hymeneal fold. 

From what has been said of the development of the external genitals, 
complicated as it is with that of the lower end of the bowel and uro- 
genital ducts, it is not difficult to understand how many puzzling anomalies 
may arise, anomalies which have led to errors in the determination of 
the sex of the infant at birth, and to most unhappy consequences in later 
life. One is, therefore, prepared to find that the principal malformation 
of the external genitals is that known as hermaphroditism, or by the 
better name of pseudo-hermaphroditism. 

The mode of development of the generative organs must be constantly 
borne in mind in the study of the malformations to which they are 
subject ; for many of these are thus at once capable of explanation. 
Certain anomalies, it is true, admit of no such easy elucidation ; neverthe- 
less it is probable that a more exact knowledge of the early stages of 
development, when obtained, will serve to clear up what is at present 
obscure. The primary etiological factor which interferes with, and arrests 
the development of the internal genital organs, may with some confidence 
be supposed to be foetal peritonitis. The malformations of the external 
parts may, on the other hand, be due to amniotic compression or adhesion. 

Malformations of the Ovaries. It is only within recent years 
that special attention has been paid to ovarian anomalies, yet these dis- 
orders affect the sexual life and responsibilities of the woman, and may 
interfere with the success of such operations as oophorectomy or ovariotomy. 

Pathology. 1. Supernumerary Ovaries. It is well to reserve the term 
" supernumerary ovary " for such rare cases as that reported by Winckel, 
in which a third ovary lay in front of the uterus, to which it was attached 
by a strong ovarian ligament. It also formed connections with the 
bladder and with the right Fallopian tube. The two normal ovaries 

F 



66 SYSTEM OF GYNAECOLOGY 

were of equal size, and then' were no traces of peritonitis in their 

neighbourhood. The supernumerary ovary was twice the natural size. 
The patient, an old woman, was sterile, notwithstanding the abundanoj 
of ovarian tissue. No ease exactly resembling Winckel's lias yet beei 

recorded, and the condition must be very rare. Embryology gives little 
help in Bolving its mode of origin. It may have been due to duplication 
of the sexual gland on one side : but Winekel suggests that it was 
developed from the anlage of the bladder (allantois), and that in this way 
Bsical attachment is explicable. 

2. <>r <'<>/is/ri<f<</ Ovaries. Accessory ovaries differ greatly 

from the anomaly which has just been described. They are much less 
pare, for they are found in from two to three per cent of autopsies! 
they are rounded bodies always smaller than the normal ovary, to which 
they have a pedicnlated. rarely a sessile attachment near its peritoneal 
border, and they vary in number from one to three. In a case observed 
by J. D. Williams, and seen by myself, the accessory ovary was of the 
size of a large pea; it was made up of ovarian stroma with Graafian 
follicles, and was attached to the anterior border of the right ovary by I 
stalk which consisted partly of fibrous tissue, with an external coating of 
low cubical epithelium, and partly of solid columns of epithelial cells 
enclosed in the fibrous tissue. In the above ease there had been dehiscence 
of ,it least one Graafian follicle, for a cicatrix was found. All accessory 
ovary may become cystic. Mr. Doran has pointed out that small fihro- 
myoiiias may arise in the ovarian ligament, and be mistaken for accessory 
ovaries ; bat in most of the recorded cases there seems to have beel 
little doubt of the glandular character of the bodies. 

Accessory ovaries are probably constricted portions of the normal 
organ which have been separated at an early period in the development! 
possibly by the agency of festal peritonitis; in rare cases the ovary has 
even Keen found divided into two nearly equal parts by such a COM 
Btriction. At the same time traces of peritonitis are not always present, 

and then it is possible that the accessory glands were produced by a ford 

of budding of the primitive sexual gland. This hitter hypothesis is 

strengthened by the fact that in some instances the accessory ovari 

~\r<\ entirely of Pfluger's tubes. It is also possible that cases of this 

kind may have ,u r i\cn rise to the notion th.it both ovary and testicle were 

it in the same individual, the accessory ovary with its tubuliferoul 
structure being regarded as a testicle. 

:;. Hypertrophy of the Ovary. Occasionally ovaries of twice the normal 
size have been found in the infant at birth. This may be due to hypen 

i of all the component parts of the -land ; or to an increase in 
the connective tissue elements frith destruction of the Graafian follicles, 
the result possibly of festal oophoritis. In twin bearing women the 
ovaries, according t< Hellin, contain an unusually large number of ovisacs] 
a persistence, in tact, of the festal character of the glands. 

l. Absena >>/!/>> Ovaries. Complete absence of both ovaries, save 
in sympodial and acephalic foetuses, is an exceedingly rare anomaly. It 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 67 

can only be absolutely proven by a post-mortem examination of both 
pelvis and abdomen ; for the glands may exist in a rudimentary state, or 
in an unusual position, and so escape notice clinically. 

Absence of one ovary is also a rare defect, but its occurrence is 
well established. It is usually, but not invariably associated with 
absence of the corresponding half of the uterus (u, unicornis), and of 
the tube of the same side ; one kidney is also wanting in certain cases. 
It would seem, therefore, that defect of the sexual gland is apt to carry 
with it absence of the Miillerian and segmental ducts and Wolffian body. 

5. Rudimentary State of the Onirics. This is much less rare than 
complete absence of one or both ovaries. The glands are small in size 
and have either the foetal or the adult form. Microscopically they may 
show no Graafian vesicles ; they may consist simply of connective tissue, 
with vessels and scanty muscular fibres, or they may exhibit a few ill- 
developed ovisacs in the midst of ovarian stroma. Sometimes, by the 
persistence of Pfliiger's tubes in an unclosed state, they may simulate 
testicles. They may occupy their normal position ; or, as in Blot's case, 
they may lie near the upper angle of the uterus ; or, again, they may 
be found herniated in the inguinal canal. They maj^ coexist with 
accessory ovaries, with rudimentary Fallopian tubes, with a bifid or foetal 
uterus, and with stenosis of the aorta. At the same time the uterus may 
be normal and the ovaries rudimentary, and conversely. Such defects in 
ovarian development may be due to foetal oophoritis or peritonitis, or to 
torsion of the pedicle of the gland. 

6. Displacement of the Ovaries. Non-descent of an ovary is a rare but 
not unknown anomaly. Mr. Bland Sutton has reported a case in which 
the right ovary was adherent to the lower border of the kidney of the 
same side, and I have seen a case in the new-born infant in which it was 
attached by peritonitic bands to the caecum. It has been stated that it 
may be found free in the peritoneal cavity, or adherent to the omentum ; 
it may then be cystic. 

Instead of non-descent, there may be dislocation of the ovary down- 
wards into the inguinal canal. According to Puech, congenital inguinal 
hernia of the ovary is much more common than acquired, and Zinnis has 

! recently reported an instance of it ; but Bland Sutton states that he 

, knows of no case in which the ovarian nature of the herniated body has been 
proved by microscopical examination conducted by a competent observer. 

I Herniation of the ovary, which may be unilateral or bilateral, is usually 
associated with displacement of the Fallopian tube, and sometimes with 
malformation of the uterus and malposition of the kidney. It may be 

I due to defective development of the round ligament and a patent 
condition of the canal of Nuck. A congenital crural, ovarian hernia has 

! not yet been observed. 

Clinical Features. The presence of supernumerary or accessory ovaries 
is no guarantee of fertility; for in certain of the recorded cases the 
patients, although married, had not borne children. The woman seen by 

\ Olshausen, however, had had three confinements. Sterility in these cases 



68 SYSTEM OF GYNECOLOGY 

is to be accounted for by the cystic or atrophic state in which the ovaries, 
both normal and accessory, arc often found : and possibly the foetal peri 
tonitis, which caused the division of the -land, led also to destruction of 
the ovisacs in it. In another direct ion, however, accessory ovaries have 1 
certain clinical importance; their presence may explain the occasional 
persistence of menstruation after double ovariotomy or oophorectomy, as 
has been pointed out by Homans and others; the removal of three 
entirely separate ovarian cystomata or dermoids is rendered possible, as 
in Sippel'fi \n\ the occurrence of pregnancy after a double ovario- 

tomy finds a very probable explanation. Their diagnosis must always 
be a matter of great difficulty ; but their occasional presence must he 
l<rne in mind when small bodies are felt in the pelvis near to, or even at 
some distance from the normal ovaries. 

The clinical importance of absence or of a rudimentary state of the ovarm 
depends greatly on the unilateral or bilateral character of the anomaly. 
If only one ovary be absent there may be no interference with the 
patient's reproductive power; for in the case reported by Busch, and 
quoted by Lawson Tait, the woman, notwithstanding unilateral absence 
of tube and ovary, had borne ten children. When, on the other hand, 
both ovaries are wanting or imperfect, indications of the defect are 
usually forthcoming at the time of puberty. Then there is an absence J 
the changes peculiar to this age, such as the establishment of the 
menstrual flow, the growth of hair on the mons veneris, and a rounding 
of the figure; the individual approximates rather to the male than to 
the female type, or possibly retains the characters of infancy, with or 
without idiocy or cretinism. Exceptions occur, however, in which the 
woman shows the normal female character and has active sexual desire. 
Epilepsy may occasionally appear at the period of puberty; Skene 
believes that defective development of the ovaries is of importance as I 
of mental weakness, and even of insanity, for normally the brain 
initiated to higher development by the demands of these organ! 
There would seem also to be more than an accidental connection between 
chlorosis and imperfectly formed ovaries. In adult life sterility is the 

nit result of a bilateral absence of the sexual glands; and it ma] 
ccompanied by the growth of hair on the face, and especially on the 

upper lip. 

It is extremely difficult, if not impossible, to determine during life 
the existence of the ovarian defects under consideration : vaginal, rectal. 
and vedcal touch, even when combined with abdominal palpation, oftei 
f;n'l to establish a >\\w diagnosis; and nothing short of laparotomy 

ntv. Yt it is very importanl thai the anomaly should be detected 

leatt inspected, if only to save the patient and her niedi 

attendant from the dissatisfaction and disappointment consequent u 
th.- employment of a long and futile course of treatment for t 
blishmen! of menstruation by means of stem pessaries and the li 

i when burly conclusive evidence of the rudimentary state of t 
ovaries exists it is by no means certain that the lesion is truly congeni 



MALFORMATIONS OF THF GENITAL ORGANS IN WOMAN 69 

1 for scarlet fever and other zymotic affections occurring in childhood may 
lead to their injury. 

Ovarian hernia is suggested by the presence of a rounded or oval 

body in the inguinal canal or labium majus, whether on one or both sides, 

when it occurs in an individual with a uterus and external genitals of 

the female type. For a certain diagnosis of the displaced gland 

microscopical examination is necessary, but the absence of the ovary 

from its normal position in the pelvis as determined by bimanual ex- 

, animation, the enlargement of the herniated body at the menstrual periods, 

' and the existence of dysmenorrhoea and dyspareunia, usually justify the 

I provisional diagnosis of inguinal ovarian displacement. It must be borne 

in mind that the dislocated gland may undergo cystic changes which will 

j mask its true nature. With regard to treatment, attempts at reduction 

almost invariably fail ; and palliative measures, such as wearing a 

hollow pad over the ovary, are rather indicated. When the gland 

becomes inflamed or cystic, ovariotomy will be necessary ; but when it 

is healthy it ought not to be removed, for pregnancy has been known to 

occur even with double ovarian hernia. 

Malformations of the Fallopian Tubes. Since it has become 
customary to perform abdominal section for the relief of various 
morbid states of the viscera, attention has been more specially directed 
to the study of the malformations of the Fallopian tubes ; and it 
is now known that these ducts may exhibit many anomalies with some 
of which earlier writers were unacquainted. The exact bearing of these 
abnormalities upon the physiology and pathology of reproduction is not 
fully determined ; but there is reason to believe that ectopic pregnancy 
may, in some instances at least, be due to developmental errors in the 
tubes. Tubal anomalies, like those of ovaries, may be roughly classified into 
j those of excessive formation, those of defect, and those of altered rela- 
tion. These terms, however, must not be taken in a strictly literal sense. 

Pathology. 1. Supernumerary Fallopian Tubes. Examples of complete 
duplication of the tube, like genuine cases of supernumerary ovary, are 
extremely rare ; the two conditions may be associated. Instances have 
been reported by Keppler, Falk, and Ruppolt ; the last named author was 
of opinion that in his case the tube and ovary had been divided into two 
parts by the action of fatal peritonitis. 

2. Accessory Tubal Ostia and Tubes. Another tubal malformation, 
which may be reckoned among those "by excess," is the presence of 
accessory ostia or tubes. Opinions vary as to their frequency ; Richard 
found them as often as five times in thirty cases ; Kossmann noted them in 
from 4 to 10 per cent ; and J. D. Williams and the present writer observed 
two examples in sixty-one consecutive autopsies (Fig. 31). From 3 to 6 
per cent is doubtless the usual proportion. Until recently more than 
three accessory ostia on one tube had not been observed, and commonly 
there are one or two only ; but Ferraresi has put on record a remarkable 
case in which there were six. The ostia are either sessile or have 



7o 



SYSTEM OF GYNECOLOGY 



pedicles consisting of accessory tubes; they are usually surrounded 
by fimbriae, They are generally situated near the normal abdominal 
opening, and on the upper convex border of the tube ; but sometime^ 
they lie midway between the normal ostium and the uterine cud of the 
oviduct. Usually they communicate with the tubal lumen. Doraj 
explains the origin of accessory ostia by partial failure in the closure of 
the groove iu the germinal epithelium which forms the upper part of the 
Mullerian duet : at the same time he thinks that they may also be due to 
splitting along the outer edge of Miiller's duct after it lias formed a 
closed tube. Kossmann, however, believes that they are occasioned bl 



A 



B 



D E 




(i 



. Anteiior view of right ateriue appendages, showing accessory abdominal ostium of tuba 

A, Dteroe; B, cat iurfa< f mesovarium ; c. right Fallopian tube"; 1>, fimbriated extremity; B, 

ostium abdominale ; P, free fold of anterior layer of mesosalpinx ; U, pedunculated cyst ; 

_-ht oviuv. 

the existence of a supernumerary embryonic "anlage" (rudiment), lyinJ 

parallel to the primary one. 

Tubed Appendages or Accessary Fimbria. Ferraresi gives the 

name tubal appendages (" appendici tube ") to certain structures, nol unj 

commonly met with, which may be identified with the "pedunculated 

of fimbriae" described by Bland Sutton. Superficially they hear a 

mblance to accessory ostia, bul their stalls is solid, and they show no 

ostium. Ferraresi found them six times in forty cases, and when present 

they occupy the same positions a >ry ostia ; two have been seen on 

me tube. Bland Sutton regards them as ruptured cysts of Kobelt'i 

tubes; bul more probably they have the same origin as the accessor! 

fimbriated ostia 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 71 

4. Anomalies in the Length of the Tubes. In cases of ovarian hernia 
the tube has often an unusual length. Even when there is no such 
displacement it may attain abnormal dimensions 16 to 17 cms. in 
length according to Sinety. The normal length is from 10 to 11 
cms., and the longest tube met with by J. D. Williams and myself 
measured 14 cms. 

The tubes may also be of unequal length sometimes the right, 
and at other times the left being the longer. Winckel says with regard 
to primary or congenital inequalities, that the embryonal causes may be 
an unequal length of the "anlage," irregular position, restricted motion 
from the pressure of neighbouring organs, or increased traction from foetal 
peritonitis. 

5. Absence of the Fallopian Tube. Absence of the tubes may be 



PlG. 32. Congenital absence of outer two-thirds of right Fallopian tube. (Post, view.) A, Fundus 
uteri; B, 15, tubercular nodules in isthmus of eacdi Fallopian tube; C, parovarian cysts; D, D, 
ovaries ; E, cone-like end of right Fallopian tube, outer two-thirds being absent ; F, cut margin of 
right mesosalpinx ; H, fibroma of right ovary ; K, adhesions on posterior wall of uterus. 

bilateral ; but more frequently one only is wanting. In the former case 
the defect is usually associated with absence of the uterus ; whilst in the 
latter the uterus unicornis is commonly present, the absent uterine horn 
being on the same side as the absent tube. Colomiatti, however, has 
reported a case in which the vagina and uterus were well formed, and yet 
the right tube and ovary were absent. Unilateral defect of the tube 
usually carries with it absence of the ovary ; but this is not invariable, for 
in Blot's specimen the gland was present but rudimentary. In certain 
instances the corresponding kidney is also wanting. The want of 
development of the upper part of Miiller's duct is doubtless the cause of the 
anomaly ; when the whole duct is absent there is also a unicornate uterus. 
6. Rudimentary State of the Tubes. In rare cases the outer part of 
the tube is absent ; thus, in a case of genital tuberculosis, J. D. Williams 
and the writer noted congenital absence of the outer two-thirds of the 
right oviduct, the inner third having a lumen and tapering to a point at 
its outer end (Fig. 32). In a post-mortem room specimen Sir T. Grainger 
Stewart observed that the tubes were shorter than normal, ended blindly, 
and were connected by bands with the peritoneum covering the rectum. 
Absence of the outer part of the tube does not necessarily carry with it 
defect of the corresponding ovary ; but in the case seen by Marchand it 



72 STEM OF GYNAECOLOGY 

Doubtless the anomaly is due to foetal peritonitis. Sometimes 
only the fimbria of the ostium abdominale arc wanting. 

Partial or complete absence of the normal tunnelling of the tubes may 
he met with : and then these organs are represented by solid cords 
of fibrollS or muscular tissue. Sometimes it is at the abdominal end only 
that the tube is imperforate: in the case described by Dr. Maintain the 
outer extremity of one tube was quite smooth, like the finger of a glove ; 
the tubal mucosa showed no folds, and the ovary on the same side was 
cirrhotic and cystic. Absence of the tubal lumen is simply the persistency 
of the normal condition of the embryo : whilst an imperforate state of the 
ostium abdominale must be due to want of development of the Mulleriaa; 
funnel which should open into the splanchnoccle. 

During foetal life the tubes normally exhibit spiral convolutions both 
in the isthmus and ampulla ; at birth these have disappeared in the 
isthmus, and in the adult they ought to be entirely absent. Sometimes, 
however, the convolutions persist, as in some of the specimens described bjj 
Popofl : but Haultain is of opinion that tubal contortion in the adult is 
more commonly due to a return to the foetal state than to a persistence of 
it. If endosalpingitis occur in such a tube it is easy to understand how 
hydrosalpinx or pyosalpinx may be initiated. 

7. Displacement of the Tubes. It is stated that the tubes may show 
an unusually low implantation into the uterus a misplacement which 
has Keen regarded as one of the causes of placenta praevia. DisplacemeJ 
of the tubes in various directions may be the result of foetal peritonitis, 
as in a specimen shown by myself to the Edinburgh Obstetrical Society 
and in cases of ovarian hernia the tube usually accompanies the glanol 
A curious case of backward dislocation of the tubes, with union of 
their abdominal ostia to form a ring behind the uterus, was reported 
by Bitter; but some doubt existed as to the congenital nature of the 
anomaly. 

8. The Hydatid of Morgagni. This name is often loosely applied to 
pedunculated cysts arising from the curved tubules of Kobelt (parovarium! 
or to -talked terminal cysts of Gartner's duct; but it ought to be 

d for the much less common cyst which is found attached bl 

i pedicle to the tube or to its fimbriae. J. D. Williams and myself met 

with it in 8 per cent of the adult cases examined by US ; it varies in size 
from that of a pea to a small bean ; it is lined by a mucosa with simple 
folds Covered by a single layer of ciliated columnar epithelial cells: its 

^all is always composed of muscular fibres arranged circularly and 
Longitudinally ; its outer membrane is the peritoneum ; its stalk is always 

mUSCUlar; and it- Contents are clear, limpid fluid. Thus it may he 

distinguished from the false hydatids of Morgagni. It has been regardel 

as the remnant of the upper end of Midler's duct. 

Clinical Features. - Malformations of the Fallopian tubes are 
seldom diagnosed during life. They may he discovered during the 

irmance of laparotomy, or their existence may he suspected when 

anomalies of the uterus or ovaries are known to be present ; hut 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 73 

the symptoms to which they give rise are not distinctive, and the 
physical signs associated with them are most difficult of recognition. 

Absence or imperforate condition of the tubes, if bilateral, will be the 
cause of sterility ; and if in such cases the ovaries be present, the rupture 
of Graafian follicles and the discharge of ova into the abdominal cavity 
may occur at menstrual epochs, with the consequent formation of small 
hematoceles and the occurrence of localised peritonitic attacks. Unilateral 
absence or imperforation is not a bar to conception, for the tube of the 
opposite side may transmit the ovum to the uterus. Spircdiiy of the 
tubes or displacement may be causes of dysmenorrhea and also of sterility. 
It has been thought that an accessor?/ ostium may be a factor in the pro- 
duction of ectopic pregnancy the ovum passing into the tube by the 
normal ostium, becoming impregnated, and passing out into the peritoneal 
cavity by the accessory orifice but there is no proof that this can 
happen. On the other hand, Sanger has recently shown that an accessory 
ostium may serve for the ovum, as a means of access to the tube and 
uterus when the normal tubal openings are closed on both sides by in- 
flammatory processes. 

Malformations of the Round and Broad Ligaments. Malforma- 
tions of the round ligament are occasionally met with, but they have 
been little studied, and are doubtless commonly associated with abnormal 
states of the uterus, tubes, or ovaries. Persistence of the canal of 
Nuck, in which the ligament lies, gives rise to hydrocele in the woman. 
The broad ligaments, like the round, may be absent, rudimentary, or 
unequally developed. The ligamenta lata also may be congenitally dis- 
placed ; and they often contain within their folds cysts which have 
developed in the mesonephric relics which form the organ of Rosenmuller 
or parovarium. 

Malformations of the Uterus. Malformations of the uterus 
form a large and interesting group of genital anomalies, the mode of 
origin and clinical manifestations of which have long been the subject 
of extended investigations. The various types of uterine anomaly are, 
therefore, well known : their pathogenesis is, with one or two exceptions, 
agreed upon, and their influence on the general and sexual health of the 
individual is, to a large extent, understood. Saint-Hilaire, Kussmaul, 
Fiirst, Lefort, and Klebs have all by their researches greatly increased 
our knowledge of uterine malformations. 

Various plans of classification have been proposed, of which that 
by Livdus Fiirst is the most complete and philosophical. He divided 
all anomalies of the uterus into three groups, according to the period of 
intra-uterine life in which they were produced those originating between 
the first and eighth weeks, those between the eighth and twentieth, and 
those between the twentieth and fortieth weeks. In the first group were 
partial or total absence of the uterus, and a solid or partly excavated 
condition of the organ, which might be single, double, or bicornate. In 
the second group were certain minor malformations characterised by 



74 SYSTEM OF GYX. ECOLOGY 

trifling alterations in external form, and by the presence of a more or 
marked Beptum internally. The third group contained a single 
variety, the uterus which retained its foetal characters so far as the 
presence of rug* and the disproportionate size of cervix as compared 
with the body of the organ were concerned. 'This scheme, although 
invaluable to the teratologist, deals too much with minor details for the 
practical purpose of the gyncologist. It will be convenient simply td 
divide uterine anomalies, like those of the tubes and ovaries, into three 
groups: those in which there is apparent excessive formation, those in 
which defect is the Leading character, and those w T hich show altered rela- 
tionship of parts. The word <i/>/><ir< nf is inserted, because that which is 
commonly called a "double" uterus is really an organ the two component 
parts of which, derived from the two Miillerian ducts, have not fused into 
one. It will lie well to study together the pathology and symp- 
tomatology of each variety, for several of them are of considerable 
interest and importance from the gynaecological standpoint. 

Uterus Accessorius and Trifid Uterus. Pathology. The uterus 
accessories and the trifid uterus are probably the rarest anomalies of that 
organ which have been recorded. In 1894 Hollander, during the per 
fori nance of laparotomy, found a second uterus lying in front of the 
normal one, between it and the bladder. This he termed a "uterus 
accessorius."' The normal organ was supplied with normal tubes and 
ovaries, had the round ligaments attached to it, and was retroflexedj 
The accessory uterus had neither annexa nor round ligaments, was 
anteverted, and contained some placental tissue. There was a single 
cervix with two orifices separated by a bridge of tissue. Each orifice 
communicated with the interior of one uterus. In a similar case, observed 
clinically by Skene, there was a small second uterus lying in front of the 
normal one. 

Depage, also during a laparotomy, found a still more complicated and 
puzzling uterine anomaly, which he termed " trifid uterus." There wai 
a bifid uterus with a single cervix and two internal cervical orifices : but 
there was also found, attached to the cervix, a third uterine lobe forming 
a closed sac containing altered blood. Blood cysts were found in the ovaries! 

It is difficult to offer a -olfactory explanation of the mode of origin 
of these two malformations. It might be thought that in the case of the 

uteri, iriuswe had to do with a uterus didelphys in which rotation 

had brought the two horns into an antero-posterior relation : but this 
Supposition utterly fails to explain the attachment of the annexa and 

round ligaments to one uterus. The most feasible explanation of boti 

the accessory and the trifid uterus is that during embryonic life a dived 
ticulum is formed from one of the Miillerian ducts, and that this develops 
into the supplementary organ. If this be so, these anomalies fully deserVS 

to be called malformationa "by excess," which the so-called "double"' 
aterus doe. not. 

UweS. Hollander's patient had had seven labours, and 
had thrice aborted, OOCe with twins, at the fourth month. The placental 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 75 

tissue was found in the uterus accessorius, that is, in the organ without 
annexa. Skene's patient suffered from leueorrhoea from the accessory 
uterus. The case seen by Depage was in a young unmarried girl ; and in 
this instance, as well as in that of Hollander, an entirely erroneous 
diagnosis was made, and the true state of affairs was discovered during 
laparotomy. 

Uterus Didelphys. Pathology. The uterus didelphys or, as it has 








Fig. 33. Uterus Didelphys. (After Eisenmann and Martin.) a, ", Double vaginal entrance ; b, 
urethral opening ; c, urethra ; d, d, double vagina ; e, e, double cervical oritice ; /, /, double cervix ; 
g, g, double uterine body ; h, h, round ligaments ; i, i, Fallopian tubes ; k, k, ovaries. 

also been named, "diductus," "duplex," or "separatus" exhibits the 
maximum degree of separation of the two laterally placed halves which 
normally fuse into the single uterus (Fig. 33). There appear to be two single 
uteri lying side by side, each, however, possessing only one ovary, tube, 
and round ligament. There may, also, be complete or incomplete 
duplication of the vagina (septa or subsepta) or that canal may be single 
(simplex). The two wombs are seldom exactly equal in size, and one of 
them may be imperforate, a condition giving rise to hsematometra at 



76 SYSTEM OF GYNECOLOGY 

puberty. Not uncommonly this uterine malformation is associated with 
deformities of Qeighbouring parts, Buch as ectopia vesicae and atresia ani 

Among the causes which have been invoked to explain the want of 
union of the two Miillerian ducts, and the consequent formation of the 
Uterus didelphys, arc distension of the allantois, the absence of closure 
of the anterior abdominal wall, and the existence of adhesions between 
the rectum and bladder. 

CU Since it is impossible clinically to separate cases 

of uterus didelphys from those of uterus bicornis, it will be convenient to 
consider the symptomatology of the two malformations together. 

Uterus Bicornis. Pathology. A much commoner malformation is the 
Uterus bicornis, in which the two halves or horns are not entirely separate, 
as in the didelphous organ, but are united more or less intimately at their 




i tenia bicornis. (After Schroder and .Martin.) a, a, The vagina?, laid open; b, the LeJ 

I the cervix, externally apparently single, hut divided into two internally ; </. </. the two 

nterine hums ; . ., the round ligaments ; ./. ./. the Fallopian ttrbea ; g, g, the ovaries. 

lower end : thai is, in the region of the cervix or lower part of the corpus 
uteri ( Pig. 3 1 ). The middle portions of Midler's ducts have evidently begun 
to fuse together, but coalescence has stopped short of the normal, and 
an organ is produced exhibiting externally clear indications of its twoj 
horned origin. The bicornate uterus is the connecting link between the 
uterus didelphys, in which the external appearances show two quite ununited 
halves, and the uterus septus or bilocularis, in which outwardly the organ 
gives no indication of duplicity. The uterus bicornis also shows all thl 
grades between the variety in which there are two horns united 
only in the cervical region, and thai in which the double character of the 
organ is indicated merely by a depression or notch at the fundus (uterm 
mtrorswn arcuahu or uterus wrdiformis). The two horns may be praej 
tically equal in size : hut, on the other hand, one may be much less 
developed than the other, and in this way there is an approximation to 
tin type of the uterus unicornis. All the intermediate varieties have 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 77 

been observed. The degree of separation of the horns varies greatly. 
In the most marked cases they are far apart superiorly, and between 
them is frequently found a band or frenum (recto -vesical ligament) 
passing from the bladder to the rectum. In less evident cases the 
horns lie close together, but are not united ; and in yet other instances 
a shallow depression at the fundus shows that fusion of the two 
Miillerian ducts has closely approached the degree found in the normal 
uterus. When the horns are markedly separate the left one is usually 
directed slightly forwards, showing that some degree of uterine torsion 
has occurred. In other cases they may lie exactly side by side. 

The cervix uteri may be broad and large, and may show a double orifice 
{uterus bicornis duplex, septus, or bicctmeratus) ; it may be large, but with 
only one os ; or it may be of normal size and provided with a single 
orifice (uterus bicornis unicollis). The vagina may be septate, subseptate, 
or single, and the external genitals are usually normal. Sometimes 
there are anomalies of neighbouring or more distant organs, for example 
ectopia vesica and Polydactyly ; and such monstrosities as cyclopia and 
anencephaly have been noted in non-viable infants with this type of 
uterine anomaly. 

With regard to the internal appearances of the uterus bicornis it is 
common to find a septum dividing that part of the organ which appears 
single externally into two compartments internally. In other cases one 
or both horns may be solid, semi-solid, or imperforate at one or more 
places. In such instances an accumulation of blood may occur at puberty 
behind the imperforation. The cervix may show a double or a single canal. 

Clinical Features. Apart from the reproductive functions the uterus 
bicornis has little clinical importance ; but it has recently been noted that 
chlorotic girls are not infrequently the subjects of this type of anomaly, 
and probably chlorosis is to be regarded as a developmental morbid state. 
It has been affirmed also that in early life difficulty may arise in the 
evacuation of the bladder and bowel from the concomitant malformations. 

The menstrual functions may be variously affected by the presence of 
a didelphous or bicornate uterus. Menstruation may occur every fort- 
night, every month, or once in two months. In the first case the discharge 
comes from both uterine cavities each month, but there is no coincidence 
of dates, and therefore it has a fourteen day interval. In the second case 
there is either a simultaneous discharge from both wombs, or else the 
menstrual flow is from one cavity the one month and from the other the 
next. And in the third instance, as is shown by a case reported by T. A. 
Emmet, there is a bimonthly flow from one-half, whilst on the other side 
there is an imperforate condition of the horn, vagina, or hymen, which 
prevents the appearance of a discharge. Dysmenorrhcea is often met 
with and amenorrhea occasionally. 

Sterility is sometimes associated with the bicornate uterus, but, on 
the other hand, the patient is often fertile. Pregnancy may occur in one 
horn, and a menstrual discharge take place from the other ; a circumstance 
which possibly accounts for the continuance of menstruation during 



;S SYSTEM OF CYNMCOLOGY 

gestation which has been occasionally noted. Decidual membranes may 
also form in the empty horn. Pregnancy may also occur in both horns 
simultaneously, oral different but not far distant dates ; and in the latter 

Mind the explanation of sonic of the anomalous instances 
iperfoetation. There is evidence to show that gestation may happen 
in each horn alternately. In rare eases a twin conception has taken place 
in one horn. 

The bicornate uterus may abort ; or labour may occur at the full 
term, when the empty horn may show contractions as well as the gravid 
one, and its os als. may open. Parturition may be normal ; there may 
be a liialpivsentation : the rectO-vesical band may cause delay in the 
ge of the fotal head, or there may be low implantation of the 
placenta and haemorrhage. When, as sometimes happens, the pregnant 
horn is shut off by a septum, gestation becomes practically extra-uterine, 
and has all the dangers associated therewith, such as uterine rupture. 
Even in cases in which there is not unilateral atresia, rupture of the 
uterus, or of the septum between its horns, may occur. 

The di i the presence of a bicornate uterus is often not 

made till pregnancy and labour have taken place; and sometimes not 
even then. When menstruation occurs every fortnight, or persists 
during pregnancy, the anomaly may be suspected. The presence of a 
double vagina, cervix, or os uteri suggests the existence of a double 
uterine cavity : and a thorough bimanual examination, conjoined with 
the careful use of the sound, if there be no evidence of pregnancy, 
ought ar up the case. The instances in which one horn is 

imperforate are rarely diagnosed. 

Uterus Septus. /WW'"///. The uterus septus, or, as it is also called. 
bilocularis or globularis, by its external appearance gives no indication of 

the fact that internally it is 
divided, more or less com 
pletely, into two cavities by 
an antero - posterior vertical 

septum or partition (Fig. 35). 
The cases in which the septum 
is imperfect have, however, 
also been -roliped together 

under the name uterus sub- 
septus, or semipartitus ; and, 

according to the extent of the 
partition, certain subvarieties 
have been distinguished. Thus, 
when it is found in both 

l.ndr -mil i-(.i-\ iv lAavina | )( >u 

ever, the OS externum uteri 
i. us near tli'- . 

opian tubes; Single, we have the utrnis 

subseptus mzfons. W hen it 

in tlie body. DUl extend beyond the os internum, there 




MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 79 

is produced the uteres subseptus unicollis. When it is present only in 
part of the body it constitutes the uterus subseptus unicorporeus ; and 
when it is found only near the os externum it is the uterus biforis supra 
simplex. From this enumeration of its varieties the pathological charac- 
ters of the uterus septus will be evident. It may be added that the 
best -marked type has a normal fundus, two uterine cavities situated 
laterally, and existing both in body and cervix, and not infrequently 
there is also a partially or completely septate vagina. The uterus septus 
shows, therefore, a more advanced degree of fusion of the Miillerian ducts 
than does the uterus bicornis ; but still the fusion is incomplete, as is 
shown by the more or less perfect septum which remains. 

(linieol Feat urts. What has been written regarding the clinical 
manifestations associated with the uterus bicornis may be applied also to 
the uterus septus. Further, an incomplete septum may be the cause of 
a malpresentation for instance, a transverse case or of a low insertion 
of the placenta. The after-birth may even be attached to the septum 
itself an arrangement certain to give rise to dangerous haemorrhage 
after the birth of the infant. It would seem that abortion is common in 
this uterine anomaly ; at any rate Ruge, by dividing the septum in the 
ease of a patient who had twice miscarried, was rewarded by finding that 
her next pregnancy went to the full term. The diagnosis of the uterus 
septus is only likely to be made during labour, when the hand, intro- 
duced into the uterus to perform version or to extract the placenta, may 
detect the presence of the partition. As with the uterus bicornis one 
cavity may not communicate with the vagina, and thus hseniatometra 
with its train of symptoms may arise. 

Uterus Unicornis. Pathology. The uterus unicornis is an organ in 
which one horn alone is well developed (Fig. 36). There are two varieties : 
that in which the second horn is altogether absent (uterus unicornis sine ullo 
rudimento cornu alter ius), and that in which there is a solid or hollow 
rudiment of it (uterus unicornis 
turn rudimento cornu alterius soliclo 
sni excavato). In the former case 
there is complete, in the latter 
partial defect of one of the 
Miillerian ducts. The uterus 
unicornis has really no fundus, 
the single horn inclining to one 
side of the middle line and 
tapering to a point at which it 

is COntinUOUS with the Fallopian Fu; 36 ._ uterus unicornis, posterior view. (After Pole 

tube, and where the round Hga- and Martin.) a, Right half of Uterus; the left horn 

' . lias not been developed ; 0, right fallopian tube ; c, 

ment IS attached. The OVary left Fallopian tube ; d , left ovary ; e, bladder ; f, 

,1 i - . v vagina ; g, right ovarian ligament. 

thus comes to lie at the apex 

of the bent cone formed by the single horn and the corresponding tube. 
The cervix uteri is usually small and the vagina narrow, absent, or septate. 
The single horn may also be imperfectly developed, and may be solid or 




SVS 7 /<:.!/ OF GYNAECOLOGY 

partly excavated Certain concomitant malformations have been noted; 
thus, the Fallopian tube, round ligament, and broad ligament are 
commonly absent on the side of the missing horn ; the corresponding 
ureter and kidney may also be wanting, and the bladder may be developed 
only on one side. The ovaries may be present, but arc often rudimentary, 
In son tf has been stated above, a rudiment of the second 

horn may be present ; it may be solid or hollow, and in the latter case 

\itv may or may not communicate with that in the first horn. 
Sn.-li nnecting links between the typical uterus unicornis 

and the bicornate organ. This rudimentary horn may be the seat of a 

ancy, or a collection of menstrual Mood may be found in it. A 
fibroid tumour may he found attached either to it or to the other better- 
formed horn, as in a case noted by MangiagaUi 

A patient with a uterus unicornis commonly 

a history of amenorrheas ; but sometimes menstruation goes on 
normally, and pregnancy occurs in the single horn. When a rudimentary 
horn is present, and when it becomes the seat of a gestation, a very serious 

of ati'airs is established ; in fact the case becomes practically one of 
rine pregnancy, and is accompanied by the same dangers, that 

ptnre and intraabdominal hemorrhage. When the rudimentary 
i ant horn has no communication with the uterus unicornis it seems 
necessary to admit extra uterine migration either of the ovum or of the 
semen. 

Tl a uterus unicornis, with or without a rudimentary 

horn, commonly passes unnoticed during life ; unless it be discovered 
daring the performance of laparotomy. If the condition be suspected, a 

.1 bimanual examination, aided by the use of the sound, will reveal 

the presence of B thin, elongated uterine body bent to one side with its 

. \ity outwards. There will also be a small cervix and a narrow 

Pregnancy in the rudimentary horn cannot be distinguished 

'ii of the tubal variety, unless rupture occur and 

bdomeo be opened. In a case seen by myself it was mistaken for a 

fibroid tumour, a mistake which laparotomy revealed. 

Uterus Rudimentarius. Pathology. The name uterus rudimentarius 
is a \ Prom one point of view it may with propriety be 

applied to such anomalies as the uterus unicornis or bicornis. Further, 

tin- distinction between it and complete absence of the organ can only be 

made ful autopsy. At the same time, it has been customary 

application ot the term to the cases in which, iii place of 

the normal one finds b body of variable form consisting of fibrous, 

musculo, ot fibro-muscular tissue, sometimes solid and at other times 

idimi \is rudimentarius solidus, uterus rudi- 

Through its partly excavated variety it is 

ingle uterus. In one form of the 

itenu tic walls are 10 thin thai it has been called mem- 

'rusmemi . More commonly, however, a small 

mnasnlar found in the middle line between the 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 8 



folds of the broad ligament, which seems in such a case to sweep in an 
almost unbroken band from one side of the pelvis to the other. The 
tubes, ovaries, cervix and vagina are usually absent or very imperfect ; 
but cases have been reported in which the annexa were normal. The 
external genitals are, as a rule, well formed. The mammae are usually 
small, and there is often a poor growth of hair on the mons veneris. 

Clinical Features. Since clinically the rudimentary uterus cannot be 
distinguished from absence of the organ, the symptomatology of the two 
conditions will be considered together. The recent literature of both 
anomalies will be given at the same time. 

Uterus Defieiens seu Defeetus Uteri. Pathology. Complete absence 
of the uterus, its annexa, and (to some extent also) the external genitals, 
is met with commonly enough in the acardiac twin and in sympodial 
foetuses ; but its occurrence in the adult and otherwise normal individual 
is very rare. It is necessary to make a complete post-mortem examina- 
tion before it can be definitely said that no uterus existed ; and in 
most of the reported cases such evidence is not forthcoming. Further, in 
certain instances the individual was evidently a male with undescended 
testicles, not a female without a uterus. 

When the Fallopian tubes as well as the uterus are absent the 
peritoneum passes directly from the bladder to the rectum ; but when 
they are present it forms a mesentery for each, although even then broad 
ligaments in the strict sense of the term can scarcely be said to exist. 
The round ligaments are generally to be found ; they end in the cellular 
tissue between the rectum and bladder. The ovaries may be absent, but 
generally they are present, and then they commonly contain no ovisacs ; 
very rarely they are normal. The tubes when present are simply solid 
rods of tissue, with usually an open ostium abdominale. The vagina is 
often wanting entirely ; but sometimes there is a shallow ml - de - sac 
(vestibular canal) communicating with a vulva which is usually normal. 
There may, however, be an absence of the vulvar hair. In rare cases the 
vagina has been found well developed. The pelvis has a feminine 
breadth ; but the mammae are often poorly developed. 

Clinical Features. A woman without a uterus, or with merely a 
rudimentary one, may have all the secondary characters of her sex ; she 
may have a high-pitched voice, rounded outlines, and an absence of hair 
on the face. Sexual desire may or may not be present a circumstance 
which is probably determined by the state of the ovaries. Amenorrhoea 
is practically constant; as, however, ovulation may occur, menstrual 
molimina may be met with, and there may be vicarious haemorrhages or 
such acute pelvic pain as to necessitate an operation for the removal of 
the ovaries. There is, of course, sterility always ; but the patient may 
be capable of coitus to a certain extent. Usually, however, cohabita- 
tion is attended by great pain. Repeated attempts on the part of 
the husband deepen the shallow vestibular canal, converting it into a 
cul-de-sac of some depth ; in other cases dilatation of the urethra is brought 
about. 



S ) STEM ( >/' G ) 'A 7 . ECOLOGY 



e> 



Although it Lb impossible clinic-ally to distinguish between absence 
and a rudimentary state of the uterus, it is always possible to ascertain 
tlif existence of one or other <>t* these anomalies. By passing the index 

finger into the rectum and a sound into the bladder, whilstthe abdominal 
wall is deeply depressed from above, one can determine that there is 
nothing like a fully-formed uterus between the rectum and the bladder. 
rse band consisting of the tubes may be palpated, as may also 
the ovaries when they are present. These physical characters taken in 
conjunction with the symptoms enable the gynaecologist to make a 
diagnosis sufficiently exact to prevent his continuing a hopeless course of 
treatment by ferruginous tonics and the like for the establishment of 
menstruation. 

Uterus Foetalis. Pathology. The anatomical characters, which are 
norma] in the uterus during intra-uterine life, may persist and be found in 
t he adult. They then constitute an anomaly uterus foetalis. The cervix 
uteri is Longer than the body, and its walls are thick, whilst those of the 
body are thin. The cervix also is conical and os externum narrow. The 
whole organ is cylindrical in form, and is small in size, the sound passin 
in for a distance of only an inch or an inch and a half. The term 
may be used as a synonym for foetal uterus; but a shade 
<f difference has been recognised by some writers. In the uterus fcetalis 
of the mucous membrane are found in the body of the organ, 
whilst in the infantile organ they exist only in the cervix. The mucous 
m. nil. rane also is poorly developed, and, according to Sinety, contains no 
tubular glands. The vagina may be short and narrow, or it may be 
quite normal The external genitals may be imperfect, and the ovaries 
and tul.es may either be normal or rudimentary. Mammary develop! 
incut is usually little marked. It may be added that the uterus f.. talis 
may be al><> a uteris bicornis. 

/</////,>. With the uterus fcetalis there is commonly 

sometimes, however, there is scanty and painful menstrual 

turn. Sterility is a constant symptom, and there may or may not be 

be. Chlorosis has frequently been found associated with a 

or inf a nt i le - uterus. The heart may be small, and there maybe a 

general hypop I I the whole vascular system. The uterine anomalj 

'" ' " - ' by means of bimanual examination, aided by rectal 

of the sound. The differential diagnosis between the 

talis and the uterus pubescens is chiefly founded upon the state 

'" the former it [a fairly firm, especially in the supra] 

ll portion : in the latter it is thiii and relaxed. The condition, how- 

oomplicated and to some extent masked by concomitant 

id metritis. Attempts at treatment of the anomaly havi 

almo i.ly ended in failure: and practically the onlv thing to he 

the dysmenorrhoea, if it be present, by the use of drugs] 

re, by oophorectomy. 

Uterus Pubescens. /w/4 w . The pubescent uterus occupies as] 

"'I the uteru- fcetalis and the normal virginal 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 83 



organ. It shows a persistence of the anatomical characters which are 
normal before the epoch of puberty. The organ is small in size, weighs 
less than normal, and has a cervix and a body of practically equal length. 
The ovaries, tubes, vagina and mamma? may or may not share in this 
condition of hypertrophy. 

Clinical Features. The symptoms of pubescent uterus closely re- 
semble those associated with the foetal or infantile organ. Menstruation 
may be absent or scanty and irregular. Sterility is common, but there 
is always the hope that the organ may yet undergo further development 
and the patient become pregnant. Signs of general weakness, chlorosis, 
or rickets may coexist ; but the anomaly may also be met with in strong 
and healthy women. The diagnosis is made by the same means as in 
cases of foetal uterus, especial attention being paid to the condition of the 
cervix and its size compared with that of the body of the organ. If the 
condition be discovered before marriage, the treatment to be adopted is a 
general tonic one, consisting in the use of gymnastic exercises, of 
nourishing food, and of iron, quinine, and arsenic. After marriage the 
periodical passing of the sound, the insertion of an intra-uterine stem- 
pessary, and electricity may all be employed with some hope of success. 
The effect of marriage itself may be beneficial ; emmenagogues are of 
doubtful efficacy. Marriage ought not to be recommended unless 
menstruation has become established. 

Uterine Atresia and Stenosis. Pathology. The uterus may be con- 
genially imperforate ; an anomaly which finds its explanation in the 
originally solid condition of the ducts of Muller from which it is 
developed. Uterine atresia is not so much an independent malformation as 
a complication of other anomalies of the organ, for instance of its bicornate 
and unicornate condition. Nevertheless it occurs also in cases of single 
and otherwise normal uteri. The whole cervix may be solid, or there 
may simply be a septum at the os externum or os internum uteri. At 
the age of puberty menstrual blood begins to accumulate behind the 
obstruction, leading in time to the distension of the uterus (haematometra). 
When one horn of a bicornate uterus is imperforate, unilateral hsemato- 
metra is produced ; when both horns are occluded there is bilateral 
hamiatometra. When the obstruction is situated at the os internum, 
only the body of the uterus becomes .distended, the cervical canal 
retaining its natural form. An accumulation of blood may be found in 
the tubes also (hematosalpinx), and it would appear that the source of 
the blood is the tubal mucosa, and that it is not due to regurgitation 
from the uterine cavity. When there is simply narrowing of the cervical 
canal without atresia the condition known as uterine stenosis is produced. 

Clinical Features. Since the symptoms of uterine atresia are mainly 
those of hsematometra, and since these are found also in association 
with atresia vaginae, their consideration will be deferred till that vaginal 
anomaly has been described. In the cases of uterine stenosis dysmenor- 
rhea is the leading symptom, and dilatation of the cervical canal is 
needed for its cure. Uterine atresia requires puncture and subsequent 



.v } 'STEM c >/' G ) X. KCOLOG V 



dilatation of the obstruction for its relief. This should be done with 
strict antiseptic precautions j and when the accumulated fluid hasescapeo] 
old he packed with iodoform gauze for some days, and 
rionally with weak antiseptic solutions. 

Transverse Septum in the Cervix Uteri. Pathology. A condition 
BOmewhal nmikr to atresia Uteri is the presence of a valvular fold or 

diaphragm in the cervical canal. When the os externum has been dilated 
the valve may present the appearance of a second cervix within the first. 
possibly produced in the same manner as the more common trans] 
the vagina] canal. 
Cli itvres. The septum would seem to act like a polypus, 

and b bo haemorrhage and pain. It has been excised with com- 

plete relief of BymptomB, It may also be the cause of dystocia ; but this 
onstanl effect 

IIinob Malformations of the Uterus. Mueller of Berne has 
tly pointed out the frequency of certain minor abnormalities of the 
idtu. Amongst these is the anvil-shaped uterus {uterus incudu 
formis or in which the normal convexity of the fundus is 

wanting, and a straight line joins the two Fallopian tubes. It closely 
resembles the uterus with a Hat fundus {uterus planifundalis) of Furst'i 
classihVatinn. and may coexist with partial or complete duplication of 
the uteruj and vagina. 

The vaginal cervix may he rudimentary or absent {uterus parvicollis cm 

I, whilst the body of the organ may be normal, small, atresic, or 

membraniform, A case of this kind has recently been reported bi 

>se. Again, a fretinm may be found dividing the os externum into 

orifices {utenu biforis), a condition which is normal in the ant cater 

Thil exists without any other trace of duplication of the genital 

canal. It may complicate labour, during which it may be torn and give 

rise to hssmorrhage. In order to prevent this it ought to be kept to one 

side or divid. n two ligatiin 

A Condition which may easily be mistaken for the uterus unicornis 

srhich there is asymmetry of the organ, one side being bettei 

I than the other. The uterus bends towards the better-developed 

Obliquity of the uterus), and the round ligament on 

is relatively Bhort. Latero-position of the uterus is mel with 

of the broad ligaments is less developed congenitally, and is to 

om the acquired condition due to unilateral inflammal 

icial contraction. 

Congenital Prolapsus Uteri. Pathology. What has been called con- 

J prolapSUfl DterJ ceedingly rare anomaly. I have recently 

ith :i well-marked example of it, in which there was a real displace] 

<U of the whole uterus as well as a hypertrophic condition 

"f th. ! i , !l as in those of Heil, Quisling, Schaefferl 

nd 1 Isospins bifida in the lumbo-sacral region. Now 

these five with which I am acquainted ; and the 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 85 

fact that in them all there was this association of spina bifida and 
prolapsus uteri, seems to point to a nervous factor in the etiology of the 
latter condition. 

Abnormal Communications of the Uterus. The uterus may in rare 
cases communicate with the rectum or bladder, or with both viscera at 
once. In an extraordinary instance reported by Mr. Doran the right 
side of a bipartite uterus opened on the outer surface of the body. There 
may also be a communication between the uterine cavity and that of 
the ascending colon. Most of these anomalies must be ascribed to a 
partial or complete persistence of the embryonic cloacal condition. When 
combined with vaginal atresia it would seem that impregnation has 
occurred per rectum or per urethram. 

Malformations of the Vagina. Vaginal malformations have 
many characters in common with uterine anomalies, a circumstance which 
is easily understood when it is borne in mind that both vagina and uterus 
are derived from the Mullerian ducts of the embryo. Further, vaginal 
and uterine abnormalities often coexist in the same case, and in many 
instances give rise to very similar symptoms. Whilst, however, it is rare 
to meet with abnormal communications between the uterus and neigh- 
bouring organs, such communications are much more frequent in the case 
of the vagina. 

Double Vagina (Vagina Septa). Pathology. A double vagina in 
the exact sense of the term can only be said to exist in certain double 
terata, such as the pygopagous twins ; but it has become customary to 
apply the name to the cases in which the two Mullerian ducts, which 
normally fuse into one canal, have remained separate, a septum interven- 
ing between the two passages in part or in the whole of their extent. 

Just as the uterus didelphys is very rare, so two vaginal canals, com- 
pletely separated and each opening externally at a separate vulva, constitute 
an anomaly of a very uncommon form. The only reported case of the 
kind seems to have been that of Katharine Kaufmann, seen by Suppinger 
in 1876. This child, who died at the age of twenty-one months, had 
two vulvae each opening into a vaginal canal. The pelvis was broad, and 
the true pelvis was divided into two lateral cavities by a peritoneal fold. 
Each half contained a bladder, a unicornate uterus with an ovary and a 
tube, and an intestinum rectum. The vertebral column began to divide 
at the level of the third lumbar vertebra, and the two coccyges were quite 
separate. This individual has been placed amongst the double terata. 

Much more common are the cases of "double" or septate vagina, in 
which the vulva is single, although the hymen may show two openings. 
The two canals are separated by a longitudinal septum ; in the great 
majority of cases this vertical septum runs antero-posteriorly, and the 
vagina?, therefore, are situated laterally ; in a very few cases only does it 
pass transversely, when of course the vaginal canals lie one in front of 
the other. In the latter case it must be supposed that the two unfused 
Mullerian ducts have undergone partial rotation. It is rare, however, to 



S6 SYSTEM OF GYNMCOLi 

find the two Canals exactly lateral in position and exactly equal in size; 
One, usually the left, commonly lies a little in front of the other, and one 
is nearly always a little smaller than the other. The septum is com- 
posed of muscular tissue covered by mucous membrane, and has the 
vagina] Beptum. It varies, however, in thickness, 
ami may - ven at certain places show perforations. It may extend the 
whole lengtfa of the canals, or it may be absent below and present aliove 
septa supra), or present below and absent above 
or supra simplex). In the least marked form there is 
only a rid-"' on the vaginal wall. In the great majority of cases the 
double, and may be didelphous, bicornate, or septate, and 
then there is usually one cervical orifice in each vagina; but in a few- 
recorded cases the litems was single, although the vagina was double, 
when of course only one canal gave access to a cervix. Instances have 
reported in which the uterus was unicornate, then one of the 
that on the same side as the absent horn, Avas usually rudi- 
mentary. This last-nai 1 type, however, scarcely deserves to be termed 

a doable vagina. The vulva and the hymen may be single, the vaginal 
septum stopping above the level of the ostium; but in some cases tin; 
hymen show-, two lateral orifices separated by a bridge; of tissue. There 

may be atresia of on both vaginal canals, leading in the adult to 

unilateral or bilateral hamatocolpos. 

itwes. -Double vagina does not usually give rise to 
tome prior to the occurrence of labour unless one of the canals be 
imp. the time of puberty blood may begin to collect 

d the obstruction, and give rise to the troubles associated wits] 
hmatocn|p<< and ha-matometra. It has been stated that during prel- 
um may be absorbed, but if it be still present at the time 
of confinement it may give rise to trouble by obstructing delivery. It 
tear and labour go on naturally ; on the other hand, the rupture of it 
d to the vagina and uterus also, and fatal consequences result. In 
the septum is pushed to one side, and no delay in labour 
occasioned Dyspareunia has been occasionally reported as an effect of 

the m Jin. i. The diagnosis of the anomaly can be easily made by 

in the cases in which one canal is imperforate! 
then the rendition might easily be mistaken for a cyst of the vaginal 

Bptum may be safely divided by scissors during 

' en, however, there is an accumulation of menstrual blood in 

mil it will be m-cessa vy to open the sac freely, more 

especiallv it the contents are purulent, and to pack the interior with 


Ui; Vagina.- -In the i ,,, which only one horn of the 

unicornis) there i s generally a similar com 

'' I" other words, the lower end of one of the 

Mullen.u, ducts has aborted, and the vaginal canal which exists represent] 

I the embryonic tubes from which it is normally 

! being so, il is not surprising to find that the vagina is 

1 o 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 87 

then narrow, and lies somewhat to one side of the middle line. The 
anomaly is so constantly associated with the unicornate uterus that any 
special description of it is rendered superfluous. 

Vagina Rudimentaria. Vagina rudimentaria, like the term uterus 
rudimentarius, is a vague expression. It denotes an anomaly which 
has also been described as simple atresia and lateral atresia vaginae ; 
and clinically no line of demarcation can be drawn between it and 
complete absence of the vagina (defectus vaginae). It will therefore be 
discussed under those heads. 

Defectus Vaginae. Pathology. Complete absence of the vagina is a 
very rare condition one which is met with chiefly in the allantoido- 
angiopagous twin foetus and in the sireniform monstrosity. In it no 
muscular bands are found between the bladder and rectum, otherwise 
the condition falls into the category of vaginal atresia or rudimentary 
vagina. Probably it is always associated with absence of the uterus, 
Fallopian tubes, and external genitals, and with an imperfect develop- 
ment of the mammary glands. 

Clinical Features. Since this is a pathological, not a clinical morbid 
entity, the consideration of its symptoms will be taken with those of 
vaginal atresia, a condition from which it is undistinguishable during the 
life of the individual. 

Atresia Vaginse. Pathology. Vaginal atresia or imperforation is of 
different degrees. In its most marked form no trace of the canal is found 
save a fibrous or fibro-muscular band in the tissue between the bladder 
and rectum ; in a less extreme form part of the vagina is present 
whilst the remainder is solidly imperforate ; and in a still less marked 
form there is simply a membranous obstruction or perforated diaphragm 
at one part of the passage. Again, the position of the imperforation 
varies ; it may exist throughout the whole length of the canal, or it 
may be present only at the upper part, the lower part, or the middle 
part. When the upper two-thirds of the vagina are occluded it has been 
supposed that the open lower third is not truly vaginal in nature, 
but is the enlarged vestibular canal, the representative of the anterior part 
of the sinus urogenitalis of intra-uterine life. Through the failure of the 
downward progress of the Mullerian ducts the vestibular canal has re- 
tained its early dimensions ; its depth also has probably been increased 
by attempts at coitus. When only the middle part of the vagina is 
obstructed it may be surmised that the upper canal is Miillerian, or truly 
vaginal in character, whilst the lower portion is vestibular. With regard 
to the condition of the other genital organs in cases of vaginal atresia 
great differences exist. The uterus may be normal, rudimentary, or 
absent. The vulva also may be wanting or imperfect, but more usually 
it is normal and the hymen is present. The ovaries are commonly 
present. The urethral canal may be dilated, the result of attempts 
at coitus. Certain pathological changes commonly occur at puberty : 
if the uterus be present and the whole vagina imperforate, haemato- 
metra is developed and the uterus converted into a large rounded 



88 <TEM OF GYX. ECOLOGY 

containing Mood, first the cervix and later the body l>e- 

listonded ; if the upper part of the vagina be patent, then 

cumulates in it, and hematocolpos is produced, whilst 

later development ; and if the vaginal obstruction 

only the lowest part of the canal, luematocolpos may be the sole 

\ the uterus remaining as a small body surmounting the distended 

al tumour. Hypertrophy of the vaginal walls may be produced, or 

the accumulation ofbl ! rapture may occur into one or other of 

the neighbouring viscera. In certain instances the Fallopian tubes also 

led and {hematosalpinx results. The contents of the dis- 

. uterus, or tube are usually treacly in character, consisting 

lo of concentrated blood. After rupture or artificial evacuation 

suppuration may supervene in the sac, and pyocolpos, pyometra, and 

pyosalpinx be produced. 

t. The symptoms associated with vaginal atresia 
biefly those due to the accumulation of blood in some part of the 
genital canal at and after the period of puberty. * In early life, it is true, 
some discomfort may be caused by the retention of mucus in the patent 
nal, leading to constipation and dysuria by pressure ; but 
the special clinical features arc all developed after puberty. There is, of 
course, amenorrheas ; then gradually, unless indeed the uterus be absent, 
Hing is developed in the lower abdominal region in which fluctua- 
tion i (ted There is sometimes abulgingin the region <>i* 
ttlva and perineum. These signs are caused by the gradual accumu- 
latioi trual blood behind the obstruction. Severe pelvic pain is 
ienced, recurring with increasing severity at intervals of a month; 
thi> i> sometimefl accompanied by vicarious menstrual haemorrhages from 
the body, for example, haemoptysis, or hasmatemesis. If the 
any, cohabitation is found to be very difficult and painful, if 
not impossible. In time, however, the vestibular canal or urethra 
becomes distended, and an imperfect degree of connection is rendered 
possible; then the urethra] dilatation leads to dysuria. There is of 
lity. In a case recently reported by Grandin the anomaly 
existed in several members of the same family. 

diagnosis of the anomaly oughl not to be a matter of difficulty. 

W h'-n, in | patient with amenorrheas and monthly pelvic pain of in- 

" abdominal tumour, which fluctuates and gradually 

red, the presence of vaginal atresia may be suspected} 

and when, in addition, it is found on examination that the vagina is 

its orifice or at its upper part, the diagnosis may M 

ttination by menus of rectal touch, aided by 

"" (1 in the bladder, abdominal palpation, and vagina] 

ina Is patent), is chiefly under* 

ding out the extent of the atresia and the con 

'"1 ovaries, so that proper treatmenl may be 

nying out this investigation it will be well to give, 

the !'' wnni The line of treatment will be largely decided b* 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 89 



the extent and position of the atresia, by the state of the internal genital 
organs, by the presence or absence of retained blood, and by the circum- 
stances of the patient. In the cases in which there is well-marked vaginal 
atresia with absence of the uterus, but with the presence of functionally 
active ovaries, as shown by recurring severe pelvic pain, the operation of 
oophorectomy has been recommended and successfully carried out 
in several instances. When, on the other hand, there is a more or 
less normal uterus, associated with hsematocolpos, entirely different 
operative interference is indicated. It is not wise to leave the blood- 
accumulation to nature ; for rupture of the sac, even when it occurs 
through the vagina, is seldom safe in its immediate or satisfactory in its 
ultimate results. An incision ought to be made into the sac and the contents 
evacuated under strict antiseptic precautious. If the atresia be slight, 
and situated low down in the canal, the evacuation may be easily and 
safely carried out ; but if a large part of the vagina be atresic, difficulties 
and dangers are met with. Dissection must be carefully performed 
with a sound in the bladder and a finger in the rectum as guides ; and the 
handle of the knife should be freely used in order to avoid wounding 
neighbouring organs. When the dissection has nearly reached the blood- 
sac, as determined by rectal touch, a trocar should be introduced to 
evacuate the fluid, and then the cavity should be laid freely open, 
washed out with antiseptic lotion, and plugged with iodoform gauze. If 
it be found that the accumulation of blood is in the interior of 
the uterus, then the same method of procedure must be followed, with 
even closer attention to antisepsis. Puncture through the bladder or 
rectum is not an operation to be recommended. 

When in a married woman there is vaginal atresia, but no hsemato- 
colpos or hsematometra, operative interference need not be urged unless 
the patient herself anxiously desires it. Then the question of the advis- 
ability of trying to create an artificial vagina will arise. It has been 
suggested that the urethra should be dilated to allow of coitus ; but the 
proposal has not been received with favour, and it would have been sur- 
prising if it had. The creation of an artificial vagina between the 
bladder and rectum is a difficult operation, requiring a great deal of 
careful dissection ; and it is followed in many cases by disappointing 
results. If it be attempted, an H -shaped incision should be made in the 
vulvar region, and then, by means of the finger rather than the knife, a 
cavity of sufficient depth should be formed ; this cavity must next be 
lined by mucous membrane and skin taken from neighbouring parts and 
sutured into position ; it must then be stuffed with iodoform gauze, and 
kept open afterwards by a wooden cone-shaped pessar}^. At a later 
period the canal is kept open by coitus. A slower method of forming 
the vagina is by means of electrolysis, and Le Fort has reported a suc- 
cessful case treated in this manner. Of course it must be borne in mind, 
that as the uterus is either absent or rudimentary, which is demonstrated 
by the absence of a blood accumulation, the operation is undertaken solely 
to allow the patient to perform her part in the act of coitus. This being 



90 M OF GYNAECOLOGY 

no matter for wonder thai certain gynaecologists have not 
tred any operative interference in such cases. 

Atresia Vaginae Lateralis. Pathology. It has been already noted 
under the head of Septate Vagina that one of the canals may be imper- 

il \ .ir end. whilst one of the uterine orifices opens into it 

In this way a lateral vaginal pouch or sac is formed, atresia 

Menstrua] blood may collect in the sac and distend it, 

giving :he condition known as lateral haniatocolpos ; suppuration 

lateral pyoeolpos. The half uterus with which 

mmunicatefl may likewise he distended with blood or pus ([((feral 

This vaginal anomaly is nearly always situated 
on tin- right side i Puech). 

Uures. As in other vaginal anomalies, symptoms do not 

ill after puberty, when the gradual dilatation of the lateral vaginal sac 

to dysmenorrhoea, pain in the hack, dysuria, and pain on 

ial examination reveals an elastic tumour on one side, 
which may he confounded with pelvic lnematocele ; but may usually be 
distinguished by its position and gradual increase in size. Rupture 
may spontaneously occur, either of the vaginal or uterine septum, and 
dark syrupy blood or pus be discharged. This is usually followed by re- 
gulation in the sac. by an increase in the severity of the symptoms, 
and possibly by the supervention of pelvic peritonitis and even of death. 
The I 8, ought to be free incision, washing out of the sac 

with an antiseptic solution, and in many eases excision of the sac wall. 
Winckel baa pointed out that inversions or prolongations of the 
d mucous membrane may be met with, and may extend into the 
muscular layers of the wall and even into the paravaginal cellular tissue. 
These pocket- have thin, smooth walls, may be from 1 to 1 \ inch in 
;. and must not be confounded with lateral vaginal atresia. 

Stenosis Vaginae. Pathology. The vaginal canal may be abnormally 
or unusually narrow. The association of this anomaly with the uterus 
unicornis, and with atresia vaginae lateralis, has been referred to; but it 
may also occur in connection with the uterus fcetahs, or even with a 

The gtenosifl may ailed the whole vaginal canal, or may 
>r*ent at Certain points only. In the latter ease it is probably due 

e colpitis occurring in foetal life or in the young infant. The 

name v be circular, diagonal, or in spiral ridges. The so-called 

SI MI 1 hymen II probably of this nature. The condition is closely 

I not identical with transverse complete or perforated diaphragms 

If the stenosis be slighl it may give rise to no 

or labour if coitus fail, usually serves to dilate 

completely. In more severe cases it may be necessary to resort 

>r even excision of the constricting bands. 

resull of vagina] stenosis if the dia- 

Rupture of the canal may, however, occur in 

lalM.ur unless the m is incised. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 91 

Abnormal Communications of the Vagina. The vagina may 
open into the rectum through an imperfect development of the 
recto -vaginal septum, which normally intervenes between the two 
canals. Further, the canal may communicate by a small orifice with 
the urethra. Most of the cases of abnormal communication of the vagina 
with the rectum, urethra, and bladder are not really vaginal, but vulvar 
anomalies ; being true instances of persistence of the cloaca of embryonic 
life, or of the sinus urogenitalis. They will be described amongst the mal- 
formations of the vulva. Very rarely, however, cases of congenital ano- 
vaginal and vagino - urethral fistula have been described. In these 
instances the anus and rectum and the urethra are normally formed, and 
the Miillerian vagina is present at the level of the fistulous communica- 
tions. In these cases the vagina may be septate. Caradec reported an 
example of this anomaly in which there was a communication between 
the rectum and vagina, the anus and rectum being normal ; and Fordyce 
recently described a new-born infant with foetal peritonitis, in which each 
of the two halves of a double vagina opened by a small aperture into the 
urethra. In the latter case both vaginal canals were atresic inferiorly. 

Malformations of the Vulva. In considering the malformations 
of the ovaries, tubes, uterus, and vagina, it has been found most con- 
venient to discuss first the anomalies of these organs separately, and then 
to refer to those combinations of the anomalies which are most commonly 
met with. Thus unilateral absence of the Fallopian tube was first de- 
scribed separately, and it was pointed out later that it was usually 
associated with a uterus unicornis and a unilateral vagina. In dealing 
with the malformations of the vulva, however, this plan is not so useful, 
for now we have to do rather with groups of anomalies than with single 
ones. Thus, whilst something must be said regarding abnormalities of 
the clitoris, labia, and hymen, our main attention will be turned to such 
associations of defects as are found in the cloacal. conditions, and in the 
cases of so-called hermaphroditism. 

Double Vulva. The anomaly to which the name double vulva may 
be correctly applied is a very rare one. In the case of Katharine Kauf- 
mann, already referred to under the head of " double vagina," there were 
two well-marked vulvae separated by a raphe. There were on each side 
two labia majora and minora, a clitoris, hymen, urethra and anus. More 
recently Chiarleoni has reported a less well-marked case in a living infant, 
thirty- three months old. In this child there were also two vulvar aper- 
tures, of which the left lay somewhat obliquely ; but the anus was 
imperforate, and the condition of the internal organs was not ascertained. 
The cases of Blanche Dumas and of Mrs. B. (reported by Wells) might 
be cited as examples of double vulva; but in them there were super- 
numerary lower limbs. 

Defeetus Vulvse. Complete absence of the vulva (defectus or atresia 
vulvce) is an anomaly met with only in non-viable foetuses, chiefly of the 
acephalic and sympodial types. The skin passes without any irregularity 






system of i;yx./-:colog: 



lution of continuity from the symphysis pubis to the coccyx. In 
such .1 case the anus is absent ; but this is not constant, for in some 
instances an anal orifice lias been found. Internally the rectum, bladder, 

and genital ducts may all open into one cavity persistence of the cloaca . 
in other cases the yjinaJ septum has developed, but the bladder 

and genital ducts have a common termination persistence of the sinus 
talis. During foetal life an accumulation of urine in the bladder 
and genital canals takes place, and the infant shows at the time of birth 
lerable abdominal distension from this cause. Cases of so-called 







Details. (After EUraschnlng.) 

b vulva in the adult woman are probably instances of the 
escribed, atresia vulva superfidalis. Defectus yulvsa 
'" li clinical importance. 

i vjb Superflcialis.- I',,//,,,!,,,,,,. The term superficial vulvar 

t may be applied cases in which, on account of adhesion 

or minora, there is an apparent absence of the nilvar 

ttOt complete, for a small orifice is 

the clitoris through which the menstrual 

Huid and urine escape. The anomaly may he present at birth, or may 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 



93 



be developed in infancy. In both cases it is doubtless due to adhesive 
vulvitis which leads to a glueing together of the labia. 

Clinical Features. In early life there may be difficulty in micturi- 
tion. After puberty the escape of the menstrual flow may be impeded, 
but hsematocolpos does not usually result. After marriage the labial 
adhesion will prevent coitus, but not necessarily impregnation. It is 
possible on a superficial examination that the condition may be mistaken 
for atresia vulvse. It is usually easy to separate the labia by traction ; 
but if this fail, a sound should be passed in through the anterior opening 
and a careful dissection made down to it. Attempts at coitus may be 
sufficient to break down the adhesion. 

Vulva Infantilis. In the adult the vulva may have preserved its 
infantile type and characters. This anomaly is usually associated with 
defective development of the uterus and ovaries, and with such systemic 
disorders as chlorosis. Its clinical importance is small compared with 
that of the associated defects ; but the existence of an infantile vulva 
may have some value as an indication of imperfect development of the 
internal genital organs. 

Abnormal Communications of the Vulva. It will be remembered 
that during development there is a time when the allantois (bladder), 
Miillerian ducts (vagina), and rectum all open into a common cavity, 
which in its turn opens on the surface of the body, and is called 
the cloaca. Normally this condition is transitory ; but in certain cases 
it is permanent, and thus the anomaly known as atresia ani vaginalis 
or vulvar anus is produced. In other cases development has advanced a 
stage further before it is arrested ; the perineal partition has grown 
downwards and separated the rectum, which now opens externally at the 
anus, from the rest of the cloacal cavity, which is now known as the uro- 
genital sinus. The persistence of the urogenital sinus, into which bladder 
and genital ducts open, gives rise to the anomaly known as hypospadias in 
the woman. Female epispadias, a somewhat puzzling and very rare 
malformation, may also be described here. 

Atresia Ani Vaginalis (Anus Vulvalis). Pathology. The term 
" persistent cloaca" ought, perhaps, to be given to this anomaly rather 
than the cumbersome and not strictly accurate expression " atresia 
ani vaginalis." "Anus vulvalis" " anus vaginalis," and " anus vulvo 
vaginalis" are also names which have been applied to this malforma- 
tion. Apparently the normal anus is absent, and the rectum opens 
into the vagina or the vulva (Fig. 38). Strictly, however, by imperfect 
downgrowth of the perineal partition, the rectum opens not into the vagina 
or vulva, but into the urogenital sinus. The Miillerian ducts have not 
yet grown downwards to form the lower part of the vagina. What is 
commonly regarded as vagina is, therefore, not truly so, but is the canal 
or sinus which precedes the development of the vagina. In the 
communication of the rectum with this sinus there is, therefore, a per- 
sistence of the cloacal stage. 



94 5 TEM OF I / J '. V. / COL OGY 

j. The chief symptom of this anomaly is the 

passage of tin' feces through an opening either in the neighbourhood of 

the vestibule >r in that of the posterior commissure. In some instances, 

when there is a sphincter, the patient has control over the faeces ; but in 

other cases there is no such control. In the latter case the external 

m hieli are kept constantly moist, are apt to be sore. So uncom- 

fortable is the patient thus rendered, that she gets into the habit of 

inducing constipation to render the emptying the bowels a weekly instead 

When there is control over defalcation there is not anv 

-iced for operative interference; but the sinus urogenitahs 

ought to be douched after each motion. When, on the other hand, there 

il incontinence if will be necessary to operate, and the age when 



P 



-.Anus vulviilis. (After D wight.) 

most likely to be successful is that of fifteen years or later. 

when the !;eccs arc fully formed and the tissues can be more easily 

l Dana] operation consists in the passage of a probe through 

I the bringing of it out in the position where the anal 

'" Tli'' parts between the probe and the skin 

" '" , "' divided, and the rectum pulled down and sutured 

however, by this hum,,. a permanent cure can verv 

B recently advocated a modification 

' , ""- "' thai the probe should be broughl out, 

d where the anus should be. but in front of it, just 

-";<"' muscle. Then the tissues above the probe are t< 

' n drawn to the B kin and fastened there, bu4 

w,tn ' 1 Ik ' - must then be sewed together. At a 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 95 

later period the fibres of the levator ani are to be split, as are those of 
the rectus muscle in gastrostomy, in order to get a good sphincter. It 
remains to be seen whether this method of operation will yield more 
satisfactory results than the older one. 

Persistent Urogenital Sinus (Hypospadias in Woman). Pathology. 
In one sense it is incorrect to speak of hypospadias in the woman 
as an anomaly, for the normal woman, as regards her external genitals, 
may be called a hypospadiac man. There is, however, a malfor- 
mation of the female genitals to which this name has been commonly 
given. Properly speaking, it is a persistence of the urogenital sinus ; 
the urethra appears to open into the vagina ; but what is regarded as 
vagina is really sinus urogenitalis. Through a common opening at the 
base of the clitoris, which, it may be remarked, often shows hypertrophy, 
both the urine and the menstrual fluid escape. The perineum is normally 
formed, and the rectum opens separately behind it at the anus. Thus 
the condition differs from the persistent cloaca of atresia ani vaginalis. 
Pozzi describes two varieties, differing in degree, of hypospadias in the 
female subject. In one, which represents the minor degree, the vestibular 
canal is long and narrow, and receives the opening of the urethra and 
vagina fairly high up. Very frequently this type is accompanied by a 
hypertrophy of the clitoris, and thus a condition of parts is produced 
which may give rise to some doubt as to the sex of the individual. In 
the second degree, which may be called hypospadia proper, the uro- 
genital canal has disappeared ; but the lower part of the allantois, which 
ought to have been changed into the urethral canal, has been included in 
the formation of the bladder. There is thus absence of the urethra, and 
the vagina and bladder open together into the vestibular canal ; so that 
it appears as if the bladder opened directly into the vagina. Cases of 
this kind have recently been reported by Strong and Frank. There will 
be incontinence of urine as a symptom. 

Epispadias in Woman. Pathology. Epispadias, as a defect of the 
upper Avail of the urethra is called, may occur alone, or it may be 
associated with malformations of the bladder and anterior abdominal 
wall. In the former case the urethra is seen as an open groove 
passing upwards in the position of the vestibule, and disappearing 
under the symphysis pubis, to end directly either in the bladder, or in 
the upper and closed part of the urethra ; for the defect may be 
present only in part of the canal. On each side of it lies one-half 
of the split clitoris, and attached to each half is the upper end of one 
labium minus. The labia majora may unite normally in front or may 
diverge. The bladder is closed in anteriorly, and there is usually no 
separation of the symphysis pubis ; it is, however, broader than normal. 
The growth of hair in the median line of the mons veneris may be defect- 
ive, as in a case of female epispadias seen by myself. The bladder- 
cavity is commonly diminished in srze. In the other form of epispadias 
the anomaly is complicated by ectopia vesica? (extroversion of the bladder) 
and by a failure of union of the arcus ossium pubis. In this case the 



96 S ) 3 TEM ( >F G 1 'N< E COL OGY 

upper ends of the labia majors are wide apart, and the urine escapes 
directly from the ureters. Sometimes it is Dot the Madder which is thus 

open to the front, but the cloaca development not having proceeded so 
far as t<> form a separate bladder. Intermediate types may he found 
between those two varieties, the simple and the complicated; and these 
serve as connecting links. It is with the first variety, however, that 
we have here specially to do. Epispadias is much rarer in the female 
than the male subject a circumstance which has not yet found a 
satisfactory explanation. Whether the anomaly be due to the rupture of 
part- already fused together, or to the failure of union of structures which 
normally grow together, has not yet been definitely settled. Durand 
Beems t<> connect it with an imperfect formation of what Tourneux terms 
the " bouchon cloacal." 

Features. The most important clinical manifestation of 
uncomplicated epispadias is incontinence of urine. The incontinence is 
not usually complete; but any sudden movement or change in position is 
followed by a gush of urine from the small bladder. As a result the 
external genitals are kept constantly wet, erosions soon appear upon them. 
and tiie condition of the patient is most distressing. Menstruation, how 
ever, commonly occurs normally, and the woman may become pregnant 
and hear a child. 'The cure of the condition is, therefore, urgently called 
for, and by paring the edges of the parts, and uniting them by sutures, a 
good result is sometimes obtained. In many instances, however, the 
operation fails for want of sufficient tissue, or on account of breaking 
down of the union artificially brought about. In such cases we have to 
tall back upon the use of a carefully fitted urinal, by means of which the 
patient's condition is rendered bearable. This was all that could be done 
for the n by me. 

Mai.k<>kmatk>ns of the Clitoris and Labia. Pathology. It ha 
been shown in the preceding pages how the vulva may be malforme 
in all it- component parts; but it must now be added that each o 
the external genital organs may alone be the subject of an anomaly 
I'hr clitoris, for example, may be entirely wanting. This happen 
sometime in connection with epispadias; but it is then more usua 
t<> find it bifid. Possibly split clitoris in the female is homologout 
with the rare cases of bifid or double penis in the male subject. 
I the clitoris is found to Ik; poorly developed, but it 

is more common to observe hypertrophy of it. This enlargement is 
doubtless more often acquired than congenital, and is then associated with 
: but it may also be present at birth, usually in association 
with pen A the urogenital sinus, or with uterine malformations. 

When hypertrophy of the clitorii i- also combined with labial hernia of 
the ovaries, the resemblance which the individual bears to the male type 
is vc ted. 

The labia majors may be absent, but this defect is nearly always 
associat.-d with ectopia yesi< 






MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 97 

They may also be adherent to each other, as has been already pointed 
out under the head of atresia vulvae superficialis, or conglutinatio 
labiorum. The labia minora may also be glued together, and probably 
this accounts for some of the cases in which they were said to be wanting ; 
they may be truly absent, nevertheless, in connection with epispadias. It 
has been stated that they may be increased in number, two or three folds 
having been found in place of one ; it is quite certain that they may be 
increased in size, and the deformity called the "Hottentot apron" is 
well known. 

Clinical Features. Enlargement of the clitoris and labia gives rise to 
irritation in the neighbourhood of the external genitals, and may thus be 
the cause of self-abuse and of nervous troubles. On this account it may 
be necessary to amputate the clitoris, or to excise the nymphae. In a 
case of my own great benefit followed the excision of the labia minora in 
a highly neurotic girl, who was thus restored from a state of chronic 
invalidism to one of health and usefulness. 

Malformations of the Hymen. Many of the malformations of 
the hymen have little clinical importance, although they are all of 
interest from the pathological standpoint, and some of them have 
a bearing upon medico-legal questions. There is as yet no general 
acceptance of any one theory of the mode of development of the 
hymen ; some writers assert that it is vaginal, others that it is 
vulvar in origin : but as it may be present when the vagina is absent, and 
may even be found in hypospadiac males, the facts are strongly in favour 
of the latter theory. Indeed, Pozzi, by whom these facts have been 
prominently enunciated, regards them as conclusive. At any rate, the 
hymen is to be looked upon, not as a " fixed " organ, but as a develop- 
mental remnant ; and it shows, therefore, a very large number of small 
anomalies as regards structure, form, and position. It consists really of 
three parts, which Pozzi has named hymen proper, pad of the meatus 
wrinarius or urethral hymen, and male bridle of the vestibule. All these parts 
I have repeatedly been able to recognise in the new-born infant; although 
in the adult they are not very distinct. It would seem that the urethral 
hymen, like the hymen proper, may present abnormalities; and in an infant 
at birth I have seen an occlusion of the meatus urinarius, by what I 
regarded as a fusion of the two lateral parts of the pad of the meatus, or 
hymen urethras. 

Double Hymen. The cases of double hymen which have been 
reported are probably errors of interpretation. What is called a supple- 
mentary hymen is usually a perforated diaphragm in the vagina a little 
above the level of the normal hymen. Two or even three of these 
diaphragms may exist, and they are doubtless due to adhesions formed 
between the vaginal walls in foetal life. Of course in the rare cases of 
double vulva there may be two hymens, but this is not what is usually 
meant by "double hymen." 

Absence of the Hymen. Absence, like duplication of the hymen, is 

H 



9 S SYSTEM OF GYNAECOLOGY 

an anomaly whose occurrence is not well established. In the infant at 
birth the membrane often consists of two pouting lateral folds which may 
easily be mistaken for the labia minora ; and in this way the notion arises 

that the hymen is absent Further, in certain cases, especially in the 
race, the hymen is situated deeply, because the vestibular canal is 
longer than norma] ; and here again the membrane may seem to be 
wanting. 'Hie medico-legal bearing of these facts in connection with the 
question of rape ia evident. 

Atresia Hymenalis. Pathology. The occurrence of imperforation of 
the hymeneal membrane is probably not nearly so common as the large 
number of reported cases would seem to show. Undoubtedly genuine 
examples of atresia of the hymen are occasionally met with; but in the 
majority of the recorded cases there is evidence to lead us to suspect that 
the membrane supposed to be hymeneal was really the blind end of the 
Mullerian vagina. It is often possible, as Matthews Duncan and others 
have shown, to find the normally perforate hymen pushed backwards and 
hidden to some extent by the bulging of the vaginal sac. Strictly speak 
i ases of hymeneal atresia are often instances of atresia of the lower 
part of the vagina; or, as some prefer to name it, of the retro-hymen. In 
another group of cases adhesion of the labia minora gives rise to an 
appearance resembling atresia of the hymen; and it is only when the 
labial attachment has been divided that the hymen is seen lying beneath. 
The pathological results of all these conditions are the same : there ia 
retention of vaginal mucus in infancy, and of menstrual fluid in later 
life, with consequent occurrence of hsematocolpos. 

icai /'"'tares. In the position of the vaginal orifice is found 
bulging membrane, sometimes of a bluish colour, which in some degree 
resembles the intact bag of membranes in a labour case, and has evei 
been mistaken for it. This swelling has gradually increased from tin 
of puberty, and its appearance has been accompanied by colickj 
pains recurring with increasing severity at intervals of a month, and b\ 
bsence of the menstrual discharge. Sometimes, also, the evacuatioi 
of tie- bladder and bowels has been rendered difficult and painful ; and ii 
instances there have been vicarious menstrual haemorrhages. In 
eaa fluctuating abdominal tumour has appeared, the result 
ion <>f the vagina with blood. On the top of this swelling a 
-mall hard mass c;m sometimes be detected; this is the undistendeq 
Uterus. In other eases i his organ also has become a blood sac, and in 
such cases hasmatocolpos and ha-matometra coexist. 

Op* interference is always required in these cases, for 

nal rupture \b uncommon ; even when it occurs it \i 

unsata . the evacuation bring incomplete, and often followed bi 

suppuration in tie- vagina] cavity. It nse<l t<> be the custom to puncture 

the r be hymen al one Bitting, and then later to make a cruciaj 

ii. and fully evacuate the contents; for it was thought that the 

Ridden escape of the vagina] contents might be attended by dangerouj 
results. I method is apt t> be followed by suppuration ; and it ii 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 99 

best to make first a small incision so as to allow the blood slowly to 
escape, and then at the same sitting to enlarge the opening, to wash out 
the canal thoroughly with an antiseptic lotion, and finally to pack it 
firmly with iodoform gauze. 

Anomalies in the form of the Hymen. Many anomalies in the 
form of the hymen may be met with, but they are of comparatively 
little practical importance. Instead of having its normal crescentic 
or semilunar shape, it may retain its infantile character; it then 
shows two lateral projecting lips, which have sometimes been mis- 
taken for the nymphse \ it is then called labiated or infundibuliform. 
Sometimes notches occur naturally in the membrane, which then is called 
the hymen denticulatus ; it is necessary to remember the occurrence of 
these folds or notches, and to distinguish them from the rents produced 
by coitus or labour. Rarely the fimbriated hymen is met with. The 
orifice is usually situated nearer to the anterior than to the posterior 
border of the membrane ; but occasionally it is quite central hymen 
circuit iris. Further, the opening may be very large (falciform), or there 
may be two orifices of equal size, situated laterally (hymen septus). Yet 
another form is that in which there are two apertures of unequal size, 
and situated irregularly (hymen bifenestratus, hymen biforis). A very 
uncommon type is the cribriform, in which there are many small holes in 
the membrane (hymen cribriformis). 

Anomalies in the structure of the Hymen. Pathology. The hymen 
may be abnormally thick, abnormally firm or rigid, or abnormally vascular. 
It may also show combinations of these anomalies. Thus it may be 
both thick and vascular, or both rigid and fleshy. To a certain extent 
these states may be regarded as due to a persistence of the foetal char- 
acters of the membrane, and they are of some clinical importance. 

Clinical Features. Abnormal rigidity of the hymen may be the 
cause of dyspareunia, or it may entirely prevent penetration in the act of 
coitus. In a case seen by myself it was found necessary to excise the 
hymen of a newly-married patient before complete connection could be 
accomplished by her husband. In other cases pregnancy occurs notwith- 
standing the unruptured state of the hymen ; and the presence of the 
membrane may protract labour, or, if it be torn, may cause a deep 
laceration also of the perineum. Cases have even been reported in which 
the hymen has been found intact after a miscarriage ; but in these 
instances the membrane has probably been abnormally elastic, rather than 
abnormally rigid. The importance of the occurrence from the medical 
jurist's standpoint is manifest in connection with the question of chastity. 
Abnormal vascularity of the membrane is also an anomaly of some im- 
portance, for, on the first occasion of coitus, it may be the cause of alarm- 
ing or indeed of dangerous haemorrhage. All these structural malfor- 
mations of the hymen are more easily understood if it be granted, as 
Pozzi affirms, that the hymen is the homologue of the corpus spongiosum 
of the male. 



ioo SYSTEM OF CYX.KCOLOGY 



Bermaphroditisw 

The exact meaning of the word "hermaphrodite," as applied to the 
human subject, has undergone a change. Whilst the older writers applied 

the term to individuals whom they regarded as possessing the organs of 
both B an anatomical and in a physiological sense, modern 

authors haw ooine t" 086 the name rather to indicate subjects whose 
true doubtful. Malformations of the genital organs, giving 

rise to doubts as to the true sex of the individual, have attracted the 
attention of ol from the earliest periods of the world's history, 

and. as I ha\e elsewhere shown (327), records of such cases have been 
found on the brick tablets of the ancient Chaldean libraries. In Kome 
individuals of doubtful sex were destroyed. In the East, on the other 
hand, there is reason to believe that they were deified. According to 

Talmud. Abraham was a hermaphrodite, and so, according to many 
authors, was Adam. 

In one sense the human embryo at a certain period of its existence 

may be regarded as hermaphrodite. There is a stage in development 

when it is impossible to state whether the sexual gland will become an 

testicle; whether the Miillerian or the Wolffian ducts will 

atrophy ; whether the genital tubercle will become a penis or a clitoris. 

embryo is then, so far as is known, potentially of either sex, and 
awaits the action of some force to determine which sex is to predominate. 

easy to understand how morbid influences, brought to bear upon the 
embryo at or about the time when it is passing from its sexually indifler- 

tage into one of differentiation, may so upset the normal process of 

iopment as to produce an individual with, for example, testicles and 

mi. It is. however, a matter of great difficulty to imagine a con- 
dition of affairs which would give rise to the presence of a testicle and 
an ovary <>n the same side; for, so far as is known, the sexual gland may 
become either a testicle or an ovary, but not both. In the Miillerian 
and Wolffian ducts, on the other hand, we have to do with two sets of 
troctarea, DOC of which normally atrophies and the other develops ; but 
abnormally both may persist in a more or less fully formed condition. 
As a matter of fact, it is very doubtful whether a genuine case of the 
of testicles and ovaries in the human subject has ever been 

1; whilst instances of pseudo-hermaphroditism, as they have been 
called. Still, it is never safe to say that the occur- 

rence of a- toloi:ie;d combination is impossible; and if we 

ie hermaphroditism has been met with in fish, 
amphibians, and evm in the goal and ]>iir, it maybe that some observer 
will yet record an undoubted case in the human subject. 

ers have classified cases of hermaphroditism in various ways. 

ft, for example, divide* them into two groups : true hermaphroditism. 

rmnphroditismm reni>, in which ovaries and testicles coexist ; and 
pseudo-hermaphrod i m. or hermaphroditismus sptmus, in which, along with 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 101 

either ovaries or testicles, there are found some of the genital organs of 
the opposite sex. Pseudo-hermaphroclitism, again, he divides into mascu- 
line or feminine, according as testicles or ovaries are present ; whatever 
may be the state of the other reproductive organs. Pozzi to some extent 
modifies this scheme of classification. He arranges all the cases in three 
groups : partial pseudo-hermaphroclitism, in which one sex obviously pre- 
dominates, only a few of the peculiarities of the other being present ; 
pseudo-hermaphroclitism properly so-called, including a large number of cases 
chiefly of the variety known as male hypospadiacs ; and supposed true 
hermaphroditism, in which both kinds of sexual glands have been regarded 
as present. It does not seem theoretically necessary to make a distinction 
between pseudo-hermaphroditism and the partial variety, although practi- 
cally the separation may be of value. The scheme here adopted is that 
which groups all the cases into pseudo-hermaphrodites and supposed true 
hermaphrodites, with certain subdivisions which will be stated under 
each head ; and I have added a new variety, or rather have resuscitated 
an old one, in which the external genitals of both sexes seem to be pre- 
sent in the same individual. Something will first be said regarding the 
cases which have been reported as instances of true hermaphroditism, 
and then the large group of the pseudo-hermaphrodites will be considered. 

Supposed True Hermaphroditism. Klebs has divided true her- 
maphroditism into three groups : bilateral (or vertical), in which an ovary 
and a testicle are found on both sides of the body ; unilateral, 
in which an ovary and a testicle coexist on one side, whilst on 
the other side is an ovary or a testicle, or neither; and lateral (or 
alternate), in which the female gland is present on one side and the male 
on the other. In the present state of our knowledge this subdivision 
is, as regards the human subject at any rate, quite unnecessary; for 
well-authenticated examples of the first and second varieties are wanting, 
and even of the third type the instances that have been reported are not 
altogether convincing. All the cases in which there is no report of a 
post-mortem examination are, of course, useless in classification ; for the 
whole value of such reports consists in the recognition by the naked eye 
and microscopically of two glands, one of which must have the characters 
of the ovary and the other those of the testicle. It cannot even be 
safely asserted, as was done by Rokitansky in the case of Catherine 
Hoffmann, that the allegation of a menstrual discharge is a proof of the 
existence of ovaries. Indeed there is evidence to show that the adult 
subjects of these abnormalities will intentionally mislead the observer 
concerning such phenomena as menstruation. 

The case reported in 1870 by C. L. Heppner of St. Petersburg has 
been regarded by many authors as a genuine example of hermaphro- 
ditismus verus bilateralis ; for in it were described a uterus with ovaries 
and tubes, and on each side also a rounded body in the neighbour- 
hood of the ovary which had the microscopical characters of the 
testicle. The external organs were like those of the woman. Now, 



SYSTEM OF GYNAECOLOGY 



with regard to this case, it must be borne in mind that the parts had 
been preserved for some time in spirit before they were examined ; and 

that the microscopical appearances of the so-called testicles might 
easily be regarded as those of immature or undifferentiated ovaries. 
The arrangement of tabes packed with cells, as depicted by Heppner, 
seems to mo to suggest a mal-developed ovary as much as a testicle. 
The probability is that the so-called testicles were really accessory or 
constricted ovaries bodies which, as has already been stated, often show 
a structure made up almost entirely of Pfluger's tubes. The case 
examined by H. Meyer, and reported by Cramer in 1857, is one of a 
considerable number in which true hermaphroditism of the lateral 
variety was alleged to be present. In this instance there were a rudi- 
mentary uterus and a vagina, and, on the right side, a normal ovary, 
parovarium, and tube. On the left side were a tube, a parovarium, and 
a body herniated in the left scrotal sac, and supposed to be a testicle. 
Cramer does not give the detailed microscopical appearances of this body ; 
but it seems more rational to regard it as an ovary, possibly in a rudi- 
mentary state, which had descended into the left labium, than as a 
testicle. In conclusion, it may be said that science still awaits the publi- 
cation of a case in which all competent observers will be able to recognise 
the existence in the same individual of two glands, one of which is un- 
doubtedly ovarian and the other testicular in nature. In the meantime 
it seems impossible to conceive how the impulse that determines sex can 
be so divided in its action as to turn one sexual gland into an ovary 
and the other into a testicle. 

Pseudohermaphroditism. Pathology. Cases of pseud -hermaphro- 
ditism are not uncommon, as a glance at the appended bibliographical 
list (for the last five years) will serve to show. In many of them the 
dubiety aa regards sex is evidently due to the existence of one or 
other of the anomalies of the female external genital organs which 
have been already described. In many more, however, we have to 
deal with malformations of the penis and scrotum, which have given 
to the external parts a somewhat feminine appearance. In the 
former group <f cases the ovaries are present, whatever may be the 
condition of the other organs, and the individual is therefore really 
a female in the state known as pseudo-hermaphrodUismus / minimis 
or iniiii'iulfii : in the latter group the subject by the possession of the 

testicles is a male, however closely he may approach tl ther sex in 

appearance, a state known as pseudo-hermaphrodUismus masculinus or 
androgyny. Individuals of the second kind are far commoner than those 
of the first. Kadi of these two varieties has been subdivided into three 
groups ?///'/////.<, externum and completus. Thus in a ease of pseudo-her- 

maphroditisnius masculinus internus there are testicles in association 

with external genitals of the male type, and a uterus, vagina, and even 

tubes. In pseudo-hermaphroditismus masculinus ezternus there are also 

les, but the externa] genitals and the build of the body are feminine. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 103 

Again, in psendo-hermaphroditismus masculinus completus sen externus 
et internus there are testicles, but there is also a uterus masculinus with 
tubes ; and the external organs approach more or less closely to the 
female form. In the same way in the three varieties of feminine pseudo- 
hermaphroditism there are always ovaries ; but in the internal type there 
are also distinct traces of the Wolffian ducts \ in the external type the 
external genitals are of the male form ; and in the complete type the 
external organs are masculine, and the Wolffian ducts and prostate gland 
are present. The enumeration of these varieties will have given the 
reader some idea of the morbid anatomy of pseudo-hermaphroditism ; at 
the same time it must be borne in mind that some of them are very rare ; 
one of them, on the other hand pseudo-hermaphroditismus masculinus 
externus is, comparatively speaking, very common. 

One of the most usual arrangements of parts to which the name of 
feminine pseudo-hermaphroditism is given is that in which a woman 
presents an adhesion of the labia along with hypertrophy of the clitoris. 
When, also, there is a labial ovarian hernia on one or both sides, and 
a development of hair on the face, the resemblance to the male, at 
any rate to the hypospadiac male, becomes very striking. The vulva, 
however, may be normal, and the subject show simply an enlarged 
clitoris, a beard, and a masculine arrangement of the pubic hair, as in the 
case of Zefthe Akaira (La Donna-Uomo), recently described by Zuccarelli 
in Italy. Examples of this kind of gynandry might be multiplied. 

Non-descent of the testicles in the male gives origin to one variety of 
androgyny. Such men are often the subjects of gynecomastia (enlarge- 
ment of the breasts) ; and since also the penis, although perforate, is some- 
times small, and the sexual functions poorly developed (infantilism), it is 
easy to understand how doubts as to their virility may arise. A more 
common type of androgyny, however, is that caused by the existence of 
scrotal hypospadias (Fig. 39). In this case the resemblance to the female 
type of external genitals is very strong, for there is a small imperforate 
penis often fixed in position under the symphysis by adhesions ; the urethra 
opens externally near the root of the penis, and below it is a sort of 
vulvar aperture or vestibular canal which may even be of some depth, 
and may be guarded by a hymen. The external genitals in such a case 
resemble, as Pozzi graphically expresses it, those of an embryo seen under 
a magnifying glass. When it is also borne in mind that the testicles 
are either undescended or at any rate atrophic, and that the individual 
has probably been mistaken for and brought up as a girl, and has thus 
acquired feminine habits, it is easy to see how extremely difficult it may 
be to ascertain the real sex. The difficulty may be still further increased 
by enlargement of the mammae, by the absence of hair on the face and 
chest, and by the occasional discovery of a uterus ; although, of course, 
ovaries are not to be detected. Doubtless most of the cases of supposed 
true hermaphroditism have been really hypospadiac men. 

A word or two may here be said regarding a form of pseudo-herma- 
phroditism not recognised by recent writers. In very rare instances 



104 



SYSTEM OF GYNAECOLOGY 



individuals otherwise apparently single show complete duplication of the 
vulva or of the penis. In a recent article (328) I have shown that in some 
of these cases of diphallus one penis only may be perforate, the other being 
small, and presenting an opening below it through which urine escapes. 





Fio. f& Pseodo-hermaphroditisra, perineoscrotal hypospadias. (After Posxt.) a, Glans; b, frsenum ; 
v>v, in.-.itiis minarlna; ov, rulvar orifice; by, hymen; ./. (bnrchette; pt, lama minora; <ji, labia 
majors. 

Such a case might easily be regarded as an instance of the coexistence of 
both male and female external genitals; and possibly some of the dis- 
counts of persona provided with a vulva and a penis, reported 
by early writers, may hare belonged to this category. Similarly in 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 105 

individuals with a double vulva the enlargement of one clitoris might 
give rise to a similar notion ; and probably the case of an infant, seen by- 
Moos takov, in which there were on one side external genitals of the 
female type with a perforate urethra, and on the other an imperforate 
penis (?) and a scrotum without testicles, may have been of this kind. 
The condition might be called external pseudo-hermaphroditism, had not this 
name been already appropriated to another type of genital anomaly. 

Clinical Features. Whilst in the histories of pseudo-hermaphrodites 
there are many details which are peculiar to each case, there are also some 
which are practically common to all. The error in the recognition of the 
true sex of the individual is usually made at birth and confirmed at 
baptism ; and, as a rule, it is not till the period of puberty is reached 
that doubts of the accuracy of the declaration at birth begin to prevail. 
In the case of male pseudo-hermaphrodites the error may even be per- 
petuated still longer, and the individual may be married as a woman and 
live with a husband, an imperfect form of coitus taking place per urethram. 
Usually, however, suspicions begin to be entertained at puberty when, 
in the case of hypospadiac males who have been brought up as females, 
the failure of the establishment of the menstrual function and the appear- 
ance of certain of the secondary sexual characters proper to the male sex 
give rise to doubts. At the same time, it must be borne in mind that 
even in these subjects haemorrhage simulating the menses may take place 
from the urethra dilated by coitus, and in a few instances a real catamenial 
discharge from a uterus has been noted. Further, the secondary sexual 
characters cannot be relied upon ; for mammary enlargement, rounded 
outlines, a broad pelvis, a small larynx, and a feminine distribution of the 
body-hair, may all be met with in male pseudo-hermaphrodites, whilst the 
secondary sexual characters of the male may coexist with ovaries. The 
habits, also, and the feelings and desires of the subject, will depend largely on 
the surroundings of early life, and cannot be regarded as diagnostic of the 
sex. Pseudo-hermaphrodites are generally sterile ; for the sexual glands 
are often mal-developed, and even when they are active the anomalies of 
the other organs prevent the successful accomplishment of the reproduc- 
tive act. Mental and moral weakness and even insanity are not uncommon; 
and in the case of Alexina B., so graphically recorded by Tardieu, the 
individual, a hypospadiac male, committed suicide. Many of the so-called 
" degenerates " show anomalies of the genital organs. That the condition 
may be hereditarily transmitted is probable ; at any rate family prevalence 
is not uncommon, and J. Phillips has recently reported four cases of 
pseudo-hermaphroditism in one family and Lindsay has seen three. I 
am also acquainted with a case in which two hypospadiac males, the 
children of one mother, have been brought up as sisters. 

The treatment of such cases presents many puzzling problems. Lawson 
Tait's rule that every infant about whose sex there is doubt should be 
brought up as a male is a good one ; for male pseudo-hermaphrodites are 
more common than female, individuals reared as males are not so apt to 
enter into marriage in ignorance of their sexual inability, and there is less 



io6 SYSTEM OF GYNAECOLOGY 

danger in bringing up a girl among boya than a boy among girls. The 
question of the advisability of surgical interference is a difficult one. In 
reported by Christopher Martin, the testicles were removed from an 
individual brought up as a girl, and castration was followed by a develop 
ment of the breasts and pubic hair ; whilst Pean records the extraordinary 
operative history of an individual whose abdomen was first opened to 
discover the sex, then an artificial vagina was made, and finally the 
abdomen was again opened and the tubes and ovaries removed. The 
division of a tight frenum in a hypospadiac male, and the separation of 
the adherent labia in a gynandrous individual, are minor operations which 
may be undertaken without hesitation : but it is doubtful whether we are 
justified in removing the sexual glands in any case of pseudo-hernia- 
phroditism, although of course the alternative procedure of making a 
redeclaration of sex is also attended with difficulty and great inconvenience. 
Possibly it may be well to consider the advisability of the establishment 
of a third class of individuals, who shall be regarded as neuter. 

The medico-legal bearings of hermaphroditism are self-evident. The 
questions of identity, of paternity, of the right to exercise the franchise, 
and to enter professions open only to one sex, when the individual is one 
about whose true sex there is some doubt, all require very careful con- 
sideration and clinical investigation. Further, the legality of a marriage 
between a man and a hypospadiac male cannot be maintained : and one 
bet wren a woman and a gynander is equally against the law. Further 
consideration of these matters is not, however, necessary in a text-book of 
gynaecology. 

J. W. Ballantyne. 



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MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 107 

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Botkina, i. p. 986, 1890. 58. Ballantyne, J. W. Trans. Edin. Obst. Soc. xv. p. 
160,1890.-59. Schwarz. Frauenarzt, vi. p. 12, 1$91. 60. Broome,' G. W. Weekly 
M. Rev. xxiii. p. 321, 1891. 61. MASSEY, G. B. Ann. Gyncec. and Peed iat. iv. p. 365, 
1890-1. 62. Hirigoyen. Rev. obstet. et gynec. vii. p. 133, 1891. 63. Curatulo, G. E. 
Riforma med. vii. p. 337, 1891. 64. Ciajo, A. Gazz. d. osp. xii. p. 670, 1891. 65. 
Nitot. Rev. obsUt. et gynec. vii. p. 340, 1891. 66. Layton, R. N. Orl. M. and S. J. 
xix. p. 412, 1891-2. 67. Schwartz, F. Orvosi hetil, xxxv. p. 294, 1891. 68. 
Berlin, F. Ann. Gyncec. and Peed iat. v. p. 193, 1891-2. 69. Halter, G. Wieil. med. 
Presse, xxxiii. p. 49, 1892. 70. Tannen, A. Centralbl. f. Gynak. xvi. p. 51, 1892. 
71. Sachs, G. Med. Obozr. xxxvii. p. 130, 1892. 72. Burke, W. H. Brit. Med. Journ. 
i. for 1892, p. 1020. 73. Williams, F. N. La.ncet, i. for 1892, p. 1185. 74. 
Drujinin, I. N. J. akush. i jensk. boliez. vi. p. 239, 1892. 75. Giglio, G. Riforma 
med. viii. p. 185, 1892. 76. Sicherer, O. v. Arch. f. Gynaek. xlii. p. 339, 1892. 77. 
Piccoli, G. Levatrice mod. i. p. 58, 1892. 78. Borde, L. Bull. el. sc. med. di 
Bologna, iii. 206, 1892 (3 eases). 79. Stoll, K. Ztschr. f. Geb. unci Gyn. xxiv. p. 275, 
1892. 80. Rossa, E. Wien. klin. Wchnschr. v. p. 501, 1892. 81. Stewart, W. S. 
Ann. Gyncec. and Peediat. vi. p. 150, 1892-3. 82. Currier, A. F. N. Y. Journ. Gyncec. 
and Obst. iii. p. 50, 1893. 83. Edebohls, G. M. N. Y. Journ. Gyncec. and Obst. iii. p. 
290, 1893. 84. Stratz, C. H. Ncderl. Tijdschr. v. Verlosk. en Gynacc. iv. p. 121, 
1893. 85. Biehl, K. Mitth. d. Vcr. el. Acrzte in Steiermark, xxx. p. 103, 1893. 86. 
Kleinwachter, L. Zeitschr.f Gcb. u. Gyn. xxvi. p. 144, 1893. 87. Cullingworth, 
C. J. Trans. Am. Gyn. Soc. xviii. p. 434, 1893. 88. Ratcliffe, J. R. Trans. Obst. 
Soc. Bond, xxxiv. p. 469, 1893. 89. Leuf, A. H. P. Med. News, lxiii. p. 490, 1893. 
90. Senfft, A. Ztschr. f. cirztl. Landpraxis, ii. p. 313, 1893. 91. Johnson, F. 
W. Boston M. and S. J. exxix. p. 643, 1893. 92. Pfannenstiel, J. Festschrift 
. . . in Berlin, p. 330, 1894. 93. Lohlein, H. Centralbl. f. Gynak. xviii. p. 997, 
1894. 94. Croasdale, H. T. Am, J. Obst. p. 359, 1894. 95. Semeleder, F. Gac. 
hSd. Mexico, p. 287, 1894. 96. Calderini, G. II Policlinico, p. 92, 1894. 97. 
Burton, J. E. Liverpool Med.-Chir. J. p. 459, 1894. 98. Gouget, A. Bull. Soc. 
Anat. de Paris, p. 24, 1894. 99. Rossa, E. Centralbl. f. Gynak. xviii. p. 422, 1894. 100. 
Ayers, E. A. Am. J. Obst. p. 104, 1894. 101. Eustache, G. Ann. di Ostet. p. 
336, 1894. 102. Schuhl. Ann. de Gynec. p. 248, 1894. 103. Werder, X. O. J. 
A ,n. M. Assoc, p. 234, 1894. 104. Kinghorn. Montreal Med. Journ. p. 442, 1894. 
105. Owen, R. O. Virginia Med, Monthly, p. 926, 1895. 106. Serejinsky, G. P. 



108 SYSTEM OF GYNECOLOGY 

Journ. akush. p. 183, 1S94. 107. SlMON, M. Centralbl.f. Qynak. xviii. p. 1313, 1894. 
108. Batcheloe, Y. C. ,'"">-f. J. Med. and Surg. i. p. 309, 1895. 109. 

ARNOLD, EL (i. K. L for 1895, p. 988. 110. Chaitis. Lyon med. p. 83, 1894. 

111. Bossu romande, p. 159, 1895. 112. Roux, 6. Arch, 

. p. 59, 1895. 113. Swope, S. D. Med. Nt ws, p. 391, 1895. 114. Penrose, C. 
B. Am. Joum. Obst p. 915, 1895. 115. Maygbiee. /A /. mM.-chir. d. mal. d. 
1895. 115a. Mallett, G. H. N.Y. Med. Joum. lxiii. p. 24, 1895. 
115/'. Mlitkniii.imki;. 0. Arch. f. Gyniik. 1. p. 221, 1895. 115c. BAER, B. F. 
Am. Qyn. and ObtL Joum. vii. p. 40, 1895. 115d. Brull, P. Arch, de Ginccopat. 
obstct. y pediai. viii. p. 651, 1895. 115c. TscHUDY, E. Arch. f. Qynak. xlix. p. 171, 
1895. 115/. Spbigg, \V. M, Am. Journ. obst. xxxii. p. 78, 1895. 115^. Eustache, 
G. Joum. sc. // "<, xviii. p. 313, 1895. 115/;.. Goullioud. Jiev. obstSt. in- 

</. p. 251, 1895. 115*. Gkifion. V. Bull. Soc. anat. de Paris, 5. s. ix. 
p. 520, 1895. 115/. MbeedbbvooBT, N. J. F. P. Arch, de tocol. xxii. p. 721, 1895. 
115*. SPIEGBLBEEG, H. Arch. f. path. Anat. cxlii. p. 554, 1895. 115/. 6lU 

Obet. Soc. London, xxxvii. p. 301, 1896. 115m. Swayne, YV. Bristol Med,* 
. Joum. xiv. p. 101, 1896. 

Uterus Septus : 116. Schramm, J. Centralbl. f. Gyniik. xiv. p. 185, 1890. 
117. Shtol, K. OUhet Mm-, ginek. otdiel, p. 47, 1891. 118. Scialdoni, A. Qior, 
'-.. '/. sc. med. xiii. p. 534, 1891. 119. Kleinschmidt. K. Uhiv.-FrauenHin. 
m Munchen, p. 129, 1892. 120. Fuchtenbuch, H. Diss. Strasburg, 1892. 121. 
Drake-Bro kman, II. K. Brit. Med. Journ. i. for 1893, p. 1220. 122. Hallow i.u., 
W. E. North-west. Lancet, xiii. p. 427, 1893. 123. Wheaton, S. W. Lancet, ii. for 
1893, p. 1562. 124. Chi:<m;ak. Centralbl. f. Gyniik. xvrii. p. 431, 1894. 12.">. MEET- 
TSN8, CenbratbL f. Gyniik. xviii. p. 1001,1894.-126. Werth, R. Arch. f. <' 
xlviii. p. 422, 1895. 127. Karra, D. A. Universitetskiya izvyestiya, p. 149, 1895. 
1l'7'/. WALTHEE, H. Ztschr.f. Geburtsh. u. Gyniik. xxxiii. p. 389, 1895. 

Uterus Unicornis : 128. Frommel. Miinchener med. Wchnschr. No. 15, 1890. 
129. Voll. Sitzuiujsb. d. phys.-med. Gesellsch. zu Wurzburg, 30, 33, 1891. 130. Ski.nk, 
A. .1. C. Treatise on the Diseases of Women, p. 33, 1892. 131. MANGIAG m.i.i. L Am 
d. Assoc, med. Lombarda, p. 29, 1892. 132. Tapie. Midi mid. i. pp. 85, 97, 1892. 
133. GE88NEE, Centralbl./. Gyniik. xviii. p. 824, 1894. 

Uterus Deficiens et Rudimentarius : 134. WEENIE, J. Deutsche med. Wchnschr. 
No. 11, 1890. 135. Fbank, K. Ztschr. f. Geburtsh. n. Gynaek. xviii. Hft. 2, 1890. 
136. Ai.i mann. Centralbl. f. Gyndk. xiv. p. 103,1890.-137. LlEBMANN. Centratbk 
f. QyntJk. xiv. p. 928, 1890. 138. RossiGNOL, F. Thesis. Paris, 1890. 139. Mak- 
CHI0NNE8CHI, O. I'isa, 1890. 140. SwiEOIOKl, V. Wien, med.Bl xiv. p. 85, 1891. 
141. Loviot. Bull. etm4m. soc. obst. et gynic. de Paris, p. 78, 1891. 142. BALADB. 
Journ. de med. de Bordeaux, xxi. p. 85, 1891-2. 143. DELAGENIERE, II. Cong, franc. 
de. chir. Proc-verb. Paris, v. p. 346,1891. 144. Snow, L B. Med. Rec. \li. p. 41, 
1892. 145. Hofmokl. Ber. d. k.k. Krankenanst. in Wien, p. 334, 1891. 146. 
HER, .1. Pat. med.-chir. Presse, xxviii. p. 274, 1892. 147. BeetTAUEB, .1. .lm. 
J. Ob$L x.wi. ). 394, 1892. 148. La Tokkk, V. Hull. ,i. ,-. Accad. med. di Bonut, 
xviii. p. 281, 1891-2. 149. Ebeklin, A. Med. Qbotr. wwii. p. 1041, 1892. 150. 
Albebtin. Province mid. vii. p. 159,1893.-151. Gelli, G. Pratico, ii. p. 123, 1892- 
3. 152. DOYLE, O. If. Journ. Am. M. Assoc, xxi. p. 773, 1893. 153. Boldt, H. .1. 
M"i. /:>. xliv. p. 790,1893. 154. A.N8CHELES, J. O. Joum. akueh. i jensk. bolicz. 
viii. ].. 7:u. \^x>,. i;,:,. Faidheebi, A. Arch, de tocol. p. 212, 1894. 156. Vine- 
. II. N. Am. J. Obst, p. 525, 1895. 156a. I'.i rrTEBS, W. Vise. Erlangen, 1895. 
L58&. Jaoobl, II I'. Am. Journ. Obst. xxxii. p. 510, 1895. 156c. Dorla.nl, YV. A. N. 
Phiia. Pdy. it. p. 485, 1895. -156& Clapham, C. Quart. Med. Joum. iv. p. 279, 1896. 

Uterus Fcetalis, Pubescens, etc.:-i:>7. .Mi i.i.i.k, P. Ztschr. f. Geburtsh. u. Gun. 
iii. p. 159, 1878. 158. BUDIN, P. Progr. med. pp. 267 and 307, i. for 1887. 159. 
Blanc, E. Arch.detocol. p. 359,1889.-160. Ti:\< in 1. Arch.di toed. xvii. p. 845,1890. 

Minor Malformations and Congenital Prolapsus Uteri: 161. Penrose, (J. B. 

Univ. Med. Mag. vi. p. 185, 1893-4. 162. Mueller, Ann. di Octet, p. 331, 1894. 

163. Quisling, N. Norsk. Mag. for Laegevidenskaben, i EL iv. p. 285, 1889. 164. 

Munch, med. Wchnschr. No. 50, 1889. 165. HlIL, K. Arch. f. Gijnaek. 

xlviii. p. 155, 1894. 165. Kim,. B. Arch.detocol. \:<ii. p. 904, 1895. 



MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN 109 

Vagina Septa : 166. Suppinger. Correspondenzbl. f. Schweizer Aerzte, p. 418, 
1876. 167. Atthil, L. Dublin Journ. Med. Sc. lxiv. p. 165, 1877. 168. Anway', 
J. D. Am. Journ. Obst. xi. p. 388, 1878. 169. Cheron. Rev. med.-chir. d. mal. d. 
femmes, iv. p. 382, 1882. 170. Galabin, A. I,. Trans. Obst. Soc. London, xxiv. p. 20, 
1883. 171. Moulton, H. Journ. Am. Med. Assoc, x. p. 666, 1888. 172. Schuler, 
C. Diss. Kiel, 1890. 173. Vasten, V. A. Bolnitsch. gaz. Botkina, i. p. 986, 1890. 
174. Paschen, Centralbl.f. Gyndk. xiv. p. 16, 1890. 175. Massey, G. B. Ann. Gyncec. 
and Pcedial. iv. p. 365, 1890-1. 176. Shtol, K. Otchet. Mar. ginek. otdiel, p. 47, 1891. 
177. Guhman, M. Journ. Am. Med. Assoc, xvi. p. 906, 1891. 178. Curatulo, G. 

E. Riforma med. vii. p. 337, 1891. 179. Ciajo, A. Gazz. d. osp. xii. p. 670, 1891. 
180. Scialdoni, A. Gior. internaz. d. sc. med. xiii. p. 534, 1891. 181. Halter, G. 
Wi> it. med. Presse, xxxiii. p. 49, 1892. 182. Drujinin, I. N. Journ. akush. i jensk. 
ioliez. vi. p. 239, 1892. 183. Giglio, G. Riforma med. viii. p. 185, 1892. 184. 
Sicherer, O. v. Arch. f. Gynaek. xlii. p. 339, 1892. 185. Piccoli, G. Levatrice mod. 
i. p. 58, 1892. 186. Eberlin, A. ' Med. Obozr. xxxvii. p. 323, 1892. 187. Borde, L. 
Bull. d. sc. med. di Bologna, iii. p. 194, 1892. 188. Fuchtenbuch, H. Diss. Strass- 
burg, 1892. 189. Umamori, S. Mino Lgakkwai Hoko, No. 1, p. 86, 1893. 190. 
Fermini. Boll. d. Poliambul. di Milano, vi. p. 55, 1893. 191. Leuf, A. H. P. Med. 
News, lxiii. p. 490, 1893. 192. Herrick, C. B. Med. News, p. 15, July 7, 1894. 
193. Robb, H. Johns Hopkins Hosp. Bull. p. 50, April, 1894. 194. Semeleder, F. 
Gaceta medica {Mexico), p. 287, 1894. 195. Osmont. Arch. d. tocol. p. 139, 1894. 
196. Chapuis. Lyon mid. p. 83, 1894. 197. Ayers, E. A. Am. Journ. Obst. p. 
104, July 1894. 198. Merttens. Centralb. f. Gyndk. xviii. p. 1001, 1894. 199. 
Raineri, G. Ann. di Ostet. p. 473, 1894. 200. Schuhl. Ann. de gynic. p. 248, 
Oct. 1894. 201. Fordyce, W. Teratologia, i. p. 61, 1894. 202. Serejinsky, G. P. 
Journ. akush. i jensk. bolicz. p. 183, March 1894. 203. Roux, G. Arch, de tocol. 
p. 59, 1895. 204. Swope, S. D. Med. News, p. 391, April 6, 1895. 204a. Chapman, 

F. B. Boston Med. and Surg. Journ. cxxxiii. p. 622, 1895. 

Vagina Kudimentaria. Defectus Vaginae. Atresia Vaginae : 205. Garde, H. C. 
Australas. Med. Gaz. ix. p. 307, 1889-90. 206. Picquj5, L. Ann. d. gynic. xxxiii. p. 
124, 1890. 207. Saehrendt, P. Ein Beitrag zu den Missbildungen der Vagina und 
des Hymen. Greifswald, 1890. 208. Jacobssohn, J. Diss. Strasburg, 1890. 209. 
Jacquemard, C. Loire mid. ix. p. 229, 1890. 210. Pascale, G. Riforma med. vi. 
pt. 1, 1890. 211. Riedinger, H. Ztschr. f. Heilk. xi. p. 237, 1890. 212. Sokoloff, 

A. P. Ann. d. gyne'c. et obst. xxxiii. p. 47, 1890. 213. Leonte. Spitalul, x. p. 611, 
1890. 214. Jepson, S. L. Trans. M. Soc. W. Virginia, p. 759, 1890. 215. Madden, 
T. M. Trans. Roy. Acad. Med. Ireland, viii. p. 292, 1890. 216. Frank, K. Ztschr. 
f. Geburtsh. u. Gyn. xviii. Hft. 2, 1890. 217. Asadulla, M. Indian Med. Gaz. xxvi. 
p. 9, 1891. 218. Robb, H. Johns Hopkins Hosp. Bull. ii. p. 43, 1891. 219. 
Swiecicki. Wien. med. Bl. xiv. p. 85, 1891. 220. Loviot. Bull, et mim. soc. 
obst. et gynic. de Paris, p. 78, 1891. 221. Roux. Cong, franc, de chir. Proc.-verb. v. 
p. 497, 1891. 222. Delageniere, H. Ibid. p. 346, 1891. 223. Vagishita, T. 
Sei-i-Kivai Med. Journ. x. p. 170, 1891. 224. Balade. Journ. de med. de Bordeaux, 
xxi. p. 85, 1891-2. 225. Kennedy, C. M. and C. F. Univ. M. Mag. iv. p. 703, 
1891-2. 226. La Torre, F. Bull. d.r. Accad. med. di Roma, xviii. p. 231, 1891-2. 
227. Martin, J. N. Am. Gtjncec. Journ. ii. p. 287, 1892. 228. Fulton, J. S. Am. 
Journ. Obst. xxvi. p. 331, 1892. 229. Mangiagalli, L. Atti. d. Assoc, med. lom- 
barda, i. p. 32, 1892. 230. Plasencia, I. Rev. de cien. med. vii. p. 169, 1892. 231. 
Swiecicki, H. de. Arch, de tocol. et de gyne'c. xix. p. 481, 1892. 232. Albertin. 
Province med. vii. p. 159, 1893. 233. Azema, H. Ann. de gtjnic. xxxix. p. 214, 1893. 
234. Barker, F. C. Indian Med. -Chir. Rev. i. p. 140, 1893. 235. Skene, A. J. C. 
Brooklyn Med. Journ. vii. p. 636, 1893. 236. Boldt, H. J. Med. Rec. xliv. p. 790, 
1893. 237. Currier, A. F. New York Journ. Gynozc. and Obst. iii. p. 1086, 1893. 238. 
Rossa, E. Centralbl. f. Gyndk. xviii. p. 422, 1894. 239. Costa, J. C. da. Med. 
News, p. 269, Sept. 9, 1894. 240. Simon, M. Centralbl. f. Gyndk. xviii. p. 1313, 
1894. 241. Grandin, E. H. Am. Journ. Obst. xxxi. p. 249, 1895. 242. Feinberg, 

B. Centralbl.f. Gyndk. xix. p. 395, 1895. 242a. Turgard. Ann. de la Policlin. de 
Lille, iv. p. 177, 1895. 242&. Muret. Wien. klin. Rundschau, ix. p. 537, 1895. 
242c. Hahn, H. St. Louis Med. and Surg. Journ. lxix. p. 265, 1895. 242d. Picque 
and Villar. Progr. mid. p. 284, Nov. 2, 1895. 242<?. Picque. Gaz. mid. de Paris, 
9. s. ii. p. 522, 1895. 242/. Webster, J. C. Am. Journ. Obst. xxxii. p. 544, 1895. 
212g. Rossa, E. Centralbl.f. Gyndk. xx. p. 145, 1896. 



SYSTEM OF GYNECOLOGY 



Atresia Vaginae Lateralis : 2 1.!. WroblewskI, 0. Diss. Greifswald, 1884. 

214. Fraenkbl, E. Breslau. aerztt. Ztschr. ix. p. 67, 1887. 245. Sachs, G. Med. 

wwii. p. ISO, L892. 246. Sicherer, 0. v. Arch./. Gynaek. xlii. p. 889, 

247. Cullingworth, C. J. Tram. Am. dim. Soc xviii. i>. 434, 1893. 248. 

Sanger. Oentralbl. f. Gyndk. xviii p. 981, 1894. 249. Muret. Rev. med. de la 

JO, 1895. 250. Kakka, 1). A. Univ. izvyestiya, xxxv. p. 1 19, 

Stenosis Vaginas :-- 251. VlNEBRRG, II. X. Am. J. Obst. p. 106, July 1894. 
252. Stone, A. K. Boston, M. and S. Journ. p. 533, 1895. 

Abnormal Communications of the Vagina : 2".:>. Caradec. (/"-.. rf. ffflp. No. 7, 
j.. 27. L863. 254. Rosthorn, A. v. J/7.//, klin. Wchnschr. No. 10, p. 183, 1890. 
255. Fordyce, W. Teratologia, i. p. 61,1894. 

Double Vulva: -256. Suppinger. Correspondenzbl. f. Schweiaer AerzU, }>. 418, 
L876. 257. Wells, B. II. Am. J. Obst. xxi. p. 1265, 1888. 258. Chlarleoni, 
G. Ann. di Osi logia, xvi. p. 469, 1894. 

Atresia Vulvae Superficialis : 259. Rausghning, P. Diss. Konigsberg, 1890. 
260. Sanger. Oentralbl. f. Gynak. xv. p. 1022, 1891. 261. Vollmer, H. Diss. 
Marburg, 1894 (two cases). 261a. Hue, V. Med. infant.^, p. 467,1895.-2616. Jan, 
M. Indian Lancet, vii. p. 123, 1896. 

Abnormal Communications of the Vulva: 262. Elgehausen, F. Dissertation, 
Kiel, 1891. 

Anus Vulvalis : 263. Rosthorn, A. v. Wien. klin. Wchnschr. iii. p. 183,1890. 
264. Spinelli, <!. Riv. din. t terap. xii. p. 173, 1890. 265. Abel, K. Arch. f. 
Gynaek. xxxviii. p. 493, 1890. 266. Szukalski, S. Diss. Greifswald, 1890. 267. 
Puech, P. Des abouchements congenitaux du rectum a la vulve et an vagin. Paris, 
1890. 268. [Trommel, R. Munchen. med. Wchnschr. wwii. p. 264, 1890. 269. 
Himmelfarb, G. [. Arch. f. Gynaek. xlii. p. 372,1892.-270. Parvin, T. Med. 
!\i. p. 69, 1892. 271. Rautzoin. Rev. mens.d. mod. de Yen/, xi. p. 27. 1893. 
272. Thompson, II. Lancet f i. for 1894, p. 408. 273. Horrocks. Brit. Med. Journ. 
i. for 1895, p. 83. 271. Btjckmastbr, A. H. Trims. Am. Gyn. Soc. \i\. p. 275, 
1894. 275. LUDWIG. Oentralbl. f. daunt, xix. p. 349, 1895. 276. Anshelesa, V. 
Univ. izvyestiya, xxxv. p. 129, 1895. 277. Dwight, T. Am. J. Med. Sc. p. 438, 
.v j nil 1895. 277a. Freeman, L. Med. News, lxvii. p. 319, 1895. 

Hypospadias : 278. Lebedeff. Arch. f. Gynaek. wi. p. 2i>0, 1S80. 279. 
Strong, C. P. Trans. Am Gyn. Soc. xvi. p. 473, 1891. 280. Frank. Wien. klin, 
Wchnschr. v. p. 413, 1892. 280a. Bittner, C Przeglad chirurgiczny, i. p. 260, 
1893-94. 

Epispadias: 281. Con-, halk, 8. Dissertation. Wiirzburg, 1883. 282. Ruther- 

ford,C. Med.Rec xxxviii. p. 192,1890. 283. Auffhet, C. Cong, franc, dechir. Proc- 

v. vi. p. 288, 1892. 284. DRANITZY, A. A. Journ. akush. i jensk. boliez. p. 

567, June 1894. 285. Durand, M. VExstropkU visicale et VBp&spadias. Paris, 1894, 

K. Kordiskt. med. Arkiv, a. f. Iv. No. 81, 1894. 2856. Ktmii:. E. 

Berlin. klin. Wchnschr. p. mi, 1895. 

Malformations of Labia : -2^0. D'Hotman DE Villiers. Arch, de tocol. xvii. p. 
272, 1890. 287. 8< htol, K. <;. Journ. akush. i jensk. boliez. iv. p. 807, L892. 287a, 
David, K. Journ, sc mid. <i, Lille, xviii. p. *'.72, 1895. 287/'. Shoemaker, <;. K. 
Am. Journ. Obst, xwii. p. 215, L896. 

Atresia Hymenalis : -288. Vam deb Mi.i.i. Nederl. Ti$dschr. v. Vcrlosk. en Gynac, 
i. p. 171, 181 II. c. Brit, Med. Journ, L for 1890, p. 780. 290. 

Mmii.k. J.J. K. Med. /: . ixxvii p. 560, L890. 291. Somers, L. N. U. Lancet, i. for 
;,. 1010. 292. <ii:' in/. CUnica. i. p. 118, 1890. 293. Sibman, a. Wien. 
klin. Wchnschr. iii. p, 189, L890. 294. Kinlooh, R A. Am. ./. Obst. wiii. p. 886, 
1890.- 295. Mam ei, 0. B. I ' , South Car. M. Ass, p. L05, 1890. 296. Bardesctt, 

297. Bevill, C. Med. Bee. wwiii. p. 631, 1890. 
298. Gichner, J. B. Maryland M. Journ. xxiv. p. 248, 1890-91. 299. WloorN, 






MALFORMATIONS OF THE GENITAL ORGANS IN WOMAN in 

F. H. Med. Bee. xxxix. p. 136, 1891. 300. Shtol, K. Otchet. Mar. ginek. otdiel, p. 
28, 1891. 301. Ross, J. F. W. Journ. Am. M. Ass. xvii. p. 1, 1891. 302. 
Hemenway, H. B. Am. J. Obst. xxiv. p. 897, 1891. 303. Strogonoff, V. V. 
Vrach, xii. p. 1058, 1891. 304. Sochinski, P. M. Vrach, xii. p. 1139, 1891. 
305. Mironoff, M. Joum. akush. i jensk. boliez. vi. p. 474, 1892. 306. Wheeler, 

lif. ffomosop. x. p. 206, 1892. 307. Minard, E. J. C. N. York M. Joum. lvi. p. 
299, 1S92. 308. Yanderveer, J. R. N. York M. Joum. lvi. p. 298, 1892. 309. 
Konelski, M. L. Vrach, xiii. p. 955, 1892. 310. Orloff, V. X. Meditsina, iv. p. 
856, 1892. 311. Rosinski. AUg. med. Centr.-Ztg. lxi. p. 2041, 1892. 312. Drake- 
Bkockman, H. E. Brit. Med. Joura. i. for 1893, p. 1220. 313. Xeugebauer, F. 
L. Medycyna, xxi. p. 429, 1893. 314. Xammack, C. E. Med. Bee. xliv. p. 81, 

-315. Thomason, H. D. Ibid. p. 235, 1893. 316. Kahn, A. Med. News, lxiii. 
p. 380, 1893. 317. Mudalier, A. X. K. Indian Med. Bee. p. 300, 1894. 318. 
MuRPHY, J. Brit. Med. Journ. i. for 1895, p. 65. 318. Rittstieg. Miinchen. med. 
Wehschr. p. 1081, 1895. 3186. Coromilas. Bull, ct mem: soc. obst. et gynec. de 
Paris, p. 445, 1895. 

Anomalies in the Form of the Hymen : 319. Schaeffer, O. Arch. f. Gynaek. 
xxxvii. p. 199, 1890. 320. Cordorelli Francaviglia, M. Gior. ital. d. mal. ven. 
xxx. p. 426, 1889. 321. Montane, L. Progreso med. ii. p. 445, 1890. 322. Purslow, 
C. E. Lancet, i. for 1895, p. 543. 

Anomalies in the Structure of the Hymen : 323. Leisenring, P. S. Omaha 
Clinic, ii. p. 216, 1889-90. 324. Destarec, J. Thesis. Paris, 1890. 325. Campbell, 
\Y. M. Edin. M. Journ. xxxvi. p. 217, 1890-91. 326. Ahlfeld, F. Ztschr. f. Gcburtsh. 
I. Qynak. xxi. p. 160, 1891. 

Hermaphroditism : 327. Ballantyne, J. W. Teratologic,, i. p. 136, 1894. 328. 
Ibid. Teratologic, ii. p. 184, 1895. 329. Debout. Normandie med. v. p. 160, 1890. 
330. Decker, C. M. St. Louis M. and S. Joum. lviii. p. 355, 1890. 331. Egea, R. 
Gac. med. xxv. p. 141, 1890. 332. Rosenthal, O. Wicn.med. Wchnschr. xl. p. 526, 
1890. 333. Winter. Ztschr. f. Geburtsh. u. Qynak. xviii. p. 359, 1890. 334. Manton, 
J. A. Lancet, ii. for 1890, p. 395.-335. Pozzi, S. Gaz. hebd. de med. xxvii. p. 351, 
1890. 336. Jones, C. X. D. Med. Bee. xxxviii. p. 724, 1890. 337. Tillatson, D. J. 
Med. and Surg. Beporter, lxiii. p. 647, 1890. 338. Abel, R. Dissertation. Greifs- 
wald, 1890. 339. Vaughan, G. T. New York Med. Joum. liii. p. 125, 1891. 340. 
Polaillon. Bull. Acad, de Med. Far is, xxv. p. 557, 1891. 341. Eliot, G. T. Med. 
Bee. xxxix. p. 564, 1891. 342. Petit, P. N. Arch.d'obst. et gynec. vi. p. 297, 1891. 
343. Jouin. Bull, etmem. soc. obst. et gynec. de Paris, p. 190, 1891. 344. Debierre, 
Ch. D Hermaphrodisme. Paris, 1891. 345. Breitung, M. Dissertation. Jena, 1891. 
346. Roerle, F. J. Trudi Obsh. Bussk. vrach v Mosk. p. 17, 1891. 347. Bishop, 
H. D. Med. Bee. xii. p. 321, 1892. 348. Worrall, R. Australas. M Gaz. xi. p. 
107, 1891-2. 349. Fehling, H. Arch./. Gynaek. xlii. p. 561, 1892. 350. Messner. 
Arch. f. path. Anat. exxix. p. 203, 1892. 351. Xonne, M. Jahrb. d. Hamb. Staats- 
Jcrankenanst. ii. p. 446, 1892. 352. Guermonprez. Une erreur de sexe avec ses 
consequences. Lille. 1892. 353. Frank. Prag. med. Wchnschr. xvii. p. 221, 1892. 
354. Richer, P. N. iconog. de la Salpetriere, v. p. 385, 1892. 355. Dailliez, G. 
Les sujets de sexe douteux. Lille et Paris, 1892. 356. Lindsay, J. Glasgow Med. Journ. 
xxxix. p. 161, 1893. 357. Kurz, A. Deutsche med. Wchnschr. xix. p. 964, 1893. 
358. Philippe, P. Union me'd. du Canada, vii. p. 505, 1893. 359. Audain, L. Ann. 
de gynec. et d'obst. xl. p. 362, 1893. 360. Bergonzoli, G. Bull, scient. Xo. 1, 1893. 
361. Pozzi, S. A Treatise on Gynaecology, iii. p. 452, 1893. 362. Brohl. 
Centralbl.f. Gyncik. xviii. p. 390, 1894. 363. Hoffmann, C. S. Am. J. Obst. xxix. p. 
367, 1894. 34. Martin, C. Brit. Med. Journ. i. for 1894, p. 1361. 365. Walker, 
M. A. New York Med. Joum. p. 434, Oct. 1894. 366. Zuccarelli, A. L'Anomalo, 
p. 78, 1894. 367. Willett. Trans. Path. Soc. London, xlv. p. 102, 1894. 368. 
Moostakov. Meditzina (Bulgaria), p. 32, 1894. 369. Schneller. Miinchen. med. 
Wchnschr. Xo. 33, 1894. 370. Hallopeau, H. Bull. Acad, de med. Paris, p. 425, 
1895. 371. Lagneau, G. Ibid. p. 415, 1895. 372. Meige, H. N. iconogr. de la 
Salpetriere, p. 56, 1895. 373. Pean. Bull. Acad, de med. Paris, p. 381, 1895. 374. 
Targett, J. H. Trans. Obst. Soc. London, xxxvi. p. 272, 1895. 375. Zedel, J. 
Ztschr. f. Geburtsh. u. Gyndk. xxxii. p. 230, 1895. 375a. Lipka, A. Gaz. lekarska, 
xv. p. 980, 1895. 375&. Bittner, W. Prag. med. Wchnschr. xx. p. 491, 1895. 375c. 



SYSTEM OF GYNAECOLOGY 



Mixot, F. Boston M rg, Journ. cxxxiii. p. 112, 1S95. 375c?. Stretton, 

J. L. . 917, ii. for 1895. 375g. Neuoebauei:, F. Przeglad chirurgiczny, ii. 

_'. 539,1894-95.-375/. KAPLAN, P. S. Diss. Berlin, 1895. 375^. Blom, R. 

bl. f. OynSk. xix. ]>. 685, 1895.-375/^. Arene. Loire mid. xiv. p. 187, 1895. 

375/. Hutchinson, J. Arch. Surg. vii. p. 64, 1896. 



J. W. B. 



THE ETIOLOGY OF THE DISEASES OF THE 
FEMALE GENITAL ORGANS 

The causes of the diseases of modern women are mainly attributable to 
the errors, direct or indirect, of modern life, which is yet very far from 
perfection. They may be thus classed 

I. Abnormalities, which are produced by 

A. Hereditary congenital deficiencies of development, with 

(a) Reversion to an anterior biological type ; or 
(/3) Imperfection of adjustment, or of function, of certain 
structures ; 

B. Congenital, or subsequent arrests of development by bacill a ry 

inflammation or accident ; and 

C. Constitutional defect, in which certain classes of cells morbidly 

proliferate, forming tumours. 

II. The training and effects of education. 

III. Unnatural personal habits with regard to dress, diet, repose, and 
the management of the excretions. 

IV. Absence of marriage, or late or ineffective marriage; the last 
including absence of pregnancy by congenital defect or incapacity of the 
husband, or of the woman; and artificial prevention of pregnancy. 

V. Excessive use and drain of the sexual organs. 

VX Bacillary contagious diseases, such as syphilis, gonorrhoea, puerpera 1 
septicaemia, tuberculosis, measles, scarlatina, small-pox, and diphtheria. 

VII. Accidental causes and those due to operation. 

I. Deficiencies and arrests of development, which render the 
genital organs useless or Lead to disease, might be attributed to inflam- 
matory interference with the circulation and nutrition due to maternal 
endometritis, or mental shock ; bu1 these influence the whole embryo, or 
not especially its genital system. The cause is rather to be found in the 
influences of hereditary sexual feebleness, progressive in certain tempera- 
ments; or of bacillary inflammation ; or of local injury in the mother. 

A. Such defective heredity is probably not generally immediate, 
but is a gradual declension, generally on the maternal Bide, tending by 
continuous degeneration to induce in the progeny feebler sexual forma 
tion. frequently in the uterus. Thus the first stage may be found in a 
woman of deficient sexual appetite, having a uterus of moderate develop 
ment, but contracted a1 it> opening, which may be lacerated in her first con- 






ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 113 

finement so, perhaps, as to prevent further conception. The child, cold- 
mannered, unsympathetic and egoistic, with a feebly-developed uterus and 
disgust at marital rites, becomes pregnant only by chance it may be 
long after marriage, or after successful operation : or, with a congenitally 
contracted, though permeable upper vagina, closed hymen, or a tendency to 
the infantile pelvis with absence of sexual appetite, she becomes the mother 
of one child, who has a yet feebler unimpregnable uterus and atrophic 
ovaries, with deficient catamenial discharge, and a premature menopause ; 
or more marked abnormality may occur, and the woman be sterile. In 
the father hypospadias may exist, or some other state of deficient con- 
genital urogenital formation. Such unions are often attributable to the 
inducements of money or position in marriage ; in a simpler state of society 
they would be prevented by the competitive success of those physically 
more robust. This heredity may be rectified in the children if the 
feebly sexual woman become pregnant by a partner of exceptionally 
vigorous type, whereby the tendency to sexual deterioration may be 
neutralised. 

Through the ancestral series a certain portion of the original germ- 
plasma has been retained, so that the special organisation is preserved, as 
well as some particular attributes, whether physical or mental, of the parents 
or earlier progenitors. The influence of the highest progressive develop- 
ment attained is thus conveyed to the offspring, but with it the 
inherent capacity of recurrence to an anterior lower type. A defective 
generative vitality may thus fail to develop to the highest type of the 
immediate ancestors, and reversion to an anterior form may occur. 

As in all cases the special type of the individual is dominant, the 
impression of descent is one of degree, and the grade is in a proportion- 
ately decreasing ratio removed from that of the immediate ancestors ; 
and this appears in some special point, in which the advanced cell-vitality 
has failed. This is particularly liable to occur in the generative organs, 
especially of women, which are more advanced and complicated. 

Darwin says that the most ancient progenitors of the Vertebrata, 
of which we are able to obtain an obscure glance, seem to have been 
a group of marine animals resembling the larvae of existing ascidians. 
These animals probably gave rise to a group of fishes, as lowly organised 
as the lancelot ; and from these the ganoids, and other fishes like the 
lepidosiren, were probably developed. From such fish a very small ad- 
vance would carry us on to the amphibians. Birds and reptiles were 
once intimately connected together, and the monotremata now connect 
mammals with reptiles in a slight degree. In the class of mammals 
the ancient monotremata led up to the ancient marsupials, and these to the 
early progenitors of the placental mammals. Thus we may ascend to the 
lemuridae, and from these the interval to the simiadae is not very wide. 
The simiadse then branched off into two great stems, the New World and 
Old World monkeys ; and out of the latter stem, at some remote period, 
man, the wonder and glory of the universe, proceeded. 

Geddes and Thomson state that in all the lower vertebrata the 



H4 



SYSTEM OF GYNECOLOGY 



two oviducts are distinct throughout the genital canal ; but in mammals 
the division is found only in the monotremata. In marsupials the vagina 

is single, but the uterus double ; and 
in most placentalia the upper portion 
of the uterus is double. 

Gegenbaur describes the progress 
in development in the marsupialia 
in which the two uteri arc distinct, 
and two separate vaginas appear 
(Fig. 40), and says that in many 
rodents (lagOStomus) acertain portion 

of the vagina retains its original 
double nature. The gradual bio- 
logical progress toward the human 
double uterus is shown in Figs. 4 1 , 
li\ 43, in which it is also seen that 
when the common portion of the 
uterus is elongated the cornua are 
shortened. In the simiadse, as in 
man, there is a single uterus. 

The same line of proof may be 
applied to lobate and multiple 
ovaries, and to the various conditions 
of hermaphrodites. Thus hereditary 

deficiencies of development are reversions to an anterior type. 

These abnormalities, however, are more particularly attributable to 

the exact point ;it which the progressive development of the germinal 




male generative organs of Halmaturus 

, ( >v;try ; od, OVidud ; ", 
. vaginal canals ; cug, sinus urn. 
lis; <". urinary bladder; r, ureter. 
* < Opening of the bladder. 








Tin' single uterus is con- 
tinued into two seps 
oornua of tin' insectivora, 
Carnivora, Cetacea, and t'n- Fio. 18. The sin^lf uterus <>f tl 
gnlata. Simis ami Man 



legaribaur} ", Uterus; >"/. oriducl : v, vagina. 

lis fails. Pure reversion to an anterior type implies a perfect develop- 
ment ;it the level of thai ancestor; this, however, may not occur. 
Probably do defective development can take place without a deficient 
germinal cell -vitality, and such vitality may he exhausted ;it a point 

dent to that Of Completion of the anterior type. Thus examples 

found in which the condition may be described as deficient in 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 115 

contrast with that of arrest. In the former the cell-vitality is low, but 
persistent ; in the latter it is worn out and atrophic. 

B. And here presents itself a special cause of germinal-cell destruction 
by bacillary action, which is, through parental influence, directly con- 
veyed to the embryo, and by local inflammation destroys the vitality and 
power of growth of germinal genital cells. Among such causes are the 
eruptive fevers, such as measles, scarlet fever, and small-pox, by which 
the foetus in utero may be attacked. Syphilis probably also exerts a 
determining influence on arrests of development in the progeny. 

After birth, and at any time previous to full development, these 
causes, or tuberculosis again, which specially attacks the mucous or serous 
membranes, may affect and destroy the vitality of the growing cells ; or 
an accident before birth, or subsequently, such as a blow on the abdomen 
producing an internal haemorrhage, peritoneal or otherwise, and affecting 
these parts, may arrest growth ; or a peritonitis may cause displacement 
and adhesion of the genital organs. 

Such destruction of vital force in the special germ -cells produces 
arrest of development at the stage which such development had 
previously attained, and a stage of arrest restricted to the special cells 
thus affected. 

There is no necessary relation between any degree of defect or 
arrest in the development of the pelvic sexual organs and the degrees 
of perfection of female form and of the rest of the woman. 

Congenital deficiencies and arrests of development are found in the 
ovaries, Fallopian tubes, uterus, vagina, hymen, and vulva. 

Should the development of the genital ridge be deficient or arrested 
the ovaries are so undeveloped that the external germinal epithelium has 
not ingrown for the formation of the Graafian follicles ; or is so wanting in 
completeness of structure, that these organs are unable to arrive at their 
successive monthly maturity. Whence result amenorrhcea and sterility. 

If the growth of the cephalad part of the Mullerian ducts, and of the 
mesenchyma of the uro-genital fold cease, the Fallopian tubes are minute 
or defective. By absence of fusion of the cephalad ends of the two 
Mullerian ducts in the genital cord, which are always tubular, the uterus 
is double ; by absence of fusion of the upper ends of the cephalad end, 
and its presence in the lower part, the uterus is bifid ; from arrest in one 
duct and development of the other, the unicorn uterus results ; after the 
normal fusion, cessation of vital growth may cause the uterus to be 
diminutive. 

When the vital force is defective or arrested in the lower half of the 
genital cord, so that fusion and absorption of the internal walls of the 
two Mullerian ducts do not occur but the remaining development con- 
tinues in each, the epithelial surfaces of each may separately continue 
their growth, meet and coalesce, closing the canals, and forming the 
proliferating cellular lamina ; the central duct-cells may subsequently 
liquefy normally, and result in two vaginae of more or less perfect 
formation. When the central cells of the ducts have failed to break 



n6 SYSTEM OF GYNECOLOGY 

down, do vagina] canal is formed ; or the cells of one may have liquefied, 
when one vagina, perhaps <>f defective size, is present. Such cohesion 
of the vaginal walls may be maintained only by a thin, delicate, easily 
separated layer of the central epithelial cells, liquefaction of the central 

lamina having jnst failed of completion. 

The hymen, a mm -muscular fold which projects into the uro-genital 
sinus, having on the outer surface the epithelium of the sinus and on the 
inner that of the vagina, may be imperforate by arrest of liquefaction of 
the lowest cells of the vagina] lamina, and non-formation of a canal ; or 
may have an opening into each canal of a double vagina by absence of 
fusion of the lower ends of the Mullerian ducts; or have two openings 
into a single vagina by non-fusion of the lowest Mullerian duct-walls, with 
liquefaction of the central epithelial cells of each. 

Deficient formation of the clitoris and nymplue is due to defect or 
arrest of development of the genital tubercle; and of the labia majora, of 
the mesodermic prominences on either side of the genital tubercle. 

The diseases which result from defect or arrest of development in 
atresia with ovaries so well formed that the catamenia occur, depend upon 
distension of the genital canal, which is patent above the occluded 
portion, by the collection of the retained menses. Thus, with a closed 
hymen, or atresic vagina, the menses may dilate the vagina, collect in 
the uterus, and fill and distend the tubes up to the fimbria;. Should 
effusion of the menses occur through the fimbria? into the peritoneum, 
peritonitis results, of a degree of mildness or severity proportionate to 
the quantity and quality of the fluid effused if it occur before operation 
for the cure of the atresia : it will probably be septic and virulent if it occur 
after it. 

Each segment of the double uterus may contain an impregnated 
ovum, the two perhaps of different ages ; and thus superfcetation may 

undated. 

The usually more feeble structure of an unicorn uterus, or of 
tent of ! bifid uterus, occupied by an impregnated ovum in progr 
of development, may cause its rupture into the abdominal cavity, an 
thus produce abdominal hematocele and peritonitis. 

Supernumerary developments, as of nipples, are multiplications due 

orrenee t<> an anterior type ; or to embryonic separation oi- migration 

of t he special epidermal cells ; and duplication, as of <\ aries, is attributable 

iibryonic cleavage. Duplication of tin ovaries, if overlooked in 

Oophorectomy for the production of the menopause, may defeat the object 

of the operation. 

The deficiency or absence of sexual appetite, and thus of engorgemenj 

of the erectile structures, i- attributable to defective nerve formation in 

iginal plexus of the pelvic or inferior hypogastric plexus, and tends 

lopment of progeny from diminished size of the supplying 

-. This is the most common deficiency of development in these organ? 

in civilised people: it is frequently, though not necessarily, associated 

with the mgenitally feeble uterus; and also, but less 






ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 117 

commonly, with a uterus which is normal, except that there is deficiency 
in size of the external opening : all these things tend towards sterility or 
limitation of propagation, either by direct prevention of the entrance 
of the sperm, or by that frequent refusal of intercourse, and subsequent 
avoidance by the husband, which is commonly known as incompatibility 
of temper. 

The uterus, with normal length of cavity but of feeble development, 
may be deficient in size, strength, and weight ; and may have a feeble 
cervico-corporeal junction, so that the body, unable to maintain its normally 
slightly anterior curvature, may fall by the pressure of the intestines above 
it into the horizontal position ; the cervix, on the other hand, readily 
yielding to the anterior force of a distended rectum, looks forwards 
and downwards ; thus the anteflexion of the feebly developed uterus 
ensues. With this in the marked condition, is coincident deficiency in 
size of the opening, so that obstruction by the angle of the anteflexion 
to the passage of the secretions increases the tendency to their delay 
within the cavity of the uterine body : the latter is thereby the more 
strongly depressed into the horizontal position, and dysmenorrhea and 
sterility result. 

The cervicitis occasionally found in connection with the feeble ante- 
flexed uterus is thus produced. The secretions collect within the cavity 
of the body by the obstruction at the inner os, which is usually caused 
by the angle of flexion ; distension then induces muscular contraction, 
and this forces the menstrual blood past the angle into the cervical canal ; 
but as the external opening is congenitally minute, escape is again hin- 
dered, and the cervical cavity is thus also dilated : the quantity of the 
corporeal secretion increases, muscular contraction follows, and escape 
is effected ; but the cervical membrane at the external os has been 
depressed, irritated, inflamed, thickened, everted, and become granular, 
and this, however slight it may be, narrows the opening yet farther. The 
cervical tubulo-racemose glands have been compressed by the pressure 
of the secretions, and their mucus is thus retained within their tubules ; 
they become irritated and inflamed, and secrete an increased quantity 
of mucus, which becomes abnormally cohesive and ropy. This mucus 
presently extends from the columnar secreting cells in the glands, occupies 
their canals, unites with the secretion of adjacent glands, fills the cervix, 
projects through the external os, and by its constant pressure gradually 
dilates the external os. Thus at the time of examination the cervix may 
present downwards and forwards, the external opening may be of normal 
size and occupied by cervical mucus, the cervical canal may be dilated, 
.the inner os, perhaps lying to the side of the central line from unequal 
lateral hyperplasia, may be difficult to find : the body of the uterus 
may be horizontal, forming an acute angle of anteflexion with the cervix, 
and the whole uterus may be of feeble structural development, although 
it may measure 2 \ inches in its canal. The dysmenorrhea may have 
ceased or not, according to the degree of stenosis, by bending or hyper- 
plasia of the inner os ; but sterility remains. 



i iS SYSTEM OF GYNAECOLOGY 

The dysmenorrhcea which occurs a day or bo before the flow is due to 
engorged vessels in the endometrium around the utricular glands and on 
the mucous membrane, of which the columnar epithelial cells and under- 
Lying connective-tissue-matrix are proliferated ; so that the general struc- 
ture is thickened, and presses on the irritable nerves derived from the 
pelvic plexus, the pain being referred to the promontory of the sacrum, 
and ceasing when escape of blood from the vessels relieves their tension. 
But the dysmenorrheas occurring synchronously with the flow, in conse- 
quence of rapid uterine distension and contraction necessary to overcome 
obstruction, is felt at the lower abdomen in the uterus itself ; and this 
- when the stenosis lias been overcome and continuous escape estab- 
lished. 

The normal uterus may he deficient only in the form of the conical 
cervix, or in the size of the external oj)ening due, in the former case, 
to deficient cervical structural development, and, in both, as to size of 
the opening, to deficiency of development of the lower part of the cervical 
canal, or to undue contraction of the lower circular muscular fibres. 
The body may be weighed down by temporary catamenial retention or 
excessive abdominal pressure, and thus be horizontal, occasioning some 
stenosis by bending at the upper cervix: generally speaking, dysmenorrheas 
and sterility will ensue. 

Again, the uterus may be well and Btrongly developed in all other 
respects, but the cervical mucous membrane at the external orifice, which 
often extends on to the vaginal face of the cervix, may extend within 
the cervical cavity. The simple early embryonic epithelium, Lining the cavity 
of the genital canal during development, changes its character in the lower 
third, which is the vaginal portion, becoming there a stratified pavement 
epithelium, which passes very gradually into the cylindrical epithelium 
of the upper, uterine portion. The change progresses upward, and, as it 
advances, the demarcation between the two kinds of epithelium becomes 
Bharper, and at the eighth month of utero-gestation is abrupt at the 
junction of the uterine with the vaginal canal ; the vaginal stratified 
epithelium often extends a short distance inside the os uteri (Minot ), but, 
on the other hand, frequently fails to reach it. This congenital, ap- 
parently granular os is attributable to one or other of the following 
conditions : 

(1) That the vagina] Gratified epithelium is deficient in extent of 
growth Up to the lower border of the cervical canal, and thus the cylin- 
drical epithelium projects into the vagina, and is exposed ; or 

I) That the Lower (cervical glands and cylindrical epithelium, being 
developed beyond the enclosed lower cervical opening, remain exposed^ 
because the circular muscular fibres, which become distinct about the close 
<f the fifth month, do not Bubsequently contract ;it the lower border of 
the cervical canal sufficiently to include them within the canal. 

The effect of this expOSUre Of the glandular structures at the external 

opening of the cervix to the influences of the acid vagina] secretions, and 

to frictlOD against the vagina on movement, intensified by fixation due to 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 119 

abnormal abdominal pressure, is the production of an excessive supply 
of blood, which causes congestion and inflammation of the glands and 
increased secretion of their strongly cohesive mucus, which plugs the 
canal : the uterine vessels thus becoming enlarged, a varicose state may 
be induced, and the whole uterus become congested, so that general 
endometritis ensues. Also, the connective tissue at the face of the cervix 
becomes hyperplastic, the lips are compressed, and thereby the secretions, 
which are usually plentiful, find difficulty in escape : the uterus becomes 
irritated by distension, so that endometritis is increased, and evolution- 
ary disease of the tubes, peritoneum, and ovaries, and (under the con- 
current influence of excessive abdominal pressure) anteflexion or retro- 
version ensue : hence result virginal monorrhagia and dysmenorrhea, and 
sterility on marriage. 

Vigorous sexual development is specially noticeable in families and 
races which bear many children, among which may be particularly men- 
tioned nations inhabiting or derived from the warmer climates. Of these, 
Jewesses are liable to the congenital granular os of strong formation, 
and to the small external opening. These conditions are compatible 
with coincidence of such a deficiency of development as permits the closure, 
or almost complete closure, of the genital canal by the hymen. 

The deficient structure of the cervix of the feeble anteflexed uterus, 
through the small opening of which the sperm has by chance passed and 
impregnated the ovum, is, even on the hypernutrition of pregnancy, ill 
adapted to bear the strain of dilatation in labour. The pressure of 
the membranes does not act to advantage on the minute opening, so 
that the cervix may be stretched out and rigid, and the wedge of the 
membranes unable to engage. Thus the circular fibres are irritated, are 
in a state of tonic spasm, and .act at advantage \ but the longitudinal 
fibres, being lengthened by the downward pressure of the rounded 
membranes, act at disadvantage. Should the expulsive force be sufficient 
and the spasm continue, laceration of the cervix may be very extensive ; 
or the lower segment of the uterus may rupture or be torn off. 

On dilatation, the circular muscular fibres are deficient in strength 
and the cervix in structural breadth ; thus laceration is frequent. 

In the strong uterus with a deficiently developed os, there is a 
liability to laceration from the comparative non-dilatability of the small 
opening. Should bilateral laceration occur, lateral eversion takes place 
from contraction of the two halves of the torn circular muscular fibres ; 
and horizontal eversion of the cervical face from contraction of the longi- 
tudinal muscular fibres, which are no longer restrained by the circular. 
But the edges of the wound are healthy, and the epithelium may readily 
spread thence on to the raw surfaces, unless prevented by subsequent 
vaginal friction from undue abdominal pressure. 

In unilateral laceration eversion is apt to be slight ; the circular 
fibres are ruptured at one side only, and the other side remains of strong- 
structure, sufficient to counteract the longitudinal contraction and prevent 
eversion of the face of the cervix ; the circular fibres, on the other hand, 



SYSTEM OF GYNAECOLOGY 



having only one line <>f laceration, retract at slight advantage. Thus 
the ('version is only unilateral, and of small extent. 

These actions, necessarily less marked in the feeble cervix because 
it is small in every direction, are accentuated in the large, strongly- 
developed cervix. 

To pressure in labour, long continued by the difficulty of dilatation 
of the small opening or other conditions of obstruction, may be due, by 
stasis of blood, the necrosis of tissue which, on separation after a few days, 
permits the passage of the excretions of the adjacent bladder or rectum 
affected, as well as of the slough, through the genital canal. Thereby a 
sinus is formed, called vesico-vaginal, recto-vaginal, or other fistula. 

In pregnancy in the strong uterus, with the virginal everted granulai 
face and hyperplasia, from the large size of the opening dilatation pro- 
ceeds readily up to a certain point, when the head commences to pass. 
But the connective hyperplasia is ill adapted to excessive dilatation ; and, 
when the great strain of expulsion of the head through the cervix is put 
upon it by the well -developed uterus, extensive laceration of the cervix 
usually results. The subsequent granular face and eversion are apt to be 
great; for the previously granular hyperplastic membrane is not readily 
susceptible to epithelial growth, and the raw and deeper newly lacerated 
central faces are thus far removed, except at the sides, from vaginal 
epithelium. Moreover, the longitudinal cervical muscular fibres act at 
advantage, so that the lower edges of the faces are drawn upwards and 
outwards, and everted. This action is not restrained by the circular 
fibres, which are torn across; hence the lateral edges of the cervical 
wound are drawn outwards, and still more everted. 

In subsequent confinements the extent of laceration is generally 
increased, since the angles of previous laceration are healed by cicatricial 
connective tissue, which is ill adapted for dilatation ; or they may also 
be hyperplastic, which is still less so, being softer and less strongly 
formed and resistant. 

When the first stage of labour has been unduly prolonged by delay 
in dilatation of the strong cervix with deficient formation of the 08, the 
Uterus is liable to become irritable, and to be aroused to excessive vigour 
of contraction, in which, owing to the pain and general excitability of the 
woman, the accessory muscles participate; thus labour is precipitated and 
the head may be forced down with violence on the perineum. Should 
the power be much greater than the resistance, the head may burst 

through the perineum before the muscular structures have had time to 
dilate: whence perinea] laceration, which is extensive in proportion t<> 
the want of due relation of these forces. Or the vagina and perineum, 
rigid in accordance with deficient sexual appetite and development, may 

not have sufficiently softened in pregnancy, and may not readily dilate, 
so that in the passage of the child perineal laceration occurs. 

From deficiency of dilatation from the foregoing causes it may be 

jary that assistance by the forceps be gi\ r en to the passage of the 

child. The State of the parts, whether of the cervix or perineum, 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 121 



rentiers a gradual advance most appropriate ; while the condition and 
feelings of the woman, weary and in excruciating pain, seem to indicate 
the desirability of speedy delivery. Under such circumstances the 
forceps are very often used without an anaesthetic, and laceration is 
frequently thus effected ; even if the head have not passed through the 
cervix the forceps may be made to draw it down quickly, after which 
the increased pain by pressure on the perineum as yet unstretched 
induces the attendant to hurry, and a few minutes only may be given to 
dilatation in place of the two hours which nature would have employed. 
But if chloroform be given these influences are lessened, dilatation may be 
quietly effected, and laceration prevented or limited. 

If the fresh, raw surfaces at the cervix or perineum, lacerated deeply 
into the broad ligament or recto- vaginal connective tissue respectively, 
absorb septic germs, a pelvic cellulitis results commensurate with the 
virulence of the sepsis. If of the most violent type, there is a general 
suppurative oedema of the connective tissue and suppurative phlebitis, 
and death probably ensues. Or, the microbic attack being less virulent, 
a suppurative thrombus may be impacted in a vein, guarded toward the 
peart by a sufficiently healthy adherent clot, and the increasing pus may 
burst through the venous wall, infecting the adjacent connective tissue 
and presenting in the direction of least resistance : if the microbes be 
detained in the lymphatic glands a similarly localised pelvic suppuration 
may occur. A local necrosis of connective tissue at the site of laceration 
may escape by the genital canal, or a benign inflammation terminate in 
resolution. 

The morbid influence of the micrococci is effective only so long as 
the power of the septic micro-organisms is greater than that of the 
phagocytes and leucocytes, so that the former force a passage into, and 
are carried by the lymphatic and blood vessels into the general system ; 
if the latter presently overpower and destroy the micrococci, the healing- 
process forms granulations guarded by an army of victorious cells, and 
parasites can no longer gain admission, though they may create a local 
superficial suppuration [vide article on Inflammation]. 

It is not rare that the angle of laceration in the cervix has been so 
high that the tension of the growth of the ovum in succeeding pregnancies 
causes such irritation as exaggerates the normal uterine contractions, and 
miscarriage or premature labour results. 

The appropriation of the absorbing, healing, and nutritive action of 
the lymphatic and blood vessels in such inflammation of the lacerated 
cervix, at the expense of that which the removal and renewal of the parts 
requires, usually results in subinvolution of the ligaments, and of the 
muscular, connective, venous, and nerve tissues of the pelvis and general 
system in proportion to the strength of the inflammation, its extent, and 
the degree of its subsequent continuance and drain. Should laceration 
of the perineum, as well as of the cervix, have occurred, subinvolution of 
all the genital structures generally results ; if only of the one or the 
other, then of the parts specially allied to the nutrition of that one. 



S YSTEM OF G YNsECOL OG Y 



The misplacements which may arise in connection with subinvolution 
are described in section .">. 

The subsequent occurrence of sterility or pregnancy is dependent on 
the degree to which the cervical circular muscular fibres and external 
cervieo-vagina] wall are lacerated, effecting more or less eversion up to 
the level 01' the uninjured canal ; should the opening in such complete 
lateral laceration be narrowed by the pressure of everted cervical mucous 
membrane and ensuing hyperplasia, whereby the norma] trumpet-shaped 

opening IS Lost, the sperm cannot enter, and sterility results; or a eel' 
vicitis and endometritis may result from vagina] friction, and mucous 
secretion plug or fill the uterine tube. But if the laceration do not 
extend through the outer wall of the vaginal cervix, the canal may be of 
an enlarged trumpet-shape, and the sperm enter with unusual readiness : 
Or the end of the penifi may penetrate such a canal, and directly inject 
the sperm into it, effecting rapidly recurring pregnancies. 

The state of constant excessive proliferation of cells of low type by 
the granular hyperplastic lacerated cervix is most favourable to the 
development of cancer, which is further discussed in section C, on con- 
stitutional causes. 

Endometritis, with or without displacement and subinvolution in the 
parous, having been induced by one or other of the causes previously 
mentioned, or by the action of special microbes, as of gonorrhoea of 
puerperal septicaemia, some thickening toward the uterine end of the 
Fallopian tube, which is only of the size of a fine bristle, takes place 
by extension of the endometrial inflammation to the tubal mucous mem 
brane and the consequent obstruction frequently increased by stenosis of 
the cervical canal, which mechanically hinders or prevents escape of the 
Uterine and tubal secretions. 

The secretions, accumulating in the tube, overflow through the fimbria 
into the abdominal cavity, whereby an irritation or inflammation of the 
peritoneum is caused proportionate to the quantity and quality of the 
fluid effused ; peritonitis being always due to the entrance of irritating 
matter gaseous, fluid, or solid into the abdominal cavity directly, or 
by transudation under great inflammatory distension. In the effusion of 
a Wand fluid .1- of .1 healthy tubal mucus, mild ovarian follicular fluid, 
small quantities of blood or healthy urine the irritation may not 

amount t-> more than an excitation of the peritoneal endothelial cells for 

the purpose of its absorption, and the fimbria may remain \vw and unin- 
jured On the relief of an existent cervical cause of endometritis, such as 
granular eversion, virginal or from laceration, the tubal stenosis may 
cease; and the tube may again become normal. Should the effusion be 
more irritating and septic, fibrin is exuded by inflammatory action of 
the peritoneum ; thickening of adjacent structures, or adhesion by eon 
nective i nisation <t the exuded fibrin occurs, and the fimbria 

of the tube becomes attached and closed ; the tubal secretions, collecting 

in the more dilatable mid-part of the tube, then distend it, and .1 pyo- 
salpinx is formed. Under pressure the uterine end may yield and the 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 123 

pus escape through the genital canal : if this do not occur and the bacterial 
virus be moderate in power and become attenuated, the secretion may 
not increase in quantity ; pus-cells may undergo fatty degeneration and 
absorption, and a more or less stationary hydrosalpinx presently result : 
or, again, if the healing process be less complete, caseous pus may persist. 
But if the bacteria be virulent in quantity or quality, pus continues to 
collect, and, by increasing pressure, a gradual thinning of the tubal wall 
at the site of least resistance takes place. As the inner coats of the 
tube break down, its peritoneal coat yields, and presently a minute per- 
foration permits a slight effusion into the peritoneal cavity. Thereupon 
an exudation of fibrin occurs about the site of such rupture, and the 
peritoneal surfaces of the tube and the adjacent viscus (commonly 
intestine) cohere. As the tubal distension continues to increase, an 
opening through the united peritoneal layers into the viscus occurs, and 
the pus escapes from the tube. Through this opening, or by penetration 
through the adherent, inflamed, distended, thin, intervening structures, 
bacilli from the viscus, such as the bacillus pyogenes fcetidus from the 
intestine, may enter the tube and render the pus fetid. Sudden pressure 
may cause rupture directly into the peritoneum and a virulent peritonitis. 
In labour the pressure of the foetal head may rupture the pyosalpinx 
into the broad ligament, and thus extensive suppurative connective tissue 
may spread in the direction of least resistance, the vigour of the extension 
being dependent on the character of the bacillary cause of the tubal 
suppuration : it is specially virulent in gonorrhoeal infection. 

Should the effusion from the fimbria be of a virulent character, such as 
septic pus, there may be a preliminary slight oozing which, while creating 
a severe inflammation of the adjacent peritoneum at the site, yet permits 
the exudation of organisable fibrin at a slight distance, so that the fimbria 
becomes encapsuled, and perhaps adherent ; but a septic abscess may thus 
be originated by this effused pus between the fimbria and the adherent 
viscus ; whence arises a tubo- peritoneal abscess, which may be tubo- 
ovarian. If there be more extensive peritonitis with distant organised 
adhesions, peritoneal abscesses, perhaps saprous by intestinal bacterial 
transudation, may be formed ; and the omentum, by lymphatic absorption, 
may be studded with abscesses and adherent to the abdominal wall. But 
if the effusion be large or continuous as of such septic pus, when organis- 
ing fibrin has not been exuded, or has not attached and occluded the 
fimbria on account of the virulence of the effused matter the peritonitis 
is general and virulent, and the exudation sero-purulent with occasional 
cohering fibrin-flakes. 

The peritonitic exuding organising fibrin may attach adjacent abdominal 
or pelvic surfaces, as those of the uterus, tubes, ovaries, intestines, vermi- 
form appendix, omentum, or abdominal or pelvic wall ; or form bands like 
floss-silk, violin strings, or tapeworm. The intestines, during the period 
of acute inflammation, are comparatively stationary, except for gaseous 
distension ; but during the period of convalescence they undergo con- 
siderable alteration in position by vermiform action. The connective 



124 SYSTEM OF GYNAECOLOGY 

tissue adhesions become stretched by these movements of the intestines; 
and, later, may constrict them, and produce various degrees of obstruction 
to the passage of flatus or fares, and to the circulation of the blood. 
Between extensive organised fibrinous adhesions serous sacs may be 
formed, either by the presence of attenuated bacilli in adjacent peritoneal 
surfaces and irritation of them, or by transudation of serum from veins 
constricted by bands or adhesions. This latter condition is seen when 
the abdomen is opened for the relief of intestinal strangulation caused by 
such a band. 

By the organisation of the exuded fibrin into connective tissue the 
tubes may be bound down at the fimbriae, or more extensively ; or the 
two fimbriae may cohere posteriorly. Thus they are in future, perhaps, 
unable to apply themselves to the site of the mature Graafian follicle ; or 
one may be thus adherent, and the other, being free, may apply its 
fimbria to the other ovary on ovarian maturation. 

The irritation produced by effusion from the fimbria of the tube causes 
a thickening of the tunic of the ovary by its inflammatory cell multiplica- 
tion and condensation ; if the peritonitis be more severe, the surface may 
be coated with exuded organised fibrin, which may form into bands. or 
be densely adherent to adjacent peritoneum. When the ripe Graafian; 
follicle has advanced from within the ovary to this thickened and 
condensed surface layer, its further progress is thereby impeded; the 
liquor follicuh may increase in quantity beyond the normal, and a 
haemorrhage take place into the cavity and so effect its rupture. The 
ovarian tunic may yield under this increased tension, when a fimbria may 
by its previous affections be unable to apply itself, and its abnormal 
contents may thus fall into the abdominal cavity. By the stress of 
such a follicle on the ovary an undue pressure on the ovarian stroma may 
create pain, and by the escape of the contents into the peritoneum 
peritonitis be caused. The opening may be quite minute, or door-like and 
valvular by contact with the adjacent peritoneum, so that the fluid 
"Ut gradually ; and, the irritation causing peritonitis being thus con- 
tinuous the temperature may remain high, tin nigh the inflammation be really 
confined to the locality of the etl'usion. Degrees of pyrexia in peritonitis 
Beem often to be dependent mi the degrees of mildness or virulence of the 

etl'usion. and on the 6XCeS8 of absorption over exudation. It is often high 
when the cause IS mild, and absorption by the lymphatics into the system 

active; normal, when the effusion is virulent and peritonitic exudation 

dominant ; and low, from debility and shock, if a large quantity of blood 

be poured into the peritoneum by rupture of vessels. 

ch ruptures of different cysts may be consecutive, producing recurrent 

peritonitis; and should blood be present in the follicles, the irritation is 

the greater. Frequently rupture is not effected, and a follicular cyal 

remain- which may be tilled with blood ; this is possibly more generally 
the case when the maturity of the follicle has been coincident with men- 
struation or sexual union. Such follicular CystS may attain to the size of 
a walnut, or occasionally larger than that ; and, finally, as the gradual 






ETIOLOGY OF DISEASES OF FEMALE GENLTAL ORGANS 125 

increase of fluid thins and ruptures the walls, they may empty themselves 
into the peritoneum and produce peritonitis. 

By the continuance of pressure of these cysts the ovarian stroma is 
permanently compressed and atrophied ; and the ovary may be composed 
of little more than such sacs. This fluid may after a time be absorbed, 
when the ovary by contraction of the sac-walls will appear to be cirrhotic ; 
but the outer walls of the cysts remain mainly as connective tissue con- 
densations. 

If in the earliest period of septic infection of the fimbria, which is 
usually puerperal, gonorrhoeal, or tuberculous, its effusion have had time to 
effect a peritoneal exudation causing cohesion of the fimbria to the ovary, 
a free escape into the peritoneum may have been prevented, and the 
fimbria may have become adherent to a subsequently ripening Graafian 
follicle, which may rupture into the lumen of the tube : the septic matter 
may thus enter the cavity of the follicle, and lead to a septic abscess of 
the ovary ; or bacteria may penetrate the thinned wall of the follicular 
cyst, which is inflamed by contact. The further progress of abscess of the 
ovary is described under section 6, as its causation is always bacillary. 

When tubal disease of a moderate degree is in progress of recovery, 
extra-uterine foetation may occur. The disease may have arisen from 
endometritis, however caused ; but specially from the virginal granular 
cervix or from a lacerated cervix, which may have been cured by opera- 
tion ; or it may have had a gonorrhoeal origin, with attenuation of the 
bacteria under conditions of free uterine drainage. There has been 
stenosis of the uterine end of the tube, and perhaps some mild peritonitis 
from tubal distal effusion : in process of recovery this stenosis has been 
mitigated, but not completely removed, and the semen has been able to 
enter the tube and impregnate the ovum. If the outer part of the tube 
be sufficiently patent, the ovum may be able to advance to the portion 
within the uterine wall, where it may be stopped by the congestion of 
fecundation external to the site of the stenosis, and there develop as a 
tubo-uterine fcetation. Should the site of the stenosis be more external 
the gestation is tubal. 

In rupture of a tubal gestation more or less of the contents of the 
ovum, with blood from the torn chorionic villi, may be discharged through 
the fimbria and form tubal abortion ; or through the lateral wall into the 
abdominal cavity, and produce peritoneal hematocele and peritonitis, of 
which the degree and progress will vary with the quantity of blood 
lost in relation to the bacilli of the original salpingitis, which probably 
escape with it from the tube external to the envelope of the ovum, 
and the subsequent necrosis of the ovum : or again into the broad liga- 
ment, forming a hematocele in its connective tissue, the blood forcing 
its way in the direction of least resistance, and perhaps suppurating 
under the influence of bacilli introduced from the tube, which may 
throughout have remained mildly septic from the original causation of its 
disease. 

If the quantity of blood lost by such rupture be so slight that the 



126 .s ) STEM OF G J W. KCOLOG Y 

ovum survives, the subsequent condition is that of a compound abdominal 
pregnancy, with such relations of the placenta as are determined by its 
situation, either below the foetus toward the floor of the pelvis or 
above it in the abdominal cavity. 

The pressure of the enlarged tube or ovary may push the uterus over 
to the opposite side, effecting latero-version, from which there may be 
recovery on subsidence of the tumour. Or a peritonitic exudation from 
tubal or ovarian effusion, or a hematocele may similarly displace the 
uterus to the opposite side ; but, on absorption and organisation, the 
Uterine body may be drawn over by the condensed exudation and per- 
manently retained on the affected side. 

C. The hereditary constitutional defects, in which certain classes of 
cells morbidly proliferate, are dermoid tumour, parovarian cystoma, 
cystoma of Gartner's tubes, ovarian cystoma, papilloma, myoma, sarcoma, 

and cancel-. 

By "constitutional" is not meant that the disease will certainly or 

probably occur because of heredity, but that there is a constitutional 
capacity for such cell proliferations, should the parts be placed under 
suitable exciting causes. Thus, as to the development of cancer from the 
continuous irritation of a granular cervix, the latter may in some cases 
persist to the end of a long life and remain benign; in others, where 
there is a constitutional capacity of such cell degeneration, it readily 
becomes malignant. 

The etiology of the dermoid tumour is attributable to the origin and 
mode of development of the ovary. From the mesothelial division of the 
mesoderm are formed the ovary and striated muscle ; from the 
mesenchyma, which is the other division of the mesoderm, com-' the con* 
nective tissue, the heart and blood-vessels, lymphatics, smooth muscle, fat 
cells, and the skeleton. The dermal bones, which are those of the head 
and face, and are most frequent in dermoid cysts, are formed by direct 

ossification of connective tissue; they are homologous with the plates 

formed by the fusion of epidermal teeth, or of the so-called placoid scales 

which air true teeth developed in the skill and supported by a base of bone : 

of them there is tin- stage of scattered independent dermal teeth (dermoid 
beeth-bearing plates formed by the fusion of the expanded bases 
of adjacent teeth (exo-skeleton) ; and membrane-bones developing without 
tin- appearance of teeth. (Minot.) 

The m. -othcli.il layer of the mesoderm is closely connected with the 

ectoderm ; the mesenchyma with the entoderm. 

From the ectoderm are developed epidermis and epidermal structures. 

such as luiirs. nails, glands (sebaceous, sudorific, salivary, and mammary, the 
mammary being a hyper-development of the sebaceous), the eye, and tin; 
mouth cavity with tin- teeth ; all of which structures are occasionally 
round iii the dermoid cyst Thus in the formation of the dermoid ovum 
some mesenchymatoufl and ectodermal cells have by migration been 
incorporated with the mesothelial, and. continuing a constitutional 
abnormal growth, originate and produce the contents. 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 127 

A projecting dermal bone may perforate the sac wall and produce 
peritonitis, whereby the adjacent structures cohere so that bones and other 
contents may escape through the bladder or intestine ; but the sac probably 
Inflames on the admission of bacteria. 

After the period of vital activity and growth of the contents of the 
tumour, growth may cease by deficiency of nutrition, caused by bending 
of its vessels from the pressure of the tumour, or by the diminished size 
of the blood-vessels after the menopause ; retrogression may then set in 
and pass through a stage of fatty degeneration, absorption, and calcare- 
ous transformation of the sac wall and its contents which may thus 
become atheromatous or calcareous. Crowding, by excessive local cell 
proliferation occluding small vessels, may produce necrosis of some part, 
as of a sebaceous gland, whereby suppuration within the sac may be 
induced ; the pus may become foetid by transudation through inflamed 
distended adherent sac -intestinal walls, or by the direct admission of 
putrefactive germs from adjacent adherent perforated intestine, or by 
operative septic puncture. Or suppuration may proceed from the irritation, 
inflammation, rupture, and necrosis from excessive proliferation of a 
papilloma within the dermoid, either on the inner wall of the sac or on 
dermal plates : or by further cell degeneration cancer may ensue. 

The parovarian cyst is caused by an embryonic deficiency of absorption, 
and a subsequent hypertrophic glandular secreting development of the 
granular cylindrical lining cells, which normally remain quiescent in the 
sexual part of the female rudimentary Wolffian ducts situated in the con- 
nective tissue of the broad ligaments. In the early embryonic state the 
future male is indistinguishable from the future female. In the male the 
developed epididymis is the analogue of the atrophied epoophoron or 
parovarium of the female. The epididymis is lined with columnar 
epithelium ; and a continuation of this layer with secreting power, and 
deficiency of resorption or atrophy in relation to hypernutrition, originates 
the parovarian cystoma. It is probably a continuance of or a reversion to an 
embryonic or local hermaphroditic type. In its enlargement it parts the 
walls of the broad ligament, and spreads out upon its surface the 
Fallopian tube and fimbria, and later the ovary ; it may extend deeply 
into the connective tissue layer of the pelvis, or on the uterus. As the 
cells lining the sac have but slight power of proliferation, probably from 
defective nutrition of a structure normally in arrest of development, the 
sac wall is very thin ; and there is no ingrowth, for this is not the mode 
of its analogue, the epididymis, nor of antecedent phases : thus the cyst 
is unilocular, unless by cystic development of more tubules of the paro- 
varium ; and veins do not become varicose and rupture internally, unless 
by rotation of the pedicle, or their kinking under pressure of the tumour. 
For the same reason secondary growths, such as papilloma, which require 
local hypernutrition, are rare. 

A cystic tumour situated laterally in the vagina may have its 
origin in a similar state of one of Gartner's tubes, which are the lower 
parts of - the atrophic Wolffian ducts, are the analogue of the male 



128 SYSTEM OF GYNAECOLOGY 

adult spermiduct and vesiculse Beminales, and run through the genita 
cord. 

As to the etiology of ovarian cystoma, in the development of the 
ovary portions of its externa] germinal columnar epithelium grow inwards, 
and some of these cells become ova; while deeper multiplied cells of the 
same description form the membrana granulosa of the Graafian follicles. 
The normal function of these cells is to conduce to the nutrition and 
further development of the ovum, which has the highest power of pro- 
gressive development in the body. But it occasionally happens that the 
tendency to continuous proliferation of the cells of this layer is greater 
than the subserviency to perfection of growth of the ovum, and their 
multiplication is in excess. At the same time the inner cells rupture and 
pour their secretion internally; by such continuous process an ovarian 
cystoma is formed, which persistently enlarges. It is a constitutional 
degeneration into a glandular secreting structure. 

As the cells of the germinal epithelium do not all arrive at the produc- 
tion of the complete Graafian follicle, but there are many less well- 
nourished primitive ova embedded in the stroma, it is possible that, while 
the better-nourished cells of the membrana granulosa are most apt to 
undergo this degeneration and the cystoma to be formed originally in a 
Graafian follicle, those in the stroma may also proliferate in a similar 
manner tinder the influence of the existing constitutional tendency. 

In this growth, morbid in man, may be seen a strong analogy to the 
development of the ova and the yolk-food in some lower creatures. In 
them from the inner wall of the germinal plasma grow cells, usually 
columnar in character, which form (a) ova, or (b) germinal cell-nests ; from 
among these one or more ova may be produced, while the rest of the cells 
serve as yolk-food and disintegrate. The number of ova, in some creatures 
nine millions in the cod, three to six millions in the conger (7, 9), 
and seventy thousand in the woman is frequently prodigious. 'The sac 
membrane may bud oil* internally, and form laminae and branches for 
further cell proliferation on their walls, and subdivision of the ovarian sac 
These partitions may break down to permit extrusion of the ripe ova. 
Some creatures, as for instance the conger, breed only once, and die by 

the enormous distension of the body by accumulation of ova, which, in 
captivity, are incapable of escape. In ovarian cystoma the multiplication 
of Cells thus closely Bimulates and is analogous to similar proliferation in 

Lower creatures, either as primitive ova-cells, or as germinal cell-nests, 
undergoing pi degeneration; and may be regarded as a morbid 

h y p er trophic germ plasma eel] proliferation reversionary to an anterior 

type. Although children have been bom with this disease, and occasional 

instances are found in the early years of life, when the condition may 

egarded as one of defective development, it is most commonly 

found to commence during the years of strong generative ovic vitality j 

and many patients, nearly a third, arc single. It is tints probable that 

ii cystoma is a degenerative reversionary proliferation of the germinal 

ovic epithelium (akin to that of the nnstriped muscular and Connective! 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 129 

cells occurring in myoma), in relation to absence or deficiency of their 
normal employment, namely, the production of the next generation. 

The degeneration being thus of a type which affects the development of 
all the cells of this class, the disease does not attack one follicle only, but 
is common to all ; not necessarily at the commencement, but subsequently. 
Hence a cystoma, on its attainment of some size, is almost always 
multilocular j one sac may, however, by appropriation of the most 
nutrition, attain to the greatest size. 

By ingrowths of the lining columnar cells a cyst may be divided, 
and by such repetitions it becomes additionally multilocular. By the 
thinning and rupture, or the necrosis of a partition by excessive 
pressure of the fluid on one or both sides respectively, two cysts may 
become one. By varicosity of veins induced by the pressure, which is 
frequently at the junction of the tumour with the pedicle, or by pressure 
of adjacent rapidly -growing cysts on a vein, the rupture of a vein may occur; 
and one or more cysts in a multilocular tumour may be filled with blood. 
By similar partial pressure on the arteries and veins reducing nutrition, 
fatty, purulent, or calcareous degeneration of the lining cells and thus of 
the contents results, whether of one or more of the cysts. 

By some kind of changing pressure, such as manipulation, descent of 
faeces, vigorous alteration of position, or tension of or pressure on the 
tumour as in lying, or by the growth of the pregnant uterus, or 
in parturition, or on removal of pressure as after parturition, or on 
change in form of the tumour, as by the emptying of a large cyst 
in a multilocular tumour by tapping, rotation of the tumour may 
take place, and the pedicle be twisted an event which may similarly, by 
the same or similar causes, be many times repeated ; thereby the 
vessels are liable to be occluded. Partial closure both of arteries and 
veins limits circulation and nutrition, and may materially restrict the 
development and growth of the tumour. But the circulation is less 
obstructed in the arteries than in the veins ; whence may result ascites 
from serous effusion through the coats of the latter on the external wall 
of the tumour ; or veins may rupture externally or internally, but in a 
limited degree for the tension is not severe. If externally, the blood 
coagulates between the sac wall and the adjacent peritoneum ; these 
cohere, vessels form, and the venous return is thus facilitated, and the 
vitality of the tumour perhaps preserved. The adhesions prevent further 
rotation of the tumour, Avhich may have been partial, so that the cyst 
may occupy a fixed position on the side opposite to its own. Such 
adhesions restrain the movements of intestine and omentum to which 
they may be attached ; and varying degrees of obstruction to the passage 
of flatus and faeces may be produced : at a later stage stretched bands 
may tightly constrict the bowel, strangulating it, compressing the veins, 
and causing actual rupture or serous effusion from them into the abdominal 
cavity. The future growth may be slow, and is subject to these 
adhesions ; and perhaps not till an advanced period of life are such results 
produced that the presence of the tumour is first discovered. 

K 



130 SYSTEM OF GYNAECOLOGY 

Should the wins 1>e occluded by a more complete or more repeated 
rotation, an intense engorgement immediately occurs : veins on the in- 
terior of the cyst wall rupture, and the sac is tilled with blood, whereby 

sudden enlargement and perhaps rupture of the sac take place ; the 
abdominal cavity may then he tilled with blood and ovarian fluid, and the 

woman faint or die. If there be venous rupture also on the outside of 
the sac but without rapture of the sac peritonitis and adhesions occur, 
which partly nourish this surface: the tension of the walls effects their 
and by transudation of the necrosed fluids through the dis- 
tended sac wall into the abdominal cavity an acute or chronic peritonitis 
will result proportionate to the predominance of absorption or exudation : 
these factors are determined by the quality and quantity of the fluid 
transuding, and by the degree of internal tension. 

If the arteries and veins be closed at once by the compression of a 
twist, no more blood enters the tumour, and it tends to necrose by lack 
of nutrition. As it necroses, transudation of its fluids produces peri- 
tonitis, and fibrin is exuded which, by its development of vessels, may 
effect such a nutrition as to maintain just so much vitality of its surface 
cells that a slow absorption occurs; the tumour decreases in size, and remains 
in a stagnant condition. Such complete closure of arteries is rare in 
comparison with that of veins, as these are more readily compressed by 
an earlier rotation. 

By a continuous pressure on a bony angle as on the sacral pro- 
montory of a tumour of which a part occupies the sacral cavity, and 
part the abdominal cavity, there may be by limitation of circulation a 
thinning of the sac wall at this site which may result in necrosis ; ruptun 
may occur, and the fluid escape into the abdominal cavity. The saint 
result may follow extreme distension from venous rupture due to a 
twisted peilide, or from a sudden blow, or fall. If the fluid itself be 
bland the resulting peritonitis may be slight, but more or less progressiva 
according to its quality and quantity, and the degree of infecting necrosis 
whi<h may presently occur in the ragged edges of the torn wall, combined 
with the influence of systemic depression and abdominal pressure effected 

by the hemorrhage from vessels which may also be torn. 

A further degenerative cell multiplication may induce papilloma; and 
one -till lower, cancer, with peritonitis by invasion, haemorrhage and 
scrou- effusion into the peritoneum. 

Papilloma of the genital organs which is a progressive multiple 
development Oi ectodermal or entodermal epithelium, enclosing a vascular 
loop formed of | capillary terminating in a small vein and thus forming a 
papilla is liable to be produced by an irritation which induces an 
increased growth in any part of the genital organs. About the vulva 

the cause may be the irritation of syphilitic discharge ; at the orifice of 
the urethra, of the friction of coition or masturbation, or exposed urethral 
membrane; in the bladder, of urinary crystals or decomposition ; in the 
onally, the hypernutrition of pregnancy: and in other parti 
of the genital organs* as in the uterus, tubes, ovaries, and in th< 



leir 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 131 

tumours and peritoneal coverings papilloma may arise from local irrita- 
tion and vascular proliferation. In connection with all internal papillomas 
the veins are liable to be large and varicose by direct pressure or bending 
on the cardiac sicie. When occurring on the internal aspect of a cyst, by 
complete local venous obstruction, or perhaps from deeper excessive cell 
proliferation, papilloma may undergo limited necrosis and thus suppurate. 
On the peritoneum, friction of its delicate structures usually produces 
serous effusion, and perhaps haemorrhage, into the abdominal cavity. 

Myoma, which is a proliferation of unstriated muscular fibres enclosed 
in a connective tissue capsule, and usually multiple, is attributable to 
absence of pregnancy, from whatever cause, in a woman of strong sexual 
development : the nutrition, which should be absorbed in the develop- 
ment of the pregnant uterus and foetus, is expended in the morbid local 
proliferation of muscular fibres. 

While the muscular fibre proliferation has proceeded a sac has been 
formed also, usually by a similar multiplication of connective tissue 
cells, which surrounds the myoma, enlarges with the progress of the 
muscle fibres, and yet maintains such strength as continually to constrict 
the supplying vessels anil retard the growth. Yet this is not necessarily 
the case ; for occasionally a myoma rapidly grows in the absence of 
synchronous connective sac development, and has the exact form and 
red appearance of the pregnant uterus ; and, in the oedematous myoma, 
the rapid enlargement by serous or lymphatic infiltration of the inner 
structures so distends and softens the sac that its density is diminished. 
In the former unrestricted form is seen the more exact tendency toward 
the pure uterine growth of pregnancy, though the stimulation of the 
ovum is absent. 

The effects of such diseases depend upon the situation of the 
original fecundity of the muscular growth, and thus of the direction of 
increase and prominence of the tumour. If such situation be nearer the 
endometrium the direction of least resistance is toward the cavity of 
the uterus, and the tendency is to the polypoid form ; by recurrent 
rotation due to muscular contraction, a long thin pedicle may be formed, 
the vessels of which by such continuous pressure may become occluded, and 
the polypus die and become septic ; or muscular contraction may expel 
the polypus into the vagina. If more central the tumour is interstitial. 
If in the external part of the muscular wall it grows outwards ; when also 
the pedicle may gradually be lengthened, thinned, and composed only of 
vessels covered with peritoneum : or it may be divided, either by the 
drag of its impaction in the pelvis while the myomatous body grows 
upwards, or by compression of the pedicle against the sacral promontory, 
or again by rotation of the subperitoneal tumour. The pelvic tumour thus 
separated may either undergo a vital degeneration by the encroachment 
of connective tissue adhesions resulting from the peritonitis induced in the 
process of the occlusion of the vessels of the pedicle ; or may necrose, 
inducing peritonitis and septic absorption. 

By cessation of arterial supply, produced by pressure on the vessels 



i 3 2 SYSTEM OF GYNAECOLOGY 

by the tension of the connective tissue capsule of the tumour, generally 
interstitial, the central cells may be so deprived of nutrition that they 
necrose ; if the nutrition be deficient, but still exist to some degree, a 
degeneration, fatty, purulent, or calcareous, may occur. If the veins be 
partially compressed at some point, or in the progress of growth of the 
tumour be kinked, the distal parts become varicose, and the tumour from 
which they are efferent may become cedeniatous. Cysts may also be formed 
by the rupture of veins from a similar cause into the myomatous substance, 
when the cavities thus formed may be found to contain blood : or, later, 
after absorption of the colouring matter, a straw-coloured fluid. By 
occlusion of the veins of the uterine cavity by pressure of a submucous 
or encroaching interstitial myoma their walls may rupture, and haemor- 
rhage, called monorrhagia, result: this is particularly apt to occur at the 
menstrual epoch, when the veins are specially engorged; but it may be 
continuous, in relation to the continued pressure; or recurrent, when the 
blood has been reformed : in the intervals fibrin may escape, which may 
be coagulated or not. With this there may be intense dysmenorrhea from 
the small size of the external uterine opening, which latter, indeed, 
may have been the original cause of the sterility, and so of the 
myoma. 

By similar obstruction to lymphatics, so that their spaces dilate and 
may become of considerable size, the tumour is rendered myomato-cystic ; 
through rupture of the cyst walls large yellowish coagulated clots of their 
secretion may escape by the uterine canal. Thus in the same specimen 
may be found an (edematous as well as a hard myoma, the condition oj 
either being dependent on the individual relation to obstructed veins 01 
lymphatics, or both. 

Suppuration may follow septic puncture. 

The encroachment of myoma in direct growth, or combined witl 
artificial abdominal pressure, by bending the uterine ends of the Fallopian 
tubes, frequently occludes them, so that the secretions cannot escape aloni 
the genital canal. Tubal distension then occurs, and there is presently some 
effusion at the fimbria), whereby is produced a peritonitis proportionate 
the quantity and quality of the effused fluid. Fibrin may be thus exuded, 

and BUCh adhesions formed as hind down the fimbria' and occlude this 

extremity ; thus the mid-tube may become dilated by subsequent col- 
li. Should the tube be septic or gonorrhoea!, the further progress 
is th.it of pyosalpinx, which, by rupture, may cause a fatal peritonitis. 

bhfl tumour in Its growth may spread OUt, elongate, and flatten the 
tubes, and lender the fimbriae cedeniatous: a frequent local peritoniti 
may occur from their congestion and effusion. 

Myoma frequently and when of any size usually compresses the 
ovaries, SO that they perform their functions with difficulty; and local 
peritonitis occurs by the rupture of the irritated Graafian follicles into 
the peritoneum, rince on account of the pressure the tubes cannot apply 
themselves fcfoeir tunic- have previously become thickened by th* 

peritoniti- induced by the fimbria] effusion above described, as well as by 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 133 

that resulting from their own rupture, the follicles presently fail to 
rupture, and follicular cysts are produced, which undergo further evolution- 
lay changes. The continuous degenerative irritation may induce malignant 
disease, which indeed is particularly liable to originate in the endometrial 
glands. 

Myoma may occur in the ovary, by similar lack in sterile women of 
normal utilisation of blood ; and an excessive development of connective 
and fibrous cells may produce a fibroma of the uterus or ovary. 

Sarcoma, originating in connective tissue derived from the meso- 
derm, has as its cause the constitutional tendency to multiplication of 
embryonic connective fibre cells ; when of the ovary, it is perhaps a morbid 
reversion to a lower type in the direction of the formation of ovarial 
laminae, which have not the capacity of development into the higher 
connective tissue structure : there is proliferation without organisation. 
The ovary is occasionally, though rarely, thus affected, and apparently in 
relation to sterility. 

Cancer, which is a continuous cell proliferation of amoeboid type in- 
vading the lymphatic spaces and vessels, and always originating in 
epithelium derived from the ectoderm or entoderm, has its cause in such 
conditions as induce excessive formation of cells of degenerating 
quality. Should the constitutional state permit such degeneration to 
descend to the lowest amoeboid type, constant multiplication takes the 
place of evolution ; and this tendency is exaggerated by the occurrence of 
obsolescence, and therefore of defective nutrition of these organs, at the 
most common period of cancerous development ; namely, at or about the 
menopause. Such sites and conditions are exceedingly common in the 
chronic granular hyperplastic face of the lacerated cervix, in which, 
unless healed by operation, cell proliferation terminates only with life ; 
and the cancerous degeneration is possible at any time. In endometritis 
the same chronic glandular irritation may persist ; and ensuing malignant 
disease occur but a few months after parturition in young women from 
hypernutrition and excessive cell proliferation with degeneration at the 
placental site from puerperal deciduoma ; changes which may be associated 
with frequent haemorrhages, leucorrhoea, subinvolution, and constitutional 
tendency to cell multiplication of rapidly descending cell type. Or the 
cancerous phase may be delayed in less feeble capacity of cell organisa- 
tion, but be attained by a slower yet progressive exhaustion through 
the same constant drain on the system. But cancer is less frequent in 
the body of the uterus, a part which is not exposed to the friction against 
the vagina, a friction which irritates the granular cervical face, and thus 
increases cell production. Nor does it occur on the granular laceration of 
the prolapsed cervix, because cell proliferation there is greatly limited by 
the dryness of the situation. 

The continued irritation of a myoma may produce a constant pro- 
liferation of a primary or embryonic type. Should this occur in the 
connective tissue element a sarcoma of the round-celled variety is pro- 
duced ; if in the musculo-connective tissue the sarcoma is spindle-celled ; 



1 34 5 YSTEM OF G J Wl EC0Z Oc7 Y 

if in the glandular structures of the endometrium a cylindrical -celled 
epithelioma may arise. 

By the invasion of the Lymphatic vessels, and pressure on veins by 
: \e multiplication of cells, oedema and local haemorrhage result. 
The continuous increase presently so occludes the arteries that central 
necrosis is produced ; at the periphery of this the open ends of the vessels 
may bleed extensively from inability of their muscular layer, which is 
infiltrated by the cancerous cells, to contract. Nature's endeavour to 
separate the slough towards the outer edge of the continuous low cell 
proliferation a proliferation too degraded in character to form healing 

illations when retained in healthy passages, as in the vagina, results 
in a dirty foetid discharge, which is in some degree absorbed; thus, and 
by haemorrhage, the system is drained, enfeebled, and poisoned. 

The excessive cell proliferation, around the nerves as well as in the 
substance of them, effects such compression of them that intense agony 
ensues j this is worse at night, either because the recumbent position 
ies the weight on the nerves, or because the nervous system, at tin's 
time exhausted by the waste during the day, is less resistant to the pro* 
pagation of the diseased actions. This pain is usually referred to the 
lumbar region at the site of the entrance of the vaginal and pelvic plexus 
to the spinal cord. 

The pressure of the tumour on the adjacent bladder and rectum may 
impede the passage of their excretions, and thus abdominal distension by 
gas and retention of faeces may affect the appetite and digestion. 

Extension of the disease to the peritoneum by local irritation produces 
peritonitis, by interstitial cell proliferation it produces venous compression 
and Berous effusion, and, by arterial obstruction, necrosis, rupture of vessels 
into the peritoneum, and thus increased temperature. The advance of the 
growth into adjacent organs, as into the rectum or intestines, by narrowing 
'hem. may produce obstruction; and subsequently, with or without 
obstruction of them or of the bladder, necrosis of the cancerous structure 
may occur, and the contents of the viscus may be discharged through an 
open trioughing hole. Further extension through the lymphatics and 
veins effects the transference of malignant cells to other more distant 
j, which there become the foci of fresh similar growths ; thus by 
continuous excessive cell proliferation, necrosis, septic absorption, 
bsamorrhage, serous discharge and pain, the system is finally exhausted. 

II. The conditions too often incident to the education of the mind 

may materially and injuriously affect the physique of women in civilised 

-i\. eight, or more hours a day dining eight or nine months iii 

the year, the girl is iii a room indoors where are many others, so thai the 

AIT M frequently impure. The arms and legs are at rest, and ill cold 

wether are chilled and the circulation impeded, so that chilblains, even 
there are no frosts, arc common. The stooping posture over desk 

or book, iii drawing or at the piano, produces one genera] curve of the 
iral column instead of the normal three upper compensating smaller 

nd frequently, by fatigue, weariness, or defective eyesight, some 






ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 135 

lateral curvature is established. There is an increased attraction of 
blood to the brain, and great call upon the mental powers. Exercise is 
Neglected, and may consist of a constitutional walk in pairs, a mode which 
is foreign to the natural habits of young people ; thus there is long- 
physical repose and merely formal exercise at an age of naturally almost 
constant, free, untrammelled play and muscular activity. Personal 
competition, culminating in place examinations, may favour the egoistic 
temperament instead of the altruistic, instead, that is, of the care for 
others, as of the next generation, which normally is a strong feminine 
characteristic. In large public schools for both sexes the close association 
of young people may induce an injurious sexual knowledge and desire, 
conscious or unconscious, without the opportunity of lawful or moral 
satisfaction. 

But the individual type must dominate all such educational habits, 
however it may be thereby modified ; and it must always be remembered 
that the strongest instinct in woman is the sexual not necessarily the 
sexual appetite, but the production of the next generation ; thus there 
may be strong or feeble sexual development with a feeble or strong 
physique ; in either case with high or only moderate mental attainment. 

The general effect of the educational course then may be to develop 
mental at the expense of physical power, and especially of the mus- 
cular power, and the strength of the vertebral column ; by diminished 
demand on the elements of nutrition, to reduce the appetite and the 
powers of digestion, and thus the quality of the blood ; and to favour 
constipation, faecal absorption, anaemia, and irritable and hypersensitive 
nerves. The important function of menstruation is thus readily de- 
ranged; and irregularities, such as menorrhagia by deficiency of coagulation, 
or of strength of the veins in the strongly sexually formed, or amenorrheea 
in feebly developed sexual organs, arise ; and, if the mind be of the 
artistic or aesthetic kind and non-passionate, the sexual organs fall in some 
degree into abeyance, and may subsequently remain feeble ; there may be 
disgust at marital rites, and a tendency to hereditary sexual degeneration. 

III. Personal Habits. There is no such care taken by us at the 
menstrual epochs as among some other races, where the women seclude 
themselves, so that the function is quietly performed. With us it is not 
unusual for a woman to inject cold water or to take a cold bath to stop 
the flow for social or sexual purposes. The feet, clad in thin shoes, often 
become damp and remain so, and in cold seasons are habitually chilled 
through the soles. The evaporation of perspiration in cotton under- 
clothing abstracts much heat from the body and chills it, and the legs are 
but little protected from cold winds. 

Any of the above causes may produce contractions of the superficial 
vessels, with engorgement of the deeper, thus throwing on the latter the 
necessity of reactionary contraction, which they may be unable to 
perform. An unequal state of blood-supply thus occurs in the body, and 
the defending army of phagocytes and leucocytes may be unable suc- 
cessfully to combat attacking bacilli, whose victory is proclaimed in the 



SYSTEM OF GYNECOLOGY 



statement that a cold has Keen taken, a cold which may be the beginning 
of further bacillary successes in this enfeebled condition. Or the deeper 

Is may he unable to hear the undue strain of such engorgement, and 
their coats yield, producing haemorrhage or hematocele ; or again, irregular 
contraction of muscular Mines, as of the Fallopian tubes, may occur, so 

that their secretions, mucous or menstrual, may effuse from the fimbria^ 
and peritonitis result in this case probably in connection with sonic 
lower uterine stenosis. 

In the case of vaginal injection of cold or very hot water during 
menstruation a similar local vascular contraction may he induced without 
subsequent reaction, and the now may cease; this sudden shock may 
subsequently induce such a local depression of the circulation that the ovic 
maturation and catamenial discharge may cease for a long period, and the 
system sutler from the local anaemia and functional arrest. 

But of all injurious influences to woman, to which is attributable the 
great mass of the disease now so prevalent, is the extraordinary custom 
of the alteration of the form of the body, and of the position and rela- 
tions of tlte internal organs, by the almost universal custom of compression 
of the lower thorax and abdomen; were this done to animals, we should 

prise its amazing injury and absurdity. The busk is a very powerful 
Lever the power of which woman does not understand ; by it she always 
compresses her body from 1 to 3 inches; and frequently, especially when 
stout, and therefore more subject to the injurious influences of com- 
pression, 1 to 6 inches. The dress is similarly tight, and usually cannot 
be fastened unless the stays have effected previous compression. 

The influence is markedly accentuated by the attachment of 
skirts and petticoats around the waist and abdomen which have 
support them. These usually weigh from four to six or eight poum 
and read especially on the organs of the abdomen and pelvis. 

Such compression affects the muscles, and invariably displaces 
is of the body to an extent proportionate to the degree of pressure 

The traction force required to approximate the husks in a natural 
separation of from 

1 to 2 inches is from 8 to :^<> lb& 

2 to 3 20 to 40 

3 to 4 40 to 60 
1 to 5 60 to 80 
5 to 8 70 to 90 

I am informed thai the compression thus exerted on the body is 

jented l>y half these weights. Thus a woman who draws In her 

from " to l inches, a very common custom, places herself undef 

a direct pressure of from twenty to thirty pounds weight. I Sut this does 

not allow for the extra pressure produced in drawing a deep breath, 
when the approximated busks, under even the heaviest of the above 

Weights, will readily part from half an inch to an inch. This, however, 

is impossible when the busks are fastened, and this additional pressure 






ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 137 

also is therefore exerted directly downwards on the pelvic organs. There 
is additional increase of pressure by the weight of the skirts and petti- 
coats, and by food or liquid taken into the stomach ; when intestinal gas 
forms from induced indigestion, the condition is thereby accentuated. 

The spinal column is placed in splints upon which it tends to rely, 
and its movements are limited ; the muscles, therefore, atrophy by 
deficient use, so that the woman says her back would break if she did 
not wear them. By the bending of the back in her education, and the 
wasting of the muscles by the wearing of stays, the normal curves of the 
spine are frequently lost and abnormal curvatures induced. The general 
strength of the body is thus reduced. Similarly, the pressure on the 
abdomen forces down the intestines, stretches the lower abdominal wall, 
and renders its muscles atrophic ; hence an important reduction 
of reflex and voluntary muscular power in labour. The compression of 
the lower ribs forces up the diaphragm, squeezes the lungs, and displaces 
the heart, so that fainting from this cause is not uncommon. The 
kidneys are affected proportionately to the degree in which the lower 
ribs approach the iliac crest. If the ribs be high, their indentation on the 
upper half of the kidney displaces it downwards, stretching the connective 
tissue which attaches it in its bed of fat ; it is then said to be movable ; 
and, from the variable pressures to which it is subjected in the wearing 
and non-wearing of the stays, it is apt to be painful : the right kidney, 
being usually the lower, is most frequently thus displaced. The liver 
is flattened by the ribs, perhaps indented by their edges, and often 
extends to the level of the umbilicus ; the bile ducts are compressed, and 
constipation and, occasionally, jaundice result. The stomach is so 
squeezed that, when food is taken after the stays have been put on, 
there is no opportunity for its normal enlargement thereby, nor for the 
long process of churning essential to normal digestion ; thus the food is 
passed on into the intestines in a partially digested form ; dyspepsia 
follows, and a tendency to ulcer of the stomach by vascular stasis due 
to the long-continued pressure. The small intestines are depressed, and 
receive the ingesta in an abnormal state ; so that putrefactive changes 
occur in them, which produce flatulence and distension ; compression 
about the ilio-csecal valve influences appendicitis. The transverse 
colon is forced downwards, tending to produce obstructing angles at its 
junction with the ascending and descending portions, which are depressed ; 
and thus impairment of the peristaltic movements, flatulence, and con- 
stipation ensue. The rectum is compressed by the pelvic contents, so 
that the faeces tend to be unduly retained. Thus it comes about that 
digestion is impaired, flatulence arises, constipation is produced, the 
moisture of the faeces is absorbed, the blood is depreciated in quality and 
rendered impure, nutrition of the body falls, and the muscular force is 
reduced ; the teeth become carious, which reacts on the digestive 
functions ; the nerves are debilitated, and neuralgias ensue ; menstruation 
is disordered, and the general evils of anaemia result ; the capacity of 
the bladder is reduced, rendering micturition frequent, and subsequently 



138 SYSTEM OF GYNAECOLOGY 

often painful and necessitous. If the uterus be Btrong, and the bladder 
not subject to much distension, relieved perhaps by frequent micturition 
set up by crowding of the parts, the pressure of the intestines forces its 
body forwards and downwards into a horizontal position, and the 
cervix is apt to follow the anterior course of the body, the whole organ 
rotating forwards on a transverse axis, so that it is anteverted ; thus 
the body unduly presses on the bladder, and additionally irritates it, while 
the face of the cervix is subject to friction on movement against the 
posterior vaginal fornix, when there is aggravation of the virginal granular 
oreviously described, and degenerative diseases often ensue. Or, 
perhaps by rectal accumulation, the cervix is pushed forwards, more 
often into the perpendicular position, and anteflexion results. If the 
Uterus be of feeble development the body has already fallen forwards j 
but, by the pressure, the condition of anteflexion is accentuated. 

Or a Btrongly-developed uterus may be unduly retroposed by the 
flattening from above of the bladder : the forcing down of intestines into 
the pelvis tends to depress it into a lower pelvic plane, and the usual 
retention of fseces in the rectum presses the cervix forwards, inducing 
a rotation of the strong uterus backwards on a transverse axis at the 
junction of the cervix with the body; thus the retroversion is completed, 
The virgin uterus rarely proceeds further, because of the strength of its 
posterior wall ; but in the parous, if subinvoluted ligaments and connective. 
tissue permit the rotation to proceed, the uterine body may descend to .1 
much lower plane of the pelvis, so that the fundus presents downwards 
and backwards ; and, if the organ be of strong construction, the pelvis 
capacious and the vaginal structures subinvoluted, the cervix may 
maintain its normal line with the body of the uterus, and the OS present 
Upwards and forwards toward the anterior vaginal fornix the extremest 
possible condition of retroversion. 

Or, instead of the continuance of the normal relative continuity of 
direction of the body and cervix of the organ, from its subinvolution and 
consequent flabbiness of tissue and pelvic resistance to the rising of the 
cervix, an angle of flexion at the cervico-corporeal junction, or even 
somewhat higher, may be formed, and retroflexion ensues, the body being 

perhaps horizontal and the cervix perpendicular. A further stage if 

attained when the body and fundus descend lower, SO th.it the body and 

cervix tend to become parallel ; this is the more induced and accentuated 
by the continued abdominal pressure on the convexity of the angle of flexion, 
so thai their impaction in the pelvis results from extreme retroflexion, 

The Fallopian tubes are liable to be bent at their junction with the 

uterus by the misplacement of the uterus in combination with pressure 

downwards of the Intestines by the stays and dress. Thus in the sexual 
engorgement in love-making, with or without union, in women of warm 
appetite, this abnormal relation of the tubes to the uterus may induce 

efl'usion of their secretions into the peritoneum, particularly during 
menstruation, and a local peritonitis; otherwise, they would pass in 
the normal direction through the genital canal. 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 



139 



The ovaries are depressed, and forced into a latero-posterior position, 
carrying the fimbriae with them by the attachment of the tnbo- 
ovarian fimbria. Thus, by the pressure of the ovaries, the fimbriae may 
be flattened, rendered (edematous, and unable to apply themselves to the 
Graafian follicles ; these discharge into the peritoneum, and may, by a 
valve-like opening occurring from the compression, produce a recurrent 
peritonitis of some severity. 

In pregnancy the stays are often worn very tight so as to conceal 
the condition : thus miscarriages and premature confinements may be 
brought about by the accentuation of the normal rhythmic uterine con- 
tractions, by induced dilatation of a previously lacerated cervix, or by 
rupture of the membranes. By pressure on the abdominal veins by 
depression, or repression on the vena cava of the pregnant uterus, varicose 
veins are induced, the legs and vulva become cedematous, the veins may 
rupture, and vulvar or pelvic haematocele be produced. 

The pressure on the foetus may alter its presentation ; pressure on 
the uterus may enfeeble its structure, as well as that of the accessory 
muscles of labour, which may be thus ineffective ; forceps are now 
applied in the women's hospital in Melbourne once in nine confinements 
of all cases, and in private much more frequently. 

There is such a forcing downwards of the uterus on the ligaments as 
must tend to stretch them, and render depression of the uterus to a 
lower pelvic plane and axis more ready after labour, leading to sub- 
involution, misplacements, and prolapse. 

Thus by the wearing of tight stays the whole system of the woman is 
enfeebled, the pelvic sexual organs are apt to be misplaced, and the basis 
is laid for that evolutionary disease and sterility which are now so 
common. 

Another mode of injury by compression is the use of the tight 
binder after labour. No doubt that a very firm pressure on the body of 
the uterus is, in civilisation, frequently necessary immediately after the 
end of the third stage, in order to prevent or stop post-partum 
haemorrhage, common from the above-mentioned causes ; but in a couple 
of hours after the cessation of the haemorrhage this danger is past, when 
binder pressure becomes injurious without compensating advantage. 

After the passage of the child the walls of the cervix for a time 
commonly lie in a state of muscular relaxation, so that an excessive 
abdominal pressure tends to evert the internal cervical or endometrial 
structure through the cervical opening. Very much more is this the case 
when the cervix has been lacerated, whereof the only satisfactory mode 
of healing is by first intention ; to this result eversion must be fatal. To 
such a cause, which also bends the uterine veins, is often due the prolonga- 
tion of the red lochia ; and by the irritation of tension on the angles of 
lacerations deep into the vaginal junction, an inflammation of the con- 
nective tissue of the broad ligament ensues, which might otherwise have 
healed by a primary and softer union. The undue pressure, too, on the 
tubes thus crushed between the large uterus and the pelvis may induce 



140 SYSTEM OF GYNECOLOGY 

an effusion from the fimbriae which may cause a peritonitis, perhaps of 
mild character, but sufficient to induce an exudation of fibrin, which may 
hind down the appendages and uterus. 

The Iig8ment8 of the uterus are maintained in a state of tension ; the 
relation of the veins, which are of great size, is altered, and the circulation 
through them to some extent obstructed, perhaps inducing thrombosis \ 
the uterus is unduly congested, and its involution impeded. On diminu- 
tion in size of the uterus, so that it regains a position in the pelvis, it is 
still large ; the subsequent pressure by the stays and the perpendicular 
position of the woman depress it into a lower plane and more perpendicular 
axis of the pelvis, and into the state of retroflexion, as previously described. 
Thus under the influence of a continuous tight binder and subsequent 
tight stays the condition presently found may be one of dee]) laceration 
with everted granular faces, perhaps some connective cicatricial thickening 
in one or other broad ligament, subinvolution and retroflexion of the 
uterus, perhaps with such adhesions as bind it down. Such influence 
may also affect the column of the vagina and its connective tissue, and 
extend to the vulva and perineum, rendering them also subinvoluted. 

The large abdomen of the parous is frequently dtie to the predisposing 
influences of the unnatural habits before mentioned, which create a 
disposition to undue flatulent distension of the intestines ; this, 
combined with the pressure on the waist by the petticoats and skirt-, 
farther forces down the lax abdominal walls, and accentuates the gaseoufl 
distension. These causes are aided by that excessive fat in the abdominal 
walls which results from deficient exercise and work. 

The application of a tight binder which depresses the uterus U 
distinct from a well-regulated bandage which serves normally to suppoi 
the abdominal walls. 

The conditions present to those who give themselves to the life ol 
society are that they expose their necks to the suddenly varying 
temperatures of heated ball-rooms, corridors, verandahs and gardens 
they wear their dresses exceptionally tight : healthy exercise 
usually deficient, but there is over-exertion : from the great and almost 
Constant excitement there are undue nerve tension, and. not seldom, dis- 
appointments : tin- diet is irregular, and dainties are preferred ; tile hours 
are bite: sleep is irregular, and taken at abnormal hours : repose of body 
and mind are deficient. 

The effect- are apt to be that colds are taken, and are with difficulty 
shaken off: the appetite is impaired, digestion enfeebled, and constipation 

dished; the formation of the blood is injured, ansemia and general 
debility ensue: the catamenia become irregular: the nerves are im- 
poverished, bo that neuralgias and hysteria arise, and the weight decline* 
Such parous women are apt to Buffer from subinvolution with endometritis 
and its consequences for reasons previously mentioned ; and the milk is 

liable tO be deficient in quantity, or of excessive quantity and of feeble 

quality, so that the systems of both mother and child are impoverished. 

The diets that act injuriously are the defective and the unfit. 






ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 141 

It is common among young girls of delicate constitution and temperament 
to have an apparent pleasure in refusing plain healthy food, or a 
necessary quantity of any kind. Thus some will take no breakfast, or 
only a glass of water ; milk and meat are refused ; and this refusal 
appears to become a point of honour. Single women from thirty-five to 
forty-five years of age, and women upon whom is a great drain of child- 
bearing and lactation, may similarly decline animal food. 

The improper diets among young girls may include eating unripe 
fruits in place of ordinary food ; or pastry, cakes, and sweets at irregular 
hours. Older women, especially in warm climates, frequently drink large 
quantities of very hot strong tea, or of water. All such aberrant diets 
tend to dyspepsia, flatulence, constipation, anaemia and amenorrhcea ; and 
in the parous also to subinvolution with endometritis, and their 
consequences. 

IV. The influence of absence of marriage, and late marriage, which 
are the tendencies of our age ; and of ineffective marriage, which includes 
artificial prevention of pregnancy, are highly deleterious. The due age of 
marriage certainly varies according to climate, and in that of Great Britain 
the perfection of development is from twenty-three to thirty j but at the 
age of thirty half the women are yet unmarried, so that about half of the 
period of their capacity of propagation has already passed. While many 
women in civilised communities are signally deficient in sexual appetite, 
many are normally developed in this respect. Such due appetite may be 
strongly present in girls of plain features, who are unattractive, ill- 
nourished, and depressed ; and it is perhaps particularly in these that a 
normal temporary congestion and unsatisfied desire lead to injurious 
habits which produce chronic congestion, endometritis, and the like. 

The common effect on the physique of postponing marriage is to induce 
a general atrophy ; the fat, which imparts the rounded outline to woman, 
falls away and she becomes angular, her muscles and tendons are distinctly 
outlined, and markedly noticeable about the face and neck ; the quality 
of the blood has suffered, and anaemia may have resulted ; the nutrition 
of the nerves has been impoverished, and neuralgias and hysteria are 
common ; the catamenia may have become irregular, and be either 
increased or diminished according to the temperament ; and leucorrhcea 
may have resulted from desire unsatisfied by marriage or pregnancy. 
Some women who have a good sexual formation, except for a small 
external uterine opening and deficiency of sexual appetite, grow fat, the 
catamenia decrease, and the organs atrophy from absence of employment. 

But the influence of the normal impulse to the production of the 
next generation is amply demonstrated in sexually well-developed persons 
who from non-marriage have not become pregnant ; or who, from whatever 
cause, have ceased for a long time to bear children ; by the frequent occur- 
rence in such persons of myoma of the uterus : in myoma the muscular 
fibres increase in many sites in an irregular manner, which, in multi- 
plication, is analogous to that of pregnancy ; indeed in an early stage 
its further development may be stopped by pregnancy, for the uterus 



143 SYSTEM OF GYNECOLOGY 

has thus been employed naturally, and its nutrition engaged in its 
proper functions. 

V. Sexual exhaustion. Under normal circumstances in healthy 
women, coitus, though at first on marriage liable to be excessive, is usually 
limited presently by custom, and pregnancy ensues. Some husbands, and 

sonic women also, have an insatiable sexual appetite. Thus on the part 
of the man the act may he repeated very frequently ; or the woman may 
be subject to many men, as are prostitutes; or unnatural habits may he 
adopted ; or pregnancy may he avoided, with consequent absence of 
satisfaction, and thus of relaxation. All these conditions are liable to 
cause a chronic congestion, resulting in endometritis; or, in case of 
pregnancy, in miscarriage or premature confinement with succeeding 
subinvolution and endometritis: the induction of miscarriage, which is 
now so common, has the same effects. The frequent strain prodtices 
debility, and the nervous system is weakened. 

Kegular child-bearing with a normal condition of the uterus and 
moderate lactation seldom injures the woman; but when, combined with 
granular cervix and endometritis, the system is debilitated by the undue 
drain of excessive cell formation, disease is apt to ensue. 

The child-bearing which would be healthily effected in a temperate 
climate is excessive to the British race in tropical countries, in which the 
blood becomes thinner and the vessels dilated; then post-partum 
hemorrhage, subinvolution, endometritis, monorrhagia and anaemia are 
common. 

The congestive thickening of the vaginal membrane near its posterior 
commissure from excessive coition may produce occlusion or stenosis 
of one or other vulvo-vaginal duct; the secretion accumulating in 
the more dilated part near the gland may continue clear, and a cyst be 
formed ; or, if septic germs gain admission by the duct or through the 
blood, suppuration occurs, 

VI. Infectious Diseases. Syphilis is said not to be conveyed to the 
foetus through the placenta, but through the germ or sperm. The foetus 
i< liable to be affected in the Congenital form when one or both of the 
parents is actively diseased in the second stage at the time of impregnation : 
after Conception the father, who may have been free from symptoms for 
many months, may suffer from a syphilitic testicle, or the mother from a 
rash : or. after a period of apparent health for perhaps twenty or thirty 

. a parent may ha\e a Specific rash. The degree to which the 

my is liable to be affected is in proportion to the virulence, attenua- 
tion, or quiescence of the parental disease. 

The effects are se.-n in hereditary congenital and simple forms. In 
the former, nialfotinat ions, from inflammatory arrest or deficiencies til 

development^ are proent at birth, being induced by an inflammatory 

action in the cells, ducts, or vessels, destroying or closing them, and 

arresting development In the latter the results, similarly caused, may 

not manifest themselves for varying periods after birth. 

The mother may. however, directly transmit measles, scarlatina, and 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 143 

Imall-pox to the foetus, perhaps through the liquor amnii, and the same 
results ensue (Hamilton). 

Syphilis, by irritation of its secretions, produces condylomata about the 
Vulva and anus, and enlargement of the inguinal glands, with the consecu- 
tive affections. 

The inflammation of mucous membranes, accompanying such diseases 
its scarlatina and measles in which micrococci have been found, may 
attack the vagina, uterus, and tubes ; and, since the outlets are of small 
size during childhood, it may continue in a chronic form, and lead to 
evolutionary affections of the peritoneum and ovaries. 

To gonorrhoea is to be ascribed a series of progressive diseases, which 
are liable to be as virulent as they are continuous. 

Miserable to relate, this disease is met with even among little girls. 
A young girl may, primarily, take it from a man who had the idea that 
his gonorrhoea was curable by contact of a young virgin ; and she may 
convey it to others by the fingers. It may possibly be contracted by 
other means, as by contact of the vulva with gonorrhoea-infected towels, 
closet-seats, or chamber utensils ; but, whatever the sex or age of the 
patient, there has been direct contact with the discharge of a previously 
diseased person. These young girls, perhaps but of a few years of age, 
may retain the disease for many months or even years, during which it is 
liable to advance into the higher genital organs, and produce evolutionary 
results. In this way it may be a common cause of the peritonitis of 
female childhood, and of adhesion and arrest of development of the genital 
organs, perhaps Avith their displacement ; of the latter results, a small 
adherent retroverted uterus and adherent atrophic ovaries may be sub- 
sequently apparent as having occurred during the years of childhood. 

The vagina is, primarily, not readily subject to the affection, an im- 
munity probably due to the absence of glands in which the microbe may find 
a nidus. Thus the gonococcus at first finds a habitation in the mucous 
follicles at the orifice of the urethra or vagina, or in the sinuosities of the 
uterine cervical glands. When thus affecting the urethra an irritation 
arises, which induces a cell proliferation suitable for successful attack by 
streptococcus and staphylococcus present in the infecting matter : thus 
suppuration results, which, in combination with the gonococcus, travels up 
the urethra to the bladder ; hence follows cystitis. Should entrance to the 
ureters be effected their inflammation ensues ; and by subsequent con- 
traction in healing, their stricture and hydro-nephrosis. If progressive to 
the kidneys, their inflammation, and perhaps suppuration, leads to pyo- 
nephrosis. 

Also, the canals of the vulvo-vaginal glands may likewise be primarily 
affected by the gonorrhceal infecting matter, and abscess in them occur. 
The vagina is thus continuously exposed to the disease, and becomes 
infected ; and presently, especially if the os uteri gape, the cervical 
canal. 

Or the gonorrhceal matter may, in union, be directly injected into the 
canal of the cervix, and take up a habitation in the gland-ducts ; and the 



i 4 4 SYSTEM OF GYNECOLOGY 

vagina be secondarily infected by the downward passage of thus diseased 
:ions. Prom the cervix the corporeal endometrium is affected, and 
the micrococci may infest the sinuosities of its gland-tubes. Thus, 
should tlie vagina, vulva, and urinary canal have recovered from the 
56, perhaps by treatment, a later downward passage of the gono- 
cocci may again infect the vagina ; hence vaginal recurrence. 

The trumpet-mouth of the Fallopian tubes renders it easy for the 
germs to enter and infect them; hence salpingitis, and the evolutionary 
affections of the peritoneum and ovaries described in detail in section 1. 

When the fimbria of a tube infected by gonorrhoea, puerperal septi- 
caemia, or tuberculosis is adherent to an ovary of which a Graafian follicle 
ripen- and bursts into it, the bacteria enter the follicle and suppuration 
ensues therein ; or when an accumulation of pus occurs in the fimbria 
adherent to the inflamed, distended, thin membrane of a follicular cyst, 
the bacteria may enter it by transudation. Septic pus having formed in 
a sac of an ovary, similar abscesses occur in other follicles, probably by 
transudation of bacteria under similar conditions; so that abscess of the 
ovary is usually multiple, though the septa between pus-sacs may break 
down and one large abscess predominate over the others, and the ovary 
becomes of considerable size. 

On increase of pus the tunic yields in the direction of least resistance ; 
and, as in pyosalpinx, on minute rupture peritonitis results, causing 
cohesion of the ovary with adjacent peritoneum, if this have not taken 
place previously. Should the attachment be to the intestine, the pus of 
the rupturing sac escapes into it; but the other sacs of the multilocular 
abscess do not thus discharge their contents, and the inflammatory con? 
dition continues. The cause of abscess of one ovary may also apply to 
the other, and thus both may suppurate ; and, since the tubes were 
previously similarly affected, double pyosalpinx is probably also present: 
ovarian suppuration, however, being dependent on rare relations and 
opportunities, seldom occurs. 

Septica'mia is a term applied to a class of diseases induced primarily 
by the entrance of putrefactive liquids into the system through the blood- 
vessels or lymphatics : different parasitic micro-organisms in these liquids 
attack and overcome the defending army of phagocytes and leucocytes, live 
upon tin- blood, and secrete a toxine or poisonous miasm which may be 
fatal : these events may arise in the puerperal state, or from accident or 
operative causation. 

In the puerperal, accidental, or operative State the site of attack is 

some laceration, wound, <>r injury : as of the perineum, vagina, cervix, 
uterus, or unclosed venous dnusef or lymphatic vessels of the ovic or 
placenta] site, generally by retention within the cavity of the uterus of 
portions of placenta, perhaps of adherent membranes or of blood-dots. 
In the absence of the use of antiseptics, micro-organisms may successfully 

attack the raw tissues, and in this state of eiidosmosis affect the -vMein. 

They are particularly infections in the state of comparative emptine 

the v< isud by the coincident ha'inorrhage ; but when the part is 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 145 

granulating such absorption does not occur, the vessels are in a state of 
fulness and tension, and the tendency is towards exosmosis in relation 
to the growing of new tissue. 

The attack is through the veins or the lymphatics, perhaps through 
lymphoid cells, by the open mouths of which canals these micro-organisms 
may enter. In the former case septic phlebitis results, in which the 
inflammation is proportionate to the quantity and quality of the sepsis. 
Thus, if the cause be virulent, the tunica interna becomes suppurative, 
and the progress of the septic germs, rapidly spreading towards the heart, 
may be at intervals temporarily checked by the formation of thrombi. 
These, however, are speedily similarly affected, they disintegrate, become 
loose in the enlarging lumen of the veins, and form the nidus of fresh 
infection which permeates the body and especially affects synovial mem- 
branes ; death is the result. If the sepsis be less virulent, the thrombi 
may maintain a firmer attachment to the venous inner walls, but are liable 
to become loose and block the heart, or form the nucleus therein of larger 
coagulations ; or they may form infarctions in the lungs, producing pleuro- 
pneumonia ; or clotting may advance toward the heart by gradual vein- 
wall infection, so that thrombosis may extend from the uterus along the 
uterine and ovarian and, on the left side, the renal veins ; and perhaps on 
both sides it may extend into the vena cava, and thence, on the right 
side, perhaps infect the right renal vein. Or perhaps in only one vein in 
the broad ligament a septic thrombus, guarded toward the heart by a 
sufficiently healthy adherent clot, may suppurate, burst through the 
venous coats, infect the connective tissue, and produce a pelvic cellulitis, 
discharging in the direction of least resistance. 

Should a virulent septic absorption take place, especially through 
lymphatic vessels, the blood may at once be so affected, probably by 
secretion of bacterial toxine, that it becomes disorganised, and death 
results from general acute septicaemia. A less virulence gives time to 
permit septic inflammation of special structures, as of serous or mucous 
membranes ; or a local suppuration from septic retention in a lymphatic 
gland in a broad ligament forming suppurative cellulitis j or, in a less 
septic degree, resulting in inflammatory induration and resolution. 

The common cause of puerperal peritonitis is the effusion of septic 
fluid from the fimbria infected by continuity from the uterine cavity. 
Thus the slight primary oozing may cause a peritonitis, inducing fibrinous 
exudation which occludes the fimbria by adhesion. Should the quantity 
of fimbrial effusion be greater the peritonitis is stronger. If the quality 
be virulent and the quantity large, the fimbrial effusion being continuous 
or recurrent, the peritonitic exudation is sero-purulent ; such adhesion 
as occurs is feeble and ineffective for occlusion, and the peritonitis is 
general and virulent. 

Or, less frequently, it may be caused by the rupture, by pressure of 
the child, of a septic suppurative salpingitis into the abdominal cavity ; 
or such a tube may thus burst into the connective tissue of the broad 
ligament, producing a virulent pelvic cellulitis. 

L 



146 SYSTEM OF GYNAECOLOGY 

Tuberculosis in the genital organs may occur either by the arrival of 
the tubercle bacillus by the intestines, by the blood, or through the 
vagina. If by the intestines, the bacilli, probably swallowed in tuberculaij 
pulmonary sputum, have penetrated the intestinal glands, infected the 
peritoneum, and thence entered the fimbria and attacked the tube, and 

perhaps spread to lower parts of the genital canal. Ooincidently the more 
distant peritoneal surface, and, by deeper attacks, the underlying structures 
of the ovaries, tubes, uterus, and broad ligaments, may be affected. And 
a nidus in the genital organs having thus occurred, farther advance into 
the heart and lungs, perhaps through the bronchial glands through the 
medium of wandering lymphoid cells, may be effected. Secondarily, 
tubercular pus may escape from the tube through the fimbria, and reinfect 
the peritoneum. 

Or the bacilli, derived from swallowed tubercular pulmonary sputum 
or tubercular ulcerating intestinal glands, may be detained in the lower 
rectum in constipated or liquid faeces ; and successfully attacking the 
lymphoid cells, may enter lymph glands, induce suppuration around the 
anus, and produce rectal fistula. Thence by progressive lymph-gland 
disease, the connective tissue of the broad ligament may be attacked, and, 
by suppurative destruction, the peritoneum and adjacent genital organs. 

By the blood bacilli, escaping from a softening pulmonary tubercle, 
may travel in the current until they arrive at a capillary in the genital 
organs, where they may conquer a lymphoid cell and develop a tubercle, 
perhaps in a lymph gland in the broad ligament, producing tubercular 
pelvic cellulitis. 

By the vagina bacilli may gain entrance from an adjacent rectal tuber- 
cular fistula, or other tubercular suppuration of which a sinus may per- 
haps open into the vagina, and the bacilli travel upwards. Or the sperm 
may contain bacilli, which advance and infect. Or the discharge of a 
suppurating tubercular gland, perhaps submaxillary, may be conveyed by 
the finger of the woman within her vaginal orifice. The bacillus, having 
-.lined entrance, is attacked by a wandering lymphoid cell, which it may 
conquer \ and thus a Becond, gaining nutrition from the tissue of these 

Cells, may enter a lymph-gland and produce tubercle, which may sup- 
purate and break down. Should the bacilli be very numerous and 

powerful, 8 general infection of adjacent structures and infection of 
cardiac proximal glands ensues, and the disease has extensive foci. I5ut 
if the bacilli be but of" moderate vigour, a strong fibroid sac wall of con 

densed connective tissue is formed about the abscess, and permeation of 
bacilli is effectually resisted. Thus a tubercular abscess in the broad 

ligament may be <., incident with a siippurat ing submaxillary gland with- 
out farther extension : but a foetid bacillus may have infected the 
pus. 

When by OncleanlineSS, or the passage of urinary crystals or sugar, 
or of small worms from the rectum. ;i vulvar or vaginal irritation has 
been caused, micrococci, as Staphylococcus and StreptOCOCCUS, finding suit- 
able nutrition, may enter the vagina and induce an inflammatory 









ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 147 

called vaginitis, causing pruritus of the vulva. This occurs the more 
readily if the hymen be contracted, so that the secretions are retained ; or 
under the influence of the venous engorgement of pregnancy. 

Hydatid tumours, which are of the animal kingdom, may have a 
situation in the wall of the uterus, ovary, tube, peritoneum, or connective 
tissue [vide article "Hydatids" in Sysi. of Med. \ The sexual organs are 
displaced according to the size and direction of growth of the tumour. 
By rupture or puncture dissemination of the fluid and of daughter cysts 
is effected ; and, if into the peritoneum, fibrinous exudation produces 
adhesions which may bind down the whole tumour to adjacent structures, 
or, being highly vascular, may resemble a skein of scarlet floss-silk ; or, 
by continuous escape of necrosed contents, may set up a progressive and 
virulent peritonitis. 

VII. Accidental and operative. 

Accident, which is here used to mean the unusual effect of a known 
cause, is the common cause of vaginismus, which is the spasmodic con- 
traction of the muscles about the orifice of the vagina, producing 
dyspareunia. When the hymen is lacerated in union, its segments re- 
tract to the vaginal opening at various sites according to its formation ; 
but most generally towards the posterior commissure. Subsequent 
frequent union and irritation may prevent the healing growth of epi- 
thelium over the raw edges, which, becoming inflamed, develop hyper- 
vascular and hypersensitive papillae. Their continued irritation by 
attempted union, by the friction of walking, or by the constant bathing 
of their surfaces in the acid vaginal secretion, may maintain the condition. 
Any attempt to enter the vagina produces a reflex contraction of the 
muscles which close the opening, as of the bulbo-cavernosus muscle, and of 
the adductors of the thighs, as well as a retraction of the pelvis from the 
source of the pain. The same effect results from a similarly produced 
non-healing tear of the posterior commissure, causing a fissure ; from the 
intense sensitiveness of an angioma or vascular caruncle at the orifice of 
the urethra ; from the repeated sexual act in nervous girls full of sexual 
disgust ; and also from repeated ineffective union of a feeble male with a 
sexually disposed female inducing a hyperactive and dissatisfied spas- 
modic muscular state. 

By direct force, as a fall or blow, cystic tumours may be ruptured, of 
which the effects are described under ovarian cystoma, and a myoma may 
be bruised, causing venous extravasation and peritonitis, and perhaps its 
necrosis. 

Of the operative causes of disease, the introduction of any kind of 
dirty instrument may convey septic germs, as of the sound tainted with 
gonorrhceal matter. Or force may effect a minute necrosis, which may 
induce inflammation, as in the attempt to pass a sound otherwise than in 
the line of the uterine canal, whence may result endometritis ; or if it per- 
forate the peritoneum, as in some cases of the production of criminal 
abortion peritonitis. 

The forcible replacing of an adherent uterus may rupture vascular 



148 SYSTEM OF GYNECOLOGY 

adhesions about the uterus or Fallopian tubes, or a follicular cyst, whence 
peritonitis. 

The application of irritants, such as carbolic acid or iodine, to the endo- 
metrium, particularly when the cervical canal is narrow and obstructive* 
readily pun's up the glandular structures sufficiently to close the inner or 
outer os. When the escape of the secretions is hindered, reflex irritation 
results, the muscular fibres contract spasmodically and painfully, and 
endometritis ensues. This is the more apt to occur when there exists 
an angle of flexion in the uterus, which may be anteflexed or retroflexed j 
and the two conditions of a narrow canal with anteflexion are usually 
coincident in the uterus of feeble development. Thus if endometritis have 
previously existed, it is accentuated, and evolutionary progress, described 
in section 1, proceeds. 

A yet more vigorous action in the same direction may he from the intro- 
duction of the tent, whether sponge, laminaria, tupelo, or slippery hark ; 
since necessarily, by their presence, there is a temporary suspension of 
escape of secretions, which are augmented by the pressure on and irrita- 
tion of the endometrial glands by the part of the tent within the uterine 
body. If the condition of the endometrium, for the diagnosis or treat- 
ment of which the tent is used, be already inflammatory, the endometritis 
may be increased. If not, such tents, and particularly when of sponge, rapidly 
become septic, and the secretions retained in the uterine cavity are thus 
tainted, and evolutionary disease, through fimbria! effusion, may advance. 

In the dilatation some laceration of the interglandular structures 
results, and the sponge insinuates itself into the gland-ducts themselve 
that such raw surfaces are the more liable to be septically infected ; an< 
particles of this septic sponge may be retained after withdrawal of the 
mass. A temperature of 105 may thus be rapidly produced 

An intra-uterine stem, which is usually more permanent, is similarly 
injurious by creating or increasing endometritis by pressure and obstruct 
ing drainage. 

Injections of fluid may be introduced into the uterus unintentionally 
by chance pressure of the vaginal tube through a Lacerated or dilate* 
cervix, and obstructing the canal, may pass through the tube into tin 
peritonea] cavity, and induce peritonitis ; or intra-uterine injections, math 
with ;i fine tube, may be retained within the uterine cavity by angularity 
or stenosis, or hyperplastic approximation of the walls of the canal, and 
induce colic and endometritis j or perchloride of mercury may be absorbed] 

and produce acute nephritis and anuria, resulting ill ursemic death, due 
provision for its return not having been made ; Or the cervical canal may 
be thickened by the irritation and become stenosed. 

Probably few operative measures more frequently cause or exaggerate 

c than D6 They BTS always septic by accumulation of seciv 

tion about them, and thus present to any abraded spot, which themselves 
may have created, the bacteria of inflammatory action. By continuous 

ire on the vagina they are liable to produce necrosis, and retaining 
bands may be formed across their bars; or they may embed themselvei 



ETIOLOGY OF DISEASES OF FEMALE GENITAL ORGANS 149 

in the rectum or bladder. By constant expansion permanent dilatation 
of the vaginal muscular fibres and the destruction of the vaginal column 
may be effected ; while, if there be vaginal subinvolution, this is con- 
tinued and usually accentuated. By the separation which they cause 
the faces of the lacerated cervix are everted ; and if the upper limb in- 
sinuate itself between them a deep furrow is created, and about it the 
hyperplasia, by irritation of the interglandular structure, is increased. 
The body of the retroflexed uterus often falls back on the upper limb of 
the pessary and becomes very tender, showing that peritonitis has been 
induced, probably from effusion from the fimbria of a compressed or 
bent tube ; and if a larger instrument be employed the preceding dis- 
advantages are the more apparent. 

When evolutionary disease has already created salpingitis, peritonitis, 
and perhaps follicular disease of the ovaries, there are usually adhesions ; 
and the pressure of the pessary on these affected parts tends to irritate 
them, and increase the rapidity of progress or recurrence of their diseases. 
Moreover, the pressure on an ovary congests it, or may effect rupture of 
a follicular cyst with resulting peritonitis. 

A metrotomy by scissors, which divides the circular muscular fibres 
so that the faces are everted, produces the effects of that degree of lacera- 
tion without subinvolution ; and induces or accentuates endometritis. If 
the operation be performed with a two-bladed metrotome, an unequal or 
excessive division may divide a vessel into the broad ligament, whence 
may result an extensive hematocele, which may become septic ; the 
passage of the knife through the lateral vaginal fornix may have similar 
results ; or, in an irregular division, the blood may escape into the perito- 
neum. 

If the os be closed by operation, as by excessive suturing in trache- 
lorrhaphy, or cicatrisation with contraction after a small metrotomy, the 
secretions such as blood and mucus after coincident curettage, and the 
catamenia are retained in the uterus and tubes, may distend them, and 
escaping through the fimbria? into the abdominal cavity, produce peri- 
tonitis. This may or may not be virulent, according to the quality of the 
sepsis or degeneration and quantity of the fluid thus effused. If secretions 
be retained in the cavity of the uterus with stenosis of the os by such 
intermittent causation, they are likely to become septic, and endometritis 
results, and perhaps further disease. 

In puncture with a trocar, for exploration or treatment, if the instru- 
ment be septic, putrefactive germs may be introduced, and necrosis and 
septicaemia result ; this may happen in a myoma pierced by an explora- 
tory trocar or electric needle. 

The introduction of an exploratory trocar into a solid abdominal 
tumour is liable to be followed by peritoneal hematocele, which, if aseptic 
and in moderate quantity, may be absorbed, and in part contract ; but if 
too large for nutrition, it may undergo necrosis and become purulent; 
it will certainly do this if septic by escape of necrosed tissue from the 
puncture in the tumour. 



ISO SYSTEM OF GYNECOLOGY 

If the tumour contain fluid, some of it, and perhaps much, may ooze 
through the small opening after the withdrawal of the canula. If such 
escape be into the peritoneum, the peritonitis is proportionate to the 
e of virulence and the quantity of the fluid, as well as of the septic 
influence oi the operation, an influence perhaps due to admission of air 
through the canula: similarly, pelvic cellulitis may thus be erysipe- 
latous and pysemic. 

The withdrawal of the liquor amnii from a tubal extra-uterine fcetation 
is liable to be followed by escape of blood : and, on removal of the 
canula, some may pass into the abdominal cavity. The vitality of the 
ovum may thus be destroyed, and its necrosis occur with tainting of the 
escaped clot, whereby a progressive and finally virulent peritonitis is 
produced. 

In the operative puncture of a dermoid cyst, the canula, blocked by 
the fat and hair, may, in its removal, discharge some of the sac contents 
into the peritoneum, inducing peritonitis ; and the inflammation, extending 
through the opening made, may affect the lining wall of the sac, and 
produce pus formation, or septic suppurative germs may be thus intro- 
duced directly. 

Perforation of the intestine, so that the gases and faeces escape into 
the peritoneum, is intensely and virulently inflammatory from the pre- 
sence of the bile, bacteria, and matters decomposed or ready for decom- 
position. In leaking puncture of the bladder, healthy effused mine is in 
itself non-irritating; but if unhealthy or decomposing, or in excessive 
quantity, very irritating. 

In the treatment of abortion, undue haste may induce attempt at 
removal of the ovum before separation of the chorionic villi or placenta 
has taken place, so that part remains in a necrosing state in the uterus : 
oi- curettage may be practised thereon, or deeply on the prominent 
placental site, from want of knowledge that such projection is normal. 

Any operation in which the peritoneum is opened, and septic -runs or 
disorganising fluids, gases, or solids are admitted, may lead to peritonitis 
of a degree proportionate to the quality and quantity of such irritating 
agent. 

W. Balls Headley. 



REFERENCES 

1. Baldt. Text-Book of Gynaecology. 2. Balfour, F. M. '-On the Origin and 
History of the Uro-genitaJ Organs of Vertebrata," .lour, ml of Anatomy and Physiology t 
voLx.1870; "On the Structure and Development of the Vertebrate Ovary," Quarterly 
Jour, of Mieroseop. Sci. veil, rviii. 1878. 3. Baktock. "On the Pathology <>f certaiii 
so-called Unilocular Ovarian Cysts," Trans. Obstet. S<>r. vol. xv . 4. Barnes. '/'//< 
Women.- 5. Bbddabo, V. Y. "Observations on the Ovarian Ovum ol 
Lepidosiren, oftheZool. Soc. of London, May 4, 1886. 6. Bell, V. J. Com- 

parative Anatomy and Phys. 7. Caldbbwood. "On the Ova of Teleosteans," JowA 
of the Harm /<'< , the United King., n<w series, vol. ii. No. 4. 8. Coats, '. 

Manual of Pathology. u. Cunningham. Journal of the Marine Biol. Assoc, of thi 
Kingdom, . voL ii. No. l ; vol. iii. No. 2. 10. Cullingworth. On 

Cellulitis. 11. Darwin. The Descent of Man; The Origin of Species. 12. 



DIAGNOSIS IN GYNECOLOGY 



Dokan. Alban. " On Myoma and Fibro- Myoma of the Uterus and Allied Tumours of 
the Ovaries," Trans. Obstct. Soc. vol. xxix. ; Tumours of the Ovary. 13. Emmet. 

'pies and Practice of Gynaecology. 14. Garrigues, H. J. Diseases of Women. 
16. GrEDDES, P. Encyclopaedia Brit. vol. xx. p. 408; vol. xv. p. 368. 16. Geddes 
ami Thompson". Comparative Anatomy. 17. Gegenbaur. Elements of Comparative 
Anatomy. 18. Grey's Anatomy. 19. Habershon. Diseases of the Abdomen. 20. 
Hamilton, D. J. Textbook of Pathology. 21. Hart, D. Berry. Female Pelvic 
Anatomy. 22. Kirkes. Handbook of Physiology. 23. Minot. Human Embryology. 
24. NAPIER, Leith. "Habitual Abortion," Obst. Trans, vol. xxxii. 1890. 25. 
Playfair, W. S. The Science and Practice of Midwifery ; " On Removal of the Uterine 
Appendages in Cases of Functional Neurosis," Obst. trans, vol. xxxiii. 1891. 26. Pozzi. 

/' and Surgical Gynaecology. 27. Ruffer, A. Quar. Jour, of the Microscop. Soc. 
vol. xxx. Part 4, Feb. 1890. 28. Savage. On the Female Pelvic Organs. 29. Sohacht. 
"On Ruptured Tubal Gestation," Brit. Gynaxol. Jour. Nov. 1893. 30. Schultze, 
Trans, by Macan. Displacements of the Uterus. 31. Shattook, S. G. The Morton 
'Lecture on Cancer, May 19, 1894. 32. Snow, H. The Proclivity of Women to Cancerous 
Diseases; On Cancer* and the Cancerous Process. 33. Sutton, Bland J. Surgical 
Diseases of the Ovaries and Fallopian Tubes; Evolution and Disease. 34. Tait, 
Lawson. Diseases of Women and Abdominal Surgery; Diseases of the Ovaries; 
Lectures on Ectopic Pregnancy. 35. Thomas and Munde. Diseases of Women. 36. 
Thornton, Knowsley. "Three Hundred Additional Cases of Ovariotomy," Med. 
Cliir. Trans, vol. xx. ; "Cases Illustrating the Surgery of the Kidney," Lancet, 1895. 
37. Wells, Sir Spencer. Diseases of the Ovaries ; Ovarian and Uterine Tumours. 

38. Wiedersheim. Grundriss der Vergleichenden Anatomic der Wivbelthiere, 1898. 

39. "Williams, J. W. " Tuberculosis of the Female Generative Organs," Johns Hopkins 
Hospital Reports in Pathology, ii. Baltimore, 1892. 40. Winkel, by Chadwick. On 
Childbed. 41. WOODHEAD, G. S. " Practical Pathology : An Address on the Channels 
of Infection in Tuberculosis," Lancet, Oct. 27, 1894. 



W. B.-H. 



DIAGNOSIS IN GYNECOLOGY 

The differential diagnosis of particular diseases will be found under 
their respective headings in the several articles of this volume. The 
object of this article is to collate, with a view to diagnosis, the various 
symptoms and physical signs met with in the diseases peculiar to women. 
The subject naturally resolves itself into two parts the history of the 
patient and the physical examination ; and it will be treated under these 
headings. 

The history of the patient. For purposes of reference a note 
should be made of the date, and of the name and address of the patient. 
The investigation may be conveniently carried out in the following 
order : 

Age. The age of the patient ; which has a direct bearing on many 
matters such as menstruation and child-bearing. Before the age of 
ten menstruation is naturally absent ; and again after the age of fifty : 
though even in healthy persons the dates of onset and cessation vary 
within wide limits. Impregnation occurs only during the period of 
active menstrual life. The age of the patient is often of importance 
also in deciding upon the nature of disease. For instance, cancer rarely 
occurs before thirty or forty years of age, and more often about the 



152 SYSTEM OF G WW ECO LOGY 

time of the menopause. Nevertheless, we must not forget that cases 
ionally occur at an earlier age; I have seen the disease in an 
advanced stage at the age of twenty-nine, and even so early as twenty- 
Hve. 

Social, Qpndition. Information as to marriage or spinsterhood, or, 
again, whether the patient be widowed or separated from her husband, 
has often an important bearing in determining the question of pregnancy, 
and in affording presumptive evidence of sexual intercourse. And the 
further information as to the length of time the patient has been 
married, widowed or separated, as the case may be, is often a 
necessary factor in deciding these important questions. Many diseases 
occur only in connection with gestation ; others only as the outcome of 
delivery ; others again follow sexual intercourse. A note of these 
matters, therefore, often provides a valuable step towards diagnosis. 

Occupation. The occupation of the patient has often a material 
bearing upon the disease from which she suffers. For instance, cooks, 
charwomen, and laundresses, being constantly on their feet and exposed 
to a hot and often steamy atmosphere which tends to relax the tissues, 
are specially disposed to various forms of prolapse. In the case of 
married women, it is well to ascertain the occupation of the husband ; 
for many deductions may be drawn from this knowledge. The occupa- 
tion of the husband not only affords some notion of the means of the 
patient, but often leads up to some conclusion concerning the nature 
of the illness. Take, for instance, the case of a patient suffering from 
vaginal discharge, one in which it is difficult and yet important to 
determine whether the discharge be merely an ordinary leucorrhcea or a 
gonorrhoea : now there are certain classes of the community on the 
male side and therefore on the female side also, when they happen to 
be married who are particularly prone to gonorrhoea, such as soldier* 
sailors, and policemen. In these cases additional information, sufficient 
to warrant a diagnosis, can usually be obtained. 

Leading Symptoms of which Complaint is made. Having made a note 
of the foregoing preliminary particulars, it is well before making further 
inquiries to ascertain generally from the patient the precise symptom or 
symptoms of which she complains. Patients often give a very indirect 
answer to the question, " What is it you complain of ?" such a reply as 
"the Insides" or "the womb"; and they arc apt t<> give as fcheir answer 
(often with considerable modification) what any doctor who has beeij 
previously consulted may have told them. It is then necessary to inquire 
what brought ber t<> seek ;idvice. In the vast majority of cases it will be 
found that actual pain or discomfort in some part or other is the leading 
symptom from which the patient seeks relief. Ilut in some cases pain 
may be entirely absent^ or only present under certain conditions, as, for 
nee, during coitus; or sexual intercourse may be effected with 
difficulty or even be impossible. Others will, perhaps, speak of a swelling id 
the abdomen as the leading feature in the case. Some, again, will apply 
for advice because there is no family; they feel well in every respect, 









DIA GNOSIS IN G YNsE CO LOGY 153 

but, hciving been married for, perhaps, some two or three years, and no 
family resulting, they come for advice on that matter. In many of 
these cases there is no particular illness or discomfort, but it will be 
found that in the vast majority of them some morbid condition is present. 
The points with reference to which the patient makes complaint, and the 
approximate length of time during which she has experienced each 
symptom, should be noted. These inquiries will probably afford some 
clue to the nature of the case, will indicate the line any special in- 
vestigation should take, and will serve as a foundation on which to construct 
the diagnosis. The object of the present article, however, is not to take 
up the leading individual symptoms of which the patient complains, and 
then, by following the clues thus obtained, gradually to elaborate a 
diagnosis ; but rather to provide a general systematic form of investigation 
which will be found serviceable in the vast majority of gy nsecological 
cases. After these preliminary inquiries the symptoms and discomforts 
of which the patient complains can be sifted and amplified. This method 
of inquiry provides a very valuable, but often neglected quantity of 
negative evidence. For it often happens that the patient comes com- 
plaining of something which may be but a trivial deviation from health ; 
yet, if her case be gone into systematically and carefully, according 
to the method I propose, important information will be forthcoming 
which will enable us to find or suspect, even before we go into physical 
examination, that she has some other and concomitant disease, either 
quite independent of the matter of which she makes complaint, or entirely 
subservient to it. 

Having ascertained, then, the main points to which the patient wishes 
to draw attention, and for the relief of which she seeks advice, it is well 
to proceed to ascertain the menstrual and obstetric history of the case. 

The Menstrual History. At the outset let me emphasise a point to 
which too little attention is given, namely, that in order to obtain first 
from the patient a menstrual history of so complete a character as to 
answer the purposes of investigation, it is necessary to ascertain the 
normal character of the menstruation in the individual. For there are 
among women wide individual differences in respect of this function. In 
order to judge whether any change has taken place in the menstruation 
of any woman after its first commencement, the natural character of her 
own menstruation must be determined in the first instance. A certain 
feature of the function which in one woman might be considered an 
abnormal variation may be the usual, and natural condition in another. 
And therefore I repeat, that in each individual case it is necessary to 
ascertain the individual character of the function in order to appreciate 
the importance of. any change in it. 

The points in the history of menstruation to which attention should 
be directed are as follows : 

The Age of Commencement -Menstruation begins earlier in some women, 
later in others ; it usually begins between the thirteenth and fourteenth 
year. In hot climates it begins at an earlier age ; and it varies also in 



1 54 SYSTEM t >F G I Wl 1. CO LOG Y 

different races. It begins sometimes as early as the eighth or ninth year j 
sometimes it does not begin till the eighteenth, nineteenth, or twentieth. 
And these variations occur, be it noted, altogether apart from disease 
SUeh as ameniia. 

The Rhfthm of (he Flow. It often happens that after the first period 
or two the patient sees nothing again for some months, perhaps for a 
year or more. After the lapse of some time the flow recommences and 
continues regularly. We are frequently consulted in such cases. A 
girl say of twelve or thirteen, or a little older has menstruated once, 
but the flow has not been succeeded by others in the ordinary way j 
she is consequently brought by her mother to the physician with a 
view to treatment. These cases, as a rule, require no treatment if the 
patient be generally in a healthy condition, and has not exceeded the age 
at which menstruation usually begins. It should be recognised that in 
some individuals it is natural for one flow to show itself, or perhaps for 
two or more to appear, and then for the courses to remain in abeyance 
for some months, often for a year or longer, before the rhythmical flow 
is established. 

Change of residence, especially from the country to London, is often 
attended with cessation of the flow during the stay ; it returns, how- 
ever, subsequently, and in the meantime the general health is unaffected. 

With most women the flow comes on at intervals of twenty-eight or 
thirty days. In some women, however, it appears at shorter intervals from 
two to three, or more frequently still, from three to four weeks. In 
others the intervals are prolonged, and the menses recur after an interval 
of five to six weeks, and sometimes longer ; yet these patients, so far as 
one can judge, are in perfect health, and the menstrual function is other- 
wise performed in a proper and natural manner. It will be found on 
inquiry that such peculiarities arc natural to the individuals. 

In other patients, again, the menses do not occur regularly, and this 
in patients who have gone on for years without any illness or disturbance 
to account for the irregularity. Such persons are never quite regular, 
but if they complain of no illness, irregularity must be looked upon as the 
regular thing for them, and is not necessarily to be regarded as patho- 
logical. 

The Duration of the Flow. Here again considerable variation is found 
within physiological limits. In the majority of women the period lasts 
four or five days; in others it lasts a shorter time, -----very often only one 
day. and even in some 0aS6 but a few hours. hi others the flow con- 
tinues four, fi ven. t>v eight days, or even a little more without 
the presence of any abnormal Condition Or any interference, so far as one 

can Learn, with the general health. In some women it by no means 
infrequently happens that the flow cornea <>u for a day or two, then stops 
for a day or two. and again comes on for two or three days. This again) 
being the natural condition of some individuals, is not by any menus 
necessarily pathological. In others it will be found that without being 
pathological the period lasts i variable time; sometimes it may last a 



DIAGNOSIS IN GYNECOLOGY 155 

Hay or two, at other times rather longer ; occasionally it is extended 
over a week. The duration of the flow in such cases depends in great 
measure on what the patient is doing at the time the more active the 
patient's life the more extended the periods. 

The Daily Amount. As a rule, the longer the flow the greater the 
amount of daily loss. But in this, too, there is room for considerable 
variation without exceeding physiological limits. It is difficult to 
estimate the amount of the daily loss ; but a rough guide may generally 
be obtained from the patient by ascertaining the number of diapers 
which she uses during a period, or during each day of the flow. Some 
patients assert that they never have been able to wear a diaper, as it 
stops the flow. Fortunately such persons do not lose very much. Of 
course, in using this guide to the loss, due allowance must be made 
for individual habits of cleanliness ; for while some will only let the 
diapers become partially soiled, others will be less nice. Still the 
number of diapers serves fairly as a rough estimate of the daily loss. 
If a patient tell you that diapers are "no good at all," and that she has 
to put on two or three at a time, or uses big cloths or towels, you may 
be quite sure she is losing very freely. Such information is exceedingly 
valuable and suggestive. Some patients will even go further, and say 
that they have to lie up during the period, and put something under 
them to protect the bed-clothes, the loss being so copious. The usual 
average is, perhaps, three or four a day say, one to two during 
the day, and one at night ; or sometimes three during the day, and one 
at night. When the patient is up and about, the more active she is the 
more she loses, and, generally speaking, the loss is less at night. 
When the amount of the daily loss is great, it is very likely that clots 
will be passed at the same time ; generally speaking, the more copious 
the discharge the greater the liability to the passage of clots. As a rule 
the menstrual fluid does not clot unless it be very free in amount. These 
clots may be quite small ; or they may be of considerable size, as 
big as the thumb, or even larger ; in this case they are due to an 
accumulation of blood in the vagina and its subsequent coagulation. The 
passage of clots is more usual in women who have borne children. With 
the flow there may also be shreds, which are often looked upon as clots 
by the patient ; but they can be distinguished by the fact that shreds 
float out in water. Such a condition is associated with severe pain, and is 
pathological. 

Pain, again, varies in different persons, though short of that which is 
of so severe a character as to come under the head of dysmenorrhcea. 
In some patients at the time of menstruation there is absolutely no pain and 
practically no discomfort : these persons, however, are rather the excep- 
tion than the rule. With women generally, as the flow approaches, there is 
a sense of fulness, congestion, disturbance, and weight in the pelvic organs. 
They become more highly sensitive at that time, and in a very consider- 
able number of cases pain is present in greater or less degree ; the pain 
may be at the bottom of the back, in the lower part of the abdomen, or 



156 S) S TEM OF G \ \\\ ECOLOGY 

may be referred to one or both ovarian regions. When it is severe it 

may extend beyond these points to the hips, or down the thighs as far as 
the knee ; in other cases it may extend up the abdomen, even to the level 
of the breasts. The amount of the pain may be roughly estimated bl 
ascertaining whether the patient has been in the habit of taking any 
remedies tor its relief such as peppermint, ginger, or alcohol in various 
forms, especially in the form of gin ; or, in some cases where medical 
advice has been sought, as laudanum and even hypodermic injections of 
morphia, besides various other remedies. The amount of the pain may 
be gauged also by the patient's answer to the question whether she has 
been able to be up and about her work, whatever it be, at the time 
of the period; or whether she lias had to take to her bed for a longer or 
shorter time, and have hot local applications such, for example, as a hot 
brick wrapped up in flannel (a useful means of removing pain in some 
cases), hot sand-bags, hot fomentations, stupes or poultices. 

The time at which the pain begins varies in different individuals. In 
some the pain will begin a day or two before the flow, in others a few 
hours before, while in others it comes on with the How. It varies also in 
duration: generally speaking, it begins two or three hours before the 
flow and stops after the first day ; in other cases it is continued to the 
end of the second or third day, and may last even to the end of the 
period. As a general rule, however, the pain is at its worst dining the 
first few hours of the flow, and begins to diminish as soon as the flow 
has come on freely. 

The Attendant Symptoms. In some patients, as I. have said, there is no 
pain and no discomfort ; in others, severe frontal, occipital, or general 
headache, sick-headache, or vomiting may be present. In other 
some disturbance of the bowels, either constipation or diarrhoea, takes 
place at the time of the menses. Most patients, especially during the 
earlier part of the period, require to pass water more frequently than at 
other times; and with this excessive frequency there is occasionally a 
little pain in micturition. Occasionally patients complain that they have 
fits hysterical fits during the flow: these are generally weakly 
patients who are below par, and, being subject to hysteria at other times, 
their tendency to it is increased at the periods. Epileptic attacks 

also seem to be more readily induced during the menstrual flow than at 
other til 1 1 

Leucorrhcea is a Bymptom rather of the intermenstrual period. In a 
healthy woman there is no discharge, or very little, after the cessation of 
the menses; but some women have nat nrally a little discharge of a 

whitish character for a day or two after the flow. In other patients it 
occurs a day or two before the Bowj in others, again, n goes on to 

iter or less extent during the whole intermenstrual interval. This 
discli of an opaque, whitish character. In patients who are re- 

duced in health there u ;i liability to a certain amount of Icncorrlneal 
discharge apart from any local pelvic trouble. Discharge of a thick 
glairy mucus in large quantity is however, pathological; or if the dischargi 



DIAGNOSIS IN GYNECOLOGY 



157 



become yellowish or purulent it passes the physiological bounds. Occasion- 
ally a peculiar odour may be noticed with a menstrual flow which does 
not pass the physiological limit ; but foetid discharges are invariably 
pathological. 

Abnormal Variations. The date at which the deviation from the usual 
course took place must be ascertained. This deviation may take one or 
more forms. The menses may have come on too frequently, at shorter 
intervals than previously ; they may have come on quite irregularly ; the 
duration may have increased or diminished, or the daily loss may have 
increased or diminished. Pain again, previously absent, may have be- 
come a prominent feature. In any case we should ascertain precisely what 
the change has been, and the time at Avhich it set in. Moreover, we should 
endeavour to ascertain from the patient herself what she considers to 
have been the cause of this change in menstruation. It will frequently be 
found to date from the onset, or from a confinement or subsequent 
miscarriage, or it may have begun with some definite illness. 

The menopause usually sets in between the forty-fifth and the fiftieth 
year. Occasionally it occurs earlier, or, on the other hand, it may be 
delayed till after the fiftieth year. Forty-eight is, perhaps, the average 
year of its occurrence. At this time also, as at the beginning of the 
catamenial periods, the menses are often irregular. Menstruation, 
regular up to a certain time, may suddenly cease, and the patient see 
nothing more. Occasionally the courses stop for a month or two, perhaps 
longer, then the patient has a period or two at irregular intervals, and 
after this they cease entirely. In other cases the periods gradually get 
less and less for a year or two and then cease ; in others, again, the meno- 
pause is ushered in by considerable fioodings. It is often difficult to 
distinguish these changes associated with the menopause from the 
symptoms of distinct and serious disease. It must always be borne in 
mind, especially in the case of flooding, that women are particularly 
liable to malignant disease at this time. An examination, therefore, 
becomes advisable in order to determine w r hether the conditions are 
physiological or due to some disease of the organs. 

Both for purposes of future reference and as a guide to the advisa- 
bility of examination by means of the sound, inquiry should be made as 
to the date of the onset of the last period, and the time at which the 
last period ceased. 

It must be remembered with reference to this point, that patients 
frequently think they have menstruated when actual haemorrhage has 
occurred during the course of gestation. Patients will frequently come 
complaining of various troubles, and stating that the last period only 
ceased, let us say, a week ago ; but careful inquiry will elicit the fact 
that for two or three months prior to that time they had seen nothing at 
all, and still closer investigation will show that this so-called last 
"period" had not the character of natural menstruation. Whereas, 
perhaps, the patient has never been in the habit of passing clots before, 
these appeared in the discharge on the occasion referred to : or, although 



158 SYSTEM OF GYNECOLOGY 

the periods had generally lasted a week, on this occasion the How had 
continued for two or three days only, and the amount lost was different. 

The Obstetric History. I have already dealt with the importance 
of ascertaining the social position of the patient. It is still more 
important to know what has been her obstetric history the history of 
her labours and miscarriages, if any ; because a very considerable amount 
of illness which presents itself to the gynaecological physician is the 
result of impregnation and of disease following upon delivery or abortion] 

The first points to ascertain in this connection are the number of the 
children, and the date of the last delivery; next, whether there have 
been any miscarriages, and if so, when they last occurred. Indeed, it is a 
good plan to go not only as far as this, but to ascertain also with 
regard to the children at what period of pregnancy they were born, for 
they may have been premature ; and as to the miscarriages, at what 
period of gestation they took place : the answers are to be entered in 
their order. All this can readily be recorded in very short compass 
if we put down the labours and miscarriages in the order of their 
occurrence, and indicate at the same time the period of gestation at 
which each of these events took place by means of figures representing 
months and fractions of months. 

Where premature labour has occurred or miscarriage taken place, it 
is well also to ascertain from the patient whether any particular cause 
could be assigned for the occurrence. A labour may be brought on 
prematurely, or a miscarriage may be induced in various ways, as by a 
fall, a fright, a blow, a strain, over-work, long railway journeys, mental 
exhaustion, and so forth ; and it is well to fortify one's self with this 
information. Therefore we inquire in each case of premature labour 
what cause the patient can assign for the occurrence. Of course, in 
many cases it will be found that no cause, or an obviously inadequate 
cause, is assigned; and it is in these cases especially that the immediate 
cause may be found in or about the uterus such, for instance, as the 
nee of a fibroid in the uterus, or chronic metritis and endometritis. 

Apart from the question of prematurity, the character of each labour 
should be ascertained ; whether a Ion-' ami difficult, or an easy one ; and 
if Long or difficult, whether it was aided by instruments. Patients will 
generally volunteer the information if "the child came the wrong way"; 
or if. as they say, it was a "cross-birth." The "cross-birth" of patients, 
however, is by no means invariably what the physician understands bi 
that name, for a breech presentation is also usually dubbed with the name 
of cross-birth. In order, therefore, to make sure that the case was in 

reality one of cross birth, it is neceary to inquire further whether 

turning was performed. A breech would probably be delivered as such; 
and no version would be performed; but If the patient states that she 

chloroformed, and that the doctor put ill his hand and turned the 
child, you conclude that the case was really a cross -birth, and not a 
breech presentation. 

Again, apart from the difficulty of the labours, it is well to ascertain 



DIA GNOSIS IN G YN& COL OGY x 59 

whether they have been accompanied by flooding or not ; and whether 
there has been any tear of the soft parts so considerable as to have 
necessitated the introduction of sutures. 

Illness daring Pregnancy and after Delivery. Ascertain also from the 
patient whether her health continued good during pregnancy. Excessive 
sickness, convulsions, oedema, and flooding should be particularly inquired 
after. Patients are generally ready to inform us as to any such illnesses 
as these. With regard to illness after delivery, however, unless questioned 
rather closely, patients are liable to mislead the doctor. It is well 
to ask the patient, in the first place, whether she got on well after 
the child was born; and if in any doubt as to her answer, ask also 
how long she kept to bed. Patients as a rule do not keep their beds 
more than a fortnight after delivery ; if that period has been exceeded 
the chances are that some definite illness occurred during the puerperium. 
It does not necessarily follow, however, that because the patient was able 
to get up after the lapse of ten or fourteen days that she had no illness ; 
for such illness may have been of a transitory kind, or she may 
have got up for a few days while still ill, and had to return to bed again 
for some weeks. 

Illness after delivery is usually of a febrile character. If the patient 
be asked whether she had any fever, she will often reply that she had a 
slight touch of " milk fever." We shall always look with suspicion upon 
such an answer, which probably indicates not mere mastitis, or a local 
trouble giving rise to a certain amount of general febrile symptoms, but 
more often than not it indicates some illness of a septic nature. Such a con- 
dition, in order to prevent alarm on the part of the patient and her friends, 
and sometimes too often I fear to shield the reputation of the doctor, is 
put down as milk fever. Mastitis and septic mischief have this in common, 
that both usually begin about the second or third day ; if, however, the 
illness be due to mastitis the breasts as a rule become very hard and tender 
with the influx of milk at that time, and the disturbance usually subsides 
within two or three days when the flow is well established. On the 
other hand, in cases where the breasts have not shown symptoms of local 
disorder (despite the fact that the patient calls the condition " milk fever "), 
but in which tenderness and pain in the abdomen (which you can gener- 
ally infer from the use of hot flannels, hot fomentations, poultices, or 
turpentine stupes) have been prominent symptoms, it may generally be 
concluded that not "milk fever," but septic mischief of local origin 
was present. It will be found necessary to cross-question patients rather 
carefully in order to ascertain these facts. If the patient had fever, but 
is unable to give information as to the height of the thermometer, she 
will often be able to afford an indication of the severity of the fever by 
stating whether a rigor or severe shiver occurred at the outset of the 
illness. It may be taken for granted that a rigor at the outset generally 
means fever running up quickly to rather a high point. In long-con- 
tinued febrile conditions repeated rigors generally occur later in the disease ; 
and these rigors are generally associated with copious perspirations. 



160 S YSTEM OF G J X. ECOLOG Y 

Again, with reference to the general condition of the patient suffering 
from febrile disease, useful additional information may often be obtained 
by inquiring whether she was able to take her food properly while lying- 
up ; or whether she had to be kept on slops, and so forth. Finally, if a 
patient tell you that she can say very little about her condition, as she 
was unconscious for the greater part of the time, you may rest assured 
she was delirious as well as febrile. 

The conditions, apart from febrile illness, which keep a patient in 
bed longer than the usual time, are either general weakness, from some 
pre-existing disease or from haemorrhage before or during labour or 
immediately afterwards, or laceration of the perineum, or some inter- 
current disease, such as pleurisy, rheumatic fever, scarlet fever, or 
measles. 

Previous Illnesses. It is advisable in the next place to ascertain 
from the patient what previous illnesses she may have had, and whether 
associated with the pelvic organs or not. Many of the troubles com- 
plained of will be found to date from illness occurring at or soon after 
delivery or miscarriage. But it may frequently be found, of course, that- 
some particular symptom takes its origin from disease not directly 
associated with the pelvis : for example, any wasting disease, or illness 
of long standing, such as typhoid fever or phthisis, often exerts an im- 
portant influence on the menstrual function. Thus at the beginning of 
a febrile illness there may be severe loss of blood, especially in mute 
diseases such as typhus fever and small-pox which are often associated 
with haemorrhage. Again, when a patient has been laid up for a con 
,siderable time by prolonged illness such as typhoid or rheumatic fever] 
the periods are frequently held in abeyance for a long interval, an 
remain so until she regains her strength. 

The History of the Present Illness. We should ascertain first of al 
the date at which the present illness began: this date will form a land 
mark from which to make more particular inquiries. We should ascertai 
also the cause which the patient assigns for her illness, as this will ofte 
give a due of considerable value to the nature of her ailment. 

Of the particular symptoms to which attention should be drawn 
put pain first, because it is one of the most common. Cinder this head 

deluded dysmenorrhea, that is, pain at and associated with the 

menses; and dyspareunia, or pain and difficulty in sexual intercourse] 
Pain in association with the functions of the bowel and bladder will be 
dealt with under the head of diseases of these organs. 

\.\t. inquiries should be directed to ascertain if, in other respects. 
the menstrual function has been naturally performed. Under this head 
arc monorrhagia, metrorrhagia, or haemorrhage during the natural intervals 
of the periods; amenorrhcea, or absence of the periods when they ought 
naturally to have been present : and, finally, leucorrhcea, a white o: 
yellowish discharge occurring between the periods. 

Attention should then be paid to the question of local swelling o 
tumour, whether in the privates or in the abdomen ; then to any interfe* 



t 



DIAGNOSIS IN GYNECOLOGY 161 

ence with the due discharge of the functions of the bladder and bowel ; 
and, finally, to such general symptoms as anaemia, wasting, fever, and so 
forth. It will be necessary for us to consider these matters in greater 
detail, and to enumerate the morbid conditions among which these 
symptoms are likely to be found. 

Pain. The site of the pain must be noted, whether it be continuous 
or spasmodic ; and its character, whether it be sharp and cutting, or dull 
and aching ; also whether it be associated with tenderness ; whether it 
be relieved by any one of various applications, such as heat, cold, pressure, 
or the adoption of a particular posture, and in what way it is apt to 
become aggravated. 

The causes of pain in the pelvic organs are very various. Inflamma- 
tory and congested conditions stand prominently forward. Under this 
head are included a very considerable number of the diseases to which 
women are specially liable : such are pelvic peritonitis or perimetritis ; 
parametritis, or disease of the cellular tissue of the pelvis ; hematocele 
haemorrhage into the pelvic peritoneum setting up pelvic peritonitis ; 
haematoma haemorrhage into the pelvic cellular tissue, which sets up para- 
metritis and perimetritis in its neighbourhood; the outcomes of inflammatory 
mischief, such as pelvic abscess ; inflammatory disease of the appendages 
(tubes and ovaries), such as hydrosalpinx, haematosalpinx, and pyosalpinx ; 
and inflammation of the uterus itself metritis. Among the congestive 
conditions I may mention prolapsed or procident uterus, and prolapse 
of the tubes and ovaries. Adhesions, or rather the stretching of adhesions 
left from previous inflammatory mischief due to ovarian or tubal disease, 
are a frequent cause of pain and discomfort j and so, finally, are various 
tumours in the pelvis, some of which originate in the uterus, some in the 
tubes and ovaries, and often cause pressure and pain, especially if 
they have become impacted. 

In the acts of micturition and defaecation it is frequently found that 
pain present in the pelvis becomes aggravated, especially if it be the 
result of inflammatory conditions and adhesions. In other cases pain 
occurs only on micturition and defaecation ; these will be considered later 
in association with bladder and intestinal troubles. 

Dyspareunia may occur from various causes. It is frequently associated 
with vaginismus. This condition may be primary or secondary ; that is to 
say, it may have existed from the beginning of attempts at coitus, or it 
may have come on afterwards as the outcome of some other difficulty in 
the act. It may arise from inflamed conditions of the vagina, from what- 
ever cause ; from excessive indulgence in coitus, or from gonorrhceal 
inflammation. It is also often found in connection with congenital defects 
and fissures about the vulva, with inflammation of the hymen, or with 
ulcers, specific or otherwise, about the vulva ; or it may frequently be associ- 
ated with gonorrhceal warts, or from warts resulting from a long-standing 
discharge, not necessarily of a gonorrhceal nature, but due to irritation 
such as occurs, for instance, in masturbators. And, lastly, dyspareunia 
and vaginismus may be found in association with urethral caruncle. 

M 



162 SYSTEM 0/- GYNECOLOGY 

Apart from these causes directly connected with the orifice of the 
vagina, dyspareunia sometimes occurs in association with some trouble in 
the immediate neighbourhood, such as a rectal fissure or piles. Difficulty 
and pain in coitus are present in some cases of prolapsed uterus ; in these 
. if tlif, uterus be outside, sexual intercourse is rendered practically 
impossible, but pain is not necessarily present. With retroverted and 
retrofiexed uterus dyspareunia is apt to be present; and in cases where 
the ovary is prolapsed and congested the pain is often severe. In in- 
flammatory conditions of the pelvis, whether of the pelvic peritoneum 
(perimetritis) or of the cellular tissue (parametritis), and in cases of 
lueniatocele and hematoma, which become secondarily associated with 
inflammatory disease, pain in sexual intercourse may result ; or again, 
from adhesions between the tubes, ovaries, uterus, intestine, and other 
parts of the pelvis, which result from long-standing inflammatory mischief. 
Cysts in the vaginal wall, though rarely of considerable size, occasion- 
ally give rise to the difficulty. Polypi of the uterus passing down into 
the vagina, and fibroid growths becoming impacted in the pelvis, will give 
rise to difficulty and very often to pain in coitus. 

Dysmenorrhea. Pain at the periods may have been present from 
the very beginning of menstruation, or have resulted subsequently^ 
The division into primary and secondary is useful. The secondary 
variety is very often of an inflammatory character, and dates either from 
a confinement or a miscarriage. In inquiries with reference to dysmenon 
rhoea we should first ascertain where the pain is situated, whether in the 
abdomen or in the back; and if in the abdomen, whether it is confined 
to one side or the other, or extends from side to side ; whether it radiates 
down the thighs, or extends for a considerable distance over the abdomen. 
The pain sometimes extends as high as the mammary region. Next, we 
should ascertain when the pain begins, Avhethcr before the flow or with 
the flow; and if before the flow, how long before. Usually it will be 
found that it commences a few hours or a day or two previous to the 
onset of the period; and in cases of severe dysmenorrheea the pain may 
come on even so long as a week before the period. The duration 
of the pain is variable. In some cases the pain which has begun 
before the period will cease when the flow begins or is freely 
established. It may cease after the first day, but sometimes in severe 
dysmenorrheea is continued for two or three days, and occasionally to 
tin- rial of the period; or again it may even continue after the How lias 
stopped. 

With the view of ascertaining, in the next place, the amount of the 

pain, we should inquire whether the patient has to lie up or not while it 

; whether she is incapacitated from following her usual occupations 

Sonic patients Who keep about will tell us that they would lie up if their 
Circumstances permitted Others will tell US that they are always 

obliged to take t. bed during the first day or two of the periods; others^ 

again, will say that to do so would be of no use, the pain being so sever* 
they cannot keep tjuiet and have to roll about on the floor. Such facts 



DIAGNOSIS IN GYNAECOLOGY 163 

as these will enable us to judge whether the pain be severe or not. In 
cases of less severity, it is possible to judge of the amount of the pain by 
the patient's answer to the question whether any particular treatment has 
been found efficacious in its relief, such as to take the most popular 
hot gin and water, hot ginger, local applications, fomentations, hot bricks 
wrapped up in flannel, or hot- water bottles ; and, finally, whether they 
have been under medical treatment during the periods. 

The causes of dysmenorrhcea are to be found either in some general 
condition of ill health, or in some morbid condition of the pelvic organs. 
Let us consider, first, those general conditions which occur apart from the 
uterus and pelvic organs. A very common example of general ill health, 
accompanied by severe menstrual pain, takes the form of a general 
neurosis, the patient suffering from what is termed spasmodic dysmenor- 
rhea. This form of the disease is always primary in character, 
beginning, as a rule, with the first period, and continuing with increasing 
intensity as time goes on. In cases of anaemia and chlorosis, and in 
cases of chronic constipation, dysmenorrhcea of some severity may be 
present without recognisable disease of the uterus or pelvic organs. 
In cases of congestion of the pelvic organs, by whatever cause produced 
secondary, it may be, to heart or liver disease and in cases of inflam- 
mation in the pelvis, dysmenorrhcea may be a prominent symptom. But 
the pain in these cases occurs not, as a rule, during, but between 
the periods. The loss which occurs relieves the congestion, and to some 
extent diminishes the inflammatory condition by depletion, so that 
as soon as the flow is freely established the pain from which the 
patient had previously suffered sometimes ceases, and returns when the 
period has come to an end. 

Certain diseases of the uterus itself are likewise apt to be associated 
with the occurrence of pain at the periods. And first may be mentioned 
the incompletely developed uterus, the uterus being smaller than it should 
be ; very often no bigger than the top of the little finger. With it in- 
complete development of the ovaries is likely to be associated ; indeed, 
these organs may be absent altogether. 

A small congenitally anteflexed uterus is another form of incomplete 
development frequently associated with dysmenorrhcea. A still more com- 
mon condition takes the form of an elongation of the cervix in its vaginal 
portion, an abnormity known as conical cervix, and usually associated with 
a small orifice or " pin-hole os." 

Fibroma of the uterus is not painful, as a rule, except at the periods. 
During the active congestion which accompanies the early part of the 
periods fibroids often give rise to considerable dysmenorrhcea. 

In cases of displacement of the uterus dysmenorrhcea may become a 
prominent symptom, especially when the uterus becomes retroverted and 
retroflexed, and impacted at the floor of the pelvis between the sacro-uterine 
ligaments. There the congestion in the fundus becomes very marked, 
and severe pain in the early part of the period results. 

Membranous dysmenorrhcea, though rare, is almost invariably asso- 



1 64 S YSTEM OF G YN. COL OG V 

ciated with severe pain, during which the patient passes a membrane 
either as a cast of the uterus or in shreds. 

Menorrhagia and Metrorrhagia. Menorrhagia is an increase in the flow 

at the periods, and takes the form of increased duration of the flow, 
shortening of the interval between the periods, or increased daily loss. 
Metrorrhagia is an irregular flow between the periods. These maladies 
often merge one into the other, so that it may become impossible to drau 
any distinct line between them. Of the estimate of quantity I have 
already spoken. 

The colour of the flow varies in different cases. When the flow 
is very profuse it has a bright hue. In other cases it is dark in colour, 
the usual colour of the menstrual discharge ; in others, again, it takes on 
a brownish appearance, especially as a free flow is beginning to clear of!'. 
There may sometimes be a mere show ; or, on the other hand, the loss 
may take the character of a pinkish serous discharge. Occasionally, if 
there be any leucorrhceal discharge as well, streaks of blood will be found 
in association with it. 

General Causes of Haemorrhage. In a certain number of cases of 
anaemia and chlorosis, in contradistinction to the usual condition of 
amenorrhcea, menorrhagia appears. This is the case rather in the severer 
forms of the disease ; indeed, the loss tends to aggravate the disorder. 
In congestive conditions of the heart and liver menorrhagia is apt to 
be present, and, of course, metrorrhagia too; for owing to the obstruction 
of the circulation an excessive flow is apt to occur not only at the 
periods, but also between them. This loss may be compared with the 
escape from a safety-valve, and should not be injudiciously checked. L 
some cases of acute specific disease, and especially in those associated 
with hsemorrhagic tendency such as typhus fever, scarlet fever, small- 
pox, and, to a less extent, measles menorrhagia is apt to set in at llu 
beginning of the fever. Sometimes it becomes marked and required 
particular treatment. In some blood diseases, again, such as purpura art 
haemophilia, an increased flow at the periods is apt to occur. 

Local Causes of Haemorrhage. From these general causes I pass next 
to certain conditions in the pelvis outside the uterus. In inflammatory 
conditions in the pelvis such as parametritis and perimetritis menon 
rhagia and metrorrhagia sometimes occur. These cases almost come into 
the same category as those in which the heart and liver are diseased; 
for in many of them, at any rate, the vessels become involved, the veins 
become plugged, and so the return of the blood to the heart is interfered 
with. The loss in such cases, therefore, unless it be excessive, has a 
beneficial tendency by depleting, and thus relieving the inflammatory 
condition. 

In pelvic baematocele and pelvic hematoma bleeding is apt to take 
place. The usual history in such cases is that, either as the result of some 
excessive work undertaken at the period, or of a chill caught after the flow i 
has begun, the discharge suddenly ceased, hut reappeared and thereafter I 
continued for a longer time than it should do, perhaps for a fortnight. 






DIAGNOSIS IN GYNAECOLOGY 165 

In some cases of ovarian congestion and ovaritis menorrhagia and 
metrorrhagia are liable to ensue. Especially is this likely to occur as the 
result of too frequent sexual intercourse soon after marriage. In 
ovarian disease proper such as ovarian cystoma amenorrhcea is the 
rule ; but in a certain number of cases menorrhagia and metrorrhagia 
take its place. The same remark also applies to cases of tubal disease, 
hydrosalpinx, hematosalpinx, and pyosalpinx ; in these, though amenor- 
rhcea more frequently occurs, menorrhagia and sometimes metrorrhagia 
are occasionally present. 

The abnormal conditions of the uterus itself, which give rise to 
haemorrhage, may be conveniently divided into those found in the unim- 
pregnated and those occurring in connection with child-bearing, whether 
during pregnancy or during the puerperium. 

In cases of metritis, with disease of the lining membrane of the uterus 
a state to which various names, such as fungous and villous endometritis, 
have been given haemorrhage is an almost constant symptom ; there is 
excessive flow at the periods, and very often a loss also between the 
periods ; the periods come on too frequently, last too long, and the 
daily loss is more than natural. 

In cases of mucous polypi of the cervix, again, haemorrhage is by no 
means uncommon ; and with this I ought to mention a condition ante- 
cedent to it, namely, the thickening of the mucous membrane of the cervix, 
with proliferation of the gland tissue, which often extends to the vaginal 
portion, and produces what is known as an adenomatous erosion. This 
condition gives rise not only to excessive haemorrhage during the periods, 
but also very frequently to haemorrhage during the intermenstrual time. 
It may be particularly noted that in this case the haemorrhage a metror- 
rhagia is apt to follow sexual intercourse. 

Fibroids or myomas in the uterus are frequently, but not invariably 
associated with haemorrhage. Fibroids projecting on the peritoneal 
surface that is to say, subperitoneal fibroids do not in themselves cause 
haemorrhage ; fibroids in the wall of the uterus, unless they encroach on 
the cavity and cause it to enlarge, do not give rise to haemorrhage ; 
but haemorrhage may be caused by fibroids projecting into the uterine 
cavity, that is to say, by submucous fibroids ; although here again bleeding 
is not an invariable concomitant. Fibroids, however, when they 
become polypoid, almost invariably produce haemorrhage. It must be 
remembered that fibroids are frequently multiple ; and that the symptoms 
may be due, not to a subperitoneal fibroid even of considerable size, but to 
a smaller mass not always easily recognised beneath the mucous membrane. 
The haemorrhage which occurs in association with fibroids is generally 
menorrhagic in character, although it occasionally occurs in the intervals 
between the courses, and is often very profuse. It is probably due 
directly to an unhealthy condition of the uterine mucosa induced by the 
presence of the fibroid mass. 

Malignant disease of the uterus, which generally affects the cervix, is 
a potent cause of haemorrhage. Especially is it one of the causes of 



166 SYSTEM OF GYNAECOLOGY 

haemorrhage occurring at the climacteric. The haemorrhage may be 
menorrhagic, but it is more frequently metrorrhagia in character* 
From the cervix the malignant disease may spread to the body of the 
uterus. Primary cancer of the body of the uterus is also associated 
with haemofrhage, but it is a comparatively rare condition, and the hemor- 
rhage when it occurs is not, as a rule, very severe. It usually takes the 
character of a watery discharge with a pinkish tinge rather than of a 
severe flow of blood; though in certain cases even of primary cancel 
of the body severe floodings may take place. In sarcoma of the body of 
the uterus haemorrhage is apt to occur and to constitute a prominent 
symptom. 

Senile endometritis is another condition occasionally met with, giving 
rise to haemorrhage after the menopause. The distinction between senile 
endometritis and cancer of the body of the uterus can, as a rule, only bj 
determined by exploration of the cavity of the organ. 

Special Catises of Haemorrhage during Pregnancy and after Delivery. 
It may be noted that occasionally the catamenia persist after impregnation 
has taken place; the periods being sometimes continued during the first, 
second, and third months, rarely later than that. It is often difficult in 
any individual case to say whether a discharge of this kind is really a 
menstrual period ; but usually, if it preserve the same character as 
period and come on regularly, it may be looked upon as such. When, 
however, from some morbid condition, bleeding occurs during gestations 
the loss is specially apt to take place just as the monthly cycles come 
round; consequently an impression of regular periods may be pro] 
duced in the patient's mind. 

Haemorrhage in association with gestation may be symptomatic o: 
threatened abortion, of bloody, fleshy or vesicular mole, or of ectopi 
gestation ; and, during the last two months of pregnancy, of accidents 
haemorrhage or of placenta praevia. It will suffice merely to mentio 
these matters here. 

It may be useful to bear in mind that the other causes of luemorrhagi 
occurring during pregnancy haemorrhage, that is, from the uterus are 
generally associated either with cancer of the cervix; or with adenoma of 
the cervix, commonly called erosion; or sometimes with mucous polypi. 

I hemorrhages occurring shortly after delivery do not fall within the 
scope of this volume. Haemorrhage setting in after the patient has left 
tier bed and the lochia have ceased may depend on one of several 
conditions. It frequently occurs in cases of subinvolution; often in 
association with inflammatory disease, or with the retention of some 
portion either of placenta, membrane or blood-clot within the uterus ; of 
with tie- presence of a fibroid growth, either in the wall or beneath the 
submucous tissue of the uterus, of of ,-i polypus. Moreover, the 
mucous membrane may take on an Irregular, villous, or fungous character; 
associated in many eases with very considerable haemorrhage. 

More or less sharp lnemorrhage will occur in some cases when (In- 
patient begins to get up: and on examination it will be found that th 






DIA GNOSIS IN G YNJE CO LOG Y 1 67 

uterus is prolapsed, retroverted, and larger than it should be from conges- 
tion, and sometimes firmly impacted in the pelvis. In cases of inversion 
of the uterus a considerable loss often takes place, with leucorrhceal 
discharge in the intervals. 

Slight haemorrhage after delivery may occur from incompletely healed 
laceration of the cervix, or from erosion. Cancerous growths of the 
cervix must also be borne in mind as a possible cause of haemorrhage. 

Amenorrhea. During pregnancy, as well as during suckling, amenor- 
rhoea is the rule. But, as already stated, the courses sometimes persist 
during the early months of pregnancy, and even later. Many women, 
too, especially those of rather florid temperament, will continue to have 
the periods regularly during suckling, and that even from a month after 
delivery. It is necessary to bear this feature in mind, because patients 
are apt to be misled in consequence, and even when far advanced in 
pregnancy will persist that no impregnation can have taken place. A 
general impression also prevails that suckling prevents impregnation. To 
a certain extent this is true, but by no means invariably. Women who 
have been suckling regularly may be found far advanced in pregnancy, 
having one child at the breast while carrying another. 

When the menopause is artificially induced, as by the removal of the 
ovaries, for fibroid disease of the uterus or other such reason, amenorrhcea 
as a rule results. Occasionally the patient will have one period after- 
wards, sometimes two or three. In cases, however, where the periods 
continue regularly it is doubtful whether the whole of both ovaries has 
been removed ; removal of one ovary does not stop the flow. In some 
cases after complete removal of both ovaries an irregular loss occurs, 
resulting from concomitant disease of the uterus itself, such as the 
presence of a small polypus, mucous or otherwise, in the cervix or body ; 
or disease of the lining membrane of the uterus. 

Among the general causes of amenorrhcea anaemia stands first in 
-point of frequency. 

Amenorrhcea is also apt to result from any cause of malnutrition, 
particularly acute illness or chronic wasting disease : it may be found, for 
example, after rheumatic fever, during and after typhoid, in phthisis and 
Bright's disease, and so forth. 

A chill taken during menstruation will sometimes stop the periods 
without producing any discoverable lesion of the pelvic organs, but often 
inflammation and other disorder is at the same time induced. 

In cases of chronic inflammation of the ovaries and tubes, in ovarian 
cystoma, in hydrosalpinx, hsematosalpinx, and pyosalpinx, amenorrhcea 
is sometimes though not invariably present. In some cases the regularity 
of the periods may not be interfered with, and in others menorrhagia takes 
place. 

In rudimentary conditions of the ovaries and uterus primary 
amenorrhcea is frequently present, and, if not absolute, it will usually 
happen that the periods occur at considerable intervals five or six weeks, 
perhaps two or three months intervening and the loss is very slight, a 



1 68 SYSTEM OF GYNAECOLOGY 

mere show on each occasion. But here again amenorrhoea is by no 
means invariable. I have known cases of small uterus and ill-developed 
ovaries with monorrhagia. 

Za ueorrhoea. In making inquiries with regard to leucorrhcea we should 
ascertain, f.rst of all, the character of the discharge. It may be white or 
colourless, opaque or glairy ; that is, either like milk or like the white 
of egg. The natural discharge from the cervix is glairy and mucoid, 
becoming opaque when it passes into the vagina. On the other hand, in 
disease the discharge may be of a yellowish or creamy colour ; or it may 
be greenish, or brown and mixed with blood. With a view to ascertain 
the extent of the discharge the patient may be asked whether it is such 
as to require a diaper. The answer will generally afford some means of 
ascertaining its amount. Then we should inquire when it occurs whether 
it persists during the whole intermenstrual period, or comes on just before 
or just after the flow and when it is of greatest intensity. As a rule 
leucorrhceal discharges are most marked just before or just after the 
menstrual flow. 

The causes of leucorrhcea are general weakness, anaemia, wasting 
diseases, and worms. Thread-worms in children are especially apt to be 
associated with considerable leucorrhceal discharge. Under these circum- 
stances the mother frequently brings the child to the doctor, imagining, 
perhaps, that she has been tampered with. We should look out for worms 
in such cases, or for the vulvitis which in children follows such diseases 
as measles, scarlatina, whooping-cough, chicken-pox, and the like. 

Leucorrhcea may be the result of vaginitis, arising either from the 
presence of foreign bodies in the vagina, from some irritation of the 
vagina, as in cases of masturbation, or from the presence of ill-fitting 
pessaries or pessaries that have been worn for a considerable time. With 
vascular caruncle of the urethra there may sometimes be a little 
leucorrhceal discharge. 

Gonorrhoea is a potent cause of leucorrhceal discharge, often in its 
worst form; but even in these cases the discharge is not necessarily 
profuse. 

Soft chancres about the vulva, again, are frequently associated with 
a certain amount of leucorrhceal discharge. Tears about the vulva, too, 
such as occur after operations or after delivery, if they fail to heal pro- 
perly, may give rise to a leucorrhceal discharge. 

Erosions of the cervix, whether merely catarrhal or adenomatous, are 
generally accompanied by a discharge which, as it poms away from the 
cervix, is glairy ; but it becomes opaque on reaching the vagina unless the 
quantity be great The discharge in some of these cases is very profuse. 

Eversion of the cervix, generally the result of a bilateral laceration 
of the cervix occurring during delivery, is attended by leucorrhcea. 

Leucorrhcea is also to be found in cases of mucous polypi of the 
cervix, in cases of cervical catarrh, in cases of subinvolution of the 
uterus occurring after delivery or miscarriage, in cases of senile cor- 
poreal endometritis, in disease of the uterine mucosa, whether associated 



DIAGNOSIS IN GYNAECOLOGY 169 

with submucous fibroids and polypi of the uterus or not, in cases of 
cancer of the uterus, in cases of chronic inversion of the uterus, and, 
finally, in some cases of pyosalpinx and pelvic abscess, or suppurating 
cyst in the pelvis, when the discharge finds its way by perforation 
through the uterus or, more frequently, through the vagina. In all 
such cases the leucorrhceal discharge is liable to alternate with unusual 
losses of blood. 

Foetor of the discharges (which necessarily means saprsemic decom- 
position) may be met with in cases of threatened miscarriage and of 
incomplete abortion ; in cases of subinvolution associated with retained 
products of gestation ; in cases of severe inflammatory mischief, such as 
occurs in gonorrhoea, and particularly when an abscess has opened into 
the canal ; in cases of cancer ; in cases of senile endometritis ; and in 
some cases of submucous fibroids and polypi in which the tumour has 
sloughed. The. discharge, however, may take on an offensive odour 
under other conditions, as, for example, with mere rents about the 
vulva, such as occur after delivery, and in some cases of cervical erosion 
and eversion. 

Local Swellings or Tumours. We should ascertain from the patient if 
she has noticed any swelling either in the abdomen or privates ; when 
the swelling first appeared, and whether it be persistent or variable in char- 
acter. We should inquire also the site where it was first noticed, and the 
direction in which it has grown. In order to ascertain from the patient 
whether any considerable enlargement of the abdomen has really taken 
place, it is well to ask whether she has had to let out her clothes. 
Uterine enlargements commence at or near the middle line ; ovarian 
tumours are usually noticed first at one side or the other, and only after 
a time, as increase takes place, do they extend upwards and towards the 
middle line. Distensions of the tubes and inflammatory effusions are 
usually found near the groins, and thence extend into the iliac fossae. 

Among unilateral swellings about the vulva may be mentioned 
abscess, cyst, varicose enlargement, inflammatory induration of the 
labium, and possibly hernia. Protrusions in the middle line are 
commonly urethral caruncle, cystocele, rectocele, or prolapsed and pro- 
cident uterus. 

The various tumours met with in the abdomen and pelvis will be 
enumerated later in dealing with the abdominal and vaginal examination 
of the patient. 

Urinary Symptoms. We should note the character of the pain, if pre- 
sent, and the time at which it occurs whether during micturition, 
previous to micturition, or following micturition. We should note also 
the frequency of micturition, and whether it takes place most frequently 
at night so as to disturb the patient's rest, or during the day when she 
is up and about ; or if, on the other hand, there be difficulty in getting 
the water to pass, or such inability as to necessitate the use of the catheter. 
Or, again, the water may constantly run away ; or be passed involuntarily 
on coughing or straining. 



170 SYSTEM OF GYNECOLOGY 

The character of the urine may be partly learned from the patient, 
and will probably also be tested. Pus, blood, or mucus from the 
vagina may be found mixed with it, and, in order to obtain a sample 
uncontaminated, it may be advisable to pass the catheter. Many 
genera] diseases such as diabetes, insipidus and mellitus ; hysteria: 
nocturnal incontinence may give rise to one or other of the foregoing 
symptoms; or affections of the urinary organs not a part of the special 
3es of women nephritis, for instance, whether acute or chronic] 
calculus either in the kidney, ureter, or Madder: pyelitis; cystitis; or 1 
displaced kidney may interfere with the urinary function. 

Associated with disturbance of micturition may be mentioned cysto- 
eele with or without prolapse of the uterus; until the swelling bo pressed 
up this frequently causes difficulty and delay in passing water. In 
of vesico-urinary and vagino-urinary fistulas, constant or nearly 
constant dribbling away of the urine takes place. Vascular caruncle 
frequently gives rise to pain in passing the water. In vulvitis, such as 
sometimes affects weakly children ; in vaginitis, from whatever cause 
such as foreign bodies, ill-fitting pessaries, and so forth, or resulting 
from general weakness; and in cases of gonorrhoea, the urethra is often 
implicated ; and pain in passing water is complained of as well as difficult! 
in getting the water to pass : occasionally there is retention. 

In cases of polypi from the uterus coming down into the vagina, and 
of various tumours (especially when impacted in the pelvis), such as 
fibroids, ovarian tumours, parovarian tumours, dermoid tumours of the 
ovary, tubal distensions, hydrosalpinx, hematosalpinx, and pyosalpinxj 
ectopic gestations, and retroverted gravid uterus, micturition may Ik 
interfered with; and incontinence, excessive frequency of micturition, 
pain in passing water, or retention may take place. The same mag 
occur in advanced cases of cancer, of sarcoma of the uterus, and of in- 
flammatory conditions in the pelvis, such as perimetritis, and parametritis 
hematocele, haematoma, and pelvic abscess. Finally, unusual frequency 
of micturition may be reckoned as one of the earliest signs of pregnancyj 

Intestinal Symptoms. We should ascertain the frequency with which 
tin- bowel- ace relieved, and if defalcation be painful, difficult, 01 
associated with tenesmus. If constipation be a prominent feature thi 
effects of remedies often afford us some information. The presence oj 

blood. DEIUCUS, or pus iii the stools should be noted. W'e should next note 

the condition of the tongue, and inquire as to the appetite and digestion 
whether nausea or vomiting be present, and if bo, the time at which 
they occur, and the character of the vomit ; facts which may have an 
important bearing on the question of gestation. 

It may be remarked that these intestinal troubles, like the urinary, 

are not by any means necessarily associated with disease in the pelvis, but 
more often result from general disease, such as chronic constipation ; or 
from disease of the lower bowel, such as haemorrhoids, stricture, malignant 
disease, and fistula in ano. I Jut among other causes may he instanced 
recto-vaginal fistula, rectocele with prolapse of tic posterior vaginal wall, 






DIAGNOSIS IN GYNECOLOGY 171 

prolapse of the litems and procident uterus, tumours impacted in the 
pelvis, cancer, sarcoma, and fibroids of the uterus. Again in inflammatory 
swellings, such as perimetritis and parametritis, haematoma, haematocele, 
and pelvic abscess, the inflammatory process often involves the mucous 
membrane of the bowel, and sometimes leads to the passage of blood and 
mucus. Pain and difficulty in defecation are apt to be present when the 
ovaries and tubes are prolapsed, and the uterus retroflexed or retroverted ; 
for, if the bowels become constipated, the attempts at defalcation force 
the faeces down above the misplaced mass, which may act as a sort of 
ball-valve on the rectum, and increase the difficulty. 

General Symptoms. Anaemia, wasting, fever, and so forth, will generally 
come to light with the other and more special symptoms of which the 
patient has already complained. 

Previous Treatment. Finally, we must ascertain and note what pre- 
vious treatment, if any, has been adopted, how long it has been carried 
out, and with what result. We should note particularly whether the 
patient had been confined to bed, and for what length of time ; and 
what local measures, if any, have been adopted, either in the form of 
applications, such as douches, tampons, pessaries, or of operative pro- 
cedures. 

The physical examination of the patient. In conducting the 
physical examination of the patient attention will first be directed to the 
abdomen ; afterwards to the internal examination. 

Examination of the Abdomen. We should note first the size and 
shape of the abdomen. If it be enlarged measurements must be taken. 
These are from the umbilicus to the xiphi-sternal articulation ; from the 
umbilicus to the top of the symphysis ; from the umbilicus to the anterior 
superior spines, right and left ; the girth at the umbilicus, and in great 
enlargements the greatest girth. 

In the next place the umbilicus is to be observed, whether it be pro- 
truded or depressed : it protrudes when there is free fluid in the abdomen 
and in cases of umbilical hernia : it is unusually depressed when there is 
much fat on the abdominal wall. 

A note also should be made of the condition of the linea alba, the 
marked pigmentation of which, at any rate in the lower part, is often an 
indication of pregnancy. 

The existence of striae or skin cracks on the external surface of the 
abdomen is to be noted ; their number, their size, their colour, their 
position, and the direction in which they run. Skin cracks are an 
indication that the abdomen is or has been distended ; not necessarily by 
pregnancy, though that is the most common cause : ascites and other like 
distensions will produce them. The colour of these cracks will vary with 
the lapse of time since the distension occurred ; fresh skin cracks are 
usually pinkish in colour ; old ones are whitish, or, if they have become 
redistencled, acquire a bluish tinge. Their number and size will 
vary not only according to the amount of the distension, but also in 
individual cases. Some women pass through full term pregnancies, and 



1 72 .V I STEM OF G ) Wl KCOLOG Y 

have not a single stria left to tell the story ; in others the abdomen may 
be scored by striae before the mid-term of pregnancy is reached. 

The thickness of the abdominal walls varies in the main with the 
amount of their adipose tissue. In women who have not had children 
they are often extremely rigid, especially in neurotic subjects ; whereat 
in women in whom the abdomen lias been distended, or who are generally 
lax of tissue, the walls may be so exceedingly thin and loose that the hand 
may sink deeply enough on the abdomen between the separated recti for 
the promontory of the sacrum to be felt ; and, perhaps, the brim of the 
pelvis may be mapped out through the anterior abdominal wall. Any 
hernial protrusion on the abdominal wall, whether at the umbilicus or 
in the groin, should be duly noted ; and likewise any considerable tender- 
ness or resistance in the abdominal walls. Neurotic patients under 
manipulation are very apt to contract the walls of the abdomen; but in 
these patients the resistance is general over the abdomen, and not limited 
to the lower part or to one side, as is usual in pelvic disease. 

Abdominal Enlargements. The main causes of enlargement, apart from 
distinct tumours in the abdomen, are the following : 

i. General obesity, a thick adipose condition of the abdominal wall, 
associated with a large deposit of fat in the omentum and other parts of 
the abdomen beneath the peritoneum. This deposit of fat often occurs 
about the menopause. The abdominal wall may be increased to some 
four or five inches in thickness, a state of matters which very muck 
interferes with any examination of the deeper structures of the abdomen, 

ii. Flatulence often produces general enlargement of the abdomen, 
and likewise interferes with examination. It is associated with a tym- 
panitic note on percussion. In some women enormous distension is thus 
produced. In young girls, also, considerable distension of a more localise! 
nature often gives rise to the impression of pregnancy; but here, again, 
the tympanitic note on percussion is distinctive enough : under chloro- 
form such swellings disappear. 

iii. General enlargement of the abdomen, due to fluid accumulation, 
is accompanied by dulness on percussion, as in ascites associated with 
disease of the heart or liver. The effusion may be serous, fibrinous, puru- 
lent, or hemorrhagic. 

iv. Occasionally a distinct tumour of the abdominal wall itself may be 
met with. I have seen a lipoma which, in its position at any rate, very 
closely simulated a small ovarian tumour for which, indeed, it had been 
mistaken ; but ci retul examination showed that it was situated in the 
abdominal wall and not beneath it. 

Intra-abdominal / If a tumour be found in the abdomen it is 

important to learn when the swelling was first noticed, and whether 
attention was drawn to it by pain or by the increase of the abdomen. 
We must also ascertain at what point it was first observed, whether in 
the upper or lower part of the abdomen, or to one side or the other. 
the direction of its subsequent growth ; its rate of progress, and whether 
its growth has been steady or variable in rate. 



DIAGNOSIS IN GYNECOLOGY 



173 



The tumour may appear to be rising out of the pelvis in the middle 
line, or to one side of it ; to spring from the lumbar region, or from the 
upper part of the abdomen under the ribs. The longest and shortest 
measurement of the tumour must be noted ; its shape and outline, 
whether regular or irregular, or ill-defined ; its consistence, whether it be 
hard, as is usual in fibroids, or soft, as are most ovarian swellings ; 
whether fluctuation be present or not, and if present, whether the fluid 
thrill is conducted equally in all directions. The mobility of the tumour 
should be determined, and also the point where it appears to be attached. 
Occasionally a tumour may be fairly movable, but limited by adhesions 
in one or more directions conditions which can readily be estimated 
by palpation through a thin and lax abdominal wall. In endeavouring 
to ascertain the mobility of the tumour one may notice a distinct 
crepitant feeling transmitted to the hand, which usually indicates that 
some inflammatory mischief has produced a considerable roughness of the 
tumour. In some cases, again, under favourable conditions of the abdominal 
wall, a pedicle may be felt. The extent of the area of dulness on 
superficial or deep percussion may or may not correspond with the 
size of the tumour. The stethoscope will enable us to ascertain whether 
there be any sounds about the tumour. Apart from the sounds of 
pregnancy, in some cases of fibroid tumour a sound resembling the 
uterine bruit of gestation may be heard ; or if the surface of the tumour 
has been roughened by inflammation, friction sounds may be distinguished: 
in many cases adventitious sounds are conducted from the aorta or 
intestine. 

Pressure on the main venous trunks gives rise, in some cases, to 
engorgement of the veins running over the abdominal wall ; in others 
to varicose veins about the vulva, thighs, and legs, and to oedema of the 
lower extremities. 

In exceptional cases, as a means of diagnosis, an exploratory puncture 
of the tumour may be allowed, and a microscopical examination of the 
fluid made in order to ascertain the nature of the swelling ; finally, 
exploratory opening of the abdomen may sometimes be called for to 
clear up an obscure case. 

In dealing with tumours in the abdomen, it is at the outset advisable 
to eliminate the possibility of pregnancy. Before proceeding, therefore, 
to a differential diagnosis of the intra-abdominal tumours it will be 
advantageous to briefly consider the indications of gestation. 

Diagnosis of Pregnancy. The shape of the uterus is to be noted, 
whether there be any marked obliquity or not ; this, if present, is 
usually directed to the right side of the abdomen. On palpation the 
tumour may present the characters of a gestation, that is to say, of fluid 
containing a solid (the foetus) ; with easy conditions of the abdominal 
wall as regards thickness and resistance, it may be possible to map out 
the position of the back, of the small parts, and of the head of the foetus ; 
and to feel the foetal movements. In some cases a thrill may be felt, 
though this is by no means common. Contractions of the uterine 



174 SYSTEM OF GYNAECOLOGY 

muscle can usually be induced, and are an important diagnostic sign, but 
they occur also in fibroid tumours. At the sixth month of pregnancy the 
fundus of the uterus reaches to about the level of the navel ; at the fifth 
month it is about half-way between the navel and the pubes ; at the 
fourth month it can be distinctly felt above the pubes; before that 
period it is not easily felt above the brim. At the seventh month the 
fundus arrives about half-way between the navel and the ensiform 
cartilage ; at the eighth month it rises to the level of the xiphi. sternal 
articulation, and during the last month, as the foetal head comes down 
in the pelvis, it sinks a little again in the abdomen. But it must be 
remembered that the size may be interfered with by various circumstances. 
In cases of multiple pregnancy twins or triplets the uterus at any 
given stage is larger than in a normal gestation: this is also the case 
when the liquor amnii is excessive, and in hydatidiform mole. The womb 
is smaller than usual when the foetus is abnormally small; when the 
foetus dies, prematurely or not, or is interfered with in its development. 
When the contents of the uterus have been converted into a mole the 
organ may remain for a long time almost stationary in size. If, on 
auscultating the abdomen, the foetal heart is heard with certainty, the 
question of gestation is at once settled. But inability to hear the heart 
sounds does not necessarily contra-indicate pregnancy, for this sign is 
naturally absent till four and a half months of development have been 
attained: and, even later, it cannot always be heard even though the 
foetus be alive. By observing the rhythm of the foetal heart, and ;it the 
same time counting the rate of the maternal pulse, the possible error of 
mistaking conducted sounds from the mother's arteries may be avoided 
While listening to the foetal heart, it is often possible, with the hand on 
the other side of the abdomen, to feel the foetal movements quite dis- 
tinctly ; and also, perhaps, contractions of the uterine muscle, induced bj 
the pressure of the stethoscope : both of these signs are valuable indications 
of pregnancy. In some cases, though not often, one may light upon an 
umbilical bruit, a sound produced by the pressure of the stethoscope or 
the umbilical card; it is synchronous with the foetal pulse, not with the 
maternal. Much more frequently the uterine bruit is heard, a sound 
which is said to be produced in the large sinuses of the uterus: this 
lruit is synchronous with the maternal pulse. The uterine bruit varies 
much in different cases, and in its characters ; it may \;iry even in the 
same case at different times. Sometimes it is a soft murmur ; sometime^ 
its note is almost hard and shrill ; it varies from time to time in 

intensity and pitch, and in the position in which it is heard. It may he 

taken as diagnostic of the uterine character of the tumour, but not 
warily of pregnancy : for it is sometimes heard in cases of uterine 
fibroid. 

If the UterUI i~ regularly enlarged, if no indication of disease be 
present, and if the uterus corresponds in size with what might be expected, 
the diagnosis of gestation is usually warranted, even in the early months 
before the advent of any certain indication. But when complications 






DIAGNOSIS IN GYNECOLOGY 



75 



are present ; or the history is misleading, as in ectopic gestation ; or un- 
reliable, as when the patient has reason to conceal the event, it is well to 
withhold an opinion until some certain sign appears. In doubtful cases 
some evidence may also be derived from the breasts. The breasts 
usually become distended and enlarged before the mid-period of preg- 
nancy is reached ; the nipples and the areolae surrounding them become 
more prominent ; the follicles which they contain stand up from the 
surface ; and the pigmentation, especially in dark-complexioned subjects, 
becomes augmented, and spreads beyond the true areolae so as to form a 
darkened area, with small spots upon it devoid of pigment : this is 
exceedingly characteristic of pregnancy, though not absolutely diagnostic 
of it, for similar pigmentation is occasionally observed in cases of fibroid 
tumours of the uterus and of ovarian cystoma. 

Further, fluid may exude from the nipple on pressing the breasts. 
Though the pigmentation and secretion afford presumptive evidence of 
pregnancy, it must be borne in mind that these signs are of little or no 
value after the first pregnancy, for they persist after delivery. 

The stria? of distension on the breasts rarely occur except as the 
result of engorgement during lactation. 

It is rare for an abscess to form in the breasts except after child-birth 
or miscarriage, so that the mark left by an abscess is also fairly 
presumptive evidence of past gestation. 

Before passing on to speak of the various tumours found in the 
abdomen it will be advisable to anticipate somewhat, by referring also 
to the internal examination in cases of pregnancy. If the patient be 
pregnant, the following points may be noted in making the internal 
examination : 

The cervical canal is often patulous during the fifth, sixth, and 
seventh, and even during the eighth month of gestation ; but it closes as 
the time of delivery approaches, and before the dilatation proper to 
labour begins. Its size, its dilatability, and its length should be noted. 
The cervix becomes thickened and softened during gestation, and during 
the last three months of pregnancy it apparently becomes drawn up out 
of the vagina. 

If the cervix is sufficiently dilated, it may be possible to feel the 
membranes within it, or possibly the placenta in cases of placenta praevia, 
or blood -clot if haemorrhage have occurred. Blood -clot may be distin- 
guished from placenta or membrane by its vanishing under pressure of 
the finger and thumb ; membrane or placental tissue will not entirely give 
way, or if doubt still remain the mass may be removed for examination. 

Through the cervix it may be possible to distinguish the presenting 
part of a foetus ; but more frequently its presence may be ascertained by 
pressure through the anterior vaginal wall in front of the cervix. 
During the mid-period of gestation ballotement can be practised, and, if 
obtained, it forms a valuable additional indication of pregnancy. 

Abdominal tumours, other than pregnancy, may be met with in the 
abdomen. Tumours of the abdomen beginning above and coming 



176 SYSTEM OF GYNAECOLOGY 

down from under the ribs, though they may be met with among 
gymecological patients, do not properly fall within that category, 
except as a matter of coincidence. Of such, for instance, are enlarge- 
ments of the liver and gall-bladder, of the spleen, and of the stomach. 
Other tumours of the abdomen take their origin very variously ; 
as, for instance, cancer of the bowel, faecal accumulations, localised 
peritonitis with effusion, adhesions the result of peritonitis (which 
I mention here because the impression of a very distinct tumour 
is often conveyed by such adhesions), omental cysts, hydatids, and 
tumours of retroperitoneal origin. Tumours of the kidney beginning in 
one or other lumbar region frequently find their way to the brim of the 
pelvis; or, at any rate, into the iliac fossa. An abnormally mobile or 
wandering kidney is frequently observed among gynaecological patients, 
for the simple reason that this condition, which is more common on the 
right than on the left side, is usually associated with a general laxity 
of the patient's parts, and with displacement of the uterus or of the 
ovaries. 

Tumours beginning below may be uterine, tubal, ovarian, or para- 
metric in origin. A full bladder should invariably be reduced, in any 
doubtful case of abdominal tumour, by passing a catheter. It is not 
sufficient to rest satisfied with the patient's statement that urine has been 
passed recently ; because, when the bladder is full, though micturition be 
frequent, the amount passed is small, and often consists merely of overflow. 

Of the various uterine enlargements some preserve the natural 
contour of the uterus, others are irregular in shape. Among the 
regular enlargements may be reckoned gestation ; hydatidiform, blood, 
and fleshy mole ; an abnormal enlargement of the uterus remaining 
after delivery, under the general term of subinvolution ; metritis ; pyo- 
metra, and haematometra. Among the irregular enlargements may lie 
instanced fibroid tumours of the uterus subperitoneal, interstitial, suh- 
mucous, or polypoid ; and malignant disease, cancer and sarcoma. 

Enlargements of the tubes, so great as to cause abdominal swelling, 
may be due to tubal gestation, which often ruptures and spreads into the 
broad ligament, or into the abdominal cavity; hydrosalpinx; pyosalpinx, 
whether gonorrheal or septic; haematosalpinx, which is often associated 
with tubal gestation, or produced by some interference with the due 
flow of blood during a menstrua] period. 

Enlargements of the ovary may be cystic or solid. Ovarian cystoma 
is the most common form of ovarian tumour. It is frequently mnlti- 
locular, and may have undergone change ; especially from congestion duo 
to impaction of the tumour, or twisting of the pedicle; and inflammatory 
mischief may alter the character of the fluid to blood or pus. der- 
moid tumours of th<- ovary frequently occur in young subjects, and ari 
associated with the formation of dermoid structures, such as bone, teeth, 
hair, skin; these, if left untreated, frequently suppurate and discharge 
through the bladder, vagina, <i elsewhere. Fibroma of the ovary and 
malignant disease of the ovary, giving rise to solid tumours, are rare 



I 



DIAGNOSIS IN GYNAECOLOGY 177 

conditions. Papilloma, a semi-malignant disease of the ovary, is apt to 
find its way through the surface and give rise to deposits associated with 
the presence of a considerable amount of free fluid, often blood, in the 
abdominal cavity. 

Parovarian cysts are nearly always unilocular and contain clear fluid; 
otherwise they have much the physical characters of ovarian cystoma. 

Local effusions of serum, pus, or blood into the cellular tissue of the 
pelvis sometimes spread beyond the pelvic region into the abdomen 
beneath the peritoneum ; and find their way to the abdominal wall, into 
the groin, behind to the region of the kidney, or to the buttocks and 
vulva. Similar localised effusions into the pouch of Douglas frequently 
extend upwards into the abdomen, but are there usually limited by 
matting together of the intestines. 

Among abdominal tumours may be included pelvic adhesions, which, 
by the matting together of the intestines, frequently give rise to the 
impression of a very distinct swelling over which a certain amount of 
resonance can usually be obtained. 

Examination by the Vagina. In making the vaginal examination 
it is advisable to deal first with the external parts. 

Any signs of irritation on the skin, such as redness, inflammation, or 
excoriations, will be noted. In some cases, in consequence of irritation, 
an eruption, usually of an eczematous character, appears. The condi- 
tions under which this is found are usually such as to give rise to an 
irritating discharge, as in cancer of the cervix or body of the uterus, in 
sloughing fibroids, and in some other conditions which have already been 
mentioned, such as erosions ; and in cases of gonorrhoea and severe 
vaginitis, not necessarily of a local specific character. Signs of 
irritation may also be present in cases of masturbation ; or again, when 
the uterus is procident, and the vaginal walls, thrust outside, are irritated 
by friction. In certain cases also of urethral caruncle irritation is set up ; 
and, finally, in diabetes the irritation by the decomposing sugar produces 
considerable irritation, and even an intractable form of eczema. 

The labia majora and minora may be hypertrophied. In patients 
subjected to the above-mentioned sources of irritation more or less 
hypertrophy often occurs. 

The clitoris, too, is a structure which varies considerably in size, and 
is, in some cases, hypertrophied. 

The orifice of the urethra may show signs of irritation, more especially 
where that irritation is associated with pain in passing water. 

In examining the vulva, its size, the colour of the surface, the pres- 
ence of varicose veins or of ulcers on the surface, of abscesses or cysts in 
the deeper structures, should be noted ; and also whether there be a 
discharge bathing its surface, or signs of chronic irritation about the 
parts, as is frequently evidenced by the presence of small warts. Ex- 
pansion of the vulva results from child-bearing, especially where the 
woman has had many children, and in its more marked forms from 
prolapse of the vaginal walls and falling of the womb ; it is especially 



178 SYSTEM OF GYNAECOLOGY 

prone to occur when not only the parts in the pelvis, but the tissues 
generally are wanting in tone. On the other hand, the vaginal entrance 
may be smaller than usual from congenital causes; or from spasm, as in 
vaginismus. 

The colour of the mucous membrane will indicate congestion, either 
active or passive, or inflammation. In congestion it takes on a sort of 
peach bloom hue, or varies from that to purple, as in the case of pregnancy, 
and of some tumours in the pelvis, particularly fibroid tumours ; this change 
may occur also in cases of heart and liver disease. In inflammatory 
conditions the redness is often associated with much swelling of the 
tissues. Varicose veins are specially apt to appear during pregnancy, 
from the pressure of tumours in the pelvis or abdomen, or from some 
general condition associated with deficient return of blood to the heart, 
such as takes place in disease of the heart or liver. 

Various forms of ulcer may be met with about the vulva. Simple 
ulcers often occur as the result of delivery, as in the case of a tear failing 
to heal ; or as the result of distension of the parts in the course of 
examination, especially where a speculum has been used. Syphilitic 
ulcers are commonly found about the orifice. As the result of acute 
syphilitic -diseases in children, severe ulceration, and even sloughing and 
grangrene of the parts, is apt to occur. 

An abscess about the vulva raises suspicions of gonorrhoea. Abscess 
of Bartholini's gland, indeed, is often the result of gonorrlneal infection 
spreading up the duct of the gland and involving the gland itself : 
abscesses, however, about the vulva are not necessarily gonorrhceal. 

The form of cyst usually found at the vulva is produced by a 
blocking of the duct of Bartholini's gland and retention of the fluid. 
Winn the cyst has persisted for some time the walls become consider- 
ably thickened, and the only satisfactory way of dealing with it is to 
dissect it out. 

The discharge about the vulva may be of a simple or specific charac- 

ttd is apt to occur in association with fibroids and polypi, cancerous 

: the uterus (cervix or body), erosion of the cervix, in diseases 

of the lining membrane of cervix, body, and Fallopian tubes, as well as 

in cases of general weakness and gonorrhoea. 

('alien-, beginning primarily art the vulva, though by no means un- 
known, is exceedingly rare. 

The posterior pari of the vulva and the perineum should next be 

-lined, and a note made whether the fourchette has been torn. 

The hymen in the virgin is various in form. Usually it is a crescentic 
fold of greater or less depth, complete at its circumference and having a 
free, complete edge. When connection takes place it usually happens thai 

one or more splits OCCUT in the t'ree margin, but no part of the circumfer- 
ence La lost As the result of delivery, if at term almost invariably* 
and often even when the patient baa not reached the full time of 
pregnancy, parts of the hymen become lost ; it is then represented by little 

- left ;it the circumference with vacancies between them, and of 



DIAGNOSIS IN GYNECOLOGY 179 

course the whole vulva becomes at the same time more distended than 
it was before. Parts of the hymen may also be lost on account of in- 
flammatory disease and ulceration and sloughing, syphilitic or otherwise. 
The hymen may be thick and fleshy, instead of thin and membranous ; and 
such a hymen is very likely to resist laceration during connection, and 
occasionally even during delivery ; especially if the child be small and the 
patient have not reached the full time of gestation. In another form of 
virginal hymen occasionally met with the vulva is closed by the mem- 
brane, which has, however, small holes here and there in it the cribri- 
form hymen, as it is called. In other cases the hymen is exceedingly 
tough and elastic, and the membrane is larger than usual, leaving only a 
small orifice in front. In such cases also the membrane may escape 
laceration, but, being distensible, it becomes considerably stretched by 
efforts at connection. Finally, the hymen may be imperforate ; if so, 
when puberty is reached retention of the menses occurs, and the flow, 
distending the vagina and uterine cavity, causes the membrane to bulge 
outwards. 

In examining the vagina, the size of it, the character of the mucous, 
membrane, the presence of discharge, tendency to prolapse, pessaries or 
foreign bodies contained within it, and cysts or growths in its wall are 
to be ascertained. 

The vagina in the virgin is much shorter than in persons who have had 
connection, though it varies much in individual subjects : it is still more 
enlarged by the process of parturition. The tone of the vagina should 
be noted ; for when the tissues are lax and wanting in tone the vagina 
may be exceedingly large. Perhaps the largest vaginas we meet with 
occur in hysterical women, in whom what is known as "ballooning" of 
the vagina occurs ; so far as I am aware no very satisfactory explanation 
of this condition has yet been given. The vagina may also be capacious 
in persons who have worn pessaries for uterine displacements or other 
conditions. 

The colour of the mucous membrane of the vagina, as of the vulva, 
indicates the existence of gestation, the presence of some tumour, or a 
congested condition produced by more or less general disease or local 
inflammation. On examination, especially with the speculum, one may 
come across spots either redder or paler than the general surface of the 
mucous membrane : the exact significance of these spots, I believe, is as 
yet unknown. 

Ulcers may also be found in the vagina, either of a simple or 
syphilitic character. 

Finally, some discharge may be present, and its quantity, colour, and 
consistence should be observed. It may be watery ; or thick and yellow ; 
or thick and clear like unboiled white of egg ; almost jelly-like in con- 
sistence ; or milky and opaque. 

The walls of the vagina are prone to eversion and prolapse. Pro- 
lapse of the anterior wall with the bladder (cystocele) is the more 
common. If this condition be not well marked it may pass unrecognised, 



i So SYSTEM OF GYNAECOLOGY 

unless the patient be directed to hold her breath and strain down, or she be 
examined in the standing posture. 

Kectocele a prolapse of the posterior vaginal wall involving the 
rectum is less common, though frequently the two occur together. On 
further straining the cervix will often come down and pass the vulva ; and 
in the worst cases even the fundus will find its way outside, the vaginal 
walls being completely everted, complete prolapse of the bladder, uterus, 
and frequently of the rectum as well, taking place. The presence of the 
bladder outside may be demonstrated by passing a sound into the bladder 
and observing the position of the point in the prolapsed mass. Rectocele 
may be recognised by passing the finger into the bowel. 

The presence of pessaries or foreign bodies in the vagina will not 
escape notice. Pessaries are sometimes put into the vagina without 
the knowledge of the patient ; or may sometimes be forgotten and left 
there for a considerable time. Their presence is apt sooner or later 
to set up vaginitis, unless the patient takes means to ensure cleanliness 
by the use of vaginal douches. 

Cysts, by no means common, are occasionally found even at the upper 
part of the passage. A case sent to me as one of small ovarian tumour 
proved to be a cyst at the roof of the vagina. The wall of the vagina is 
frequently infiltrated by malignant disease extending from the cervix. 

The cervix may be outside the vagina, or high up, even out of reach, 
especially when the bladder is full ; it may be just within t'he vulva ; it 
may be far forwards j it may be backwards on the perineum, or back- 
wards and high up ; or it may be to one side or other of the middle line. 
Its shape is to be noted. The length of the vaginal part of the cervix 
the part, that is, which projects into the vagina must be observed ; its 
consistence also ; its mobility, whether it appears to be free or attached 
and limited in its movements ; the condition and colour of the mucous 
membrane will be seen by using a speculum (generally, for purposes of 
diagnosis, a Fergusson's speculum) ; as also any erosion on one or other 
lips of the cervix, or ulceration j and, finally, the secretion passing from 
the cervix. 

In speaking of the conditions which cause the position of the cervix 
to vary I must anticipate a little, for the position of the cervix has often 
considered in relation to the position of the fundus. The cervix is 
lower than it should be in cases of prolapsed and of procident uterus, and 
in supravaginal and infra vaginal elongation; but when the uterus is 
merely prolapsed or procident the fundus falls with it, and their relative 
position is preserved. In cases of infra vaginal elongation, in which the 
cervix il usually lengthened out into a cone surmounted by a small orifice, 
the fundus maintains its proper position ; but the cervix itself is elongated 
and the canal lengthened. This is a congenital affection usually associated 
with dvsmenorrhcea and, if the patient be married, with sterility also. 
In cases of supravaginal elongation the intravagina] cervix is not 
elongated ; but the cervix falls while the fundus relatively maintains its 
normal position, though it is often associated with some descent of th< 






DIAGNOSIS IN GYNECOLOGY 181 

uterus as a whole : extension takes place between the attachment of the 
uterus to the parts around and the roof of the vagina. In this case also 
the canal is lengthened. In anteflexion the cervix usually maintains its 
position so long as the anteflexion is anteflexion pure and simple ; but 
where version takes place the cervix is found higher up and farther back 
than usual. In retroflexion pure and simple the cervix maintains its 
position though the body fall; but when retroversion takes place the 
cervix approaches the symphysis while the body tilts backwards. 
Anteflexion is not infrequently found in association with retroversion, 
in which case the body falls in the pelvis, and at the same time the 
cervix approaches the symphysis and its orifice becomes directed 
forwards, often looking towards the top of the symphysis instead of 
downwards and backwards. Irregularity of the cervix may be the 
result of laceration occurring during delivery or in the course 
of an operation. Lacerations occurring during parturition are more 
frequently found on the left than on the right side, and if both 
sides are involved the left is usually more so than the right. Where, 
too, bilateral laceration has occurred, the lips of the cervix may become 
everted so that they actually fall into the same plane. All cases of 
flexion and version are apt to be accompanied by some descent of the 
uterus as a whole. Carcinoma produces more or less irregular nodula- 
tion either in the substance of the cervix or on its surface, which im- 
parts to the examining finger a gristly feel. A cauliflower excrescence 
springing from the cervix may be at once put down to malignant disease. 
In consistence the cervix may be rendered much harder than usual by 
chronic inflammation set up in consequence of lacerations and tears, such 
as occur after repeated deliveries, especially where instruments have 
been used. Primary syphilitic sores are rarely found on the cervix, but 
when present preserve their usual hard character. The cervix is rendered 
hard also by malignant disease which, after a time, breaks down towards 
the centre, still leaving a hardened infiltrated margin. In consistence it 
is diminished in pregnancy, in subinvolution, and in many cases 
of inflammation of the lining membrane, especially when associated with 
haemorrhage and copious discharge. The mobility of the cervix may be 
diminished either from the presence of some extraneous tumour pressing 
the uterus downwards or to one side ; or as the result of some inflam- 
matory condition with effusion, adhesion, or cicatricial contraction resulting 
therefrom \ or, finally, as the result of cancerous growth in its substance 
which has spread and involved the cellular tissue outside. The mobility 
is abnormally increased when the parts are lax and the ligaments have 
become stretched, as occurs in cases of prolapse, procidentia, etc. 

The colour of the mucous membrane will indicate congestion or 
inflammation. In cases of metritis it becomes of a florid red colour ; its 
colour is dull or bluish when the blood-supply is partially arrested, either 
from incomplete strangulation, as in prolapse ; or from the pressure of 
tumours in the pelvis or abdomen ; or as the result of inflammatory 
effusions, or of obstruction to the circulation in disease of the heart and 



182 SYSTEM OF GYNAECOLOGY 

liver. In prolapse of the vaginal walls the mucous membrane after a 
time becomes thickened and the surface dry. 

Erosions vary much in appearance. Sometimes they are florid; 
sometimes they are (edematous and readily bleed when touched. When 
healing they talc on a bluish line at the margin: the part which has 
healed over, which has become cicatrised, that is, with a stratified layer 
of epithelium, is of a whity-bluish colour, different from the rest of the 
cervix. Proliferation of the gland structures often takes place; the 
follicles become distended with mucus, and, the ducts being plugged, the 
follicles stand out as glistening points dotted over the surface of the 
erosion. 

Simple ulceration is uncommon, except as the result of laceration 
or of caustic applications. Syphilitic ulceration a hard sore of the 
cervix is occasionally met with and has the same characters as hard 
chancres elsewhere. 

The secretion from the cervix is naturally a thick glairy mucus, but 
in cases of severe inflammatory mischief it often becomes purulent. 

The presence of mucous polypi in the cervix itself, growing from the 
lax mucous membrane, is usually associated with a very considerable 
amount of secretion from the canal and often with haemorrhage. 

The body <>f the uterus may present changes in size, shape, consistence, 
or mobility ; and it may be tender to the touch. 

The displacements of the body which may be met with are prolapse 
that is to say, a falling downwards, which, when existing to a marked 
extent, is known as procidentia; anteflexion; retroflexion; anteversion 
and retroversion; and a combination of anteflexion and retroversion. 
Lateral displacements may sometimes be observed, especially where a 
growth or swelling in the broad ligament displaces the uterus to the 
opposite side, or adhesions draw it to the same side. But lateral 
displacement may be congenital from a shortening of the ligaments on 
the side to which it is inclined. Extraneous tumours may displace the 
Uterus downwards as does ovarian disease, which frequently at the 
same time produces retroversion j upwards as does especially a full 
bladder; forwards as by any swelling in the pouch of Douglas, such as 
hematocele, <>r a mass of fasces in the rectum; backwards as again by a, 

full bladder or ovarian cyst ; and laterally as by any swelling in the 
broad ligament itself, sneh as an extra uterine gestation, a parovarian 

swelling, or sometimes a small ovarian tumour. 

The Uterus may be found of less than normal dimensions; either as a 

congenital defect, in which case the ovaries may also be absent or 
imperfectly developed ; after delivery as the result of wh.it is known as 
superinvolution ; oral the menopause, as the result of natural atrophy. 

The uterus frequently increases in size. For purposes of diagnosis 
it is well to divide these enlargements into those which are regular in 
character, and those which are of .in irregular form. Uniform or regular 

enlargement OCCUrS in gestation ; and. of COUTSe, such enlargement is also 

met with after delivery, in the lying-in period, before tin; uterus has 






DIAGNOSIS IN GYNECOLOGY 183 

returned to its normal dimensions, and in cases of subinvolution. In 
cases of inflammation (metritis and endometritis) the uterus is increased 
in size ; the sound usually passes half an inch to an inch more than the 
natural distance. In cases of mole pregnancy a regular enlargement of 
the uterus occurs ; though occasionally an irregular bulging may be found 
especially in blood mole over the site of the effused blood. Again, 
more or less regular enlargement of the uterus takes place in cases of 
pyometra and haematometra ; cases, that is to say, of pus and blood inside 
the uterine cavity. Pyometra is usually met with in old women, but is 
not a common condition ; haematometra, as a rule, belongs to cases of 
imperforate hymen. 

Among irregular enlargements of the uterus, myomas or fibroid 
growths are the most common. Cancer of the uterus also produces more 
or less irregular enlargement of the body ; though it may appear uniform, 
as it may also in enlargement due to fibroid. Cancer of the body, in com- 
parison with carcinoma of the cervix, is a rare disease, occurring late in 
life. Sarcoma of the body, another rare condition, also produces more or 
less irregular enlargement. 

As regards consistence, we may take it as a general rule that soft 
enlargements of the body of the uterus are usually the result of 
gestation, when, be it noted, there is a hard body inside the fluid 
one. In hydatidiform mole enlargement takes place rapidly and is of a 
soft character. In subinvolution the consistence is diminished ; and the 
same description usually applies to metritis unless it has become chronic ; 
and also to pyometra and haematometra, unless the distension be very 
great, in which case the enlarged organ is hard. In rapidly growing 
fibroids and fibro-cystic swellings the enlargement is usually soft and 
semi -fluctuating, and a uterine bruit may often be heard. 

The enlargements, in which the consistence is increased, are usually 
the result of fibroid masses, unless rapid growth be taking place or 
oedema be also present, as for instance when the enlarged uterus becomes 
impacted in the pelvis. Cancerous enlargements are usually hard ; so 
also are sarcomatous tumours. Blood and fleshy moles (in contradistinc- 
tion to hydatidiform moles) cause abnormal hardness of the uterus. 

In considering the mobility of the uterus, it has to be remembered 
that it is usually increased, as the result of laxity of the tissues, by 
frequent child-bearing or by operations in which the uterus has been 
dragged upon. It is decreased as the result of extraneous tumours pre- 
venting free movement, whether these tumours be above, below, to one 
side, or at the back of the uterus. In cases of inflammatory mischief the 
uterus may be either pushed to one side by the effused products, or 
drawn by adhesions to surrounding structures ; or, if the effusion have 
occurred in the cellular tissue ; it may be drawn and fixed by the con- 
traction which subsequently occurred. In any case the movements of 
the uterus are restricted. The mobility is decreased also by new 
growths spreading and involving the tissues beyond the uterus, as in 
cancer and sarcoma ; or when from any cause the uterus falls into the 



184 SYSTEM OF GYNAECOLOGY 

pelvis and becomes impacted. In severe cases of retroflexion and of 
retroversion the fundus may be grasped and held down in the floor of 
the pouch of, Douglas by the sacro-uterine ligaments. 

The uterus becomes tender to the touch from congestion, from 
inflammation of the tissue of the uterus itself, or from such inflammatory 
mischief, in the immediate neighbourhood, as occurs in ovaritis, pro- 
lapsed ovaries with congestion, pelvic peritonitis, and, lastly, as the 
result of adhesions to surrounding structures. 

Tumours in the Pelvis. In investigating pelvic tumours the points to 
be noted are their position ; their size; their shape; their consistence; 
their mobility ; the presence of tenderness on manipulation ; and their 
apparent attachment, which is estimated by endeavouring to move the 
tumour, and ascertaining upon what parts it appears to drag, and upon 
what parts the movement of the tumour has no effect. 

The tumours in the pelvis may be divided, according to the part 
from which they originate, into eight heads, as follows. (In this category 
tumours of the vagina and vulva are not included because those affecting 
the lower part of the canal have been already mentioned.) 

i. Tumours of the Uterus itself are Inversion, either partial or com- 
plete. Fibroid polypi, which may be either in the vagina, lying in the 
cervix of the uterus and distending it, or still remaining in the cavity of 
the uterus : myoma of the cervix very frequently grows down into the 
vagina, occasionally into the broad ligament : myoma of the body of the 
uterus begins in various parts and grows in various directions as sub 
mucous, interstitial or subperitoneal. Fibroids are frequently multiple, an 
interstitial growths are frequently found in association with a polypus o 
a subperitoneal fibroid ; as they grow, they may extend into the broad 
ligament, especially when they begin low down or on one side of the 
uterus, and subperitoneal fibroids are apt to fall into the pouch of Douglas 
and become impacted there. Cancer of the cervix, subsequently extend 
ing to the body as well as to the vagina : primary cancer of the body 
Sarcoma of the body of the uterus. The body of the uterus itself, taking 
up a faulty position, such as has been already mentioned in retroflexion 
or version, may form a tumour. Retroversion of the gravid uterus im- 
pacted in the pelvis must also be mentioned. 

ii. Tumours connected with the Fallopian Tubes. One or both tubes 
may be distended with serum, pus, or blood, giving rise to hydrosalpinx, 
Ipinx, and luematosalpinx respectively; the tubes themselves being 
usually thickened and adherent. Tubal gestations frequently rupture 
either into the peritoneal cavity, giving rise to hematocele, or into the 
broad ligament, giving rise to hematoma. Occasionally part or the whole 
of the gestation sac may be extruded from the fimbriated extremity 
(tubal abortion), or, l'ss often, find its way into the uterine cavity. 

iii. Tumour* o! the Ovaries. Prolapsed congested ovary, forming a 
swelling not usually of large Ease, U by no means an uncommon condition ; 
and is frequently found associated with retroversion of the uterus and 
general laxity of the tissues. Cystoma of the ovary, that is to say, the 









DIAGNOSIS IN GYNECOLOGY 185 

ordinary cystic ovary ; dermoid tumours of the ovary, and parovarian 
cyst, which is really a tumour of the broad ligament, arise in the ovarian 
region. 

iv. Tumours of the Cellular Tissue are haematoma, serous effusion, 
(parametritis), and abscess. 

v. Tumours of the Pelvic Peritoneum are hematocele ; serous peri- 
metritis, that is to say, a localised peritonitis with effusion ; and abscess. 

Adhesion and the matting together of the intestines, tubes, and 
ovaries in the pouch of Douglas frequently gives the impression of a 
distinct tumour in that situation. A loop of intestine containing faeces 
may easily be mistaken for some other tumour in the pouch of Douglas. 

vi. Tumours connected with the Kectum are faecal accumulation ; 
malignant and other growths. 

vii. Tumours connected with the Bladder. The most common is 
scarcely worthy to be called a tumour, though it frequently simulates one, 
namely, distension of the bladder from the accumulation and retention of 
urine. Stone in the bladder is a very uncommon condition in women, 
but may occasionally be met with. 

viii. Retroperitoneal Growths are such as lipoma, sarcoma, osteoma 
of the bones of the pelvis ; a contracted pelvis. 

II. Examination by means of the Sound. For purposes of diagnosis 
the sound serves as a measure of the length of the uterus, of the size of 
the canal, and of its direction ; moreover, by careful use of it other facts 
may be inferred, such, for instance, as disease of the mucous membrane 
from the passage of blood or discharge after its use. To some extent, 
also, the condition of the canal may be inferred by noting whether its 
introduction or removal is associated with pain as it passes the inner 
orifice. 

When the sound touches the fundus it usually produces pain which 
is generally referred to the region of the umbilicus. 

In speaking of the conditions which produce increase in length, it 
must be remembered that after child-birth the uterus rarely returns to 
the size of the unimpregnated organ ; but the difference is usually not 
more than a quarter of an inch. Elongation of the canal may be due to 
subinvolution ; to chronic metritis ; to polypi, submucous and interstitial 
fibroids ; to sarcoma and carcinomatous disease of the body ; and to 
supravaginal and infravaginal elongation of the cervix. Shortening of 
the canal may be due to partial inversion (in complete inversion it is 
obliterated) ; to superinvolution ; to the natural atrophy which occurs after 
the menopause, and to faulty development. 

The canal may be congenitally narrow, especially at the inner orifice ; 
or contracted and even obliterated by caustic applications ; or as the result 
of operation, for example, supravaginal amputation. The canal may 
be dilated in various conditions during pregnancy and after delivery ; 
also by the passage of polypi and from loss of blood. Its direction may 
be altered by versions and flexions, or by the presence of fibroid or 
other mass encroaching upon its lumen. 



1 86 SYSTEM OF GYNECOLOGY 

IV. Examination by the Bladder and Rectum. In some cases where 
a tumour seems to be in the pouch of Douglas, but cannot be well defined] 
an examination by the rectum may Bet aside the possibility of its rectal 
origin ; and in many cases examination by the rectum with the finger of 
one hand may be combined with that by the vagina with the finger of 
the other. Examination by the rectum is often of considerable use in 
determining the height of the fundus ; the size of the fundus ; the size 
of the body, and the presence or absence of the ovaries and disease of 
the tubes. In some cases, to determine the size of the uterus or the 
presence or absence of the uterus from its normal position, it may be 
advisable to examine through the urethra either with the sound or with 
the finger j for instance, in some doubtful cases of inversion. If the finger 
be employed, it is often better to incise the vesico-vaginal septum, which 
readily heals, than to dilate the urethra with the risk of permanent incon- 
tinence. Examination of the bladder may be combined with a digital 
examination by the rectum. 

In all cases I would recommend a bimanual method in making internal 
examinations ; it is accomplished with far greater ease and ensures much 
greater accuracy. 

V. Additional Means of Examination. In some cases, however, it 
will be found that the means already suggested, even if adopted, are not 
sufficient to clear up the nature of the case. Especially is this so when 
the patient is difficult to examine, as in cases of vaginismus; when the 
parts are contracted; when the patient holds her breath and strains, am 
particularly when it is necessary to ascertain the exact connections of 
tumour in the pelvis, and to determine whether it be freely movable 01 
not. In such cases the advantage of an anaesthetic are very great. Ii 
other cases, again, some difficulty arises in passing a sound, whicl 
may get fitted into little pouches in the canal. If the passage of the 
sound be necessary to diagnosis, it is well to fix the cervix with a volsella. 
This docs not necessarily involve the use of an anaesthetic in married 
women; but it is frequently expedient that the examination may be 
complete. In the examination of young unmarried women an anaesthetic 

< n desirable on other grounds. 

There are other cases, again, when it is necessary to dilate the cervix 
and explore the uterus. Dilatation may be effected under an anaesthetic 
with Begar'8 dilators: and is often called for, not only in deciding the 
of haemorrhage from the uterus, but also as a preparatory step 
in operations for its relief. When the cervix is unusually rigid laminarM 
tents may also be used frith advantage. 

Finally, it may be necessary, before arriving at a diagnosis, to remove 
portions of I issue for microscopic examination ; as in the case of erosions of 
the cervix of doubtful malignancy, and in cases of haemorrhage from the 
uterus with irregularities of the surface, which may be of a malignant 
nature; or, again, to determine whether retained products are the result 
of gestation or of some inflammatory condition of the mucous membranes 

It is cot always possible to arrive at a correct diagnosis on first 






INFLAMMA TION OF THE UTER US 187 



seeing the patient ; time is often an important factor in forming a correct 
opinion. But while the precise nature of the case remains undetermined 
the patient may often with manifest advantage be placed under provisional 
treatment to give relief to her instant sufferings, and to assist the physician 
in arriving at a complete diagnosis of the case. Take, for instance, the 
case of a swelling in the pelvis, the nature of which is at first undeter- 
minable. The symptoms and physical signs point to inflammatory mis- 
chief ; and for a time it may not be possible to distinguish, and to exclude 
some cystic or other swelling at the bottom of it, such as a ruptured 
ectopic gestation. The patient is put to bed and kept quiet ; hot douches 
are ordered to allay inflammation ; and the bowels are regulated with a 
view to avoid irritation of the inflamed parts in the pelvis. If, after a 
time, the temperature, which perhaps was considerably raised, has under 
this treatment fallen to normal ; if the tenderness and pain have gradu- 
ally subsided or disappeared ; if the swelling has diminished in size, and 
the parts which Avere previously fixed have become mobile, it may be 
reasonably concluded that the swelling probably consisted entirely of 
inflammatory effusion. But such cases do not always end thus. For 
example, after the temperature has been normal for a week, and the 
patient has then risen from bed, the inflammatory mischief may reassert 
itself. We are thus led to think that something more than the mere 
inflammatory mischief remains behind ; and after a time some definite 
swelling may be recognised. In cases such as these a correct diagnosis 
can only be reached by care and vigilance. It is important also to have 
the opportunity of noting any changes in the symptoms and physical 
signs while the patient is under treatment, and to be prepared to modify 
the diagnosis according to the results. 

KOBERT BOXALL. 

REFERENCES 

1. Cohnstein, J. "Die gynakologische Diagnostik," Volkmann's Sammlung, No. 
89. Leipzig, 1875. 2. Keating, John M. and Henry C. Coe. Clinical Gynaecology, 
Medical and Surgical, by American Teachers, 2 vols. Edin. and Lond. 1895. 3. Mann, 
Matthew D. A System of Gynecology by American Authors, 2 vols. Edin. 1887, 
1888. 4. Pean, J. Diagnostic et traitement des tumeurs de V abdomen et du bassin, 2 
vols. Paris, 1880, 1885. 5. Veit, Johann. Gynakologische Diagnostik. Stuttgart, 
1891. 6. Wells, T. Spencer. Diagnosis and Surgical Treatment of Abdominal 
Tumours. Lond. 1885. 

R. B. 



INFLAMMATION OF THE UTERUS 

Few subjects in gynaecology are so difficult to handle as inflammation 
of the uterus. Seldom fatal, and therefore not lending itself to the pre- 
cise methods of the pathologist, its pathological anatomy is being but 
slowly worked out. Clinically it includes a long series of cases showing 



188 SYSTEM OF GYNAECOLOGY 

the most varied changes. Beginning with those in which the only 
symptom is pain, and the only physical sign undue sensitiveness on 
examination cases which led that careful clinician Gooch to describe 
what he called the "irritable uterus," it further signifies groups of cases 
which show all the marks of local inflammation, but usually present no 
distinct line of demarcation between the acute and the chronic. Besides 
being rarely fatal, except in cases of puerperal sepsis, which belong rather 
to the domain of obstetrics than of gynaecology, another peculiarity of 
inflammation of the uterus is the rarity of suppuration which is so 
common a result of inflammation in other organs. We are not sur- 
prised, therefore, to find a great divergence of opinion among leading 
gynaecologists in Britain and elsewhere on the nature and relative im- 
portance of the various forms of uterine inflammation. 

A retrospect of the opinions held during the last half century on the 
significance of the various inflammatory lesions in the pelvis brings out 
two curious facts. The first is the influence of methods of examination in 
accentuating a lesion. The speculum concentrated attention on the 
cervix, the sound on the position of the uterus; the bimanual examina- 
tion on the cellular tissue and peritoneum ; the exploratory incision on the 
uterine appendages, and the microscope on micro-organisms. On the 
introduction of each of these methods of examination the corresponding 
lesion has been emphasised out of all proportion to the rest. An expert 
in any one method of examination is disposed to say This is the lesion, 
and there is no other. At present abdominal section and the microscope 
hold the field ; and a historical survey warns us that at the present time 
we are exposed to the danger of emphasising the significance of inflamma- 
tory lesions of the uterine appendages, and even of the part played bj 
micro-organisms, at the expense of other lesions and other factors of n< 
less importance. 

Another striking feature in such a retrospect is the progress in the 
mode of regarding disease. Half a century ago the standpoint was 
symptomatic one. Tyler Smith's book on Leucoirhom, in which the most 
1 1 conditions are grouped together because they have this symptoi 
in common, is an illustration of the symptomatic standpoint. At th< 
present [day the standpoint is pathological; the "entity leucorrhceaT 
has been replaced by "endometritis" and "cervical catarrh," under 
which names the lesion is localised and described. But the change! 
standpoint docs not simply mean seeing another side of the same thing. 
We an not merely walking round a hill, we arc ascending it ; the 
pathological standpoint is a step higher than the symptomatic: a step 
higher still will bring us to an etiological standpoint, inasmuch as 
etiology deals with causation, and is the basis of preventive medicine. 
Where it has been demonstrated, as in the case of gonorrhoea, that the 
inflammatory conditions of the uterus are due to a micro-organism, this 
view of inflammation from the etiological standpoinl has simplified our 
conception of it. Instead of being broken up artificially into different 
affections according to the tissues involved for the time being, it has 






INFLAMMATION OF THE UTERUS 



become an organic unity, gathered round the life-history of a micro- 
organism. Clinical experience tells us that this is the true mode of 
regarding it. 

And yet, if it should be shown that all the changes which we associate 
with metritis have a microbe at the bottom of them as the essential factor 
in their production, this would not produce a great revolution in our con- 
ception of metritis, although it would materially influence our treatment 
in so far as it might emphasise preventive treatment by antiseptics. 
After all the micro-organisms have been discovered and described, atten- 
tion will again revert to the local and general conditions which determine 
their growth. If the microbe or spore be the seed the uterus is the 
soil, and those subtle influences which we speak of as constitution and 
diathesis are the climate. The seed is an essential factor in plant life, 
but equally important factors for development and growth are soil and 
climatic conditions. The discovery of the seeds has for the time thrown 
the study of constitutional states and diatheses into the background. 
But because we know little about them we need not minimise their 
influence. No science is so vague as meteorology, and yet nothing 
bulks so largely in the farmer's mind as the weather. Of the importance 
of soil no better illustration could be found than in the case of the puer- 
peral uterus. If Winter's observations are correct, the staphylococcus 
pyogenes albus, aureus, and citreus, as well as various forms of streptococci, 
are present beforehand in the uterus, but lie harmless until the puerperal 
state supplies the conditions favourable for their development. 

To Henry Bennet is due the credit of drawing attention to the 
importance of inflammation of the uterine mucous membrane (2). 
Although he described it as in many cases going on to ulceration, so that 
his opponents fastened on the alleged " ulceration," and criticised it as the 
essence of Bennet's teaching, it is only fair to him to say that he regarded 
ulceration as but one of many phases of inflammation. Perhaps he laid 
himself open to criticism by stating that inflammation was to be treated 
by surgical means. 

Bennet's views were opposed by Lee and West (40) and Tyler Smith. 
In reading their criticisms it is interesting to come upon statements, then 
based only on clinical observation, which have since been established by 
microscopic investigation. Thus Lee, speaking of the appearances which 
Bennet described as ulceration, says : " These apparent granulations are 
usually considered and treated as ulcers of the os and cervix uteri, but 
they do not present the appearances which ulcers present on the surface 
of the body, or in the mucous membranes lining the viscera, and they 
are not identical with the granulations which fill up healthy ulcers. They 
present the appearances often observed on the tonsils which are said to 
be ulcers, and are not" (21). Thus Lee, writing in 1850, forecasts the 
work of Ruge and Yeit in 1878. The comparison of the "ulcerated" 
cervix to a hypertrophied tonsil is a happy one. So also Tyler Smith 
forestalled the view of Emmet and Roser, that the appearance is pro- 
duced by an ectropion of inflamed cervical mucous membrane, when he 



1 90 S YSTEM OF G J TV. K COL OGY 

Bays: "The granulations which are sometimes found surrounding the os 
uteri which may secrete mucus or pus abundantly, and which may bleed, 
on being roughly handled are, I have no doubt, the result of inflamma- 
tion ; but they resemble the granular state of the conjunctiva rather than 
the granulations of a true ulcer, the granular os uteri offering no edges or 
signs of solution of continuity, l>y which Ave might satisfactorily declare 
it to be an ulcer (37)." 

Unfortunately, and in spite of such criticism, the term "ulceration," 
introduced by Bennet, took hold of the professional mind. It led to a 
routine treatment of inflammatory conditions of the cervix by caustics, 
as slowly healing ulcers in other situations are treated. An erroneous 
pathology opened the door for a pernicious treatment, from which British 
gynaecology suffered until it found a true pathological basis. 

Etiology of Uterine Inflammation. While for descriptive purp 
we divide inflammations of the uterus into inflammation of the cervix or 
cervical catarrh, of the mucous lining of the body or endometritis, and of 
the substance of the uterus or metritis, it must be borne in mind that no 
one of these occurs by itself. Before looking at these conditions separately 
it will be convenient to consider the etiology of all three together, inasmuch 
as they are produced by the same causes. Clinically the inflammation is 
not limited to any one tissue ; and all that is meant when a case is spoken 
of as endometritis, is that the changes in the mucous membrane in the 
body of the uterus are for the time being more prominent. 

In studying the etiology of inflammation of the mucous membrane <>r 
the uterus, we must bear in mind that the uterine mucosa is not func- 
tionally analogous to other mucous membranes, as for example those of 
the stomach, the respiratory tract, or bladder. These belong to orga 
whose function is constant and necessary to life. They are in daily 1 
while the function of the uterus, namely, reproduction, is only called into 
exercise occasionally. Even the periodic changes connected with men- 
struation can hardly be considered as a function necessary to life, for 
there is no evidence to support the old idea of its being a monthly cleans- 
ing or katharsis, which would make the uterus practically an excretory 
organ. Menstruation is connected with the function of reproduction, and 
-nrreiice is not necessary to life. If then the uterine mucosa be not 

analogous to other mucous membranes, we must be cautions in transferring 

to the etiology Of its diseases notions gained from the study of patholo- 
gical processes in these other-. Thus we are prepared for the fact that 

many of the processes which we have to describe under endometritis are 
more allied to new formation than to inflammation, <r. ;it any rate, to the 
inflamniMtioii we are aOCUStOmed to study in muCOUS membranes elsewhere. 
Were we to gubjecl the li.-t ero-em .1 i.- mass of pathological conditions 

grouped under endometritis bo exacl criticism, much would disappear and 
the residuum would be small. Thus endometritis fungosa is more of the 
nature of a new growth than of an inflammatory process; the glandular 

form of endometritis IS more akiD to ail adenoma than to a catarrh of 









INFLAMMATION OF THE UTERUS 191 



mucous membrane ; and many cases of endometritis after abortion should, 
according to Kiistner, be considered as deciduomas. 

Pozzi, however, in his admirable chapter on Metritis in his treatise on 
Gynaecology, justifies the grouping of these varied conditions under 
Metritis, because they have these features in common that their com- 
mencement is an infective process, and their evolution defensive and 
limiting in its action. This, however, does not exhaust the features of an 
inflammation as contrasted with a neoplasm. The final product of an 
inflammatory process is a degenerated tissue rather than the tissue 
characteristic of the organ in which it has occurred. Of the former we 
have illustrations in those forms of endometritis which end in the destruc- 
tion of the mucosa ; of the latter in those which end in hypertrophy. 

On the other hand, the uterine mucosa, and especially that of the 
cervix, is analogous to other mucous membranes in its tendency to be 
affected in certain diatheses or constitutional states. Thus in tuberculosis 
and syphilis, in rheumatism and gout, in anaemia and chlorosis, there is a 
tendency to cervical catarrh as there is to bronchial or gastric catarrh. 

We are not yet in a position to classify satisfactorily the causes of 
uterine inflammation. All we can do, in the present state of our know- 
ledge, is to arrange them in two groups, those which are constitutional, 
and those which are local. It is evident that this classification is 
not satisfactory, because in many cases the factor is a micro-organism 
which, as it gains access through the mucous membrane, is a local cause, 
but in so far as the whole system becomes affected by it, is a general 
cause. 

The constitutional causes of uterine inflammation are even more 
deserving of study than the local causes. Being less obvious, they do not 
force themselves upon our attention : more subtle in their action, they 
are more difficult to estimate ; and the more their constitutional quality, 
the more difficult they may be to treat. In scrofula and tuberculosis 
there is a tendency to uterine catarrh, affecting specially the cervix ; as 
there is a tendency in the same diathesis to bronchial or gastric catarrh. 
So also in patients suffering from rheumatism and gout, we find a similar 
tendency, and likewise in girls suffering from anaemia and chlorosis. 
Apart, indeed, from any special diathesis, a generally enfeebled state of 
the constitution will bring out tendencies to cervical catarrh, as it may to 
tonsillitis. Hence the gynaecologist must direct his attention to those 
modes of life which tend to undermine the health. Once we fully 
appreciate the connection between the general health and local conditions, 
we shall make out a strong case against the current mode of bringing 
up young girls, especially during the years of school education. The 
present system undoubtedly favours the development of menstrual dis- 
turbances which frequently end in uterine inflammation. 

Passing from constitutional states to specific diseases, we find that the 
uterine mucosa, like other mucous membranes, is affected in the course of 
the exanthemata. Thus in measles, scarlatina, and small-pox, as well as 
in typhoid fever and cholera, endometritis is liable to occur. In the 



1 92 SYSTEM OF GYNAECOLOGY 

recent influenza epidemic monorrhagia was a not infrequent symptom. 
Gottschalk found haemorrhages in the uterine mucosa in influenza, but 
no microbes. Organic diseases which favour passive congestion also lead 
to inflammatory changes in the uterus. Thus in diseases of the heart and 
kidney, and especially of the liver, uterine inflammation may be pre- 
and can only be dealt with by recognising and treating the primary 
affection. 

Inflammation of adjacent organs excites inflammatory changes in the 
uterus, apart from simple extension of inflammation. This occurs in 
inflammation of the uterine appendages, and especially of the ovaries. 
Czempin, who has studied this point in patients in Dr. Martin's clinique 
in Berlin, mentions four kinds of such causes : inflammation of the ovaries 
with or without that of the tubes ; old parametritis which has become 
acute; irritation of the peritoneum, as in cicatrices after Tait's operation 
and ovariotomy ; and other slowly developing conditions of the appendages, 
such as pyosalpinx and sarcoma of the ovary. Should an etiological rela- 
tionship be established between disease of the appendages and uterine 
inflammation, it will give additional reason for the removal of the former 
when diseased. 

Irritation of the rectum also keeps up uterine inflammation, and the 
latter has been known to disappear on removal of a rectal polypus. 

Passing now to the local causes, we note the importance of exposure 
to cold or great fatigue at the menstrual period. If a woman take a 
chill during menstruation its effects will probably appear in the pelvic 
organs. And apart from undue exposure, the congestion of the 
menstrual periods plays a very important part in the exacerbations of 
uterine inflammation. 

The ovaries play a special part in the development of endometritis. 
Brennecke, who has drawn attention especially to this point, makes one 
group of cases of endometritis fungosa arise under their influence. These 
cases are characterised at the outset by amenorrhcea for one or two 
periods. This he explains by the ovarian stimulus, which, while exciting 
the hypertrophy of the mucosa which precedes normal menstruation, is 
insufficient to cause haemorrhage. Thus arises a hyperplasia of the 
mucous membrane from which ha3morrhages afterwards occur. I have 
not seen any cases of endometritis beginning with pathological 
amenorrhoea, such as Brennecke describes, but have always been able to 
account for the amenorrhcea by an early abortion. On the other hand, 
the irregular bleedings at puberty point to a tendency to endometritie 
changes in connection with the initiation of the functions of the ovaries. 

Pelvic congestion, due to excessive sexual intercourse or to masturba- 
tion, is also given as a cause of uterine inflammation. In prostitutes 
cervical catarrh is common, but this is probably the result of gonorrhoea! 
infection. 

Septic infection occurs usually in connection with the puerperal state, 

whether after abortion or labour, in this state we have a combination of 
circumstan ces favourable to septic infection ; namely, raw surfaces, (lead 






INFLAMMATION OF THE UTERUS 193 

matter liable to decompose, and low vitality of the tissues. It is, there- 
fore, in the puerperal state that we find the best examples of acute 
metritis, and in connection with it the pathology of the malady has 
been chiefly studied. Hence acute metritis as described in the text- 
books, concerns the obstetrician rather than the gynaecologist. The 
pathology of the chronic forms of uterine inflammation which come under 
the attention of the gynaecologist is being worked out but slowly ; they 
Ire, however, likewise septic in origin. This is a fact which cannot 
be too much insisted on, as it gives the reasons of the treatment which is 
here preventive, and consists in carrying out thorough cleanliness with 
antisepsis in all gynaecological work. The activity of germs depends in 
part upon the media in which they are cultivated. Some that have lost 
their virulence regain it in a favourable soil. And the post-partum 
uterus is practically an incubator, at a suitable temperature for their 
development, containing the necessary pabulum in the form of retained 
decidua or blood-clot ; we can therefore understand how the microbes 
may multiply and become virulent there. Abortion, even more frequently 
than full-time labour, is the starting-point of uterine inflammation, owing 
in part to the greater tendency to retention of portions of the ovum, and 
in part to the fact that patients do not take the same care of themselves 
after abortion. Lacerations of the cervix [see " Morbid Conditions of the 
Female Genital Organs resulting from Parturition" in this System], which 
occur in abortion as in labour, form channels for septic absorption and 
consequent cervical catarrh ; and in a large proportion of cases we may 
trace the inflammation back to such causes. The interior of the uterus 
after delivery also is practically a large raw surface ; hence endometritis 
in multiparas can often be traced back to the puerperium. The term 
subinvolution, introduced by Sir James Simpson, covers all the changes 
in the cervix, the endometrium, and the body of the uterus thus produced 
during this period. 

Besides acting as foci for the production of septic material, portions 
of retained decidua occasionally cause endometritis by maintaining their 
vitality instead of breaking down in the lochia. In such cases islets of 
decidual cells have been described in the inflamed endometrium. We 
have thus a form of endometritis after abortion which is a new formation 
rather than an inflammation, and which can only be treated by the 
curette. 

The introduction of septic matter by the gynaecologist in his use of 
septic sounds or tents, or the neglect of antiseptics in operations, need 
only be mentioned as sources of uterine inflammation which should not 
exist, and which are becoming rarer as the importance of antiseptics is 
generally recognised. 

If in fertile women puerperal sepsis is the most important cause of 
uterine inflammation, in sterile women the ravages of the gonococcus are 
deserving of careful study. While those who have written on gonorrhoea 
certainly convey the impression of exaggerating its frequency, it is 
nevertheless a malady which, in its subtle invasion and its far-reaching 





194 SYSTEM OF GYNECOLOGY 

effects, requires careful investigation. Of these effects sterility is the 

Dl08t important. When patients seek advice, many years after marriage, 

on account of barrenness, persistent leucorrhcea, monorrhagia, and dys- 
menorrhea, symptoms all dating from the time of marriage, the possibility 
of gonorrhoea] infection must be kept in mind. Here also we note the 
importance of the etiological standpoint; for if we can be sure of the 
cause, the whole case, as regards both diagnosis and treatment, assumes a 
different complexion. 

Uterine inflammation as the result of displacements is of interest, as 
it gives ns the clue to the difference in the opinions of gynaecologists 
concerning the significance of these lesions. Where retroversion lias not 
interfered with the involution of the uterus during the puerperium the 
displacement is symptomless; but if endometritis and chronic metritis be 
present, we have then symptoms due to these pathological conditions. 
Chronic metritis and endometritis are by no means such invariable 
accompaniments of retroversion as they are of prolapse, in which there is 
always some hypertrophy due to their presence. For the full discussion 
of the relation of displacement to inflammatory conditions, seethe chapter 
of this work on "Displacements of the Uterus." 

Chronic metritis and endometritis also accompany fibroid tumours of 
the uterus and mucous polypi, as described in the chapter on kv Simple 
Growths of the Uterus." 

We pass now to the various forms of inflammation, dividing them, 
according to the seat of the lesion, into (A) Cervical catarrh ; (B) End< 
metritis ; and (C) Metritis. 

The cervix is sufficiently distinct from the body of the uterus t< 
justify its being treated separately. Structurally it is quite different 
from the latter: on its vaginal aspect it is covered with squamoujj 
epithelium resting on papillae of connective tissue, and without mucouj 
follicles; its canal is lined with a Bingle layer of cubical epithelium eh 
folded as to form shallow recesses with racemose mucous glands ; its 
mucous surface differs, therefore, from that lining the body of the uterus, 
Its muscular tissue is not arranged in layers, but consists of liluvs 
icattered irregularly through the connective tissue which preponderates, 
Functionally, it differs from the body in that it plays a passive pari in 
menstruation and pregnancy. Pathologically, it differs in that the 

tumours which are common in it are rare in the body of the uterus, and 

conversely. We are therefore prepared for the fad that chronic 
inflammation of the cervix may not spread to tin; body of the uterus. 

Though clinically we frequently find cervicitis accompanied by inflam- 
mation of the body, vrt the fact that tin's association does not by any 
means invariably occur warrants our considering the cervix by itself. 

An anatomical and pathological basis for classification of the various 
forms of uterine inflammation is preferable to a purely clinical one. AJ 
an illustration of tie- latter, we have Pozzi'e classification according to 
the dominant clinical characteristic. n He thus describes (i.) Acute 
inflammatory metritis ; (ii) Bssmorrhagic metritis \ (iii.) Catarrhal metritis) 






INFLAMMATION OF THE UTERUS 195 

(iv.) Chronic painful metritis. While agreeing with all that he says as 
to the artificial nature of the various classifications of varieties of uterine 
inflammation, and agreeing with him also on the importance of the clinical 
standpoint, we question whether merely to select a prominent symptom 
as the basis of classification, is an advance in our method of classification. 
Though much can be said in its favour, it is practically to return to the 
s\ mptomatological standpoint regarding disease. 

A. Chronic Cervical Catarrh. Acute cervical catarrh can seldom 
be studied as a separate condition. It occurs as part of the general in- 
flammation of the uterus seen in puerperal sepsis, and is often the initial 
stage of the chronic affection, from which, however, it is not marked off'. 

Chronic cervical catarrh is one of the most important conditions which 
the gynaecologist has to treat. Matthews Duncan said that, according to 
its gravity, it would not be placed higher than the third rank ; but that 
on account of its frequency it ranks with chronic ovaritis and chronic 
inflammation of the uterus. 

Clinical History and Symptoms. The patient, usually a multipara, 
comes complaining of a weak back and " whites." The pain is generally- 
found to be in the sacral region, the seat of sympathetic pain for the cer- 
vix ; sometimes it is a sense of dragging or bearing down on the pelvis. 

The white discharge may simply be an exaggeration of the normal 
secretion of the cervix, which is viscid and opalescent, or it may be 
yellow and purulent. In the former case it is difficult to draw the line 
between the normal and the morbid, as many women normally have a 
certain amount of leucorrhoeal discharge, especially after the menstrual 
period. The discharge may have probably lasted some time, unless 
suddenness of onset with urinary symptoms, which is often suggestive of a 
gonorrhoeal origin, lead her to seek advice at once. The most striking 
feature of cervical catarrh is its chronic character ; the condition is one 
which sometimes lasts for years. The patient may show one of the con- 
stitutional conditions referred to under etiology, such as anaemia or the 
gouty diathesis ; and the more remote causes leading to the congestion of 
the uterus, as of other organs, should always be inquired into. The 
symptoms will most frequently be traced back to child-birth or abortion, 
sometimes to exposure to cold or undue fatigue at a menstrual period, or 
to the commencement of gonorrhoeal infection. In acute cases urinary 
complications are often present. Menstruation is sometimes profuse and 
painful, which is probably due to accompanying endometritis just as the 
pain in sexual intercourse, which is sometimes complained of, may be 
explained by associated parametritis ; the cervix uteri itself is not 
sensitive. If the condition have persisted for a long time, symptoms of 
general weakness come on. The patient complains of lack of energy and 
of being easily tired, and she may have a poor appetite and slow 
digestion. Sterility is also present in some cases, although it is difficult 
to say whether this is due to a plug of mucus in the cervix or to some 
affection of the mucous membrane higher up in the genital tract. The 



196 SYSTEM OF GYNAECOLOGY 

explanation of the sterility is more probably vital than mechanical, as 
the discharge affects the vitality ^i the spermatozoa 

Pathology in Relation to Physical Signs. Pathology renders a 
peculiar service to the clinician in giving him a basis for physical diaj 
gnosis. It accounts for appearances which he lias noticed clinically. The 
study of disease is the study of a life history. At each successive stag! 
in its progress the pathologist steps in and gives a physical basis for each 
sign and symptom. He clears away the crumbling remnants of a broken- 
down hypothesis, and enables the clinician to put his foot down on the 
rock of anatomical fact. We consider pathology, therefore, in its relation 
to physical signs. 

Nowhere has this service of pathology been more strikingly illustrated 
than in the physical diagnosis of cervical catarrh. The use of the speculum 
to determine the source of the discharge shows a red granular surfaei 
round the os externum, which bleeds easily. Though more difficult to 
use, Sims' speculum is superior to either the bivalve or tubular one, 
because it disturbs less the normal condition of the parts, and enables ul 
to judge of the presence of laceration and the amount of ectropion. 

The surface looks like an ulcer, because it is red, granular, and 
bleeds; and looking like an ulcer it was called an nicer, and treated bj 
surgical methods as ulceration. Notions derived from ulceration of the 
skin were imported into the region round the os ; and herpes, pern] 
phigus, varicose ulcers, and cockscomb granulations were described. The 
condition round the os was dissociated from the catarrhal inflamma- 
tion within the canal, or was regarded as secondary to it, the irritatinl 
lew orrhoea causing destruction of tissue. The term ulceration not onH 
suggest c(l a wrong treatment, but gave the condition an undue important 
in the mind of the patient. 

All this was changed by the microscopic work of Ruge and Veil (3(1 
who showed that the apparently raw surface is covered with epitheliu 

and that the granular points arc ne\ 

formations which have no relation to the 

granulations of an nicer. The microscopic 

characters of the mucous membrane, t> 

be readily understood from Fig. 1 1. which 

% Mtfmm ^W^fe'^ ( c ) i''p IVS(,,lts '' clipping from one of these 

% f'''*Sj fc'f a} ^'V catarrhal patches, are as follows. The 

( -^f /|f M^p\^K surface is covered with a single layer 

of epithelium, the cells are smaller than 
those which line the normal cervical 
canal, and being narrow and long, have 
called ulcer) on the ct oi a paiisaon LiK< arrangement. I he thin 

ti>-->-vix T '" ",' layerof cells allows the subjacent vascular 

with a single layer ol columnar *i m t li.-- . J 

Hum. [t is folded into papillary eleva- tissue to shine through, hence the red 

tions. Below the surface are eland sp e i mi c 

cut across which may become dilated appearance of the surface. 1 he surface 

IS further thrown into numerous folds 
producing glandular recesses and processes. These processes cause the 







INFLAMMATION OF THE UTERUS 197 

granular appearance of the surface. If the recesses be long and narrow, 
the surface is split up into distinct papillae. This constitutes the papillary 
erosion. If the ducts of the glandular recesses become obliterated, the 
secretion distends the glands below and produces retention-cysts ; these 
increase in size, and may come to the surface and burst. Thus is formed 
the follicular erosion. 

The raw-looking surface is therefore a newly-formed glandular secreting 
surface, which in structure resembles the cervical mucous membrane. This 
addition to the extent of secreting surface increases the leucorrhoeal dis- 
charge, which is the leading symptom. The so-called ulceration is thus 
seen to be simply a part of the process of cervical catarrh, and this not 
the most important part. If the cervix have been lacerated the swollen 
mucous membrane causes a gaping of the cervical canal at the cleft ; and 
thus we may be misled as to the extent to which the catarrhal patches 
spread beyond the os externum. By rolling in the everted lips with the 
tenacula until the laceration closes we can estimate the probable position 
of the os externum. 

From this it is evident that the process is not one of ulceration, 
and the term should be abandoned. The German term " erosion " is 
open to similar objections. "Ectropion" or "eversion" of the mucous 
membrane describes the condition in its relation to laceration, but does 
not describe the extension of the secreting surface beyond the os 
externum. The term is preferable to ulceration, however, as it is not 
so misleading. Thomas describes these conditions under the name 
of granular and cystic degeneration of the cervix uteri, and Palmer 
makes a compromise between the new and the old by treating of them 
under the title of "ulcerations and degenerations of the cervix uteri." 
We are not yet in a position to introduce a term based on pathology, 
even if it were desirable to give to this appearance a special name, and 
thus to suggest a difference in nature from the inflamed mucous mem- 
brane in the canal. Probably the best name for these red patches lying 
outside the os externum is " catarrhal patches," as it suggests that they 
are portions of the mucous membrane in the same catarrhal condition 
as that lining the cervical canal. 

Fischel and other observers have confirmed these observations of 
Ruge and Veit in their essential points. Fischel considers, however, that 
the secreting processes, though new formations, have the structure of 
papillae, and are not mere foldings of the mucous membrane. 

While there is, therefore, no disagreement as to the microscopic 
appearance of the so-called " ulcerations," the origin of this new epithelial 
structure is disputed. Ruge and Yeit hold that this single layer of small 
cylindrical cells is produced by proliferation of the cells of the deepest 
layer of the rete Malpighi, while those of the superficial layer are shelled 
off. It will be observed also that they regard the simple follicular and 
papillary "ulcerations" as the results of one and the same process, 
namely, proliferation of epithelial cells. On the other hand, those red 
patches are generally continuous with the mucous membrane of the cer- 



1 98 SYSTEM OF GYNAECOLOGY 

vical canal, and resemble it in their microscopic structure. It is therefori 
much more probable thai they arc occasioned by proliferation of the epij 
thelium which lines the cervical glands, leading to an extension of the 
glandular surface beyond the os externum. Fischel holds that there 
is not only a proliferation of epithelial cells, but of connective tissue 
also, and that as the one or the other preponderates the follicular of 
papillary tonus are produced. He also thinks that erosions are due to the 
persistence of the cylindrical epithelium (found outside the os externum 
in the foetus) into adult life, and to the desquamation of the squamous 
epithelium which had come to cover it. 

The question of the origin of the cylindrical epithelium found in 
erosions is rendered more difficult by the fact that the boundary-line 
between the squamous epithelium outside the cervical canal and the 
cylindrical within it varies at different periods of development and in 
different individuals. In the foetus, according to Hugo's investigational 
the cylindrical epithelium extends beyond the os externum ; and we have 
a hint of the persistence of this foetal condition in the congenital ectropion 
described by Fischel. Klotz describes two types of cervix distin- 
guished by the distribution of the squamous epithelium: one, cavernous 
in texture, and having the squamous epithelium extending some distance 
into the cervix; the other, glandular in its substance, and having the 
squamous epithelium stopping at the usual seat of the os externum. 

The foregoing description is based on what is found in multiparous 
patients in whom the cervical changes, as seen through the speculum, are 
obvious. In nulliparous patients cervical catarrh may manifest itself by 
catarrhal patches beyond the os externum, but more frequently th 
vaginal aspect of the cervix, though soft and swollen, looks healthy 
The mucous membrane within the canal, however, is in a similar con 
dition to that described above. The os is sometimes unusually small, an 
the cervical canal becomes distended with the secretion. 

The diagnosis of cervical catarrh is comparatively easy, the eeivi 
being accessible to examination. The condition found on vaginal examina 
tion varies as the patient is a nullipara or a multipara, In the former cas 
the cervix feels enlarged and softened, and when there is extension of the 
Catarrhal area beyond the OS externum the margins of the os are soft and 
Velvety. In a multipara the os will probably he notched by old lacera- 
tion.-, and may be BO patent that the tip of the finger can he passed into 

the cervical canal. The area round the os is soft and velvety, or rough 
and granular \ and when the Nabothian follicles have been converted 

into retention Cysts, these are felt as small nodules, like peas or shot, in 

the mucous membrane. Polypoidal projections may he present, and, 
more rarely, the whole cervix i> converted into a cystic mass. The 
speculum can now be w>^\ t<> confirm what the fingers have felt, and 

is absolutely necessary in training the finger to recognise the various 

Conditions present. The extent of catarrhal area, the amount of eversion, 

and the appearances corresponding to the velvety, granular, and nodula 
feelings are demonstrated by it. Hut once the finger has been educa 



INFLAMMATION OF THE UTERUS 



199 



the speculum, for diagnosis at any rate, comes to be less and less used. 
When it is desirable to determine the extent of lacerations with a view 
to operative procedure, tenacula are useful to roll in the everted lips 
of the cervix. The sound is only of service in diagnosing catarrh in 
nulliparae, where it may show a cervical canal unusually dilated by 
accumulated secretion. 

Under differential diagnosis we have only to consider the diagnosis of 
cervical from vaginal or uterine leucorrhoea, and of simple induration of 
the cervix from syphilitic ulceration and commencing malignant disease. 

The normal secretion from the glands of the cervical canal is clear and 
viscid, resembling unboiled white of egg ; and it is alkaline in reaction. 
It may be of an opaque white due to an escape of mucous corpuscles, or 
yellow when pus corpuscles are present. Frequently it is tinged with 
blood. In the worst cases of catarrh the discharge is a thin yellow or 
greenish pus. The diagnosis of cervical from vaginal leucorrhcea is made 
by the speculum, for in the former case we see the leucorrhoea, with the 
characters above mentioned, coming from the cervix ; or by Schultze's 
method of placing a tampon at the os externum to catch the cervical secre- 
tion. The diagnosis of cervical from uterine leucorrhoea is more difficult. 
Menorrhagia, with increase in the length of the uterine cavity and irre- 
gularities in its mucous membrane, point to the presence of endometritis. 

Syphilitic ulceration of the cervix is extremely rare, and the history, 
with the indications of syphilis in other parts, makes diagnosis easy. On 
the other hand, the diagnosis from commencing malignant disease is 
exceedingly difficult. If we are dealing with a case of advanced car- 
cinoma, in which ulceration has occurred, there is no difficulty ; the 
finger at once recognises the friable bleeding surface with firmer margins, 
and the infiltration of the cellular tissue causing fixation. If, however, 
the cervix be simply nodular, and ulceration has not occurred, it may be 
impossible to say at this stage whether the case be one of cancer or not. 
Bennet drew attention to the fact that the lobulation of the cervix in 
chronic inflammation was more regular, the furrows radiating from the 
cervical canal being in fact old lacerations, while in cancer the lobulations 
are irregular. According to Spiegelberg, when a tent is placed in a 
cervix affected with malignant disease the infiltrated parts do not dilate 
like normal tissue. This subject belongs, however, to the diagnosis of 
commencing cancer, for which the chapter of this work on "Malignant 
Diseases of the Uterus " must be consulted. 

Treatment. The importance of constitutional treatment must be 
fully recognised, as there is no doubt that far too much attention has 
been given to local treatment. In most essays on the treatment of cer- 
vical catarrh we find pages given to local applications and to operative 
procedure, while general treatment is dismissed in a paragraph. This 
makes the local, as against the general treatment, bulk far too largely in 
the mind of the practitioner. While, on the one hand, it may be argued 
that there will always be a class of patients who are not satisfied unless 
something is being done directly for them, we must remember that, on 



200 SYSTEM OF GYNECOLOGY 

the other hand, irreparable harm often results from lines of treatment 
which direct the patient's attention to the pelvic organs. 

The care of the patient's general health is to be put in the forefront. 
Change of air, light aourishing food, and a certain amount of exercise, art 
beneficial ; and cold hip-baths in the morning are of service. Disturbances, 
of the digestive system, which are frequent in chronic cases, must be care- 
fully treated. Where rest from sexual activity is desirable, this is often 
secured by recommending that the patient leave home fora time. Tonics, 
such as arsenic, quinine, and iron, are useful. Sir James Simpson 
recommended arsenic, believing that it acted beneficially on the cervix 
as it does on skin eruptions. 

The diathesis should also be carefully studied. In strumous or gouts 
patients, for example, cervical catarrh is simply one of many manifesta- 
tions of the constitutional state, and is only of significance as directing 
OUT attention to it. 

Of local applications the most important is the vaginal douche. This 
treatment, as well as the mode of applying various therapeutic agents to 
the uterus, is described in the chapter on "Gynaecological Therapeutics"; 
so that here mention need be made only of special points bearing on their 
use in uterine inflammation. The douche, to be effective, should be given 
by means of a douche-can, and consist of not less than a quart of water; 
The patient should he semi-recumbent. The temperature of the water 
must be adapted to the individual case: if pain or haemorrhage be pre 
sent the hot douche is preferable. The douche is given for cleanliness, 
and for the application of antiseptics and astringents. Corrosive sublimate! 
( 1 to 4000) is very useful h* chronic catarrh, especially if a gonorrhoea] o 
septic taint be suspected. Sulphate of zinc (1 dr. to a pint), sulphate of 
alumina or sulphate of copper (2 drs. to a pint), are also beneficial. The 
action of these on the catarrhal patches has been specially investigated hy 
Bofmeier, who found that the pale, squamous epithelium gradually crepi 
in tongue-like processes over the red patch. Fig. 45 shows how the super 
tiei.il glands hecome filled up with squamous epithelial cells. The deepe 
glands have their ducts narrowed or even plugged while the gland cavity 
persists below, Kiistner found similar changes produced by antisepti 
doucfc 

Medicament- may also le applied on vaginal tampons, the bes 
excipienl being glycerine. The glycerine itself acts by withdrawing! 
serum from the engorged tissue. To it may he ;i<l<led boric acid (50 per 

-cut), tannin (I dr. to ] <>/.), ichthyol ( 1 (.) percent), and iodoform. 

Applications may also 1m- made on forceps dressed with cotton 
wadding, dry wadding being \\^'i\ first to swab oil' the mucus. 

Churchill used B preparation of iodine consisting of 75 grains of iodine 
and 90 of potassium iodide in 1 ounce of alcohol. Weak solution- of 

nitrate of silver are al <> beneficial 

Where the cervix is much indurated and studded with retention-cysti 
scarification i< \cry useful ; it acts by depletion, and also by letting on 
the inspissated mucus. Bleeding by scarification has largely taken th 



INFLAMMATION OF THE UTERUS 



place of leeching. Various scarificators have been devised, but an 
ordinary bistoury does perfectly. A tepid douche given afterwards 
promotes bleeding. Scarification is preferable to the actual cautery, 
which has been recommended by Prochownik, as the latter is followed 
by cicatrisation. In very chronic cases the only remedy is to destroy 
the diseased glands, as we excise the tonsils in tonsillitis : this is done 
by caustics, the curette, or the knife. Of caustics, potassa-fusa was 
recommended by Sir James Simpson, and the zinc-alum sticks of Skold- 
berg by Matthews Duncan. This use of caustic must be distinguished 
from the application of it to touch the so-called ulcer so as to make it 
heal, and has many advocates. It is better to use the curette, as recom- 
mended by Thomas, or the knife as in Schroeder's operation (32). In 
fact, where the glandular tissue has to be destroyed, the most efficient 




Fig. 45. Healing of a catai-rhal patch treated by astringent or antiseptic injections (Hofmeier). From 
c to b is seen part of a catarrhal patch (compare Fig. 44) which from b to a has become covered over 
with newly-formed squamous epithelium ; dd, glands whose ducts have been obliterated ; c, gland 
duct which has persisted. 

and cleanest way of doing it is by excision of the mucous membrane, 
although the cases in which this operation is called for are compara- 
tively rare. In Schroeder's operation the cervix is laid hold of by two 
volsellse, one on each lip, and drawn downwards. It is then divided 
laterally, as far as the fornix, with the scissors, so as to form an anterior 
and posterior lip which are separated as far as the vaginal roof. A trans- 
verse incision (seen in section at a, in Fig. 46) is made across the base of 
the anterior lip dividing the whole thickness of cervical mucous mem- 
brane. The point of the lip is next pierced at c, and the knife pushed 
in the direction bb till it reaches the cross incision a ; the blade is then 
carried outwards, first to the one side and then to the other, so that all 
outside of the line a, b, c is removed. The flap of the cervix is now 
turned in and stitched (Fig. 47), and the angles of the wound in the 
fornix closed. 

Emmet's operation is also useful in cases of deep laceration, especially 



SYSTEM OF GYNECOLOGY 



where there is cicatricial tissue al the base of the cleft: it has not ful- 
filled all that was expected of it, however, and it is not performed nearly 
so frequently as was the case some years ago. It simply conceals, with- 
out removing the diseased mucous membrane, and should always bf 
combined with measures directed to the treatment of the catarrh. 

For marked hypertrophy of the substance of the cervix amputation 
is the only treatment. 

In the cervical catarrh of nulliparae, where there is a narrow os 
externum, the bilateral division of the cervix is of service. It allows 
the secretion to escape instead of accumulating; and application- call 
be made to the cervical canal. It is also said to favour the occurrence 
of conception. 

These operations are described in the chapter on "Plastic Gynaeco- 
logical Operations." 





Fig. 46. 



Fio. 47 



Schroeder's operation for excision of the cervical mucous membrane In cervical catarrh. 

line of incision in mucous membrane ; Fig. 47, mucous membrane excised, and flap be turned 
on db. 



Acute Metritis and Endometritis. In the acute condition 
cannot separate these two affections. Clinically they are met with in 
the puerperal state, and as exacerbations of the chronic condition to bl 
described presently. Except in the puerperal state they are never fatal 
and hence the classical descriptions which are handed from text-hook to 
text-boob belong to a treatise on puerperal fever rather than to a system 
of gynsecol 

Wyder (11). from ;i >tndy of the ineml>r;ine exfoliated in Cases of 

membranous dysmenorrhcea, has recently described the pathological 
changes which he regards as those of acute endometritis. The cells in 
the stroma are greatly increased in numbers, and are so closely packed 
together thai little of the matrix is seen. Gottschalk, on the other 
hand, finds in the exfoliated membrane changes characteristic of a 
haemorrhage interstitial endometritis. Membranous dysmenorrhoeal 
or, as it has been called, exfoliative endometritis, is a rare affectionj 






INFLAMMATION OF THE UTERUS 203 

and its pathology can hardly be considered to be the same as that of acute 
endometritis. 

B. Chronic Endometritis. This is a sufficiently well-marked con- 
dition to merit separate treatment. I would limit the term to those cases 
in which the patient has the general symptoms of chronic uterine inflam- 
mation, which I shall describe under chronic metritis, with in addition 
increased discharge either of blood at the menstrual period, or of leucor- 
rhoea in the intervals. As the presence of either of these symptoms 
points to changes in the uterine mucosa as the more prominent condition, 
there is sufficient reason for treating chronic endometritis as a condition 
distinct from chronic metritis. 

Clinical History and Symptoms. The history may be traced back 
to abortion or labour, to an attack of uterine inflammation as the result 
of chill, or to gonorrhoeal infection. In a considerable number of cases, 
however, the symptoms begin insidiously, and develop gradually without 
any assignable cause. Endometritis is more frequent in multiparous 
patients, and more common later than earlier in life ; though it also 
occurs in nulliparae, especially when there is stenosis of the os externum. 
Euge describes one-half of his cases as occurring after forty years of age 
(29). After the menopause a senile form of endometritis may appear, 
which has to do with the retrogressive changes taking place at that time 
in the uterus. 

The symptoms characteristic of endometritis are leucorrhoea and 
menorrhagia. The secretion from the body of the uterus is less viscid 
than that from the cervix, and may be clear ; but more frequently it is 
muco-purulent. It may be tinged with blood so that the patient believes 
herself to be more or less continually unwell. Sometimes it comes away 
more freely than at others, as if it collected in the uterus, or as if there 
were hypersecretion at intervals. It may be so irritating as to excoriate 
the vulva. 

Menorrhagia is generally present, but not always. In some cases the 
loss may be so considerable as to suggest malignant disease, and even to 
endanger the patient's life by profound anaemia. 

Of the exact relation of these symptoms to the anatomical changes to 
be immediately described, we do not yet know enough to make definite 
statements. Olshausen, who first described endometritis fungosa a state 
in which the changes are interstitial drew attention to haemorrhage as 
the prominent symptom in these latter cases. Wyder also, who has 
studied the mucous membrane changes found with fibroid tumours, 
maintains that bleeding occurs in interstitial, but not in glandular 
endometritis. On the other hand, Veit holds that bleeding may occur 
with either variety. Whatever be the reason of the haemorrhage, this is 
the symptom which most immediately affects the patient's health and 
calls for prompt treatment. 

Pain at the menstrual period is sometimes present, although it is 
less frequent in endometritis than in inflammation of the uterine append- 



204 SYSTEM OF GYN. ECOLOGY 

It is, of course, characteristic <>f the exfoliative form. The weak 
back and other pains will be considered under chronic metritis. 

The reproductive function is liable to be affected, although it is sur- 
prising how many patients show all the symptoms of endometritis in the 
intervals betweeq conception. Sterility is occasionally found, but it is 
difficult to say whether it be not due to associated inflammation of the 
uterine appendages, as undoubtedly is the case in gonorrhoea! infection. 
Definite information as to the effect of uterine secretions on the vitality of 
the spermatozoa is wanted. Cases in which conception after a period 
of sterility follows shortly on curetting, point to the fact that the 
diseased mucosa in some way prevents conception. Abortion is un- 
doubtedly often due to the morbid condition of the mucous membrane, 
which leads to haemorrhages into it, and to bad implantation or death of 
the ovum. 

Pathology in Relation to Physical Signs. Pathology has here 
rendered service by explaining the conditions found by the sound and 
curette, the two instruments usually employed in the recognition of 
endometritis. 

The only changes in the uterus are the increase in the size of its 
cavity, and the swollen and soft condition of the mucous membranej 
The latter, moreover, is sometimes thrown into rough projections, and is 
also so congested that it bleeds easily. All of these features are recog- 
nisable by careful use of the sound. In fact, it is for the exploration of 
the mucosa rather than for determining the position of the uterus, that 
we find the sound of service; it shows that the cavity of the uterus i> 
always enlarged in cases of endometritis. Rough granulations can b< 
detected by holding the handle delicately; and even the peculiar soft 
haracter of the thickened membrane may be thus recognised. If bleedinJ 
occurs after its use, congestion of the mucosa exists. It is also sail 
that its introduction is accompanied with pain, and that areas painful to 
touch can be made out over the fundus (Routh), or in other parts of the 
uterus (Veit). It is extremely difficult, however, to exclude peritonitid 
or cellulitic conditions which would also cause pain from the movement 
given to the uterus as the sound is introduced. 

The hypertrophied mucosa can be easily scraped away by the curette, 
and its mi'Toscopic examination by the pathologist has done much to 
clear up our conception of endometritis, although much has yet to be 
learned Corm'l, de Ninety, Beinricius, Kustner, Olshausen, Ruge, and 
W'yder have all made important contributions on the pathology of ihe 
changes of the endometrium in endometritis. Olshausen describe! 

changes in what he calls endometritis fungOSa, of which the leading 

symptom is haemorrhage Be found the mucosa hypertrophied to three 
"i- inwv tim.v- its normal thickness, and elevated throughoul in a cushion- 
like swelling, or in discrete Bpongy masses. The change stops at the cm 
internum, and does not affect the cervix. The portions removed by the 
curette -how, on microscopic examination, great "hypertrophy of the 
mucosa, with incre <\\ its elements, moderate dilatation of tl 



INFLAMMATION OF THE UTERUS 205 

uterine glands, enlargement of the blood-vessels, and marked cellular 
infiltration of the connective tissue." The glands are not enlarged so as 
to produce cystic dilatations. 

De Sinety describes three forms of vegetations removed by the 
curette. In one the tissue consists mostly of dilated blood-vessels ; in 
another of dilated hypertrophied glands ; in a third of embryonic tissue, 
with but few blood-vessels and only traces of glands. These three forms 
of granulations he associates with the three kinds of discharge san- 
guineous, leucorrhceal, and muco-purulent. 

Ruge (29) describes three forms "the glandular, the interstitial, and 
the mixed." In the glandular a section shows that the glands, instead of 
rum ling more or less straight downwards, are cut across in all directions. 
Their appearance on section varies as the glands have changed their 
direction, or their epithelium has been altered, star-like and saw-like 
figures being produced. Sometimes they are dilated into cysts. In the 
interstitial form the stroma is filled with small round cells, and the 
vessels are dilated and tortuous ; but the glands are not affected. The 
mixed form is a combination of the other two. The glandular occurs in 
more advanced life ; the interstitial at all periods. 

Wyder (44) has studied the changes in the mucous membrane in endo- 
metritis accompanying fibroid tumours. He describes Ruge's glandular 
form as principally accompanying subserous fibroids, and not having 
haemorrhage as a symptom. In the interstitial variety, in which haemor- 
rhage is prominent, the glands are constricted at various points and 
transformed into cysts ; or they are compressed and atrophied. As the 
result of this the glands are few in number. The interglandular tissue 
is marked by the abundance of its vessels : it appears in parts as a tissue 
rich in spindle cells with processes which give it a striated appearance ; 
in other parts it is transformed into a fibrous tissue with few cells. The 
constricted glands may appear as clear, transparent vesicles, projecting 
above the surface of the membrane. The cicatrisation of the connective 
tissue compresses the vessels and leads to haemorrhage. The process may 
go on till all the glands have disappeared, and the mucous coat is repre- 
sented by a homogeneous connective tissue, wavy in outline, which may 
be covered by a layer of epithelium. When the dilated cystic glands 
form distinct projections on the surface we have a polypoidal glandular 
endometritis, which passes insensibly into mucous polypi. 

Cornil in his lectures on metritis gives a very complete account 
of the appearance of the mucous membrane. Its surface is fungoid 
instead of smooth, and shows villous projections and cysts the size of a 
pin-head. On section it is 2 to 10 mm. thick instead of 1 mm. as in 
the normal condition. The glands are more tortuous ; and, what is un- 
like a non-malignant condition, have grown beyond the usual limit into 
the muscular wall. The glandular cells, though chronically inflamed, 
retain their cilia. The layer of flat cells separating them from the inter- 
glandular tissue is also undisturbed, which is of importance in diagnosing 
it from epithelial cancer. That it is a true inflammatory change is seen 



206 . SYSTEM OF GYNECOLOGY 

from the excess of mucus, the multiplication of epithelium, and the 

migration of leucocytes. Mucous plugs may be seen, recalling the hyaline 

of albuminuria. Karyo-kinesis can often be observed in the gland 

cells. Lymphoid cells arc found in the gland cavities which have escaped 
from the capillaries and passed through the gland cells. The inter- 
glandular tissue shows dilatation of its vessels and infiltration with 
wandering lymphoid cells, while the closely-packed ovoid cells, of which it 
is normally composed, swell up and become spherical. 

Heinricius has also described specimens taken from cases of endome- 
tritis fungosa. He finds the stroma between the glands to consist of a basis 
of stellate corpuscles, with anastomosing processes, upon and between which 
lie two varieties of cells some large, oval, and faintly stained; others 
small, round, and deeply stained. The former are the nuclei of an endo- 
thelium, the latter are lymph corpuscles. His description of the inter- 
stitial tissue makes it consist, then, chiefly of lymph sinuses. As the result 
of the inflammation, the lymph corpuscles and those of the endothelium 
proliferate and produce an appearance which resembles a small-eel led 
infiltration, as the basis of the network is obscured by the cells. Tints 
he differs from other observers in regarding the small cells as occupying 
lymph spaces. 

Relation of Micro-organisms to Endometritis. We have already 
referred to this matter in speaking of the etiology of uterine inflammation ; 
but it is especially in connection with the pathology of the endometrium 
that the subject comes up for consideration. While attention is being 
directed more and more to the part played by micro-organisms in inflam- 
mation of the uterus, and too much stress cannot be laid on the germ- 
theory in so far as it leads to rigorous antisepsis in practice, the question 
is naturally asked, What direct proof is there of the part played by 
micro-organisms in endometritis? It can only be answered from observa- 
tions made directly on the endometrium. 

As an illustration of the importance attached to micro-organisms, we 
may take the most recent classification of the varieties of endometritis 
given by Winckel, who arranges them in two groups, as they are 
due to micro-organisms or not. In the latter group he places- i. Simple 
catarrh due to disturbance of circulation, as in chlorosis, uterine displa< 
ments, tanks in dress, mode of life, etc. : ii. Hemorrhagic endometritis, as 
in acute and infect ions diseases : iii. Decidual endometritis after abortion ; 
and iv. Exfoliative endometritis. In the former group he places -v. Gonor- 
rhoea} endometritis: \i. Tubercular endometritis: vii. Puerperal septic endo- 
metritis, usually due to the streptococcus longus, more rarely to a staphylo- 
or to the bacterium coli commune: viii. Saprophytic endometritis, 
due to combination of cocci and bacilli, of which the senile purulent 
endometritis is probably one form: ix. The so-called diphtheritic endometritis 
which is due to streptococci : \. Si/j>hilitic endometritis -the cervical mucous 
membrane exposed by laceration being a favourable nidus, but infection of 
the decid us the more important cause: \i. Endometritis due to fungi, the 
plant having been cultivated from the secretion ; and xii. Endd 



INFLAMMATION OF THE UTERUS 207 

metritis due to amoebce protoplasmic bodies with nuclei and vacuoles 
being present in the dilated uterine glands, and causing proliferation of 
epithelium. 

Such a classification suggests that micro-organisms are very important 
factors in the changes. At the same meeting, however, of the German 
Gynaecological Association, Bumm gave the results of the direct examina- 
tion of the secretions from forty-five cases of endometritis in the living 
subject; and he concludes that the affection of the mucous membrane is not 
kept up by micro-organisms, and that their presence is accidental, and varies 
with the character of the secretions. He adds, however, that the supposition 
that chronic endometritis has nothing to do with micro-organisms is not in- 
compatible with the fact that it may be the result of a septic or gonorrhceal 
infection. So also Gottschalk and Immerwahr, after examining sixty 
cases of all forms of endometritis, found micro-organisms in the secretions 
of only one-half of them ; and to these they could not attribute a patho- 
genetic importance, although catarrhal inflammation might be attributed 
to their agency. 

The mucous membrane has also been examined in portions of the 
uterus removed at operations ; and I have already referred to Winter's 
results, which, however, were not made specially on cases of endometritis. 
Menge has examined the mucous membrane from seventy-three specimens, 
including all forms of endometritis, and concludes that neither in the 
secretion nor in the mucous membrane are micro-organisms present, with 
the exception of the gonococcus and the bacillus tuberculosis. Further 
observations upon this subject must be waited for ; but for the present 
we may assume that micro-organisms play a subordinate part in chronic 
endometritis. 

The observations of Pfannenstiel, Doderlein, Gonner, and others on 
the lochia in the puerperium show the importance of the streptococcus in 
puerperal sepsis ; but this subject belongs to obstetrics rather than to 
gynaecology. 

The diagnosis of endometritis before the days of the curette was 
often uncertain. Haemorrhage may be due simply to congestion, 
without permanent changes in the mucous membrane ; and some 
enlargement of the uterus often persists after delivery. Unless the 
uterus be curetted, and the morbid condition of the endometrium 
demonstrated, our treatment is still often empirical. We may satisfy 
ourselves that there is no cause outside the uterus to account for the 
haemorrhage or leucorrhoea, and, finding the uterus enlarged, we may 
assume that endometritis is present. Where it can be traced back dis- 
tinctly to abortion, diagnosis is more certain. 

Of the use of the curette for diagnosis the following illustrations will 
serve : Figs. 48 and 49 are sections of scrapings taken from a case of inter- 
stitial endometritis the endometritis fungosa of Olshausen. The patient 
was a multipara in whom profuse menorrhagia dated from her last 
confinement. She was curetted on two occasions, as the haemorrhage 
recurred after the first curetting. Since the last curetting her menstrual 



20S 



SYSTEM OF GYNAECOLOGY 



periods hint' been normal for some time. The sections show small-celled 
infiltration in the interglandular tissue, but no hyperplasia of the glands. 





PlO. 48. 






Section of tissue removed by curette from a case of interstitial endometritis. Fig. 4s shows the 
glands and interglandular tissue under a low power; Fig. 49, the same under a high power, tn 
show the small-celled infiltration. 

The section given in Fig. 50 was taken from another case in which 
the endometritis was of the glandular type. The patient, a nullipara 
has for five years suffered from considerable haemorrhages, and has be6 
curetted on different occasions during this period without the benefit see 
in the former case. The portions removed by the curette on the las 
occasion showed marked hyperplasia of the glands, with proliferation <> 

the glandular epithelium, as is we] 
seen in the portions of the gland: 
shown in Fig. 50. Though the uteiu 
is enlarged there is no infiltratio 
round it; but from the proliferatio 
of epithelium the case may in tli 
end prove to be one of commencing 
cancer of the endometrium ; mean] 
while, therefore, the prognosis musl bl 
guarded. 

The curette has thus come to be 
of great value in the recognition of 
endometritis, and of t he various changes 
present in the mucous membrane. 
[t use, however, is primarily for treatment, except where commen] 
(in- malignant disease is suspected ; and even here, where 
diagnostic means it might be of most value, it often fails us. Th 
portions of tissue removed are too small to enable us t form a defini 
conclusion ;>- t. the presence or absence of malignant disease. I 

BOme Cases the malignant cells may le too characteristic for doubt : bu 




: n i of the glanda from i 
glandular endometritis. The epithelium is 
undergoing multiplication. This may pass 
into a malignant affection. 



INFLAMMATION OF THE UTERUS 209 

in the majority of cases in which I have used the curette for this purpose, 
the appearance of the tissue, if " suspicious," has not amounted to a 
demonstration. This subject, however, belongs to the diagnosis of com- 
mencing malignant disease, which is treated elsewhere. 

Treatment. The constitutional treatment of endometritis will be 
discussed under chronic metritis. The local treatment consists in appli- 
cations made to the uterine mucous membrane, with or without previous 
curetting. Before having recourse to local applications we should be 
satisfied of the necessity for them. As in the case of cervical catarrh, 
local treatment has received undue attention. Vaginal injections, ergotine, 
and other uterine haemostatics should always have a fair trial in the first 
instance. 

Applications are made in the solid or liquid form ; the latter, 
either by means of injection or on a sound dressed with cotton wadding. 
The technique of intra-uterine medication is fully described in the chapter 
on Gynaecological Therapeutics. Here we have to consider it only as 
applied specially to endometritis. With regard to the methods mentioned, 
I may say that I believe only in the latter ; the introduction of the 
caustic in solid form, so as to melt inside the uterus, is too indefinite in 
its action. The use of intra-uterine injections has not found favour in 
British gynaecology owing to the dangers connected with them. I do not, 
of course, refer to the washing out of the uterus with Fritsch's catheter 
as part of the operation of curetting, but to the injection of caustics by 
special syringes, such, for example, as Braun's. Lantos' syringe, 
in which the point is wrapped in cotton wadding, into which the fluid 
exudes through holes at the side, is a safe instrument ; but it does not 
possess any decided advantage over a dressed sound. I prefer to make 
applications with the ordinary sound dressed with cotton wadding ; the 
only objection to it being that the fluid is liable to be squeezed out of the 
wadding as it is carried through the os. This difficulty can be got over 
by using a thin film of wadding, by making more than one application, 
and by preliminary dilatation of a narrow cervix. It is always well to 
use a dry sound first in order to swab away the mucus, so as to allow the 
medicament to act. The applications I prefer are iodine, iodised phenol 
(consisting of 40 grains iodine in one ounce of carbolic acid), and pure 
carbolic acid prepared by liquefying the crystals. This mode of intra- 
uterine application has been recommended by Dr. Playfair, who has 
devised a special probe for it. 

Dr. Atthill advocates the use of strong nitric acid, and the preliminary 
dilatation of the cervix so as to allow of its free application. He uses an 
intra-uterine speculum of vulcanite to prevent the acid from acting on the 
cervical canal. Dr. Barnes has devised an ointment-positor for intro- 
ducing ointments or fluids. He applies the iodide of mercury ointment by 
this means, or tincture of iodine on a sponge. Munde uses a 20 per cent 
solution of chloride of zinc in the manner described above ; he recom- 
mends also pencils containing 5 grs. of powdered alum and of iodoform, 
which are left to melt in the uterus. 

p 



210 SYSTEM OF GYNAECOLOGY 

The best results from intra-uterine medication arc obtained when it 
is applied after previous curetting. It is difficult to define the limits of 
this operation, but it is perfectly safe, and I have never seen any bad 
results after it. For this very reason it is liable to be abused, and to be 
performed in cases where it is not called for. The fact that the uterine 
mucosa can be so easily removed, and is so rapidly regenerated, is no 
argument for its removal ; and the notion of a substitution of new 
mucosa free from germs, under aseptic conditions maintained for several 
weeks by the use of intra-uterine injections, is ingenious but open to 
doubt. 

I would limit the operation of curetting to cases in which there is a 
clear history of recent abortion, in which there is considerable menoi -rliagia 
which has not yielded toergotine, or in which the sound shows the cavity 
to be distinctly enlarged and roughened with vegetations. It is not 
called for in cases of catarrhal endometritis, and of course should not be 
performed when there is acute or subacute inflammation of the uterine 
adnexa. Curetting for the endometritis of fibroids, and for the diagnosis 
of malignant disease, does not belong to the subject we are considering. 
The mode of performing the operation is described elsewhere. After it 
is done the uterus is to be washed out with a weak antiseptic, and the 
other applications then made as mentioned above. Where distinct por- 
tions of tissue are removed, they should be preserved for microscopic 
examination. 

Electricity has also been used to check the haemorrhage in endometritis. 
As it acts simply by cauterisation of the uterine cavity it does not ] tie- 
sent any advantages over curetting. It is of service, however, in tin 
endometritis of fibroid tumours, where, in certain cases, it has an effect 
also on the growth of the tumour. 

C. Chronic Metritis. As in the case of endometritis, I do not con 
rider acute metritis deserving of separate consideration; it appears h 
most treatises by reason only of the artificial division of affections generally 
into acute and chronic. The description of its pathology and treatment 
is taken from cases of puerperal inflammation which do not concern us 
here. We have good authority for discarding it as a separate affection] 
when Kloli Mates that he lias not met with a single case ; Kokitanskv. that 

the uterine tissue is scarcely ever affected primarily ; Schroeder, thai it 
extremely rare; while Thomas regards it as but a complication of endJ 
metritis. Sir William Priestley's description of it, in his admirable article in 
Reynolds 1 System of Medicine, is taken from puerperal sepsis; and in the 
nun pregnant condition he describes it as occurring chiefly after operations 
The use of antiseptics in vagina] operations during the last twenty yens, 
since his article wrai written, has Lessened the frequency of such - 
In the American System of Qynacology Palmer says that pure and uncorij 
plicated metritis rarely if e\r\- occui 

Acute metritis does occur as an exacerbation of the chronic condition, 
especially in connection with the congestion at the menstrual period, yd 



" 






INFLAMMATION OF THE UTERUS 



here the chronic affection is more important. We may note also, in 
passing, the great rarity of suppuration in the uterine wall ; most of the 
cases thus described were abscesses in the cellular tissue beside the 
uterus. 

With regard to the frequency of chronic metritis there is a difference 
of opinion ; but it is largely a question of terms. In the present state of 
our knowledge we are disposed to relegate to chronic metritis all cases 
of chronic uterine inflammation which do not come distinctly under the 
category of chronic cervical catarrh, or chronic endometritis. In doing 
this we make chronic metritis one of the most important of the in- 
flammatory conditions of the uterus. It may be argued that our 
ignorance of its pathology, and the difficulty of exactness in its diagnosis, 
are not a sufficient reason for making it include a large group of cases of 
chronic invalidism which cannot be classified under the better known 
affections. For the present, however, this seems the best course for us 
to take. Under chronic metritis we include those cases which Sir James 
Simpson described under subinvolution (20), a term which, however aptly, 
only describes the conditions under which chronic metritis most 
frequently arises. 

Clinical History and Symptoms. No better description could be 
given of the general features of cases of this class than that of Bennet ; 
although he made the inflammatory condition of the cervix, rather than 
the accompanying condition of the body of the uterus, the important 
factor. " To this class belong a large proportion of the population of 
sofa, bath-chair, nervous, debilitated, dyspeptic females, who wander 
from one medical man to another, and who crowd our watering-places in 
summer ; most of them are suffering from chronic uterine inflammatory 
disease unrecognised and untreated, and most of them would, if their 
disease were only discovered and cured, become amenable to the resources 
of our art, and eventually recover their health, spirits, and powers of 
locomotion. It is a singular and instructive fact that amongst the male 
part of the community there is no similar invalid population, always ill, 
Unable to walk or ride, constantly requiring medical advice, and yet living 
on from year to year, neither their friends nor themselves knowing what 
is amiss with them, beyond the evident weakness, dyspepsia, etc." (2). 

The symptoms, also, which Gooch ascribes to the irritable uterus we 
now attribute to chronic metritis. " To embody them in one view, let 
the reader fancy to himself a young or middle-aged woman, somewhat 
reduced in flesh and health, almost living on her sofa for months, or even 
years, from a constant pain in the uterus, which renders her unable to 
sit up or take exercise ; the uterus, on examination, is unchanged in 
structure, but exquisitely tender ; even in the recumbent posture, always 
in pain, but subject to great aggravations more or less frequent." He 
thus describes exacerbations which are characteristic : " No disease, how- 
ever, is so liable to relapse. The patient, feeling easy, finding herself 
feeble, and supposing that air and exercise are necessary to the recovery 
of her health, rises and goes about again, and after a short interval of 



SYSTEM OF GYNAECOLOGY 



caution, throws aside her fears, engages in walks, rides, and gaiety, or 
takes a journey t<> the sea for the recovery of her health. This conduct 
commonly occasions a complete relapse, and the patient and her attendant 
are again involved in the former suffering, apprehensions, and difficulties'] 

It may be said that some of the cases described by Gooeh were 
..f affections of the Fallopian tubes, which were not recognised at the 
time at which lie wrote. The line of treatment, however, adopted and 
the improvement under it show that Ave are justified in considering 
them as cases of chronic metritis. Gooch's reason for not calling the 
condition a chronic inflammation namely, that the latter is a dis- 
organising process, while the irritable uterus shows no alteration in 
structure proves, on the contrary, that his cases were just what we 
would now describe as chronic metritis, the results of which tend to be 
permanent. 

The most constant symptom is pain in the lower part of the abdomen 
and in the loins. Sometimes it is spoken of as fulness or weight in t he 
pelvis, or bearing down. In one word, as Pozzi puts it, the patient 
knows that she has a uterus. The pain is worst when she is going about, 
and relieved when she lies down. In this respect it differs from the 
pain of cancer, which is independent of exertion, and is often described as 
worse when she is resting at night; probably because there is less to 
distract iter attention from it. Whatever increases abdominal pressing 
and tends to move the sensitive uterus produces pain. Well-to-dj 
patients, who can take relief by lying on the sofa, gradually come 
spend most of their time there. 

The fact that the pain is aggravated by movement, and relieved In 
rest, raises the question whether the cause of it be not sensitiveness h 
the attachments of the uterus, rather than in the organ itself; whether 
be no t an associated parametritis or perimetritis ''. In many cases, howevei 
we cannot find evidence of these affections. If I were to draw a fine did 
tinction 1 should say, that when pain is aggravated by movement of the 
uterus as may le demonstrated on bimanual examination, or the u 
the Bound rather than by simple pressure in the iliac regions, the lesion 
is chronic metritis, not perimetritis. We cannot always he swvc that 
painful cicatrisation in the broad or uterc-sacral ligaments is absent] 
The pain LS often more marked in the left iliac region, which may 
indicate cicatrisation in the left broad ligament : as most cases of chronic 
metritis date from the puerperal condition, in which left sided cellulitis is 
more frequent because of the greater frequency of left-sided laceration! 
of the cervix. Pozzi ascribes this pain to inflammation of the left 
Fallopian tube, though he can give no reason why the left tube should 
be affected rather than the right. The pain, moreover, is increased hy 
the congestion of the menstrua] period, an increase which is ascribed to 
the flushing <>f the painful uterus with blood. Sometimes, however] 
patient- are relieved by the menstrua] How, as by a local depletion. 

Neuralgic pains are frequent, though it is difficult to say whether 



INFLAMMATION OF THE UTERUS 



213 



these are due to a source of irritation in the uterus, or to the general 
" run-down " condition of the system. The disturbances of digestion may 
more justly be regarded as reflex neuroses such as the gastric dis- 
turbances of pregnancy, which depend upon the close relation between 
the uterus and the digestive system. The constipation, which is a con- 
stant complaint, results probably from the want of exercise ; but sometimes 
it is due to shrinking from the pain of defalcation. In the acute exacerba- 
tions, indeed, there may be diarrhoea with tenesmus, due to extension of 
inflammation to the rectum ; as there may be frequent and painful 
micturition from the extension of inflammation to the bladder. 

Disturbances of menstruation are often given as symptoms of chronic 
metritis. Painful menstruation is certainly one of them, and is accounted 
for by the congestion of a tender uterus. Profuse menstruation should, 
however, be referred to an accompanying endometritis ; though Fritsch 
thinks the connective-tissue formation in the wall affects the contractile 
power of the uterus, which he considers one of the factors which regulate the 
amount of the menstrual loss. This distinction is not a refinement, but 
bears on treatment ; for such cases can be treated by curetting, which we 
do not consider to be applicable to metritis. The possibility of the 
haemorrhage being due to an associated salpingitis, which has its own 
appropriate treatment, should also be borne in mind. 

The disturbances of the reproductive function (sterility and abortion) 
are also to be accounted for by the accompanying endometritis. 

The general effect on the patient's nervous system is perhaps the 
most important of all the consequences of this malady, and shows itself 
in asthenia and hysteria. It is extremely difficult to say how far these 
elements enter into individual cases, but an accurate appreciation of the 
proportion between the general and the local factors in these very complex 
cases is of the first importance when treatment has to be considered. By 
asthenia we mean the real loss of energy, which can only be made up by 
such a line of treatment as the Weir Mitchell. [See the section on "The 
Nervous System in Relation to Gynaecology."] Hysteria, of which the 
treatment is rather a mental and moral regime, is also an important 
element in the malady. It is only by taking into account the condition 
of the central nervous system that we can explain the great variability 
in the amount and seat of the pain in chronic metritis, the sudden im- 
provements and relapses, and those cures in which the result bears no 
proportion to the means employed. 

Pathology in Relation to Physical Signs. Still less is known of the 
pathological changes in chronic metritis than in endometritis or cervical 
catarrh.. We have seen that the accessibility of the cervix to microscopic 
examination in the living subject has, during the last twenty years, given 
precision to our knowledge of its pathology, and that the curette is 
performing a like service for the endometrium in enabling us to study 
its pathological changes during life. An opportunity, however, for 
examining the condition of the wall is only given in the rare cases of 
extirpation of the uterus. 



214 



SYSTEM OF GYNAECOLOGY 



Scanzoni's classical monograph on chronic nut litis deals entirely with 
the naked-eye characters. 

The microscopic changes have been described by De Sinety, Fritsch, 
and Cornil, but further observations are needed. 

Scanzoni describes two stages, an early stage in which the uterus 
is enlarged, hvpenemic, and soft, and a later one in which it is indurated, 
antemiC] and hard. Clinically it is impossible to distinguish two such 
Btages : sometimes we find a soft uterus, and sometimes a firm one ; but 
no clinical observations have demonstrated that the one condition follows 
the other in the same patient. Scanzoni's description is the result more 



mf>t- 



mf,l 




mfj 



p-i, ; _ ;,i. Section of the uterine tissue in a COM of chronic metritis: ct, connective tissue round 
blood-vessels, bv; l, dilated lymphatic spaces; mf, I, muscular fibre cut Longitudinally; mf, 

muscular fibre cut trtUlSI i -inety). 

of logical deduction from what we know of pathological changes in other 
a than of direct study of the uterus. 

De Sinety follows Scanzoni in describing two stages. 'Die first is 
characterised by "the presence in great number of embryonic element! 
throughout the whole thickness of the muscular wall. These element! 
are met with specially round the blood-vessels, or form islands of variabll 
dimensions which are more or less apart." \]\ the second stage he 
describes marked dilatation of the lymphatic spaces, and a localised 
hyperplasia of the connective tissue round the Mood vessels. Fig. 51 is a 
section of the uterine tissue from one case which he examined. 

I'Yitseh's observations were made on uteri which, extirpated for 
cancer, also showed the naked-eye appearances of chronic metritis. EH 
found that the disposition of muscular fibre and connective tissue is lesl 






INFLAMMATION OF THE UTERUS 215 

regular than in the normal uterus, the individual muscular bundles being 
split up into small irregular ones. The connective tissue is greatly 
increased in amount, and its bundles show remarkable bulging and 
undulations in their course. Areas of normal tissue may be found in the 
same uterus, showing that chronic metritis may occur in patches. The 
blood-vessels are more numerous and tortuous, and thus in places pro- 
duce the appearance of a cavernous tissue ; their walls are thickened, 
especially in the middle coat ; the contour of the vessel is masked by a 
connective tissue replacing the muscular elements in the wall, and the 
lumen of the vessel is often diminished. The lymphatics appear as 
gaping spaces instead of narrow clefts. The peritoneum is also thickened. 
Fritsch holds that the muciparous uterus must always be richer in con- 
nective tissue than the nulliparous ; seeing that where the special tissues 
are destroyed by inflammation connective tissue takes their place, and 
that few multipara have not had inflammation in the puerperium. 

Cornil also describes, in cases of chronic metritis independent of 
parturition, a new formation of connective tissue between the muscular 
fibres ; in the tissue opaque points are seen, which represent arteries 
undergoing atheromatous degeneration. Their walls are thickened by 
elastic tissue. There is no cicatricial contraction of this connective tissue, 
but a permanent increase in volume. 

It is not necessary here to recapitulate the views advanced under the 
head of pathology in the works of other writers on chronic metritis ; 
these opinions resolve themselves into a discussion of the meaning of 
chronic inflammation, instead of giving pathological data for determining 
the features of the changes in the uterus. The observations of De Sinety, 
Fritsch, and Cornil go to show that the essential change in chronic 
metritis is increase of connective tissue in the uterus. It is, therefore, 
somewhat analogous to that which occurs in fibroid tumour, save that 
the connective tissue formation is diffused through the uterus instead of 
being localised in masses. 

Thus pathology is the key to the physical signs. The uterus is enlarged 
throughout : there is no alteration in its form ; its consistence may be 
either firm or yielding. This equable enlargement of the uterus can be 
made out by careful bimanual examination and confirmed if necessary by 
the use of the sound. 

Diagnosis. The conditions which are most likely to be mistaken for 
chronic metritis are enlargement of the uterus from commencing pregnancy, 
small fibroid tumours, and malignant disease. 

In the case of early pregnancy, amenorrhoea and other symptoms 
should put us on our guard. The cervix is softened, although this 
softening is not so well marked in a multipara where the cervix has been 
previously indurated by chronic inflammation : the bimanual examination 
shows the change in the form of the uterus due to growth of the ovum. 
In chronic metritis there is no alteration in the shape of the uterus, but in 
pregnancy there is a globular enlargement : the vaginal finger recognises 
the anterior wall bulging out from the cervix while the abdominal hand 



2 1 6 SI 'STEM ( )/' G J Wl /.' CflZ <9C F 

feels the rounding out of the fundus, combined with a softness which 
prevents us from distinctly defining its outline. Where resistance of the 
abdominal walls makes the bimanual examination difficult, the finger may 
be able t recognise through the rectum the bulging and softness of the 
posterior uterine wall in contrast with the thin and compressible lowed 
uterine segment Pregnancy can be detected by careful bimanual ex- 
amination as early as the eighth week. Where there is any doubt, by 
waiting a few weeks the diagnosis from chronic metritis becomes easy. 

Small fibroid tumours closely simulate chronic metritis. The symptoms 
are the same; and on bimanual examination it is often extremely difficult 
to distinguish the uneven enlargement of a fibroid from the uniform 
enlargement of chronic metritis. By passing the sound so as to detine 
the course of the uterine canal and the position of the fundus, and then 
making a careful bimanual examination with the sound in position, we 
are able to detect small fibroids of the anterior or posterior wall. Intra- 
uterine fibrous polypi can only be recognised by dilating the cervix. 

While the diagnosis of chronic metritis from small fibroids is often of 
little moment, the diagnosis from early malignant disease is of great 
consequence. The age of the patient, the character of the pain, and the 
nature of the discharge, must all be taken into account. Free bleeding is 
also more suggestive of malignant disease, especially after the menopause 
although I have seen patients with fungous endometritis and chronic 
metritis lose a considerable amount of blood. In doubtful cases the 
cervix should be dilated so as to allow the endometrium to be carefully 
examined with the finger or curette. 

Treatment rests upon pathology : and the view we take of the natim 
and etiology of chronic metritis determines our treatment. The path* 
logical facts, so far as we know them, are that the lesion consists in 
increased formation of connective tissue in the uterus, and that the most 
favourable circumstances for its development occur during the puerperiuzN 

Sir dames Simpson rendered a great service by calling it "sub- 
involution," thus drawing attention to the importance of the puerperal 
state in connection with its etiology. The best treatment is preventive) 
and the removal of whatsoever interferes with the involution of the uterus, 
i> to be put in the forefront in the treatment of chronic metritis. 
Attention to the complete emptying of the uterus after delivery, and e.irly 
removal by curetting of portions retained after abortion, are of the first 
importance. To stimulate the involution of the uterus by douching 

during the puerprriuni, to administer ergot, to Order sufficient rest, and to 

forbid patient.- to return too sunn to their ordinary duties, are measure! 
of preventive treatment which cannot be overrated in importance. 

Fortunately patients with chronic metritis are nol often sterile; and 
it is to the proper management of a subsequent puerperium that we must 
look for the treatment of this, condition. The natural cure that then 
takes place is the only efficient one. 

On passing now from preventive treatment to the general treatment 
of metritis, we shall find that t<. describe the treatment recommended by 






INFLAMMATION OF THE UTERUS 217 

the various writers on this subject would be simply to recapitulate all the 
resources of gynaecological therapeutics. Thus is revealed the importance 
of the lesion, inasmuch as all the means at our command have been 
employed in dealing with it, and with more or less success ; yet variety 
of treatment generally means ignorance of the nature of the disease : as 
our knowledge grows our treatment is simplified. 

The main object of local treatment is to diminish passive congestion 
of the pelvic organs ; and here again the first indication is rest. Con- 
tinuous rest, however, is bad, for it favours congestion ; daily exercise in 
the open air is as necessary as an hour or two of rest on the sofa in the 
middle of the day. Tight garments which compress the abdomen should 
be discarded ; on the other hand, where the abdominal muscles are flabby, 
a well-adjusted abdominal belt often makes the patient more comfortable. 
Lax abdominal muscles are occasionally associated with a relaxed vagina 
and a tendency to prolapse : in such cases a ring pessary to support the 
heavy uterus is useful. 

To stimulate the pelvic circulation the hot douche is invaluable. It 
should be administered freely in the recumbent posture, and, if possible, 
by a trained nurse. It is of little value unless it is done thoroughly. 

Preparations of ergot also lessen uterine congestion. It is in the 
puerperium that we expect the most permanent benefit from this drug, 
on account of its action on the muscular fibres of the uterus, promoting 
their contractions and favouring their involution. Ergot is also useful in 
other circumstances, especially where there is menorrhagia. The liquor 
hydrastis canadensis may be used alternately with ergot, although it is 
not nearly so trustworthy. 

The passive congestion can also be relieved by depletion, although 
this is not used nearly so much now as formerly. The best mode is by 
scarification of the cervix ; but we would limit its use to cases where 
there is marked cervical hypertrophy. A more practical method is the 
abstraction of serum from the tissues by glycerine tampons, which have 
this advantage that they can be applied by a nurse, or even by the 
patient herself. A 10 per cent solution of ichthyol and glycerine I have 
found even more serviceable than simple glycerine. A course of systematic 
douching, combined with ichthyol tampons, in the hands of a trained nurse 
for several weeks is, in my experience, the most satisfactory local treatment 
for chronic metritis. Where the parts are too tender for the regular 
application of ichthyol tampons, ichthyol pessaries are a useful substitute. 

Attention to regular evacuation of the bowels is of the greatest 
consequence not only for lessening pelvic congestion, but also for improving 
assimilation. The benefit derived from certain mineral waters is probably 
due largely to their aperient action as well as to the regular mode of life 
prescribed at the different health resorts. 

When exacerbations occur, showing that the affection has become 
acute for the time, we have recourse to hip-baths or warm fomentations 
with complete rest, and to morphia suppositories to relieve the pain and 
check the diarrhoea which are sometimes present. For the irritability 



218 SYSTEM OF GYNECOLOGY 

of the bladder the hot vaginal douche and the usual sedatives are 
useful. 

Where cervical catarrh or endometritis are the prominent features, 
these must be treated in the first instance ; and the treatment directed to 
them will lessen the chronic metritis. While separating these various 
affections for the purpose of studying them, we must remember the 
intimate relation that exists between them ; so intimate is it, that some 
writers prefer to consider inflammation of the uterus as one affection 
varying in its manifestations according to the tissue involved. I do not 
accept this view, inasmuch as it suggests that there is an entity inflam- 
mation appearing in one tissue after another. Of the close causal con- 
nection, however, between inflammation in one part and another, there 
is no doubt. Chronic metritis is intimately related both to endometritis 
and to cervical catarrh, and can sometimes be treated only through these. 
Thus, after curetting the uterus for endometritis after abortion, or after 
amputating a hypertrophied cervix, we find an enlarged uterus becoming 
smaller, and the general condition of the patient undergoing improvement. 

Attention to the general health is of great importance. The patients 
diet requires careful study, and we must have regard to digestion as well 
as to appetite. While some patients require feeding up, others call for 
a restriction of food. A patient may eat well and largely, and yet 
assimilation may be defective. When this is the case, alcohol is often 
taken, from the idea that it aids digestion instead of retarding it 
Marked improvement in the patient's general condition often follows on 
the prescription of a dietary of light and easily digested food, with 
diminution in the amount of stimulant. Each case must, of course, b 
studied by itself. No rules can be laid down except that we should no 
let the condition of the uterus divert attention from the condition of th 
stomach. 

Change of air, change of scene and occupation, are invaluable. It i 
to their influence as much as to the mineral waters that the benefit fro: 
visiting the various spas is due. It would be out of place here 
enumerate them, and the subject has become of such importance tha 
special works on the subject must be consulted. 

The operative treatment of chronic metritis occupies a very subordinate 
place. Ami r operations on the cervix it has been noted that an enlarged 
uterus diminishes in size: this is specially the case after amputation ol 
the cervix. Although this is a very important result of the operation, the 
value of which I have noted repeatedly, I should hardly describe it as I 
mean iting chronic metritis, as the operation is only called for 

where the hypertrophy of the cervix itself is so great as to justify 
amputation on independent grounds, of the diminution of the uterus 

after Emmet's operation 1 have not been able to satisfy myself, although 

Emmet and other American operators claim this as one of its beneficia 
results. Of the igni-puncture of bhecervii advocated by Prochownik, 
have had no experience. 

A. II. Frbeland Barbour. 



h 



INFLAMMATION OF THE UTERUS 219 



REFERENCES 

1. Atthill. "On Endometritis," Dublin Journal of Medical Science, Jan. 1873. 
2. Bennet, Henry. Practical Treatise on Inflammation, Ulceration, and Induration 
of the Neck of the Uterus. London, 1845. 3. Ibid. A Review of the present State of 
Uterine Pathology, p. 11. Lond. 1856. 4. Brennecke. " Zur Aetiologie der Endo- 
metritis Fungosa," etc., Archiv f. Gyn. Bd. xx. S. 455. 5. BUMM. " Ueber die 
Aufgaben weiterer Forschungen anf dem Gebiete der puerperalen Wundinfection," 
Archiv f. Gyn. xxxiv. S. 325. 6. Cornil. Lecon sur V Anatomic pathologique des 
Metrites, etc. Paris, 1889. 7. Czempin. " Ueber die Beziehung der Uterusschleimhaut 
zu der Erkrankungen der Adnexa," Zeits. f. Gcb. u. Gyn. Bd. xiii. Hft. 2.- 8. Doderlein. 
"Ueber Vorkommen nnd Bedentiing der Micro- organismen in der Lochien gesunder nnd 
kranker Wochnerinnen," Centralb. f Gyn. 1888, No. 23. 9. Duncan, Matthews. 
Diseases of Women. London, 1886. 10. Fischel. " Ein Beitrag zur Histologic der 
Erosienen der Portio Vaginalis Uteri," Archiv f. Gyn. Bd. xv. S. 76. 11. Fritsch. 
Die Lagcvcranderungen und die EntzUndungen der Gebdrmuttcr. Stuttgart, 1885. 12. 
(Bonner. Ueber Micro-organismen im Secret der wieblichen Genitalien ivdhrend der 
Schwangerschaft unci bei puerperalen Erkrankungen, 1887, S. 444. 13. Gooch. On 
some of the most important Diseases peculiar to Women, etc., pp. 156, 157. New Syden- 
ham Society. Lond. 1859. 14. Gottschalk. Centralb. f. Gyn. 1895, No. 27. 15. 
Hart, D. Berry. "The Pathological Classification of Diseases of Women, with a 
Plea for a Revision of Current Views," Eclin. Obstet. Trans, vol. xix. p. 82. 16. 
Heinricius. " Ueber die chronische hyperplasirende Endometritis," Archiv f. Gyn. 
Bd. xxviii. S. 163. 17. Hofmeier. " Folgezustande des chronischen Cervixkatarrhs 
und ihre Behandlung," Zcitsch. f. Gcb. u. Gyn. Bd. iv. S. 331. 18. Immerwahr. 
Centralblatt f. Gyn. 1895, No. 26. 19. Klotz. Gynakologische Studien uber die patho- 
logischcn Verdiulerungen der Portio Vaginalis Uteri. Wien, 1879. 20. Kuestner. 
Beitrdge zur Lehre von der Endometritis. Jena, 1883. 21. Lee. Trans, of the Med.' 
Chir. Soc. vol. xxxiii. p. 270. 22. Menge. Centralb. f. Gyn. 1895, S. 714. 23. 
Olshausen. "Ueber chronische hyperplasirende Endometritis des Corpus Uteri," 
Archiv f. Gynak. Bd. viii. Hft. 1. 24. Palmer. The Inflammatory Affections of the 
Uterus: a System of Gynaecology, by American Authors. Edited by Matthew D. Mann. 
Edin. 1887. 25. Pfannenstiel. " Kasuistische Beitrage zur Aetiologie des Puer- 
peralfiebers," Centralb. f. Gyn. 1888, S. 617. 26. Playfair, W. S. " Intra-uterine 
Medication," British Medical Journal, Dec. 1869, March 1880 ; Lancet, Jan. and Feb. 
1873. 27. Pozzi. Treatise on Gynaecology, Clinical and Operative, The New Syden- 
ham Society Translation, 1892. 28. Priestley, Sir W. 0. Inflammation of the Uterus, 
A System of Medicine, edited.by J. Russell Reynolds, M.D., vol. v. London, 1879. 
29. Ruge. "Zur Aetiologie und Anatomie der Endometritis," Zeits. f. Geb. u. Gyn. Bd. 
v. S. 317. 30. Ruge and Veit. " Zur Pathologie der Vaginalportion," Zeits. f Geb. 
u. Gyn. 1878, Bd. ii. S. 415. 31. Scanzoni. Die chronische Metritis. Wien, 1863. 
32. Schroeder. Charite annalen v. Berlin, 1880, S. 340. 33. Simpson, Sir James. 
Diseases of Women, p. 585. Edin. 1872. 34. Sinclair, Wm. Japp. On Gonorrhaial 
Infection in Women. Lond. 1888. 35. Sinety, De. Manuel de Gyne'cologie, p. 327. 
Paris, 1879. 36. Ibid. Pp. 315, 351. 37. Smith, Tyler. "Observations on the 
supposed Frequency of Ulceration of the Os and Cervix Uteri," Lancet, vol. i. 1850, p. 
474. 38. Spiegelberg. ' ' Die diagnose des ersten Stadium des Carcinoma Colli Uteri, " 
Archiv f. Gyn. iii. S. 233.-39. Thomas. Diseases of Women. Edited by Paul F. 
Munde. London, 1891. 40. West. On the Pathological Lmportance of Ulceration of 
the Os Uteri, Croonian Lectures. London, 1854. 41. Ibid. Diseases of Women. London, 
1856. 42. Winckel. " Bericht liber die Verhandlungen der sechsten Versammlung 
der deutschen Gesellschaft fiir Gynakologie," Centralb. f Gyn. 1895, No. 26.-43. 
Winter. " Die Micro-organismen im Genitalcanal der gesunden Frau," Zcitsch. f. Geb. 
u. Gyn. Bd. xiv. Hft. 2, S. 443.-44. Wyder. Tafeln fiir den gynak. Unterricht. 
Berlin, 1887. 45. Ibid. " Die Mucosa Uteri, bei Myomen," Archiv f. Gyn. xxix. p. 1. 

A. H. F. B. 



220 SYSTEM OF GYNAECOLOGY 



THE NERVOUS SYSTEM IX RELATION TO GYNAECOLOGY 

In the study of gynaecology a cardinal factor, which is often linden 
estimated and even altogether overlooked, is the highly sensitive nervous 
organisation of the female sex. The mobility of the nervous systemj 
especially in the sphere of the emotions, which distinguishes the woman 
from the man, influences the character and progress of all kinds of disease 
in women, but more especially diseases of the reproductive organs. This 
factor calls for very careful consideration. 

Up to the time of puberty there is little if any marked difference 
between the sexes, either in health, in disease, or in any other condition. 
Conventionally they are separated; but boys and girls will play together! 
work together, and associate generally in perfect equality ; the qualities 
which distinguish one sex from the other being either latent or seen but 
obscurely. As soon, however, as the great function of menstruation is 
established, which is henceforth to influence the woman during the whole 
period of her sexual life, the entire system undergoes a marked change : 
the asexual child becomes a woman; her body undergoes characteristic 
modifications fully described in all works on physiology and obstetrics] 
and with them are to be observed the not less important changes in 
character, and in the general development of the nervous system, whic 
distinguish the woman from the girl. It is at this important time tha 
the conduct of the health of the growing girl may influence for g 
or for evil the whole future of the woman. Judiciously managed, sh 
may be so trained that she will be able to meet successfully the straj 
on her nervous system during her future life; the duties of a wil 
and mother, the struggle with domestic anxieties and worries, or th 
Sorrows which arc rarely altogether absent from the Lot of mankind. 
Injudiciously managed, as is the case with so many at this important 
epoch, all those things, which the strong- bodied and healthily-minded 
woiii.ni may bear with no permanent bad results, will tell terribly 
upon her. She will have no stamina, no power of resistance ; and she 

may become the vrretched, broken-down invalid so often met with in the 

Mt day, especially in those ranks of life in which the evil effect! 
of unbalanced culture, and tin- bringing up of girls like hothouse plants, 

frequently seen. 

This being BO, it may be well to preface wh;it has to be said on the 
influence of the nervous BVStem on gym-ecology by a few words on 
the education and training of girls at and after the establishment of 

puberty. This is all the more necessary since the higher education of 

women has taken such enormous strides of late years that it is now 
regularly recognised, and is almosl universal. The "High Schools" foi 

girls are to be met with everywhere, and the still more advanced college: 






THE NERVOUS SYSTEM IN RELATION TO GYNAECOLOGY 221 

of the type of Girton and Newnham are rapidly increasing in number, and 
are full of students. The old-fashioned girls' boarding-schools, with their 
perfunctory education and their elegant accomplishments, are driven out 
of the field ; and a movement which at first was scoffed and jeered at 
has now gained the day. 

Let me say at once that, with limitations which are essential because 
of the difference of sex which cannot be got over, the movement is one 
which seems to me an enormous gain, and of it I write in no spirit 
of opposition. This statement is needful, since there is an unfortunate 
tendency on the part of many mistresses of high schools to listen to the 
warnings of medical men with incredulity, and to accuse them of narrow- 
mindedness and opposition, of which, as a matter of fact, the great 
majority of them are in no way guilty. The recognition of possible evils, 
and due warning against them, are neither the one nor the other. 

The one great fault of those who manage these educational establish- 
ments is that they have too often started on the absolutely untenable 
theory that the sexual factor is of secondary importance ; and that there 
is little if any real distinction between a girl between the ages of 14 
and 20, and a boy of the same age. 

I know of no large school for girls where the absolute distinction 
which exists between boys and girls as regards the dominant menstrual 
function is systematically cared for and attended to. The feeling 
of all school mistresses seems to be antagonistic to such an admission. 
The contention is that there is no real difference between an adolescent 
man and woman ; that what is good for one is good for the other ; that 
the apparent differences are due to the evil customs of the past, which 
have denied to women the ambitions and advantages open to men, and 
that these will disappear when a happier era is inaugurated. If this be 
so, how comes it that while every physician of experience sees many cases 
of anaemia and chlorosis in girls, accompanied by amenorrhoea or menor- 
rhagia, headaches, palpitations, emaciation, and all the familiar accompani- 
ments of break-down, an analogous condition in a school-boy is so rare 
that we may well doubt if it is ever seen at all ? 

These disorders certainly do not necessarily result from the work. 
The successes of women in the schools have been so striking and numerous 
that their capacity for intellectual work cannot be doubted for a moment. 
On the other hand, the male's work is safeguarded by an amount of 
physical exertion in the way of sport which serves to keep him in health. 
It is true that in university colleges and in a few girls' schools attention 
has been paid to this point of late ; but in a perfunctory sort of 
way at the best. There may be a gymnasium, or some form of games ; 
but while at a boy's school cricket and football are compulsory to say 
nothing of the natural disposition of a boy to athletic pursuits at a 
girls' school, exercise is optional ; and if a pupil tending to ill-health 
avoids it, little or no attention is paid to the matter. Within the past 
week as I write, I have been consulted in the cases of two young ladies, 
aged respectively 14 and 16. One was chlorotic, and her menstruation 



222 SYSTEM OF GYNAECOLOGY 

had erased for a year. On taking her time-table at a well-known high 
school, she had 7 -J hours' work, an amount not in itself, perhaps, exces- 
sive in a healthy girl. From 2.30 to 1 there were no lessons, and, if the 
weather permitted, she might if she liked take a walk; but it was not 
insisted upon : and as she was naturally languid and listless, as all such 
girls are. she rarely did so. There was no other opportunity for exercise 
at all. The other girl suffered from pronounced monorrhagia, anaemia, and 
debility. Her time-table was also seven to eight hours, and she "occa- 
sionally took a walk." In neither of these cases had the school authorities 
ever inquired into the state of an all-important bodily function, which 
in both was very markedly aberrant; yet, considering the paramount 
importance of such symptoms of impaired health in girls of these ages. 
it might fairly be held to be part of the duty of those in authority in 
such schools to make the necessary inquiries, and to modify the course of 
study or mode of life accordingly. 

While it is questionable whether in boys' schools the attention given 
to exercise and athletics may not be excessive, in girls' schools it is, on 
the other hand, not nearly sufficient. And yet this is a fault which 
might be very easily remedied. It would not be difficult to make the 
games of girls' schools compulsory as they are in public schools for boys 
there are many games admirably adapted for women, as, for example, 
golf, hockey, lawn tennis, rowing where it is feasible, or, it may be. 
bicycling. Each of these exercises the muscles generally without tin 
spasmodic efforts required in cricket or football, which may be too violent 
for some girls. The result when such games are freely used must b( 
well known to all wdio have a knowledge of what a thoroughly health \ 
English girl may be. No better description of it could be given thai 
that contained in a leading article in the Speaker, on what the writei 
calls " The Lawn Tennis Girl " : 

usible peoph- have long ago agreed to accept this new type el' woman 
hood as being distinctly admirable. She has made her influence felt every 
where, both in real life and in fiction. In real life we meet her in ever} 
country house, in every foreign hotel, and almost in every London square 
And wherever we meet her we come upon an excellenl example of the healthy 
well developed, and unsentimental girl the girl who does uol think 

to devote herself to the study of her own emotions, and who finds i 
active physical exercise an antidote to the morbid fancies which arc too apt 
creep into the mind of the idle and self-indulgenl L3 . 






Thtt IS ;m excellent description of a type with which we are all 
familiar, and. it Ifl DeedleM t say. W6 nil admire. If high-class schools 
could succeed in turning out girls of this kind in larger numbers than a 
nt, they would do more towards lessening the number of neiiroti* 
women the medical profession has t<> deal with than the medical professio: 
can possibly do by any exercise of its own ait. 

It is an obvious corollary from what has been said, that it is the 
bounden duty of mistress, parent) and doctor to insist at once on the 



IS 






THE NERVOUS SYSTEM IN RELATION TO GYNAECOLOGY 223 

cessation of all severe study when any of the physical signs of illness, such 
as it is impossible to mistake, have shown themselves, as, for example, 
chlorosis, amenorrhcea or menorrhagia, wasting, loss of appetite, and the 
like. In my judgment it is not work which hurts, but perseverance in 
work after nature has hung out its danger-signals work in an unhealthy 
body, the attempt, in fact, to fight nature. Then, indeed, the careless, 
prejudiced, and unwise mistress or parent may well find out that the 
results of "over-pressure," the very existence of which so many deny, are 
a stern reality, and may shatter the whole future of the girl. 

In the present article we are not called upon so much to consider 
the subject of the nervous system in general, as its special influence on 
our work as gynaecologists. Still, the important question naturally 
suggests itself, Are morbid nervous states, of the type now generally 
known as neurasthenic, on the increase amongst us 1 Or is their sup- 
posed prevalence due to more careful observation, and the recognition 
of conditions formerly unobserved, and not referred to their proper 
source 1 

To these questions it is not easy to give a satisfactory reply, for no 
definite statistics exist by which they can be settled. It is pretty certain 
that morbid functional neuroses are far more common in the cultured 
and educated classes than in the comparatively uneducated. This 
accounts for the absence of cases of advanced neurasthenia in our hospital 
wards and out-patient clinics in England. Such states are indeed almost 
limited to private practice among the upper classes of society ; and they 
may explain, to a great extent, the comparative neglect of such illnesses, 
all-important : though they be, by our clinical teachers, whose material for 
instruction is chiefly, if not altogether, supplied by hospital patients. 
There can be no doubt that culture and education, and their results in 
increased nerve stimulation, have taken enormous strides within the last 
fifty years. This has been well illustrated by Max Norclau in his 
remarkable work on Degeneration. "In 1840," he says, "there were in 
Europe 3000 kilometres of railway; in 1891 there were 218,000 kilo- 
metres. The number of travellers in 1840 in Germany, France, and 
England amounted to 2 J millions; in 1891 it was 614 millions. In 
Germany every inhabitant received in 1840, 8 letters; in 1888, 200 
letters. In 1840 the post distributed in France 94 millions of letters, 
in England 277 millions; in 1881, 595 and 1299 millions respectively. 
In Germany in 1840, 305 newspapers were published; in 1891, 6800; 
in France 750 and 5782 ; and in England (1846) 551 and 2255. All 
activities, even the simplest, involve an effort of the nervous system 
and a wearing of tissue. In the last fifty years the population of Europe 
has not doubled, whereas the sum of its labours has increased tenfold, 
in parts even fiftyfold. Every civilised man furnishes at the present time 
from five to twenty-five times as much work as was demanded of him 
half a century ago." 

It is reasonable to conclude that nervous breakdown and morbid 
states of the nervous system of all kinds should increase pari passu with 



224 SYSTEM OF GYNECOLOGY 

the increasing developments of nerve work referred to, and such is probabW 
the < 

It is indeed likely that many illnesses, formerly misunderstood and 
neglected as being beyond the power of the practitioner to alleviate, art 
now referred to their proper cause, and correctly diagnosed. 

This is the view taken by Professor Allbutt, who contends that 
neurasthenia is not more. frequent than it has been for some generation! 
-ut that it is better understood. Every one will concede the con 
rectness of his contention that the more a nervous system is worked the 
better it is for its owner, with this reservation, which he fails to insist 
on. that this must be in a healthy body. As has already been pointed out, 
it is not work that seems to hurt, but work plus something else, such as 
physical frailty, worry, anxiety, and the like; and these persisted in in 
spite of warning. It will probably be generally admitted that the conditions 
of modern society are such as to make this kind of addition to work of 
the nervous system increasingly common. It is remarkable, moreover, that 
this type of disease is far more frequently met with in what may be called 
the centres of nervous energy and strain. I have constantly observed that 
such cases are enormously more frequent in such centres of active work 
as Glasgow, Liverpool, Leeds, and Manchester, than in the comparatively 
idle a n< I fashionable members of West End London society. This is 
borne out by the returns of the Registrar-General, which show that in 
the census year the death-rate from nervous diseases in London was 
only about 22 per 10,000 persons living, while it runs tip to 28*6 tor 
Lancashire, 29*5 for the West Hiding, 31*8 in Leeds, 32*8 in Blackburnj 
33*7 in Preston, and 34*5 in Sheffield. 

The reason of this is probably complex. Partly it may be due to 
heredity, since patients from such places are generally the daughters of 
busy, active, pushing business men, who have been the architects of thei 
own fortunes; partly it may be due to the fact that such patients live 
an atmosphere of strain and bustle, and in which vicissitudes of fortuoj 
BTO far from uncommon. 

Similarly these types of diseases are said to be much more frequent 
in such new and very "go ahead " countries as Australia and America : so 
much BO, that neurasthenia has been by some described as the American 
It is often said thai national peculiarities have a great deal to 
do with determining the liability to these illnesses. Thus it is remarkable 
how comparatively rare in this country are the aggravated types of hystero] 
neurosis (such as are apparently common enough in France, if we may 
judge by the writings of Charcot), accompanied by trance, contracture^ 
and the like; and this may justly be attributed to the greater genei 
excitability of French women. This disease is, however, very unlike 
general neurasthenia, which. is certainly something altogether different froi 
the bo called hysterical state, and is by no means necessarily or even mod 
frequently in my experience met with in women of yevy excitably 

temperament ; or at any rate not in idle and fanciful women ; it i 
rather in women of more than average intellect, who have exhaust 



THE NERVOUS SYSTEM JN RELATION TO GYNECOLOGY 225 

I \ " \ " 

their nervous systems by undue strain or anxiety, and who have struggled 

with the early symptoms of " nerve- tire," and refused to take note of the 

signs of impending mischief. 

Having said so much as to prevention, which is so much better than 
cure, as regards the healthy action of the nervous system in women, let 
us now proceed to consider it in its morbid action as we observe it in the 
study of gynaecology. 

Functional neuroses arise easily in women ; they may assume 
tremendous proportions, and their growth may be readily fostered and 
encouraged until, like some noxious weed, they choke all health of body 
and mind. But it is not easy, when once they are fully established, to 
trace them to their source ; and unless we get at all the "fontes et origines 
mali," which may differ much in different cases, any rational system of 
cure is practically impossible. 

Broadly speaking, we may say that there are two classes of eases 
with which we have chiefly to deal : 

1. We may have some definite uterine or pelvic lesion, which may be 
the starting-point of secondary reflex neurotic complications, and in these 
cases attention is mainly to be directed to the cure of the originating 
local complaint. 

2. We may have a condition in which some local lesion, in itself of 
I minor importance, may be found, or has been found. This, indeed, may 

even be only a secondary result of the general neurotic condition which is 
the dominant factor in the patient's health ; and the treatment of it may 
not only be inadmissible but, injudiciously carried out, may be intensely 
prejudicial, and very gravely increase the general ill health from which 
the patient suffers. As a further development of this, we may often meet 
with cases in which some definite existing local lesion very probably 
started the illness, but which has in time become so over-shadowed by its 
own secondary consequences that the judicious practitioner will minimise 
any treatment of it as much as possible. 

The importance of the first class of case is certainly very great, and 
deserves the most careful study on the part of the gynaecologist. 

There can be little doubt that secondary functional disturbance of 
remote organs very commonly originates in some definite morbid 
local condition of the uterus or ovaries, the irritation being conducted 
along the ganglionic and spinal nervous system. Every practitioner is 
familiar with the influence of the reproductive system in producing such 
a disturbance of distant organs as the neuroses of pregnancy ; not only 
the commonly observed morning sickness, which may run into uncontrol- 
lable and even fatal vomiting, but other neuroses of an obviously similar 
type, but less commonly recognised, as, for example, excessive salivation, 
cardiac disturbances, the so-called " lypothymia," or partial trance, and 
such well-marked mental conditions as extreme depression of spirits or 
insanity. 

It is familiar to the obstetrician that in many of these cases all general 
treatment fails, while local treatment, such as the application of carbolic 

Q 



SYSTEM OF GYNAECOLOGY 



acid or iodine to an inflamed or abraded cervix, or the lifting of a 
retroverted gravid uterus out of the pelvic cavity, may give relict' at 
once. 

That similar local irritations in the non-pregnant woman may set up 
marked distal disturbances is a fact which the general physician is very 
apt to overlook ; hence many a sufferer has been uselessly treated by 
incessant (bugging, whose symptoms would at once have disappeared if 
the coexisting uterine or ovarian source of irritation had been detected 
and relieved. 

Of course it is imperative that care should be taken not to overlook 
any unsuspected source of illness of this kind. Should some obvious 
lesion be found such, for example, as a hyperplastic uterus, a badly 
lacerated and everted cervix, profuse uterine or cervical catarrh, swollen 
and tender ovaries and tubes, well-marked flexion or version then no 
judicious practitioner would fail to remedy it by appropriate treatment, 
the details of which are fully considered in the several articles of this 
work. Above all things, however, it is essential that there should be 
no mistake about this that the lesion we are treating should be real, de- 
cided, and unmistakable, and that the local treatment should be judicious 
and minimised as much as possible. We shall presently have to dwell 
more particularly on the evil effects which in nervous and emotional 
women are apt to follow injudicious and over-frequently repeated local 
treatment. 

There are two possible errors which may be made in connection with 
this matter. One is that a distinct local lesion, which is the originating 
cause of a secondary nervous disturbance, may be overlooked and not 
treated at all; and thus the nervous condition may be maintained. The 
other is that exaggerated importance may be attached to some local 
lesion which is detected; that the error of diagnosis maybe accompanies 
by an error of judgment, and that much needless local treatment oi 
what may be called the "tinkering" kind is adopted : thus the coexisting 
neurosis is aggravated. Both mistakes are serious ones; but 1 am conj 
strained to say and the more I see of neurotic women the more convinced 
I am that the latter is much the more serious and common of the two. 
Nothing can be more deplorably bad for a nervous, emotional woman, 
whose genera] health is at a low ebb, than to have her attention con 
stantly directed to her reproductive organs by vaginal examinations 
repeated two or three times a week, pessaries constantly introduced for 
-light displacement," the cervix frequently cauterised, or the endoj 
metrium curetted, and the like; and yet these are things one incessantly 
sees in case* in which, on examination, ao definite reason for such inter- 
ference is found to exist. No doubt it it generally done in good faith ; 
but the results are often disastrous, and I feel it to be my duty to insist 
v.-rv emphatically OH the necessity of carefulness in this direction. 

These remarks apply more especially to the second class of cast; 

referred to, in which we are justified iii concluding that the local affectioi 
was either .f secondary importance from the beginning, or has become s( 



THE NERVOUS SYSTEM IN RELATION TO GYNECOLOGY 227 

in consequence of long-existing bad bodily health and the supervention 
of a morbid neurotic condition. 

It is scarcely consistent with the limits of this paper, which specially 
contemplates the discussion of such neurotic complications as come under 
our observations as gynaecologists, to enter into a detailed description of 
the conditions known of late years as "Neurasthenic"; these will 
naturally be more fully discussed under this head. Indeed they are 
protean in character, and in no two cases are the symptoms identical. 
This one might expect, as the main element in the morbid state we have 
to deal with is the unhealthy action of a subtle and invisible function, 
quite beyond those ready means of examination which we can apply to 
the heart, lungs, or digestive organs, but which influences any or all of them 
nevertheless. Hence the risk of mistaking disturbed action of various 
parts and viscera as, for example, insomnia, headache, spine-ache, pal- 
pitations, nausea, loss of appetite, and a host of other conditions for 
diseased states of parts which, in themselves, may well be substantially 
healthy. Exactly the same error may be, and often is made with 
reference to apparent disorders of the reproductive system ; in these we 
may find cessation or disorder of menstruation, some increase of dis- 
charges or secretions, uterine and ovarian pains and aches of various 
kinds, but yet no structural lesion of any real moment. 

One permanent characteristic, however, is to be found in all cases of 
this sort which merits the most careful attention, and is constantly over- 
looked ; this is defective general nutrition, involving as this, of course, 
does, badly nourished and therefore imperfectly acting nerve centres, 
and, as a consequence, defective action of all the viscera supplied and 
controlled by them. 

This defect is, indeed, the keynote to the treatment of a large number 
of cases of ill health in women, which are often associated with morbid 
conditions referable to the reproductive organs, but are quite incurable until 
the general nutrition and health of the patient is placed on a satisfactory 
basis. A woman has some headache, or other disturbance, and for this she 
is perhaps advised to rest. Gradually all healthy habits of body are 
dropped, one by one, until she hardly leaves her sofa, and takes no kind 
of exercise. As a consequence the appetite fails, less and less food is 
taken, and progressive emaciation and great general debility supervene, 
with all the well-known attendant symptoms of chronic invalidism. Or 
it may be that another type of defective nutrition shows itself, attended 
with a deposit of unwholesome flabby fat in the subcutaneous tissues ; 
and the patient, while weak, a poor eater, invalided and sofa-ridden, 
becomes overburdened with unwholesome and useless fat. 

These are precisely the conditions in which emotional disturbances 
of the worst kind appear. Some injudicious relative or friend is 
rarely lacking in such a case who adds fuel to the fire by constant 
unwise nursing and unduly sympathetic attendance. In many instances, 
it is to be feared, the medical man, at his wits' end to do something, 
makes matters worse by constant visiting ; endless talks as to symptoms ; 



228 SYSTEM OF GYN.-ECOLOGY 

and incessant prescriptions in which the inevitable bromide, and similar 
harmful drugs, play a prominent part. It is a happy thing for his 
patient if amongst them narcotics have not found a place; too often 
chloral, sulphonal, morphia, and the like have been resorted to, until 
at last the patient may have insensibly sunk into the deplorable habitJ 
of a chloral or morphia taker. 

This description, of course, refers to the case of the confirmed 
neurasthenic invalid so often to be seen. But short of so advanced a 
type of neurotic illness the gynaecologist cannot fail to call to mind 
numberless women on the down grade, who were drifting into some such 
state of chronic ill health, the physical path to which is defective 
nutrition, and who could almost certainly have been arrested in their 
downward course if the real cause of their illness had been thoroughly 
appreciated and acted upon. 

It follows from what has been said that, in the large majority of 
neurotic cases coming under our observation in gynecologic practice, the 
main object of treatment should be to improve the general nutrition, and 
so to aim at better general health. How is this difficult task to be 
accomplished ? It is far easier to point out how it is not to be done ; and, 
unluckily, the path which certainly does not lead to success is the one 
most generally followed. It is certainly useless in a confirmed case of 
this kind to attempt to cure the patient by way of the chemist's shop. 
Gallons of physic have generally been swallowed by her already, and 
the judicious practitioner will not add to the number of useless or 
possibly harmful prescriptions which a patient of this kind invariably has 
to show. If the case be a comparatively mild one, a little common sense, 
a quality not too generally found in the regulation of the treatment of 
neurotics, may be all that is required. An endeavour to ascertain and 
remove any more immediate causes, if such exist, whether physical or 
mental; the insistence on a proper amount and quality of easily assimilate! 
food; the removal from unwholesome domestic Burroundings, which may 
be brought about by change of air and scene, these, or similar prescrip- 
tions, which vary in accordance with the peculiarities of each individual 
case, may suffice to restore the patient to health, and give hack to her the 
efficient control of her nervous system which she had lost. 

In the more severe cases, in which the symptoms of neurasthenia are 
well marked and of long standing, something more definite is required tl 
give the patient a fair chance of recovery. Here that combined attae] 
on defective nutrition known of late years as the "rest cure," or "The 
Weir Mitchell" treatment (so called after the well-known American 
physician to whom we owe its introduction as a systematic method of 
tment), may, in properly selected cases, prove an invaluable resource. 

Suffice it to Bay that) properly and judiciously carried OUt in well-selected 

cases, its result- are most striking and satisfactory, and hundreds <>f 
women are now going about well and strong who but for this would -till 
be tin- wretched invalids they formerly were. 

As the present writer was mainly instrumental in introducing thi 



THE NERVOUS SYSTEM IN RELATION TO GYNAECOLOGY 229 

method of treatment into Europe, he may perhaps be regarded as unduly 
prejudiced in its favour. He ventures, therefore, to quote the estimate 
formed of it by the late lamented American gynecologist, Dr. Goodell, 
Avhich was probably one of the very last things he ever wrote : 

One of the grandest discoveries in the treatment of the nervous phase of 
women's diseases is the rest cure, for which we owe a large debt of gratitude to 
Weir Mitchell. Formerly there were in every city, town and hamlet, sofa- 
ridden and bed-ridden women who were doomed to helpless invalidism under 
the label of " weak spine," of " spinal irritation," of " irritable womb," or of 
"chronic ovaritis." So countless were these cases, in the young and in the old, 
in the married and in the single, in the fruitful and in the barren, so much 
misery was entailed on the sufferer and on her kin, so many homes were 
blighted, so powerless was the medical profession to give help, that the pathetic 
lament of the Hebrew prophet could not have been better applied than to this 
great and wide-spreading scourge, " Is there no balm in Gilead ? Is there no 
physician there ? Why then is not the health of the daughter of my people 
recovered ? " Yet now I think myself safe in the assertion that very few of these 
cases are incurable, and that no other discovery in medicine has raised so many 
women from their beds and restored them to lives of active usefulness. It is 
the miracle of modern therapeutics. 

It is, however, essential that if treatment of this kind is to prove 
useful it should be adopted in properly chosen cases only, and that when 
it is attempted it should be done thoroughly and well. Constant failures 
arise from neglect of one or other of these points, especially of the latter. 
There is much that is disagreeable about this treatment, at least in 
appearance ; especially the removal of the patient from her usual domestic 
surroundings, and her seclusion in a properly managed medical home. 
This is naturally disliked, and it leads to much expense. Pressure is, 
therefore, put on the medical man, to which he is often weak enough to 
yield, to treat the case in what is called " a modified way," by " trying a 
little massage " (this being one of the remedial agents) at the patient's 
own home, or in some other way to try to play " Hamlet " with the part 
of Hamlet left out. The inevitable consequence is failure and disappoint- 
ment, a really good and valuable method of treatment is discredited, 
and the patient's state is made worse rather than better. I have seen so 
much of this that I cannot too urgently insist on the necessity of 
thoroughness in any attempt to carry out this means of cure. 

An interesting question in relation to diseases of the nervous system 
in gynaecology arises in connection with insanity. Some have held 
that insanity may actually depend on morbid conditions of the repro- 
ductive organs ; and it has even been suggested that for the cure of 
certain forms of insanity associated with pronounced sexual aberrations 
such as excessive masturbation and erotic manifestations -the uterine 
appendages should be removed by operation. Of this alleged connec- 
tion I have never been able to find any reliable evidence at all. Of 
course insane women are liable to uterine disease as sane women are ; 



2 30 S YSTEM OF G YN. E CO LOGY 

and when they have marked disease of the reproductive organs, of what- 
ever type, it should be appropriately treated, whatever the condition of 
the mental functions. Inasmuch as the medical staff of asylums are 
rarely expert in gynaecology, it is likely that where so many women art 
congregated together there may be found a considerable amount of 
undetected pelvic disease which should be made the subject of treat- 
ment. 

In a paper on this subject Brown contends that fully 25 per 
cent of the female patients in asylums in the United States suffer from 
some form of pelvic disease. If this be true, it follows that alienist 
physicians should not neglect the study of gynaecology more than anjj 
other department of medicine. But while this may be admitted it does 
not follow that the one has any direct connection with the other. In 
happily it has been very common to revert in a haphazard way to 
operative interference, which, in my opinion, is unscientific, unnecessary] 
and often hurtful. The excessive masturbation and various erotic 
manifestations so common in certain types of insanity are, it cannot be 
reasonably doubted, phenomena of central, and not of peripheral origin : to 
remove the ovaries or tubes by way of curing them seems to be altogethel 
unreasonable. It may be laid down as an axiom, which is consistent with 
the most generally received opinion of the profession, that no operation 
of this kind is permissible in an insane patient unless some structural 
lesion exist which would call for or justify the operation were the patient 
sane. Of the uselessness of such a procedure a marked example is given 
in Case IV. of Brown's paper above referred to. 

There are other forms of neurotic disease, however, in which this 
operation has also been recommended and performed, in which, in nn 
opinion, it is still less admissible. Of late years, unhappily, it has beei 
a not uncommon practice to remove the uterine appendages in variou 
intractable forms of functional neurosis, not because they showed anj 
kind of Structural disease, but because the neurotic condition had pr< 
viously resisted all ordinary means of treatment. In a paper on thi> 
subject, published in the thirty-third volume of the Obstetrical Tram 
tions, I have fully discussed this procedure, and have brought forward 
evidence to show its utter uselessness. It is impossible to speak toi 
emphatically in condemnation of a rash and irretrievable experiment oj 
this kind. 

The only class of case iii which such operations have any reasonable 
claim for consideration are those of hystero-epilepsy, or other very severe 

form- of QervOUS disease, which are regularly aggravated at the mens- 
trual periods, and may therefore be assumed to be in some way connect* 
with that function. It does not follow that because sndi cases are worst 
during menst mat ion. when all the bodily functions are naturally in 

state of unstable equilibrium, that they depend upon it. Still tie 
supposition that the artificial production of the menopause should havj 
a curative effeci in such oases is a sufficiently reasonable hypothesis, an] 
it is not surprising that the operation should have been often perform* 



STERILITY 231 

in such eases. The records, however, are not satisfactory. Of the cases 
of this kind which have been published of late years, something like 50 
per cent were complete failures ; and even in a well-marked case the 
outcome of experience tends to show that operative interference should 
not be resorted to unless distinct evidence of coincident structural mis- 
chief exist. 

W. S. Playfair. 



REFERENCES 

1. Allbutt, Prof. Clifford. "The Nervous Diseases of Modern Life," Contemporary 
fieview, Feb. 1895. 2. Baker, Fordyce. " Uterine Diseases as a Cause of Insanity." 
Journal <>f flu: Gynaecological Society of Boston, Jan. 1873. 3. Boldt, H. I. "Cardiac 
Neurosis in connection with Ovarian and Uterine Disease,'' American Journal of Ob- 
stetrics, vol. xix. 4. Brown, John Young. "Pelvic Disease in its Relationship to 
Insanity in Women," American Journal of Obstetrics, vol. xxx. 5. Goodell, Wm. 
"The abuse of Uterine Treatment through mistaken Diagnosis, "' The Medical News, 
Dec. 7th, 1889; Clinical Gynaecology by American Authors, vol. i. 6. Mtjret. " Le 
role du systeme nerveux dans les affections gynecologiques, " Tevue rnMicale, de la Suisse, 
June 1884. 7. Nordau, Max. Degeneration (English translation), William Heine- 
mann, 1895. 8. Ohr, C. H. " Genital Reflex Neurosis in Females," American Journal 
of Obstetrics, vol. xvi. 9. Playfair, W. S. " On the removal of the Uterine Ap- 
pendages in cases of Functional Neuroses," Obstetrical Transactions, vol. xxxiii. 10. 
Bemon, Felix. "The Sensory Throat Neurosis of the Climacteric Period," British 
Medical Journal, Jan. 5th, 1895. 11. Skene. "Gynecology as related to Insanity in 
Women," Diseases of Women, p. 929 et seq. 12. Store. The Cowrae and Treatment of 
Reflex Insanity in Women. 13. "The New Woman and the Old," The Speaker, Jan. 
12". 1895. 

W. S. P. 



STERILITY 



Sterility implies that condition in a woman in consequence of which 
she either does not conceive, or if she conceive is unable to bear a 
living and viable child. 

Sterility depending on generative defects in the male will not be 
considered here, although unquestionably a certain percentage of cases 
of sterility in the woman (variously estimated by writers on the subject 
as from 7 to 15 per cent) depends upon some such defect in the 
husband. The cognate subject of the sterility of a woman with one 
husband but not with another, when in neither there appears to be 
any physical defect, will be considered under the heading of relative 
sterility. To apply the name sterility to the incapacity to conceive 
which exists before puberty and after the menopause appears scarcely 
appropriate. Sterility under these circumstances is strictly physiological ; 
it is not governed by the commencement or decline of menstruation, 
except in so far as these epochs coincide with the commencement and 
cessation of ovulation. Provided ovulation continue, fertility may pre- 



SYSTEM OF GYNECOLOGY 



cede menstruation, exist during intervals of its suppression, and beyond 
the menopause. Hut. although the capacity to conceive may continue 

until menstruation ceases and even for some time afterwards, in the 
majority of women child-bearing terminates some six or seven years 
prior to that occurrence. The small minority in whom conception occurs 
not only up to the usual time of the menopause, but also beyond it, is 
largely constituted of healthy women who have married late in life, and 
in whom there may, consequently, be an unexpended reserve of fertility. 

The statistics given by writers of the proportion of sterile to prolific 
marriages vary much; and this is scarcely surprising considering the 
wide range of conditions under which marriages take place. Such con- 
ditions include the age at marriage, individual health, social habits, and 
the customs peculiar to countries or districts. But probably the con- 
clusion of Matthews Duncan, whose works on this subject are classical 
is fairly near the mark when he estimates that in Great Britain the propor- 
tion of one in ten represents the number of sterile marriages; that the 
most nsual time after marriage for the first birth to occur is from twelve 
r. fifteen months, but that three years may be allowed to elapse before 
any strong presumption of sterility need be entertained: lastly, he con 
aiders the most fertile period of a woman's life to extend over twelve years 
from about twenty-six to about thirty-eight. 

Classification of the Conditions leading to Sterility. The most 
usual classification is into absolute and relative; another is into con- 
genital and acquired; another into permanent and temporary. Di 
M. Duncan's division is threefold. His first class he terms the class <f 
absolute sterility ; in it he includes all cases "in which there is no child, 
no miscarriage, no abortion, however early"; this class, he adds, is some- 
times called congenital. His second class he defines as including rases 
of "sterility not absolute"; by which he implies the failure to produci 
a viable child while there maybe evidence of conception. His third class 
he calls relative or acquired sterility, and in it he includes cases "where a 
woman produces one or even several living children, but in number not 
according t<> her conditions of age and length of married life." The term 
relative sterility, however, is more frequently used to indicate the sterility 

which a woman manifests with one husband, but not with another, and in 
which, therefore, tin- fault may be on the husband's side; or, on the other 
hand, she may have been suffering from some defect of the generative 

hi during the time of her earlier marriage which ceases to be potent 
before her second. The term relative sterility would appear to be more 
appropriate to these cases than bo those to which Dr. Duncan applies it 
as tie- equivalent of comparative sterility. I venture to suggest the 

ification oi i sterility into absolute and contingent, and eadj 

may be subdivided into congenital and acquired. 

Cases of absolute sterility will include all those in which, from organic 
defect of the organs concerned in the formation, transmission to the uterus] 
or nidation of the ova, or in the access of the Bpermatic fluid, conception is 
rendered Impossible. The congenital subclass of this division will includi 






STERILITY 233 

cases of absence of the ovaries, or of the tubes ; of absence or non-develop- 
ment of the uterus, and of atresia of the vagina in which operation is 
impracticable. 

In the acquired subclass will come cases of a similar deficiency in the 
generative apparatus, but due to non- congenital causes, or to surgical 
operation. The cases of contingent sterility are much more numerous, and 
may also be divided into congenital and acquired. The congenital subclass 
will include cases of defective or delayed ovulation associated with im- 
maturity of the ovaries ; of certain cases of imperfect patency of the 
tubes ; of certain cases of malformation of the uterus, and especially of 
the cervix, and of such vaginal obstructions as are capable of removal. 
The subclass of cases of acquired origin will include cases where patho- 
logical but remediable conditions of the ovaries, tubes, uterus, or vagina, 
inimical to conception, have occurred subsequently to birth. In this 
class would also come those cases of so-called relative sterility, to which 
reference has been made, in which a woman does not conceive with one 
husband, but does with another. An extreme case of relative sterility 
would seem to be one in which the generative organs of both husband 
and wife are normal. But obviously, after all, the explanation of relative 
sterility may simply be that some abnormal and unrecognised condition 
of ovary, tube, endometrium, or vagina, present during one marriage, 
may have been cured, either by nature or art, before the second is 
contracted. Considering the causes of sterility seriatim we have then 

I. Cases of absolute sterility in which there is (A) congenital 
organic defect of an irremediable character. 

1. In Connection with the Ovaries. The ovaries are very rarely absent 
altogether. In such cases the uterus is generally imperfectty developed 
also, and there is complete amenorrhcea. To attain a certain physical 
diagnosis of this condition is scarcely possible ; but an approximative 
diagnosis may be made if with an ill -developed uterus we find the 
association of complete amenorrhcea, the absence of any indication of 
periodic congestion, and of the special changes characteristic of puberty. 

2. Cases of absence of the tabes are occasionally recorded ; but they are 
generally associated with some congenital malformation of the uterus, as 
might be anticipated from their common origin in the ducts of Muller. 
Sometimes one tube with its cornu of the uterus is absent ; sometimes 
both. Sometimes one or both may be represented by a solid cord-like 
structure. Sometimes with a normal uterus the tube is represented only 
by a short projection from the uterine angle, and in this case the supposi- 
tion is that its condition is due to some necrotic torsion in early or intra- 
uterine life. The diagnosis of these malformations is probably beyond 
our powers ; but if both tubes be affected an absolute sterility must result. 

3. Complete absence of the uterus is also a rare condition, but cases 
where the uterus is only rudimentary have frequently been recorded. In 
these cases it is generally the amenorrhcea which calls attention to the 
state of the pelvic organs ; and on examination by the vagina, either no 
indication of uterus is felt at its upper end, or there may only be a 



234 S YS TEM OF G YN. K COL OGY 

small projection representing the cervix: on further examination by tin* 
bimanual method and by the rectum the uterus may be found only as a 

small body of a size varying from a ridge of the diameter of a crow-quill 
to an organ no1 lsfger than a bean. In these eases sterility is of coursj 
absolute. 

I. Congenital atresia of the vagina leading to absolute sterility is not 
common ; but many cases are on record where, on account of the shorn 
of the pocket which represents the vagina, and of the anatomical 
difficulties in the way of dissection associated with the position of the 
bladder and rectum, it is not possible to open it up so as to reach the 
uterus. Not infrequently in these cases of abortive vagina rectal examina- 
tion will detect also a very rudimentary uterus. 

B. In the second class of cases of absolute sterility, which includes 
those of acquired origin, will come instances of somewhat similar organic 
defects, but due to pathological causes which occurred after birth. 
ensued upon surgical operation. 

I. As regards tJie Ovaries. The destruction of ovarian tissue by 
inflammatory, neoplastic, or atrophic disease may be so complete as to be 
incompatible with ovulation. It is presumed, of course, in these i 
that both ovaries are affected, and to a sufficient extent to destroy their 
capacity to ovulate. This result is not very uncommon in council ion 
with pelvic peritonitis of septic or gonorrhoea! origin, or in connection with 
progressive ovarian atrophy; it is less common in connection with non- 
septic ovaritis, or with neoplasms such as malignant, fibroid, or cystic 
growths. Occasionally the ovaries are so completely covered with peri- 
tonitic or embedded in parametric exudations that, even if ovulation 
could proceed, the ova could not escape from the follicles and reach the 
tubes. In this class would also come the results of such operations as 
double ovariotomy for ovarian cystoma, and removal of the appendices 
either for disease in themselves, or in certain cases of uterine fibroid. 

_'. /// con nect ion with the tubes occur such cases as their complete 
obstruction by inflammatory pelvic exudations, or by the pressure of 
pelvic tumours, or by adhesive salpingitis or tubal tuberculosis. 

.". The removal of the uterus, either from fibroid or malignant dise 
OT by PoTTO'l Operation, would obviously be a cause of absolute acquired 

sterility. 

4. A similar result will follow complete and incurable otr<'.<i,i of tlu 

vagina by cicatricial obliteration, whether arising from sloughing due to a 
protracted labour, in connection with an exanthem, or from local injury 

of an accidental or criminal character. 

II. CASKS <>r CONTINGENT sterility are also divisible into (A) eon< 
genital and (B) acquired. 

A. Into the congenital class would ootne 

1. Cases where the ovaries are present and free from organic dis< 
but immature; and where ovulation is either unduly delayed, or the 
ova secreted are imperfect. With this are often associated impaired 
general health and an imperfect development of the other generative 



STERILITY 235 



organs. The uterus is small, often anteflexed, the external genitals are 
of a more or less infantile character, the general signs of puberty are 
either absent or but feebly developed, and menstruation either does not 
take place at all, or occurs irregularly and scantily, and accompanied by 
much ovarian pain. But, contrary to what occurs in the corresponding- 
class under the heading Absolute Sterility, in these cases, with the 
improvement of the general health an improvement may also occur both 
in the structure and functions of the ovaries ; and with the establish- 
ment of normal ovulation pregnancy may ensue. The cases of this kind 
which come under notice on account of sterility are few, the state of 
health which accompanies the sterility being often also a bar to marriage ; 
but occasionally such cases come for advice and treatment, and in some, 
improvement of the local and general conditions has been followed by 
pregnancy. In some, indeed, marriage has proved an efficient stimulant 
to an improved condition of ovaries ; menstruation and ovulation have 
become healthily established, and pregnancy has followed. In a certain 
number of women, however, there is also irregular, often painful, and 
sometimes delayed menstruation ; but instead of being associated with a 
general appearance of immaturity, and more or less ill health, the physical 
development and the general health may both be good, and the irregular 
menstruation and associated dysmenorrhoea be their only troubles. In 
many of these cases some affection of the uterus, such as a displacement 
or an endometritis, may be found on examination ; but, whether this be so 
or not, the delayed and irregular menstruation need of itself be no bar 
to marriage : marriage indeed, as in the previous case, is often followed 
by an improvement in the functions of the ovaries and occasionally by 
pregnancy. 

2. Sterility depending upon some congenital interference of a temporary 
kind with the patency of the tubes is probably uncommon ; but in some cases 
cysts are found in the neighbourhood of the fimbriated ends of the tubes 
which might subsequently rupture and disappear, but which, if they 
remained, would more or less interfere with the entrance of ova. Or the 
occurrence of some adhesion in the course of the tubes, due to a transient 
salpingitis which had disappeared with the progress of development, or to 
some torsion of the tube on its axis rectified by casual changes in the 
relative position of the pelvic viscera, may likewise be causes of con- 
tingent sterility. Diagnosis of these conditions would rarely be practic- 
able, and they lie beyond the range of any treatment except perhaps 
an empirical catheterisation of the tubes, a proceeding which can hardly 
yet be spoken of as always safe or even possible. 

3. Sterility depending upon congenital malformations of the uterus 
capable of treatment is chiefly associated with those which involve the 
cervix. One such malformation is an undue elongation of the cervix, 
which is often of a conical outline, and projects into the vagina to the 
extent of an inch and a half or even two inches. The os uteri in these 
cases is generally minute in size, round or " pin-hole " in form, and is 
often placed, not centrally at the end of the cervix, but rather on one 



236 SYSTEM OF GYNECOLOGY 

side. In ;i less frequent number of cases a minute os uteri is found 
associated with a short and rounded cervix. There are also congenital 
cases of greater or less stenosis of the cervical canal without any very 
marked malformation of the cervix, the stenosis being more frequently 
at the site of the outer os, less frequently at the inner os ; in this latter 
case it is generally associated with anteflexion of the uterus. Occasionally 
there is narrowing both at the external and internal os, the intermediate 
canal being of average size; and sometimes, but most rarely of all, 
there is a distinct constriction in the canal itself. The relation of stenoskj 
of the cervix to the production of dysmenorrhea is a much-debated sub- 
ject, and need not be entered upon here ; but of its influence as a factor 
in the production of sterility I have no doubt. The accumulated clinical 
evidence in favour of the view that the removal of stenosis facilitates 
imp] c-nation is, I believe, decisive. I have known some cases in which 
a single dilatation after an unfruitful marriage of many years' duration, 
varying from five to fifteen, has been followed by pregnancy; and a con- 
siderable number in which a series of dilatations, as may be required by 
the conditions of the case, has been followed by a similar result. Such 
cases are also recorded by Duncan. Yet, of course, this result may not 
follow even after complete dilatation has been accomplished ; the strong 
probability in such cases is that some other pathological factor, besides the 
cervical stenosis, is present. But even if this be so, the removal of the 
stenosis is a useful as well as a logical proceeding, as it assists in the 
cure of any other conditions present which may be antagonistic to im- 
pregnation. For instance, the cervical stenosis may have led to dysmenor- 
rhea, or it maybe associated sequentially with some congestive condition 
of uterus, tube, or ovary, either of which disorder in its turn may be a 
cause of sterility. With the relief of the dysmenorrhea this sequence of 
congestions may subside, and as a result the influences hostile to concep- 
tion may disappear. On the other hand, the endometritis or salpingitis or 
ovaritis, of which the narrowed cervical canal was the primary cause, 
may have been of such long Btanding, and accompanied by so much tissua 
change, that even after the cervical canal has become normal, it may 
be difficult or impossible to bring about a sufficiently healthy condition 
in the uterus or in the ovaries to permit conception. 

A hypertrophic elongation of the cervix is an occasional congenital 
defed ; and, as it simulates prolapsus uteri, it is sometimes called infra- 
vagina] prolapse. in these rases the cervix is sometimes so unduly 

elongated ;i- \>> reach down to, or even to pass beyond the vaginal orilire, 
and thus to give rise at first sight to tin' impression that the case is one 
of ordinary prolapse. Sometimes this condition has not been noticed 
before marriage, at it causes little or no inconvenience, unless it be 
sense of bearing down, and some dysmenorrhea. But after marriage it 
becomes a source of marital inconvenience, and the surface become! 
inflamed and possibly excoriated That it is not an ordinary prolapss 
is proved by the OSS of the sound ; and by the normal position of the 
body of the uterus in tin- pelvis, as shown by bimanual examination. Its 



STERILITY 



237 



removal by amputation removes both the dyspareunia and a cause of 
probable sterility. Fertilisation in these cases is perhaps not impossible, 
but I have seen several such cases, and in none did impregnation take 
place prior to the removal of the elongated cervix. 

4. Cases of contingent sterility of congenital origin include mal- 
formations of the vagina and of its vulval entrance. 

An imperforate hymen is at once a barrier to intercourse and to 
conception. A cribriform hymen, or an unusually thickened annular or 
crescentic hymen, may also render intercourse difficult, and so may im- 
pede the occurrence of conception ; but it would not necessarily lead to 
sterility. Occasionally, also, we meet with cases in which a transverse 
septum exists a third or a half way up the vaginal canal. Such a 
septum, if imperforate, might permit intercourse, but would obviously 
prevent conception ; yet if an opening were present in it, permitting 
the exit of the menstrual secretion, conception would be at least possible, 
although if the opening Avere a minute one it would not be probable. 
These diaphragms probably arise from some limited adhesive inflammation 
of the vaginal walls in very early life ; and there are grounds for sup- 
posing that imperforate hymen itself is due to adhesive inflammation, 
in early or even in intra-uterine life, uniting the free edges of an annular 
hymen. In both -cases the division of the hymen or the division of 
the septum is necessary. Occasionally the vagina terminates in a 
ml-de-sac, and between this and the uterus a greater or less thickness 
of cellular tissue is interposed, with the bladder in front and the rectum 
behind. In many of these cases, as stated under the heading of 
absolute congenital sterility, to dissect through this tissue to the uterus 
has, for the reasons there given, proved difficult or impossible : in some 
cases, however, the dissection has been attempted with success ; and 
if the uterus, tubes, and ovaries be healthy, conception becomes possible. 
Sometimes that rare condition, a double vagina, may be a cause of 
sterility. If associated with a double uterus and bifid cervix, with one 
cervix projecting into each vagina, the sterility may arise rather from 
the imperfect character of the uterus and of the cervix, the two halves of 
which are often abnormally developed, than from the divided vagina 
being a barrier to intercourse. One cervix may be quite short and 
rudimentary, while the other is of average size ; and in one or both the 
os is apt to be situated laterally, and to be very minute or of an 
irregular outline. 

Cases are also met with in which the two vaginas are so narrow as 
to make sterility probable, by preventing effective intercourse ; a difficulty 
to be removed by the division of the intervening septum so as to throw 
the two into one. In such a case, if the uterus and organs beyond be 
normal, there is no further barrier to conception ; but more commonly 
the uterus shares in the malformation. Occasionally one vagina is of 
average size and the other much smaller. Vaginismus may possibly be 
a congenital cause of contingent sterility ; but as it is more frequently 
of acquired origin it will be considered further on. 



SYSTEM OF GYNECOLOGY 

B. Acquired Contingent Sterility. 

1. From Abnormal Conditions of the Ovaries. The ovaries maybe so 
damaged by acute or chronic ovaritis that for a time the Graafian follicles 
do not mature luvmallv, and ovulation is either performed imperfectly 
or not at all. Bat in the cases belonging to this class the damage is 
not irretrievable. With a return to a healthy condition of the ovary, its 
function is restored and the possibility of conception returns. Subacute 
ovaritis may arise from the lesser attacks of septic or gonorrhceal in- 
fection, from limited congestive haemorrhage into the structure of the 
ovaries, from a chill during menstruation, or in association with endo- 
metritis and backward displacements of the uterus. It will of course 
le understood, as in the other classes of cases in which the condition of 
the ovaries is the cause of sterility, that sterility only occurs when botl 
ovaries are affected. But from many of the causes just enumerate*; 
both ovaries do become involved, though often one more markedly 
than the other; not infrequently after an attack of double ovaritis, one 
ovary, usually the right, will apparently recover completely, so far, 
at least, as can be judged by examination, while the other remains 
tender, swollen, and possibly displaced. And in many of these 
there is sterility, although apparently one ovary is healthy. The 
probability in such cases is that recovery is incomplete, and that the 
inflammatory attack, to which one ovary has succumbed, has also 
brought about some change in the structure of the other which cannot 
be estimated by a bimanual or other examination. Possibly also func- 
tional disturbance in one may be sympathetic with structural change 
in the other. In addition to ovaritis other affections of the ovaries 
have been referred to under the head of absolute sterility which, if 
less serious in extent and character, may be only temporary can- 
sterility. Such would be cases of pelvic peritonitis in which peritonitis 
exudation, instead of forming an impenetrable investment to the ovary, 
is slighter in character, and after a time becomes sufficiently thin to 
yield to the distension of a maturing Graafian follicle, and to permit the 

ovule to pass through and reach the tube. Or a parametric exudation, 
which has pressed upon and covered up one or both ovaries for a time, 
may he so absorbed as to permit their function to be rest ored ; or possibly 
eVen cystic disease may be present, but to so limited an extent that 
healthy tissue sufficient for ovulation remains. Temporary malposition 
of the ovaries, the result of an ovaritis which lias led to enlargement and 
increased weight, and so to more or less prolapse, or the downward 
displacement of both ovaries which often accompanies retroversion and 

retroflexion of the uterus, may be ;i cause of difficulty in the way of the 

ova reaching the tube, and bo lead to a temporary sterility. And, lastly, 
apart from tissue-changes and displacements, the ovaries may share in 
a general condition of depressed innervation, and perform their function 

as imperfectly as do other organs of the body under similar conditions 

leral he;ilth, whether these conditions le ;iss< ui.it o< I with anaemia 

or plethora, or some more serious morbid diathesis. Their innervation 



STERILITY 



239 



and blood-supply being faulty, the ova they secrete will be faulty too j 
and sterility will continue until, with improved health, their condition, in 
common with that of other organs of the body, becomes normal and their 
function is normally performed. 

2. The pathological conditions of the tubes which lead, while they 
continue, to sterility, would include the slighter forms of double salpingitis, 
generally of septic or gonorrhoea] origin, which terminate without 
rendering the tubes impermeable, whether by internal adhesions or by 
distension with serous, sanguineous, or purulent collections. Mechanical 
interference with the tubes by pressure from some pelvic tumour would 
cease as a cause of sterility ; either by removal of the latter (were it 
undertaken for any reason), or by some such shifting of its posi- 
tion as might occur with either a pediculated fibroid or an ovarian 
cyst. 

3. But much more frequent and so more important than any affections 
of the tubes in leading to contingent sterility are certain diseases of the 
uterus. And chief among these are endocervicitis, endometritis, and metritis. 
The influence of a severe and established endocervicitis in favouring sterility 
is well marked. The swollen and abraded lining membrane and the 
tenacious muco-purulent discharges offer together a distinct obstruction 
to the ingress of spermatozoa, while the character of the inflammatory 
discharges is prejudicial to their life. The word obstruction is used here 
in its widest sense ; it is not limited simply to mechanical obstruction, 
but includes whatever obstacles may be offered by the hypersemic con- 
dition of the tissues of the cervix to that physiological dilatation of the 
canal which favours the ascent of the spermatozoa into the uterine cavity. 
That the obstructive influence of endocervicitis is not simply hypothetical 
is supported by extended clinical evidence and the observations of 
numerous authors. Repeatedly on the cure of endocervicitis pregnancy 
has ensued in a patient previously sterile. With slighter attacks of mere 
cervical catarrh, which is an extremely common malady, the hindrance 
to conception is proportionately less. With chronic endometritis, if this 
term be applied to inflammation of the lining of the uterine cavity, the 
influence on sterility is somewhat different ; for, on account of the swollen 
condition of the endometrium, there is probably also obstruction to the 
ascent of the spermatozoa through the uterine cavity, and to their 
entrance into the tubes ; especially if the membrane around the orifices 
of the tubes be involved. The inflammatory secretions of the cavity are 
also inimical to the life of the spermatozoa ; while a further effect of 
endometritis is the strong tendency which exists with it to abortion on 
account of the diseased endometrium failing to offer a safe nidus for the 
support and sustenance of the ovum. The forms of endometritis known 
as membranous and villous, and that due to syphilis, are particularly 
hostile to the occurrence of pregnancy ; and if conception should occur, 
abortion is almost certain. 

In chronic metritis it is probable that the tissue of the uterus is never 
affected without the endometrium being also involved, either in the interior 



240 SYSTEM OF GYNAECOLOGY 

of the body or in the cervical canal, or in both. In endometritis, on the 
other hand, the muscular tissue immediately subjacent to the mucous 
membrane may only be affected; but it is often the starting-point of a 
general metritis, aided by abnormal states of the general health, and 
by certain conditions of the portal system and heart which lead to pelvic 
hyperemia. However started, metritis, when chronic, becomes a well- 
recognised cause of sterility. The term metritis, without reference to 
the disputed point whether the muscular fibres of the uterus are capable 
of inflammation in the strictly scientific sense, is here used to include 
the results of chronic hyperemia in the increase of connective tissue 
formation ; and to include also the condition sometimes spoken of as 
subinvolution of the uterus, which I believe to be essentially a chronic 
metritis whose starting-point has been some traumatic or septic influence 
connected with labour. In these conditions of uterus the sterility 
which frequently accompanies them is due not merely to the endometrial 
changes already referred to, which interfere with fertilisation and dis- 
pose to abortion, but to the slow inflammatory changes which spread 
to the tubes and ovaries, which interfere with ovulation or with the 
transit of ova through the tubes, and, if complete, remove the case from 
the hopeful to the hopeless class. Hyperplasia limited to the cervix 
would affect impregnation in so far as the calibre and the condition of 
the lining membrane of the cervical canal are affected, and in proportion 
to the loss of elasticity in the tissues of the cervix itself. 

Versions and Flexions of the Uterus. In cases in which the uterus is 
simply displaced, either backwards or forwards, without any bend on 
its own axis, if there be no associated metritis or endometritis, I do 
not think such displacements would have much hostile influence on 
conception, unless a backward position of the fundus with the os directed 
towards the anterior vaginal wall should interfere with the access of 
spermatozoa into the cervix, or should also cause a displacement of the 
ovaries from their normal relation to the fimbriated ends of the tubes. 
Possibly also displacement may, in intercourse, prevent that adaptation 
of the Cervix to the male organ which some writers hold to be favourable. 
if not essential, to impregnation, and which by Rainey was believed t< 
be brought about, under normal circumstances, by the action of the 
round ligaments. But cases of version without flexion are comparatively 

all events as regards cases of retroversion, which, unless as a 
of prolapse, is rarely seen without some associated flexion. When versiond 
there is a tendency to progressive uterine hyperemia with the 
results, as regards conception, indicated under metritis. But where 
flexion is added to version and the uterus is benl on itself, the tendency 
to the dysmenorrheas of uterine colic is rarely absent, and more or li 
endometritis and chronic metritis result. 

Anteversion and anteflexion are recognised as but an exaggeration 
of the normal Btate and position of the uterus in early life, prior t< 
puberty; and, in cases in which this condition persists, the uterus as 
a whole not infrequently remains infantile in character with a small 



STERILITY 



241 



pointed cervix and a minute os. In these cases dysmenorrhoea is the 
rule, and not infrequently amenorrhoea more or less complete, showing 
probably an immature condition of the ovaries also ; should marriage 
take place, sterility is almost invariable. But these cases are not hope- 
less. Both by medicinal and local treatment the condition may be 
improved, normal menstruation become established, and the uterus and 
its appendages may take on a distinct if slow improvement. It has been 
stated that in rare cases versions may exist without any associated 
flexion ; but still more rarely, if ever, is there flexion without some co- 
existing version. And as with anteflexion there is generally anteversion, 
so with retroflexion there is almost invariably retroversion ; but contrary 
to what obtains in anteflexion, retroflexion is rarely congenital. It is 
comparatively rare in the nullipara, but in the multipara very common ; 
and this is so because its most frequent starting-point is to be found in 
the conditions of the puerperium. Its influence on sterility is twofold : 
firstly, the flexion as a rule produces a virtual stenosis of the cervix, 
which constitutes an initial difficulty in the way of impregnation. In 
cases in which with flexion there is no stenosis this difficulty of course 
does not occur ; but where there is stenosis dysmenorrhoea is rarely 
absent ; and in its train come, secondly, endometritis and chronic uterine 
hyperemia with leucorrhoea, menorrhagia, and, as a rule, sterility. It 
has frequently happened that on reposition of the uterus and its subse- 
quent return to a healthy condition, pregnancy has resulted even after a 
long interval of sterility. It must not be forgotten, also, that if pregnancy 
occur in cases where some retroflexion exists, but in which the uterus 
continues fairly healthy, there is always a risk of its premature termination 
by incarceration of the fundus in the sacral cavity, and by the pathological 
changes which then ensue. The last displacement to be noticed in con- 
nection with sterility is prolapse. In the various degrees of incomplete 
prolapse of the uterus there is not much interference with the possibility 
of conception if the organ itself continue healthy ; but if prolapse be- 
| come associated with chronic metritis, a tendency to sterility, in propor- 
; tion to the extent of the metritis, will ensue. In complete prolapse 
I endometrial and metritic changes are generally present which, if impregna- 
tion took place, would militate against a normal continuance of the 
pregnancy. But the majority of these cases of complete prolapse occur 
in women who have passed the usual limits of child-bearing. 

Occasionally an elongation of the cervix takes place in women after 
child-birth, which appears to be secondary to congestive changes in the 
i cervix resulting from some pathological incident of labour, and resembling 
in character those cases of congenital elongation, or infra- vaginal prolapse, 
which have already been considered. In these the tendency to sterility 
is not so strongly marked as in those of congenital origin ; but from the 
accompanying endometrial changes there is a distinct tendency to early 
abortion, and so practically to sterility. 

Of the uterine tumours which promote sterility those requiring the chief 
consideration are fibroids ; and their precise influence, as regards sterility, 

R 



242 SYSTEM OF GYNAECOLOGY 

will depend not only upon their size and position, but also upon the local 
changes they produce within the pelvis. Subperitoneal pediculated 
fibroids by themselves, if the uterus be otherwise healthy, will not 
necessarily interfere with impregnation, nor perhaps with the process of 
pregnancy, although there must always be the possibility that by some 
casual twist of the pedicle uterine disturbance may be set up, and prema- 
ture labour either come on or even require induction if any symptoms of 
strangulation of the fibroid occur. A case of this kind occurred in my 
experience where, even after pregnancy and delivery had been safely 
accomplished, an accident led to partial severance of a pediculated 
fibroid, followed by intraperitoneal haemorrhage and peritonitis, which 
necessitated abdominal section, and hysterectomy. 

"When fibroids are situated in the uterine wall they may have an 
obstructive influence on the possibility of impregnation if their situation 
be in or near the cervix, and they press upon, distort, or harden the canal. 
This, however, is their least common position. But not infrequently, if 
in the anterior or posterior wall, they will also affect the canal, though 
to a less degree ; sometimes, however, in the case of multiple fibroids to a 
very high degree, the uterine tissue around and between the fibroids being 
dense and unyielding in character. But supposing this not to be so, and 
that they do not interfere with the physiological dilatation of the canal, 
and that impregnation occurs, there is still the great probability that the 
highly vascular and hypertrophied lining membrane, which coexists witl 
a fibroid projecting into the interior, and the resulting menorrhagi; 
may prevent the normal fixation of the ovum. Even if these initial 
difficulties do not occur, and the ovum continue to develop, there are yet 
great probabilities of early abortion or premature labour. 

And beyond the influence upon the prospects of pregnancy due tc 
the effects of fibroids upon the uterus itself, we have also to con- 
sider the effects of pressure exerted by them upon the other pelvic 
viscera, including the tubes and ovaries; especially if the tumour be 
large, or if it be multiple. Under these circumstances the ovaries arc not 
infrequently displaced and pressed upon, and the tubes twisted oi 
flattened; and often also more or less pelvic peritonitis supervened 
Leading to adhesions and matting together of many of the pelvic 
contents. 

In the case of polypi a pediculated submucous fibroid thus projecting 
into the uterine cavity has a twofold influence upon the causatioj 
rility. If the cavity of the uterus be much enlarged, and if the 
polypus spring from the fundus and press upon the orifices of the tubes, 
;i difficulty in the way of the spermatozoa either reaching <n 
entering the tubes. However, supposing this not to occur, and fertilw 
tion to take place, a difficulty might arise in the passage of the fertilise* 
ovum into the uterine cavity. It is believed, indeed, that in somj 
cases such obstruction has been a cause of tubal gestation. Supposing 
lastly, neither of these obstructive difficulties to occur, there would stil 
be the endometritic condition of the lining membrane of the uterus tc 



STERILITY 



243 



contend with, kept up by the presence of the polypus and its attendant 
leucorrhcea and menorrhagia, both highly provocative of abortion. 

In the case of cervical mucous polypi the tendency to sterility is partly 
from the obstruction offered by the polypus itself which may act like a 
ball- valve against the ingress of the spermatic fluid, and still more from 
the catarrhal condition of the cervix. In the case of large fibroid polypi 
projecting through the cervix and filling the vagina, sterility is almost 
certain until the removal of the polypus has made impregnation possible. 

In carcinoma of the uterus in the early stage, whether the disease have 
attacked the vaginal aspect of the cervix or the cervical canal, sterility is 
certainly not absolute. Pregnancy in such conditions occasionally occurs. 
But in the later stages, when the cervix is the seat of a soft, friable, and 
easily bleeding papillary growth, or when its canal is filled with a soft 
vascular growth, or is excavated and granular, or again when the body 
of the uterus is affected, pregnancy is unlikely. In many cases of 
cervical carcinoma, in which pregnancy has occurred, the amount of the 
disease at the date of fertilisation was probably not large ; for its growth 
is largely stimulated by the heightened uterine vascularity which accom- 
panies gestation. The causes of the sterility in the majority of cases 
of carcinomatous cervix are perhaps partly mechanical, according to the 
extent to which the cervix was occupied with cancerous growth, and 
partly the effect of cancerous discharges on the vitality of the spermatozoa. 
In many cases, also, intercourse is followed by so serious and sometimes 
by so alarming a haemorrhage that there is but slight prospect of fertilisa- 
tion. In cases in which impregnation does take place there is always 
a tendency to abortion. 

4. Lastly, in the vagina and vulva causes of sterility are not infre- 
quently met with. Vaginitis may be a factor in the causation of a tem- 
porary sterility, both by rendering intercourse too painful to be borne, 
and by the excessive acidity of the inflammatory secretions being fatal 
to the spermatozoa. Undue shortness of the vagina and a ruptured peri- 
neum may also interfere with the proper retention of the seminal fluid. 

Tumours of the vagina, even if innocent like cysts or fibroids, offer 
a mechanical obstacle to normal intercourse, and also, by provoking 
an excessive leucorrhceal discharge, endanger the vitality of the sper- 
matozoa. In sarcoma and carcinoma of the vagina there is an additional 
adverse factor in the frequent haemorrhages and, ultimately, in the 
necrotic discharges which occur with the advance of the disease. The 
presence of a vesico-vaginal fistula is not necessarily, perhaps, a cause of 
sterility, but the probability of its being so is considerable. 

Certain diseases of the vulva are mainly operative by way of 
dyspareunia, which either prevents marital intercourse altogether, or 
renders it less efficacious for fertilisation. Such are vulvitis, especially 
if it be of the follicular type and accompanied by scattered small ulcera- 
tions generally superficial in character, but highly sensitive to any touch. 
Cystic enlargement or abscess of one of the glands of Bartolini generally renders 
intercourse impracticable until it is cured. Eczema affecting the labia 



244 SYSTEM OF GYNAECOLOGY 

majora, with which [a often associated a sensitiveness so acute that even 
sitting is painful, often renders any attempt at intercourse impossible, 
Pruritus, whether inflammatory or neurotic, is likewise a cause of sterility 
in proportion to the dyspareunia it produces; and this it is parti- 
cularly apt to do, as the clitoric area of the vulva is generally chiefly 
affected. Caruncle of the urethra is another and very persistent cause 
of dyspareunia. So exquisitely sensitive is it in some eases that even 
the passage of urine gives extreme pain, and intercourse is impossible. 
Occasionally on the vulva, and not infrequently on the remains of the 
hymen, are found little bright red vascular patches of an extreme sensi- 
tiveness. Not infrequently these are gonorrhceal in origin, and found in 
association with inflammation of the orifices of the ducts of Bartolini. 
These patches are exquisitely sensitive, and are very generally barriers to in- 
tercourse. Hypertrophic enlargement of the labia majora, or, more rarely, of 
one or other nympha, has occasionally been so considerable as to interfere 
with intercourse. And, lastly, there is the condition termed vaginismus 
by which is understood a spasmodic contraction of reflex origin of the 
muscular fibres surrounding the vulval orifice of the vagina. In a few 
of these cases, and for the most part in patients of a highly neurotic 
type, no local abnormality can be detected ; but in the majority local 
pathological conditions are present which induce more or less violent 
spasm of the sphincter on the least touch. Whether the hyperesthesia 
be neurotic, or dependent upon some obvious pathological condition, th( 
resistance in some of the worst cases to any attempt at intercourse I 
extreme; the spasmodic contraction at the vaginal entrance is violent 
and, if the attempt be persisted in, epileptiform convulsions or attacks 
of syncope may occur. In these severer cases sterility is, of eourst 
invariable. Occasionally these cases come before the courts of lal 
as a ground for divorce, and I gave evidence in one such case in whiel 
for the first time in English law, a divorce was granted for what w; 
but a virtual obstacle to the consummation of marriage. Any attemj 
at intercourse rendered the respondent for the time being piact 
eally maniacal. Among the pathological conditions which are moi 
Usually found to coexist with and to induce this singular sensitiveness 
;nc an undue rigidity of the hymen, an inflamed condition of t lie 
membrane occurring either before or after its rupture, unhealed fissures 
of the hymen following its rupture, eczema of the vulva, and small 
ulcers about the inferior vulval commissure or at the edge of the perl 
nruni, vascular excrescence of the urethra, fissure of the anus, and 
occasionally sonic form of uterine displacement or periuterine inflamma- 
tion. 

It will he understood, of course, that these contingent cases differ 
from those of the absolute class, iii that there is always the possibility 
of impregnation in spite of the existing pathological conditions. If 
spite of a vaginismus Insemination occur at the orifice of the vaginl 
it is quite possible for spermatozoa to reach the uterus, and undei 
favourable circumstances fertilisation may be effected. And in the 



STERILITY 



245 



of a cervical catarrh, attended with tenacious and obstructive discharge, 
occasionally the canal may be fairly healthy, may be free from dis- 
charge, may permit a normal dilatation, and fertilisation become possible. 

In the case of vaginismus, again, especially where the cause is neurotic, 
the pain and consequent dread felt at one time may be absent at another. I 
have known more than one case where sometimes on attempt at intercourse 
the patient has not only resisted but violently attacked her husband, 
while on other occasions she . has received him without opposition. In 
one case of the kind the patient would sometimes spring out of bed at 
her husband's approach, while at another time she would be quiescent 
and unresisting. 

It may be stated here that neither sexual desire nor sexual pleasure 
is essential to impregnation. Impregnation has been known to follow 
criminal and forcible assaults, with fright and horror and suffering as 
their necessary concomitants. It is also certain that desire may exist 
without any pleasure in intercourse, and that pleasure may occur with- 
out desire. Under various circumstances, such as unhappiness in the 
relations between husband and wife, any feeling of desire may be in 
abeyance, and yet the act itself be pleasurable ; and sometimes, even 
if there be a strong feeling of antipathy to the generative process 
altogether, the act itself may not be unattended with pleasure. On the 
other hand, desire may exist, but from the presence of some of the 
pathological conditions named any feeling of pleasure may be more than 
neutralised by pain and suffering. Occasionally we meet with patients 
in whom there is neither desire nor pleasure, who are always apathetic 
and passive. But in all these cases, whether desire or pleasure or both 
be absent, fertilisation may occur. In several cases in which one or 
other or both of these defects were present in women in whom pregnancy 
had not occurred, I have found some condition present which, while 
insufficient, perhaps, to render intercourse actively painful, has evidently, 
and in a way difficult to explain, interfered with its pleasure : the ex- 
planation may be that any faulty link in the chain of incidents which 
constitutes the entire generative process may interfere with the complete- 
ness of those physiological sensations which accompany . its initiation. 
And still further, I have known several sterile women, with a more or less 
active dislike of intercourse, and to whom it gave no pleasure, who found 
both pleasure and desire after some pathological condition was remedied, 
such as a cervical stenosis by dilatation, or a retroflexion of the uterus 
by replacement. But although desire and pleasure are not essential to 
impregnation, there can be no doubt that they are favourable to its 
occurrence, as showing that the organs concerned are healthy, and their 
function likely to be healthily performed. The absence of pleasure is 
probably, therefore, significant of some pathological condition ; although 
it is quite possible that to ascertain in what it consists may in many 
cases be beyond our diagnostic powers and beyond the application of 
any remedy. Excess of sexual excitement, on the other hand, is 
prejudicial to fertility in so far as it induces certain pathological 



246 SYSTEM OF GYNECOLOGY 

results, such as a sustained congestion of the uterus and its appendages! 
leading to ovaritis, and with it to defective ovulation; or to salpingitis, 
and with it to more or less obstruction to the descent of ova and the 
ascent of spermatozoa \ or to metritis, and with it a tendency to the 
occurrence of abortion. 

With the treatment of these various pathological conditions this 
article docs not deal: this is discussed in other sections of this System 
in connection with the several pathological conditions. In cases of 
absolute sterility, whether congenital or acquired, there is, of course, 
from their very nature no treatment possible ; but in the larger number 
of the contingent cases much may be hoped for from successful treat! 
ment. Here the question of diagnosis is of the essence of success : yet 
in many cases it is beyond our powers. A very slight change, for 
example, in the mutual relations of ovary and tube, quite beyond our 
capacity to diagnose, may prevent ova entering the tube and allow them 
to drop into the peritoneal cavity and be lost; or a faulty condition 
of the ovary itself, depending possibly upon some defective local innerva- 
tion, and beyond the scope of any possible physical diagnosis, may be the 
cause of imperfections in the ova. In a great many cases, however, a 
painstaking investigation will disclose some faulty link in the chain 
which connects insemination with fertilisation. We must also remember 
that the causes of sterility may be multiple ; and that, because one has 
been removed without the occurrence of pregnancy, it is not necessari 
to regard the case at once as hopeless. A cervical stenosis may be cure 
by appropriate dilatation, and yet imperfect ovulation, depending 
a chronic ovaritis or the condition of the general health, may remai 
A dyspareunia, sufficient to prevent intercourse, depending upon th 
presence of a vascular caruncle of the urethra, or an inflamed hymen, ma 
be cured by the removal of the caruncle or the relief of the local intlani 
mat ion : and yet conception may not occur because of a viscid catarrha 
discharge blocking the cervical canal, or of a gonorrhceal salpingitis whio 
has resulted in tubal stenosis. It must not, of course, be forgotten tha 
in B certain number of cases (variously estimated at from eight to fifteen 
percent) it Lb the husband who is at fault; but of the nature and caused 
these faults no consideration is undertaken in this article, which is written 
from the point of view of the gynecologist, and treats only of the patho- 
ft] conditions with which he has to deal. 

A few woids may be given to the consideration of certain remedial 
which may be proposed, often somewhat empirically, either 
without a sufficiently careful investigation of the possible causes of th 
sterility, or after such investigation has disclosed nothing obviously 
wrong. Certain watering-places are frequently recommended as cur 
sterility, and in many oases the desired result has been obtained ; but 
probably only when the waters happen t< be adapted to the cure of the 
pathological condition on which the sterility depends. 

Where some chronic congestion of the pelvic viscera, associated with 
a gouty diathesis or live* troubles, indicates an alkaline and saline treat- 






STERILITY 247 



ment, Brides-les-Bains, Kissingen, and Ems may be useful. Where some 
previous inflammatory attack has produced parametric thickening of the 
broad ligaments, with associated subovaritis and metritis, the waters of 
Kreuznach are of distinct value. In cases of uterine fibroids their value 
would appear to be less. Where ansemia exists, with scanty catamenia, 
impaired general health, and probably imperfect ovulation, the waters of 
Franzensbad, of Schwalbach, of Pyrmont, and of Spa are indicated. The 
Marienbad waters, including, as they do, both alkaline and ferruginous 
springs, can be resorted to according to the indications of the case [vide 
art. "Balneology," Syst. of Med. vol. i. p. 318]. And, lastly, if the 
general health be at fault, and more especially the nervous system, 
without any predominance of anaemia or obvious pelvic mischief ; and 
if there be a dyspareunia, of neurotic origin, a residence for a time in 
mountain air has been found beneficial. 

As to medicines for sterility, apart from such as influence its recog- 
nised pathological causes, there is probably none of any certain value : 
but possibly in some cases where, without organic defect or functional 
disorder or impaired general health, there may be some limited failure 
of ovarian innervation, and so a secretion of defective ova, the use of an 
ovarian extract may be tried in the same way as thyroid or thymus or 
splenic extracts have been given in cases of defective function in the 
corresponding glands. 

Of artificial fertilisation it need only be said that Sims, who wrote on 
this subject, appeared at one time to have much hope from its adoption ; 
but during two years, in which he carried out fifty -five injections, he 
succeeded in one case only, and in this an early miscarriage occurred. 
He subsequently gave up the practice, and no writer has advocated it since. 
The least that can be said about such a suggestion is that it is wholly 
empirical. The cause of sterility being, in the great majority of cases, of 
the contingent class of pathological origin, its remedy is to be sought 
rather in minute diagnosis. 

Many of the causes named are so slight in themselves, and of such 
slight importance to the patient's health, that unless she seek advice on 
account of her sterility she may consider herself in good average health ; 
and without any local defect likely to be a cause of sterility. A per- 
sistent but not excessive leucorrhcea, a moderate dysmenorrhcea, a 
tendency even to monorrhagia, may all be thought of little importance, 
or not sufficiently important or unusual to need advice ; and yet may 
be the indication of a pathological condition adequate to account for 
sterility. 

Two or three points in connection with the subject generally remain 
for consideration. Obesity has been held to be adverse to fertility, but 
without any very decided observations to support the opinion. Probably its 
concurrence with sterility may be due to pathological conditions which 
exist with the obesity, or as its result, rather than to the obesity itself. 
With obesity not infrequently both portal and cardiac disorders, suffi- 
cient to lead to pelvic congestion, are associated ; and, as a result, dis- 



2 4 8 SYSTEM OF GYNAECOLOGY 

turbed function of the pelvic organs would follow. There would also be 
the possibility of a heavy omentum pressing upon the pelvic contents, 
and interfering with the normal relation between the ovaries and 
tubes. 

The influence of alcohol in excess is also held by some to be adverse 
to fertility ; if so, this would probably arise from a somewhat similar 
series of pathological incidents. Following upon portal congestion would 
come congestion of the pelvic viscera, with its various adverse possibilities 
in connection with a fertile ovulation ; and there Mould also be a gradual 
deterioration of the general health, leading to disordered innervation and 
to inefficient performance of the functions of the body generally. 

Excess or deficiency of menstruation is regarded by some writers as 
unfavourable to fertility. Impregnation may certainly take place whether 
the catamenia be profuse or scanty ; but both these extremes point to 
some pathological condition of the uterus or its appendages, or to some 
disorder of the general health which may be unfavourable to con- 
ception. 

The marriage of near relations has also been held to be adverse to 
fertility, but probably without any very good grounds ; and when in 
such a case a sterile marriage has resulted it would probably be explicable 
by some pathological tendency common to both husband and wife, and 
affecting in a similar way the various functions of the body, and among 
them those of the generative system. If both husband and wife, 
though related, are free from any common diathetic taint, and of average 
health, there is no reason why sterility should attend their union. 
Marriage with heiresses has been regarded by some writers as undesirable 
from the point of view of fertility. If an heiress be the sole survivor of 
a family (and the fact of her being an heiress in many cases signifies as 
much), this circumstance may indicate some family pathological tendency 
which has led to the premature deaths of other members of the family 
these tendencies she may share, her generative in common with her other 
functions may be abnormally performed, and her marriage from the 
point of view of fertility may be undesirable. But if she have become 
an heiress less as a result of an undue pathological mortality among the 
members of her family than from accidental circumstances, such as the 
chances of travel, war, or epidemics, and if her health be good, there 
would appear to be do ycry valid reasons against her marrying, even if 
the perpetuation of a family name were specially desired. 

In conclusion it may be remarked that, although with the lap 
every succeeding year after the third from marriage, without the occur- 
rence of conception, the prospect of child hearing 1.. comes less, yet if no 
obvious cause of sterility be discoverable, either absolute or contingent 

the patient may -till be encouraged to entertain some hope. There are 

sufficient casts on record of conception occurring after a marriage sterile 
even for fifteen or twenty yea is, to prevent entire despair ; a slight change 
in the mutual relation of the pelvic viscera; a slighl improvement in 
some local innervation : a subsidence of some little chronic congestion in 



GYNAECOLOGICAL THERAPEUTICS 249 

ovary, tube, or uterus, even after the lapse of many years, may rectify 
the minute pathological condition on which the sterility depended. 

Henry Gervis. 

REFERENCES 

1. Barnes, Robert. Diseases of Women, 1878. 2. Budin, Paul. ObsUtrique et 
Gynecologic Becherches cliniques, 1866. 3. Doran. Tumours of the Ovary, 1884. 4. 
Duncan, J. Matthews. On Sterility in Women, 1884. 5. Ibid. Fecundity, Fertility, 
Sterility, 1866. 6. Galton, Francis. Hereditary Genius, 1867. 7. Scanzoni, F. W. 
von. Diseases of Women. Translated from the French of Dor and Socin, 1861. 
8. Sims, J. Marion. Clinical Notes on Uterine Surgery, 1866. 

H. G. 



GYNECOLOGICAL THERAPEUTICS 

It is a mistake to treat Gynaecology as a narrow specialism. Successful 
treatment of pelvic disorders depends upon a correct view of the organic 
and functional integrity of the other organs of the body. It involves also 
a somewhat close investigation, and very often considerable modification 
of the habitual regime of the patient. In other words, it is based on 
general principles as well as on local lines. 

The successful gynaecologist is not one who treats the pelvic disorder 
as an isolated event, but who views it either as arising out of an existing 
(or pre-existing) constitutional state, or faulty regime of the patient ; or, if 
purely local in its origin, as likely sooner or "later to injure the general 
health. 

Frequently we have to deal with a " vicious circle," with local and 
constitutional states so interacting, that no real improvement is pos- 
sible until the " circle " is broken, and both the general and local states 
receive their due shares of attention. 

Thus the circulation, the digestion, and the other important systems 
may influence or be influenced by the pelvic organs ; and the woman 
must be treated as a whole, able only to enjoy perfect health as regards 
one set of organs, when all her other organs are equally healthy. 

Professor Clifford Allbutt has drawn attention to the influence of the 
nervous system on the symptomatology and treatment of Gynaecology. 
He says " the uterus has its maladies of local causation, its maladies of 
nervous causation, and its maladies of mixed causation, as other organs 
have." This element of neurosis it is which, whether cause, complication, 
or effect, tends to baffle the gynaecologist ; and, if disregarded, will prevent 
the complete cure of a patient whose pelvic organs seem to have regained 
their organic and functional integrity ; especially if attention have been 
paid correctly, but too exclusively, to these viscera. 

Instances of such complexity could be multiplied indefinitely, but 



250 SYSTEM OF GYNAECOLOGY 

would merely serve to emphasise the fact that general therapeutics are 

itial to the efficient treatment of almost all cases which, owing to the 
predominant, or perhaps the almost exclusive, pelvic character of the 
symptoms, come, (orrectly enough, under the term "gynaecological." 

Notwithstanding this, it is obviously impossible to do more than 
to indicate briefly those therapeutic methods which are immediately pelvic 
in their application ; and the more general methods must be rigidly 
omitted from consideration. 

The subject of Gynecological Therapeutics may be discussed under the 
following subdivisions : 

1. General Hygiene (Routine, Clothing, Diet, Baths, Exercise, etc.) 
2. Rest (General, Local, Physiological). 3. Drugs (General and Special). 
4. Balneology. 5. Local Therapeutical measures : (i) Heat and Cold : 
(a) External and (b) Internal application. (ii) Medicinal agents : (a) 
to skin; (b) to vulva; (c) to vagina; (d) to uterus. 6. Blood-letting. 
7. Operations, General measures : (i) Antiseptics ; (ii) Preparation of 
patient; (iii) Anaesthesia (a) Local, (b) General. 8. Therapeutical 
Operations : (i) Dilatation of uterus ; (ii) Curetting the uterus. 

1. General Hygiene. Dr. Robert Barnes' dictum remains tine, 
" Occupation, physical and mental, is the great panacea ; something to do 
is the great female cry." 

There are two conditions of life which tend to aggravate, if not 
actually to produce pelvic disorders. The first is luxury, which allows I 
woman to spend her existence in indolence and ease, leaving her mind a 
prey to morbid introspection, and her body prone to functional debilities, 
which tend in the one case to hysteria, in the other to neurasthenia. These, 
especially the latter, are much more frequently observed in the wealthier 
classes. The second condition of life which aggravates pelvic troubles i 
continuous over-exertion; this is chiefly found in women of the poors 
classes, who have not the opportunities of adequate rest, or the change o: 
environment after illness and parturition, which their richer sisters can 
ensure. 

The mode of living ought then to be between these two extremes of 
indolence and over- exertion. The mind should be free from anxietl 
and strain, yet ;it the same time actively occupied with some healthy 
intellectual pursuit, which should prevent mental stagnation ; the body 
should l>c Stimulated by exercise suited to age, tastes and circumstances ; 
and, above all, the importance of functional regularity should be insisted 
upon. 

The human function- of menstruation and gestation are instances of 
rhythm in the movements of nature; the intermissions of the hollow 

ira occur is cycles,, which are approximately rhythmical; the morl 
regular the woman in these functional observances in defsecationj 

micturition, the toilet of the skin, and exercise both mental and physical 
the healthier she will be: ;ind regularity of meals and sleep, both as 

regards time and duration, are no less important 

A daily cold bath or cold sponging heightens arterial tone, strengthens 



i 



GYNECOLOGICAL THERAPEUTICS 251 

the heart's action, increases the corpuscular richness of the blood, and 
the haemoglobin richness of the corpuscules, and is at the same time 
a powerful nerve stimulant. Occasional hot baths, as means of more 
perfect cleansing, are also essential, and should either be taken just 
before bed ; or, if at other times, should be followed by cold sponging 
and rough towelling. The daily routine, especially as to baths and 
exercise, may need some modification during the menstrual period or in 
pregnancy. 

The women of all centuries are affected, more or less, for evil or for 
good, by the fashions of their generation. Clothes should be light and, 
as regards underclothing, loose in texture ; made either of silk or, far 
better, of wool ; or, if these cannot be worn, of loosely woven cotton, 
such as " cellular clothing "or " flannelette." Clothes should not prevent 
the freedom of muscular and respiratory action, and should uniformly 
cover all parts, not leaving the genital organs to be the least protected, 
as in the usual arrangements of underclothing. 

Exercise should never be excessive, and should be very moderate during 
menstruation. There are certain forms of exercise, such as rowing, which 
are less suited to women than to men j but even these are harmless if 
taken carefully during menstruation. Skill in such exercises should 
be acquired in early life, so as to avoid heavy strains and falls. It 
should always be remembered that active exercise in moderation 
does far less harm than passive exercise ; for when actively engaged, 
all the muscles of the body are at "attention," not "off guard" and 
relaxed. Thus riding and driving are often better than being driven, 
and bicycling is better than the pedal sewing machine, in which the leg 
muscles only are engaged. In cycling it is most important that the saddle 
should be wide enough to reach beyond the ischial tuberosities, which 
are wider apart in some persons than in others ; otherwise the perineum 
gets superficially hard and rigid, and the pelvic contents are unduly 
affected. Pneumatic broad or double saddles, with a very slightly 
elevated peak, are therefore the best. 

There are other forms of beneficial exercise, such as dancing, which 
are harmful only when indulged to excess or in rooms where the air, is 
rendered impure by overcrowding, or by gas. Football and gymnastics, 
unless of the parlour variety, are quite unsuited to adult women. 

2. Rest. General; Local; Physiological. 

In no department of medicine is " rest " more essential, whether in 
prophylaxis or treatment, than in gynaecology. In the pelvis as else- 
where, pain and disordered function are indications for rest. 

Pelvic rest may be obtained in two ways : by the complete quiescence 
of the individual, or by a local quietude. The former is a method which 
the leisured class can usually adopt, but is one of which the poorer 
classes, unless in a hospital or " home," are unable to avail themselves. 
For this reason some surgeons have considered it right to treat 
hospital patients more radically than private ones, and would, for 
example, remove the uterine appendages for certain varieties of tubo- 



252 SYSTEM OF GYNAECOLOGY 

ovarian disease in a woman whose livelihood depends upon her activity j 
whereas a lady with Leisure and means might undergo a prolonged course of 
rest and palliative treatment, with a view, if possible, to avoid that opera- 
tion. As a routine practice this is wrong, though in individual eases it 
sometimes seems unavoidable. Each case must be judged solely by its 
own needs, and independently of the social or domestic engagements and 
desires of the patient, which often seem to her more important than 
medical advice. 

Local rest, so useful in cases of uterine displacements with congestion, 
may sometimes be obtained by means of the various forms of pessary, 
which may permit the patient to take active exercise, whilst the pelvic 
congestion, or the relaxed state of the uterine supports, are being simul- 
taneously improved by constitutional or other local measures. Such 
"local" rest is particularly useful where the patient belongs to the 
working classes and cannot obtain " general " rest. 

Whatever mechanical means be used, general or local, physiological 
rest can only be obtained by total abstinence from coitus ; and unless the 
husband will co-operate in this respect, all our efforts may prove fruitless. 
Sometimes, however, it is either unnecessary or undesirable to enjoin 
sexual continence. 

3. Drugs. A wide and precise knowledge of the action and uses f 
drugs is essential in the treatment of disease, whether of one set of 
organs or another. This is especially true in gynaecology, where, 
already indicated, so much depends upon the functional and organid 
integrity of the rest of the individual. By the stimulation of extra-pelvic 
secretory organs great relief can be afforded to the intra pel vie viscera. 
A few words, then, may be devoted to the principles which should guid 
us in the administration of the more general drugs. 

Purgatives. In no class of diseases are purgatives more useful. Con 
stipation, acting locally by the collection of scybala, may seriousl 
displace the pelvic viscera; or, by exerting pressure on the veno 
plexuses round the uterus and in the broad ligaments, may cause much 
congestion and discomfort; or, again, acting constitutionally, may dispose 
to systemic and portal congestion, which injuriously affect the pelvic 
In many cases of chronic pel vie disease a course of purgatives, 
such as sulphate of magnesium, cascara, or aloes, with a few dos< 
calomel, as occasion may require, will greatly relieve the patient. 

In certain obscure* cases of pseudo-ileus (Olshausen) Malcolm, Tait, 

Treves, and Lockwood have shown thai a speedy evacuation of the 
bowel may prevent a life being lost from that form of blood-poisoningj 
which ia caused by the invasion of the system by bowel bacilli (bacterium 

coli Commune), which, though always present and usually harmless, 

may become extremely active and virulent in disease?, or even on such 

braising Or over-Stimulation of the intestines as may result from an undue 

manipulation of the bowel during an abdominal section. 

In many cases of acute pelvic inflammation il is far better to keep the 
bowels open daily by means of ;i simple mixture of cascara and sulphate 









GYNECOLOGICAL THERAPEUTICS 253 

of magnesium, than to keep the patient under the influence of opiates ; 
it is certainly better to do this than to alternate the use of opiates with 
strong forcing purgatives every two or three days. 

In suckling women purgatives are apt to affect the child. Castor oil 
and calomel seem, however, to be exceptions to this rule. Enemata and 
rectal injections of glycerine are useful alternatives. 

Tonics of all kinds may find a place in the treatment of pelvic 
disorders. 

Without going so far as G-oodell, who says " one cardinal rule in 
the treatment of all uterine disorders is the internal administration of 
iron, and of other tonics, unless contra-indicated," there can be no doubt 
that iron is well borne in nearly all such cases. Iron should be given 
almost always with purgatives, otherwise it is often inert ; and in such 
cases as anaemia and chlorosis, with scanty or absent catamenia, it should 
also be combined (Barnes) with arsenic and freshly prepared acetate of 
ammonia. The perchloride of iron is very useful in cases of a septic nature, 
as in sapraemia and septicaemia ; and even in such cases as periuterine 
inflammations, where the "septic" element is not so obvious. Iron is 
sometimes ill borne in cases of hypertrophic endometritis, unless the 
vascularity of the uterus be simultaneously lessened by ergot. 

Permanganate of potassium, in doses of three grains (best combined 
with unguentum kaolin in the form of a pill), is very useful to increase 
the effect of iron ; in cases of anaemia with amenorrhoea it should be 
given thrice daily for three days, upon the date when menstruation should 
appear. 

Arsenic is valuable especially when leucorrhcea is present in anaemic 
girls, with a chronic catarrh of vagina or cervix ; in them local treatment 
is not advisable until a fair trial of constitutional treatment has first 
been made. 

Quinine, which has a special tonic action on the uterine muscle, is a 
useful adjunct ; and in cases of debility or irritability of the involuntary 
muscles of the body it is usefully combined with strychnine, arsenic, 
and some sedative, such as belladonna, stramonium, or conium. 

Sedatives must be given with great caution. States for which they 
may be indicated are often recurrent ; and the repeated administration of 
alcohol, opiates, etc., to women whose nervous system is overwrought or 
not under due control, especially at the climacteric, leads to continued 
use, or rather abuse of these agents. All such drugs should be given 
sparingly, and, if possible, so disguised or given in guarded prescriptions, 
that patients may not readily obtain a continuous supply. 

Special Gyncecological Drugs. There are very few drugs for internal 
administration which are especially valuable for gynaecological purposes, 
and all of them are used for other purposes also. 

The most important of these are ergot ; cannabis indica ; viburnum 
prunif olium ; hydrastis ; chloride of ammonium ; the bromides ; a few 
coal tar derivatives, such as phenacetin ; chloride of calcium ; mercurial 
preparations, and some others, such as castor and apiol. 



254 SYSTEM OF GYNAECOLOGY 

Ergot of eye is used for two main purposes to encourage uterine con- 
traction and to lessen uterine haemorrhage. Its main action is on involun- 
tary muscle fibres, causing a more prolonged and more definitely intermittent 
contraction, and, according to some observers, leading to a true tonic con- 
traction if given in sufficiently continuous or large doses. Thus it is said 
to act upon the heart ; it causes also contraction of the arteries, and 
heightens arterial pressure. It may also cause some intestinal or vesical 
irritation, and may have to be given with belladonna to prevent such 
unpleasant sequences. Owing to its special action on the uterine muscle 
it is largely employed for the treatment of passive uterine haemorrhage, or 
for that due to organic changes, as in uterine fibroids or fungous endo- 
metritis, where diminished vascularity tends to lessen growth. It is also 
given to promote indirectly the absorption of effete products, and at the 
same time to reduce uterine congestion, by encouraging contraction ; it 
may thus lessen the bulk of the uterus in cases of subinvolution, and in 
cases of fibroids it may both starve the tumours and favour their ex- 
trusion. Ergot is apt to increase the pain of spasmodic dysmenorrhcea, and 
may therefore have to be omitted just before and at the commencement 
of a menstrual period: with this occasional interruption ergot may bj 
given continuously for months, or even for years, without deranging the 
health. Every now and then, however, large doses will, by contraction of 
the arterioles, give the heart more to do than it is equal to, and it may 
have to be discontinued. Ergot should be avoided during pregnancy, 
except in doses of 5 or 10 drops in certain cases of haemorrhage 
(usually grumous), where we find on examination that the uterus has Inst 
its normal firmness, its definite outline, and its intermittent contractions. 
Ergot should not be given during lactation, as it speedily enters the 
milk and produces infantile colic. Ergot, though usually given by the 
mouth in the form of the liquid extract, or as ergotin, may, in either of 
these forms, be subcutaneously injected, the former deep into a gluteal 
muscle, the latter hypodermically, and though somewhat apt to irritate, 
can usually be tolerated. Ergotinine, in doses of 2731^ to Tfr^h f a 
grain, is also useful hypodermically, but though less irritating, it is less 
efficacious, and is also costly. In chronic haemorrhages, or where given 
fur long periods, ergot should be combined with acids and purgatives] 
but when given in severe acute haemorrhage it should be combined \\ ith 
ammonia. 

Hydrastis canadensis. The best preparations are the tincture (dose 

111 w. to \\\ \\.) and hvdrastine (gr. \ to gr . 1). Though occasionally dis- 
appointing, this drug has a decided ecbolic action, and if taken regularly 
will check chronic ha-niorrhages not due to serious organic changes. 
The drug has also a -ed.it ive ell'ect which ergot has not. 

Cannabis indica is usually given in the form of the extract ( .[ to ! i^v.) 
or of tannateof cannabiii (gr. ij. to <^v. x.) It is extremely useful in 

of monorrhagia with pain, acting even better than hydrastis; where the 
pain of dysmenorrhcea ii present, as in some cases of fibroids, il 

far better than ergot. e\en when belladonna Is added to the latter. 






GYNAECOLOGICAL THERAPEUTICS 255 

Indian hemp varies greatly in strength, and should be ordered from one 
source ; it must be remembered that it is one of those drugs which are 
apt to affect certain women peculiarly, and at first must be given cautiously 
in small doses. Vertigo is a frequent symptom of an overdose. 

Viburnum prunifolium is an antispasmodic, relieving painful con- 
traction and cramps both of voluntary and involuntary muscle ; it is 
useful, therefore, to prevent abortion in cases where uterine contraction 
precedes the death of the foetus (extract, dose gr. ij. to gr. x.) 

A large group of antispasmodics and sedatives may be used in the 
treatment of uterine colic, but it will suffic here to name the good effect 
which phenacetin, antipyrin, exalgine, and other coal tar derivatives, as 
well as apiol and castor, have in the relief of all sorts of pelvic pain, 
including the pain of dysmenorrhcea, cancer, and neuralgia. Nitro- 
glycerine (gr. T ^th) also relieves pain, and is especially useful in the last 
stages of cancer of the uterus, where ursemic symptoms, such as headache, 
scanty urine, and nausea, may have supervened. 

The bromides of potassium and ammonium allay the pain and general 
restlessness due to increased local tension, as for instance in cases where 
congestion of the ovary, or rapid growth of a fibroid, causes a painful 
distension of their enveloping capsules. They also tend to lessen 
haemorrhage of a passive type, and are particularly useful when taken so 
as to anticipate menstruation where menorrhagia is associated with ante- 
menstrual dysmenorrhcea, headache, and nausea. 

Chloride of ammonium has also good effect in relieving pelvic con- 
gestion, probably by its action on the liver, and is therefore useful in all 
cases where the vascularity of the pelvis is increased, as in fibroids, 
subinvolution, chronic metritis, and simple congestion. 

Chloride of calcium, in doses of 10 to 20 grains thrice daily for two 
or three days, answers like a charm in some cases of menorrhagia, where 
ergot has failed, though the appropriate class of cases is not yet ascertained. 
It acts (13) by encouraging the ready coagulation of the blood. 

Perchloride of mercury, and other preparations of that metal, have 
some special use in promoting absorption of long-standing inflammatory 
exudations, such as are found in the chronic metritis of subinvolution, or 
as persistent thickenings about the pelvic floor, after pelvic inflammation. 

4. Balneo-therapeuties. Such a large subject as this can only be 
very briefly outlined, but the following remarks and table will not be 
out of place : 

There are certain health resorts and spas, at home and abroad, noted 
for springs of water which have been found useful in pelvic disorders. 
Some of the best are here tabled, but it must be remembered that it is 
often necessary to send a patient to a resort where the water is suitable 
rather to the constitutional diathesis than to the actual pelvic condition 
which may be a complication. Thus anaemic patients may be sent to 
Schwalbach, Nauheim, Levico, or Strathpeffer ; and gouty persons to 
Wiesbaden, Homburg, Bath, Harrogate, Kissingen, and many others. 

Sea-water, again, is a very good substitute where it is not possible to 



2 5 6 



SYSTEM OF GYN. ECOLOGY 



go to one of the following or other suitable resorts. Sea-water, when pure, 
i> somewhat similar to Woodhall Spa Water ; it is rich in salines, bromine^ 

and iodine, is a powerful hepatic stimulant and purgative, and can be used 
internally as well ;.s in the form of baths and douches, in some cases of 
portal and pelvic congestion, with great advantage. 

The following are some of the baths which are especially useful in 
cases of chronic pelvic congestion, subinvolution, or fibroids, and serve 
to hasten complete recovery after acute inflammatory attacks, where 
exudation into the uterine or periuterine tissues has been well marked. 

[For a more ample account of Balneology the reader is referred to the 
article by Dr. Weber in Syst. of Med. vol. i.] 

Table of Baths and Health Eesorts for Chronic Pelvic Disorders 



Names of Places and Altitude. 


Season. 


Character of Water. 


Special Uses. 


Bex, Switzerland, 1400 ft. 


May to Sept. 


Saline water, bromo- 


Chronic pelvic exuda- 






iodnrated 


tions. Fibroids. 


Carlsbad, Bohemia, 1214 


May to Oct. 


Alkaline saline. 120 


Chronic pelvic con- 


ft. 




F. to 170 3 F. 


gestions. Gout. 


Contrexeville, France, 


June to Sept. 


Alkaline effervescing. 


Wheregravel or urin- 


1000 ft. 




55^ V. 


ary diseases com- 
plicate pelvic dis- 
orders. 


Franzensbad, Bohemia, 


May to Sept. 


Alkaline effervescing 


Pelvic congestion 


1900 ft. 




and ferruginous 


with haemorrhoids. 


Kissingen, Bavaria, 600 


June to Sept. 


Cold saline 


Pelvic congestion 


ft. 






with constipation. 


Kreuznach, Germany, 


May to Oct. 


Bromo-iodurated and 


Subinvolution. Chr. 


350 ft. 




saline 


inflammation. Fi- 
broids. 


Marienbad, Austria-Hun- 


May to Sept. 


Ferruginous mud- 


Chronic exudations 


gary, 910 ft. 




baths 


in cellular and 
peritoneal tissue. 


Plombieres, France, 1330 


June to Sept. 


Ferruginous. 66 F. 


Chron. endometritis 


ft 




to 143 F. 


with anaemia. 


Pyrmont, Germany, 440 


May to Sept. 


Effervescing, ferru- 


Chron. catarrh with 


ft. 




ginous, and saline 


anemia. 


Royat, France, 1480 ft. 


June to Sept. 


Alkaline, ferruginous, 


Pelvic congestion 






and arsenical. 45 


with gout. 






1'. to 95 K. 




Schwalbach, Germany, 


May to Oct. 


Ferruginous . 


Anaemia with chro- 


ft. 






nic catarrh. 


brnnn, Bavaria, 2800 

ft. 
Vittel ; France, 1000 ft. . 


May to Oct. 


Iodine springs . 


Chronic congestion. 


June to Sept. 


Alkaline effervescing 


Congestion with ob- 








stinate constipa- 








tion. 


Woodhall, Lincoln, 


May to Oct. 


Saline bromo-iodor< 


Subinvolution. Chro- 






ated 


nic inflammation. 
Fibroids. 



5. Local Therapeutical Measures. i. Heat and Cold. (a) External 
Applications. -Cold will excite reflex local contractions in both voluntary 






GYNAECOLOGICAL THERAPEUTICS 



257 



and involuntary muscle. In vigorous persons it increases the exhalation 
of carbonic acid. The effect of cold externally and suddenly applied is 
well seen when it is applied to the abdomen to cause uterine contraction 
in post-partum haemorrhage ; or to the skin of the new-born child to excite 
diaphragmatic movement. The reflex effect of cold upon distant glandular 
organs is less well understood ; but we know that cold locally applied 
temporarily checks secretion in all the glands a check to be followed, in 
health, by a reactionary period of augmented secretion. 

Heat, if moderate, is sedative ; but if great, may excite muscular con- 
traction as does extreme cold, producing this effect with less shock to the 
individual. Hot baths are mainly sedative, relaxing the skin and its 
glands, dilating peripheral vessels, and thus relieving congestions of 
internal viscera : they are useful, therefore, in congestive dysmenorrhea, 
prolapsed ovary, and the like ; and are very soothing to the flushings, the 
restlessness, and the irritability of the menopause. They also relieve 
muscular spasm and severe tension, and are therefore found serviceable 
in spasmodic dysmenorrhea, and in cases of uterine, tubal, intestinal, 
hepatic, and renal colic. 

Hot foot and sitz baths act somewhat similarly. In the bath, blood 
is drawn from the internal organs to the surface and to the legs ; these 
baths are therefore useful in relieving pelvic congestion, and in cases where 
the catamenia have been suddenly arrested by " a chill " with resulting 
stagnation of the pelvic circulation. After the bath the blood returns 
more freely to the pelvis, the circulation of which is re-established ; 
and the menstrual flow is thus encouraged to continue. Mustard added 
to such baths increases these effects. 

Poultices and fomentations, as regard both their utility and action, 
may be considered as local baths. If a sedative effect be required, bella- 
donna or opium may be added to the fomentations ; if a stimulating 
effect, turpentine may be added. 

Poultices should be continuous, and should be repeated every three 
hours, or oftener if need be. If made thick and covered with oiled silk 
and flannel, and applied in the first instance 
very hot, they may remain somewhat longer 
at a suitable heat. If the local relaxation 
produced by a poultice be not wanted, a pad 
about a foot square can be made by sewing 
up some bran in quilted flannel. This can 
be put into the oven and applied dry, 
or may be kept hot by a Leiter's coil. 
By dipping this bran pad in very hot 
water it becomes a very light and ready 
poultice. FlG - 52 -- Leiter ' s coils - 

Leiter's pliable metal coils (Fig. 52) have now taken the place formerly 
occupied by Chapman's spinal bags. Chapman showed that the heat or cold 
of these bags acted upon the spinal and ganglionic nerves going to the vessels. 
Thus ice-bags applied to the lower dorsal and lumbar regions in arrested 

S 




2 5 8 



SYSTEM OF GYNECOLOGY 



menstruation, by partially paralysing these vaso-motor nerves, and m 
causing dilatation of the pelvic vessels, encourage a freer pelvic circulation^ 




I'ii.. 58. Application of Letter's coils. 




Pio. 64 - ltat 1 1 speculum. 

Hoi applications to the same regions are, by analogous action, very useful 
in checking monorrhagia. Leiter's coils fulfil these objects admirably 
and the water can be regulated and kept al any given temperature eil 



G YNAi COL O GICAL THERA PE UTICS 



259 



by the addition of ice to the reservoir of water, or by a spirit lamp under 
it ; and cooling can be increased or lessened by the rate at which the 
continuous stream of water is allowed 
to pass through the tubules of the coil. 
The pliability of the coil allows it to 
be moulded to any part of the body, 
and if the tubes be made of alumin- 
ium their weight is trifling. 

For reducing temperature, a coil can 
be moulded to the back of the head, 
and iced water allowed to run through 
it. For rallying a patient suffering 
from shock, heated coils applied to the 
feet, on the chest, and under the arms 
answer admirably. If moist heat be 
required to imitate a poultice, cloths 
wrung out of warm water can be wrapped 
round the hot coil. 

(b) Internal Applications of lieu t ami 
Cold. Whilst in a bath, water can be 
made to enter the vagina by means of a 
grilled speculum (Fig. 54). The more 
usual means, however, is a douche 
apparatus. In all cases the flow into 
the vagina should be continuous from 
an elevated supply of water, as from a 
suspended douche-can, or from an ele- 
vated syphon arrangement (Fig. 55) ; 
not intermittent, as when a hand-ball 
enema is used. If a douche-can be 
; the vessel employed, the outlet should 
be slightly above the level of its base, 
lest imperfectly mixed powders, or other 
ingredients, should escape in too con- 
centrated a form. 

If cleansing alone be needed, two 
' or three pints of water are sufficient ; 
but for relief of local congestion irri- 
gation is employed, and several pints are used for twenty to thirty 
minutes. The value of this procedure, however, is probably over- 
estimated. 

The vaginal nozzle should be of toughened glass, and capable of being 
, easily cleaned. The patient should lie flat on her back, with the pelvis 
raised on a bed-bath (Fig. 56), or projecting over the edge of a couch. 

For the mere application of heat, all that is necessary beyond' these 
points is that the temperature of the water should be properly regulated. 
In prolonged douching for relief of congestion, lukewarm water (95 F. to 




Fig. 55. Syphon douche. 



26o 



SYSTEM OF CYN. ECOLOGY 



V.) is indicated ; but for arrest of haemorrhage, or the production of 
muscular or vascular contraction, a temperature of 118 F. is required 

Extremely cold water will also check haemorrhage, though it will not pro- 
mote coagulation of the Mood; it is, however, obviously unsafe to em] 
ploy it, as it may unduly check secretion, or prevent the menstrual How 
from appearing if due. It is also much more trying to the general 
health of the patient, and water at so low a temperature is not readily 
obtainable. 

It must he remembered, however, that, in addition to the thermal 
properties of the vaginal douche, it also has a very well-marked mechanical 
action. This is best obtained by so elevating the douche-can as to maka 
the continuous current of water somewhat forcible, and capable of 
ballooning the vagina, This action raises the uterus with its appendage! 






Fig. 56. Bed-bath. 

and the other pelvic contents, empties engorged lymphatic vessels, glan< 
and distended veins, and gently stretches, and perhaps promotes il 
absorption of chronic inflammatory thickenings. 

This ballooning of the vagina can he increased by further elevation 
the reservoir, or by the patient arresting the outflow of the water hoi 
the vagina by hand pressure on the vulvar orifice. 

By the addition of medicinal agents the douche can be rendered 
antiseptic, anodyne, astringent, or sedative. These further actions will be 
discussed later ip. l'61). 

iii) Medicinal a</ents applied to (a) the skin; (b) the vulva; (c) the 
vagina ; (<J) the uterus. 

Counter-irritation to the skin may be applied in a 
variety of ways, by such drugs as cantharides, mustard, turpentine, iodine 
liniment. croton oil, and others in ordinary u 

They all Lessen pain and appear to check the spread of inflammatioJ 
and also to promote abaorpl ion of inflammatory exudations. Th< 
results are probably brought about by influencing the vaso-motor oervej 
but, by stimulating the skin, they lead also to its increased vascularity 



GYNECOLOGICAL THERAPEUTICS 261 

and presumably to a relatively diminished vascularity of subjacent tissues. 
It is clear too that there is some distinct action upon the terminations of 
the nerve filaments from the spinal cord ; and for this reason counter- 
irritants should be applied over the position where the nerve trunks, 
which supply the inflamed organs, send branches also to the surface of the 
skin. These areas, as Dr. Head has shown, are not necessarily at the site 
of greatest pain, but where the touch of a blunt point like a pin's head 
detects hyperesthesia. It is found that these areas are supplied by the 
posterior root of the same nerve which also sends sensory nerves to the 
inflamed viscera. Thus the ovary, when inflamed, causes referred pain 
and cutaneous tenderness along the tenth dorsal area ; the nerves going 
to inflamed Fallopian tubes are particularly associated with the eleventh 
and twelfth dorsal segments ; so also are the nerves supplying the upper 
parts of the cervical canal and the internal os : the lower part of the 
cervix is related to the third and fourth sacral areas. Much valuable 
information on this subject may be found in Dr. Head's paper. 

It is difficult, of course, to estimate the curative effect of counter- 
irritants in those cases where rest in bed is a coincident factor in the treat- 
ment, and wherever possible these two means should be associated. 

(b) Applications to the Vulva. The various inflammatory and other 
morbid states of the vulva are dealt with as are other places in the body, 
which resemble it in being covered partly by skin, partly by mucous 
membrane, with a good deal of transitional epithelium at the points of 
union. Ointments, lotions, fomentations and baths have each their 
appropriate usefulness. If the vulva alone be affected, especially in young 
children, baths form the best means for applying sedative or stimulating 
lotions. 

(c) Applications to the Vagina. Medicaments may be applied to the 
vagina in many ways. Among them may be mentioned injections, 
douches, tampons of prepared wool or gauze, pessaries made up with cacao 
butter or gelatine ; or applications, in the form of ointment, powder, or 
solution, may be made to definite areas of the vagina through a grilled 
or duckbill speculum. 

Douches are a very convenient way of applying medicaments to the 
vagina where only temporary influence is required. If used for antiseptic 
purposes, perchloride of mercury may be used in the proportion of 1 to 
4000 or 2000; or if prolonged use be needed, carbolic acid (1 in 100), 
or tincture of iodine (5j. to pint), or borax or boric acid or izal may be 
substituted in the same proportion. Corrdy's fluid and sulphocarbolate of 
zinc are also useful, and creolin or lysol (1 in 200) is more suitable before 
a vaginal operation when it is important that the vagina should be soft 
and supple ; most of the other antiseptics render it temporarily unyielding 
and contracted. For rendering the vagina absolutely antiseptic more 
complete measures may be needed (see p. 270). Douches can be made 
sedative by means of the addition of liq. plumbi subacetatis (3ij. to 
Oiij.), laudanum, or liq. opii sedativus (oj. to Oj.), chloral hydrate (gr. 
xx. to Oj.), borax or bicarbonate of soda (,^ij. to Oiij.), or Condy's 



262 SYSTEM OF GYNAECOLOGY 



fluid well diluted. ( )f astringent preparations, alum, sulphate of zinc, am 

tannin (in tin- proportion of half a drachm to the pint) are the best. 

Medicated pessaries can be used for all purposes. Absorption is s]<>\ 
and imperfect through the vaginal mucous membrane, and at least doubH 

the usual dose of a drug should le thus administered. Only those drugl 
are thus used which are known to have a local effect. They are best com 
hined with gelatine or with cacao butter, the latter being itself very 
soothing. The drugs most often used as sedatives are cocaine (gr. Lj.l 
morphia (gr. j.), extract of belladonna (gr. ij.), henbane extract {^\\ v.), 
hemlock extract (gr. v.) Astringent pessaries should he made up with 
cacao butter j alum and tannin are the agents most used. 

If we desire to relieve vaginal congestion, or to encourage secretion 
from the vagina, a pessary of glycerine (~uss.) combined with gelatine (3ss.| 
is very efficacious. This agent has one of its most useful applications as I 
preliminary to rapid dilatation of the cervix, the nurse being directed to 
introduce the pessary up to the level of the cervix two hours beforl 
the operation. If desired, drugs may be added to these pessaries to 
make them antiseptic or sedative : and it is in this form that ichthyol 
mjij. in each pessary, has its most useful sedative and absorbent applied 
tion. Ichthyol pessaries are also very beneficial in subinvolution 
ciated with endocerx icitis and granular erosion. 

Tampons may be employed to plug the vagina, or lightly to pack it; 
hut they are sometimes used as a convenient method of applying 
medicinal preparations to the walls of that passage. For this purpose 
gauze is easily applied saturated with various ingredients, such as carboli 
acid, eucalyptus, iodoform, sal alembroth, salicylic acid, sanitas, or thymol 
or plain gauze previously dipped in the desired drug, such, for instance, 
a 4 per cent solution of ichthyol and glycerine, may he used. Wool liki 
wise, tied into convenient sizes, maybe used, and can be obtained satural 
with boracic acid or iodoform, or containing perchloride of mercurj 
eucalyptus, iodine, carbolic acid, or salicylic acid. Wool tampons can 
made with astringents, such as alum or tannin, either mixed throughout 
the wool or rolled up inside it. Wool tampons steeped in glycerine maj 
d of glycerine pessaries, and are very beneficial where the 
UterUJ Ueeds SUpporl and depletion at the same time. 

If it be desired to elevate the uterus, to keep the cervix forwards or 

backwards, Or merely to Pest the uterus after some operation in which it 
hafl been much drawn OUt of position, or in which adhesions to other 

viscera have been broken down, there is no need to pack the vagina very 
tightly : but this lb very desirable where there is ^\w^ uterine 
haemorrhage, though it is better to plug the uterine cavity itself, | 
much more certain hemostatic procedure. 

If the vagina is to be packed for haemorrhage it should be rendered 
absolutely antiseptic, and tin- rectum and Madder should be emptied. Tin 
patient should lie in tin- Sims position, and a duckbill speculum should hi 
passed. A piece of gauze should he inserted into the cervical canal, an 
the pOUChefl around the cervix should he firmly packed with ;intisepti( 



GYNAECOLOGICAL THERAPEUTICS 



263 



gauze ; a piece should also be laid over the cervix. Pieces of wool rolled 
up into cylinders about as large as the first thumb joint should be then 
passed up and pressed firmly against this roof of gauze, and the vagina 
completely filled; the strings attached to the wool tampons should be 
allowed to hang out of the vagina. As a rule they should be left in for 
twenty-four hours, and it will generally be found that the haemorrhage 
has been arrested by coagula in the upper gauze layers. 

Ointments containing useful drugs may be conveyed into the vagina 
by ointment carriers, such as Allingham's or Matthews Duncan's {Fig. 57). 




Fig. 57. Ointment carrier (Matthews Duncan's). 

The basis of such ointments should be lanolinated lard. 

Direct applications of drugs can be made through a speculum to any 

affected area of the vagina, and in variety they cover a wide range. 

Nitrate of silver up to a strength of gr. x. to oj., or an 8 per cent solution 

of. sulphate of copper, is useful 

in some inflammatory states ; pure 

carbolic acid, chromic acid, acid 

nitrate of mercury, bromine dis- 
solved in spirits of wine (1 in 4) 

are all useful, with appropriate 

precautions, in cases of new growth 

or malignant ulceration. 

(d) Applications to the Uterus. 

Medicaments used for the vagina 

may also be employed for the 
; vaginal portion, but more care is 

required for intra-uterine applica- 
j tions. 

To apply substances to the 

endocervix it must be exposed in 

a speculum, such as Neugebauer's 
I (Fig. 58), in a good light; after its 

lining membrane is wiped free from 

mucus, the solution or powder 
I should be applied on a probe, such 

as Playfair's, armed with cotton- 
wool. The substances most used 
1 are acidum carbolicum liquef actum, iodised phenol, 1 iodine liniment, 

iodine paint 2 or Churchill's solution of iodine, 3 liquor ferri perchloridi, and 

1 Iodine 1 part, and liquid carbolic acid 4 parts. 

2 Iodine, iodide of potassium, spirits of wine, and water, equal parts (Samaritan Free 
Hospital). 

'' Iodine, 78 grains ; iodide of potassium, 90 grains ; rectified spirits to one ounce. 




Fig. 58. Diverging speculum (Neugebaur's). 



264 SYSTEM OF GYNAECOLOGY 

ichthyol (4 to 10 per cent solution). Another good method is to pour 
down ,i Fergusson's speculum a solution which can be encouraged to 
enter the cervical canal freely by means of an armed probe. One 



l "' , VH''tfH-l,TH 

I'layt'air's probe. 



of the best solutions for this purpose is an 8 per cent solution of sulphate 
of ruppen 

If there be much congestion, the cervix should be first punctured till 
it has assumed a light pink colour. 

Where the endometrium is extensively inflamed, or is the seat of 
adenomatous overgrowth, dilatation and curetting become necessary ; but 
there are many milder inflammatory conditions of the endometrium, in 
which a cure can be obtained by several careful applications of one or other 
of these or other drugs to the cavity of the uterus. They are best used 
through a Fergusson's speculum, and should be carried into the uterus on 
a Playfair's probe x suitably curved. The cervix should be exposed and 
cleansed, and a sound passed to ascertain the exact uterine curve. If this 
curve be acute, the cervix should be held and drawn down by a tenaculum 




I'm. GO. Uterine tenaculum forceps (Sims'). 

60) : and if the sound prove any constriction to exist, a few bougie* 
should first be passed : indeed, in any case the application of a powerful 
medicamenl may usefully be preceded by a partial dilatation, as uterine 
colic is thereby prevented and good drainage facilitated. Except in rare 

these proceedings should be taken when the patient is in bed and 
able to be at rest for some hours. After the application, it is a good plan 
to pass into the uterus, above the level of the 08 internum, a thin strip of 
gSUZe or lint, soaked in iodine and glycerine, to ensure a watery discharge 
and fiee drainage. It should be removed iii twelve hours, and an 

antiseptic douche given. When it is advisable to apply a medicament 
th- end ometrium only, it may be done through a cervical speculum, such 
as AtthflTa (I'm. 61). 

1 The best variety <>f Playfair's probe is thai in Fig. 59. It lias not a bulbous end, but 
tapers slightly, and the wool. though held sufficiently firmly not to come oft when tli<- probi 
is withdrawn, will come off readily enough afterwards withoul 






GYNAECOLOGICAL THERAPEUTICS 



265 




Fig. 61.- 



Intra-uterine canula ( Atthill's) ; platinum 
canula, with stilette. 



Intra-uterine injections should never be used without security of free 
exit ; and in any case no very irritating solution should be injected lest 
sudden uterine contraction should 
occur. It must be remembered 
also that occasionally the Fallo- 
pian tubes remain patent as a 
result of disease, or as part of a 
general pelvic subinvolution. 

6. Blood -letting. Some- 
times it is desirable to relieve 
congestion by the local abstrac- 
tion of blood. This may be 
done by applying leeches, by 
puncturing, scarifying, or dry 
cupping; or the result may be arrived at by the extraction of blood- 
serum, as when blisters are applied, or when vaginal glycerine tampons 
are introduced. Whatever be the precise method adopted, it should 
either be carried out at the place actually congested, such as the vulva or 
cervix uteri, or at a part supplied by blood-vessels, which are either 
branches of the same main trunk or anastomose freely with its off- 
shoots. 

Thus leeches applied to the perineum relieve pelvic congestion, by 
depleting the superior, median, and inferior hemorrhoidal vessels coming 
from the common iliac, internal iliac, and pudic arteries respectively ; 
between all of which there is free anastomosis. Eelief is, of course, thus 
afforded to the portal as well as to the general system, as the superior 
hemorrhoidal vein belongs to the portal, while the middle and inferior 
belong to the general venous system. Mr. Marmaduke Sheild has drawn 
attention to the relief afforded to vesical and pelvic congestion and irrita- 
tion by the applications of leeches or counter-irritation to the inside of 
the thighs. This he accounts for partly by vaso-motor influence, but 
mainly by the depletion of the capillaries fed by the pudic branches of 
the femoral, relieving thus the areas of congestion by lowering the blood 
pressure in the branches from the internal pudic of the internal iliac, 
with which they freely anastomose. 

Leeches to the groin can be shown to act in a similar manner, and 
the signal relief thus afforded to swollen ovaries is probably produced by 
depleting the small twigs from the ovarian artery which pass along the 
round ligament to the inguinal canal, as well as, more indirectly, through 
the anastomoses between the superficial and deep epigastric vessels and 
deep-lying twigs from branches of the internal iliac vessels. 

Leeches to the Cervix. Blood may be abstracted from the cervix by the 
application of leeches, by puncturing, or scarification. Blood thus drawn 
relieves the whole pelvis. The cervix is mainly supplied from the uterine 
arteries ; but these anastomose so freely with the ovarian and vesical 
arteries that the relief becomes very general. The vagina should be 
douched with some warm antiseptic solution, such as borax (3ij. to Oiij.), 



266 SYSTEM OF GYNAECOLOGY 

the patient being in bed in a warm room. She should lie on her Bide 
whilst a Fergusson's speculum is passed, which should exactly embrace 

the cervix uteri. The cervix must then be carefully cleansed, and its 
Cavity, especially m parous women, should he occluded by some antiseptic 

wool. If it he desired to apply the leeches to any particular spot on 
the vagina] portion, they can he passed down to the cervix in a hollow 
tube, or held lightly in a pair of forceps ; but as a rule it suffices to throm 
the leeches up the speculum, which is kept well pressed up against the 
fornices of the vagina. The leeches seize hold where they will, and a 
large wool tampon is then passed up nearly to the cervix and kept in for 
ten or fifteen minutes : the wool is then removed, and the leeches, 
probably then detached, can he easily rolled out. The cervix may then 
he painted with iodine solution, or an antiseptic douche given. Care 
should l>e taken that the leeches do not attach themselves to the vaginal 
wall, as serious haemorrhage may follow by perforation of a small vessel. 
If a leech-bite should thus bleed, pressure applied by means of a vaginal 
tampon, or the application of strong- iodine or perchloride of iron, usually 
stops it; but if these methods fail, a red hotwire, or the point of a 
Paquelin's cautery knife at a dull red heat, always succeeds. Where the 
parts are too tender for a vaginal plug this method should be at once 
employed. 

If it be desired to keep up a little oozing after leeching or puncturing, 
warm douches may he given, or a glycerine tampon introduced. 

I 'nurturing and Scarifying the Cervix Uteri. Sometimes leeching tin 
cervix appears to be of less permanent good than puncturing; foralthougl 
more blood is lost by the former method, say two drachms to cad 
leech, there is more suction of blood to the part than where puncturinj 
is employed. In cases of congestion of pathological origin, with market 
blueness of the cervix, instantaneous relief is afforded by the abstraction! 
by puncture, even of two or three drachms the cervix becoming am 
remaining pink: thus it becomes evident that the circulation, which w; 

nit. h restored Puncturing is done by exposing the cervix in 

Speculum, rendering the surface antiseptically clean, and then with a long- 

handled sharp-pointed knife (Fig. 62) gently stabbing the vagina] aspect 



'/* SCALE 

Uterine scarifier. 

of the cervix These stabs Bhould he \n-y slight al first, 
indicate the tendency to bleed; they may then he increased in depth 
and number till the loas is considered suflicient. Cross cuts (scarifying] 
may he employed Instead of these punctures, or as an addition to them. 
The subsequent treatment ba as for leech bites. Such an abstraction of 
blood may be required once ;t week, tor two or three times, the effect 
being continued by drugs, hot douches, and glycerine pessaries, with rest 
and diet according to circumstances. If much congestion he present 






GYNAECOLOGICAL THERAPEUTICS 267 

cases of enclocervicitis, or endometritis, a preliminary puncturing is 
advisable before applying remedies to the lining membrane. 

7. Operations. General Measures: (i) Antiseptics. There is 
nothing peculiar to gynaecology in the rules of antisepsis, except that it 
is more difficult to ensure absolute asepsis in the vagina and endocervix 
011 account of the folds and glands there found. The importance of 
antiseptic vaginal surgery cannot, however, be too strongly insisted upon, 
for it must be remembered that there is a direct communication between 
the vulva and the peritoneal cavity, with only partially protective 
anatomical barriers at the hymen, external and internal os uteri, and 
uterine cornua. The danger, therefore, of conveying infective or septic 
products by incautious handling from a lower to a higher level of the 
genital tract is very evident. Every one has heard of septic inflammation 
following the use of a sound doubtless traumatism plus sepsis and it 
is, of course, useless to cleanse the sound well if it be allowed to pass 
through a septic vagina en route to the uterus. The sound should there- 
fore either be passed along an antiseptically clean finger, and through an 
equally clean vagina, or it should be introduced through a speculum; and, 
if there be any suspicion of taint, it is safer to pass afterwards a Playfair's 
probe armed with wool dipped in tincture of iodine or other antiseptic 
solution. No one nowadays would dream of dilating a uterus except 
under strict antiseptic precautions ; yet similar precautions are rarely 
thought necessary for the passage of the sound, where precisely identical 
risks are run. Indeed, the risk of passing a sound may be greater, 
because drainage may be very incomplete, and any infective material 
carried up is almost necessarily retained in the womb. Without anti- 
septics the most trifling operation on the generative organs may end in 
disaster ; with rigid antisepsis it seems possible to do almost anything 
with impunity. 

The subject of antiseptics may be subdivided as follows : (a) Anti- 
sepsis as regards the operator and assistants, (b) Antisepsis as regards 
instruments and sponges, etc. (c) Antisepsis as regards ligatures, sutures, 
etc. (d) Antisepsis as regards the patient, (e) Her environment. 

(a) Antisepsis as regards the Operator and his Assistants. The operator's 
(and his assistants') arms should be bared to the elbow, and he should 
be covered with a clean mackintosh apron reaching from neck to ankles. 
The hands and arms should be thoroughly washed in two basins with 
soap and water, especial care being taken of the nails. The skin should 
then be rinsed with clean sterilised water, and dried by a previously 
sterilised towel. In most cases all that is further required is to steep 
the hands for two minutes in a 1 per 1000 solution of corrosive sublimate 
solution, and allow them to dry ; but if the operation be an abdominal 
one, further precautions are desirable. Thus the hands and arms may be 
.steeped in a saturated (4 per cent) solution of permanganate of potash (the 
resulting stains may be removed in one minute by a 1 in 20 sulphurous 
acid solution or a saturated oxalic acid solution), and finally in the 
corrosive sublimate solution as above. Sanitas or turpentine, poured on 



268 



SYSTEM OF GYNAECOLOGY 






J 



the hands after an operation, renders them quite free from any offensive 
odour. Cold water removes blood from skin better than hot. 

(h) Antisepsis as regards Instruments, Sponges, etc. Instruments 
should be placed in boiling water or steamed (Fig. 63) before as well as 

after the operation, and then laid in 
a tray, similarly prepared, containing 
hot carbolic solution, 1 in 40 to 1 in 
20. Both corrosive sublimate and 
iodine solution corrode steel and 
plated instruments, and Condy's fluid, 
lysol, and creolin solution obscure the 
transparency of the water. All in- 
struments should either be capable of 
being taken to pieces and thus easily 
cleaned, or should he made out of a 
single piece of metal, handles of wood 



or bone being avoided. During the 




i-'i... 68. Steriliser for Instruments 

(Harrison Cripps). 



operation all instruments should either 
be placed again in the tray of carbolic] 
or they may be laid upon a clean 

towel, and dipped in the carbolic solution before being again used. 

Extra care must be taken to clean the eyes of needles and the rough 

surfaces and joints of needle-holders, artery and other forceps, scissors, 

and the like. It is important that instruments used at an operation 

should not be allowed to dry before being cleaned. 

in most operations sponges may be superseded by the use of antiseptic 

wool carried on holders, or made into pads or pledgets. These pads .ire 

best made by having gauze sewn round them; they should then he 

rendered antiseptic by boiling for two hours, and kept in a solution of 

carbolic acid, 1 in 20, or in sublimate solution, 

1 in 1000. Before use they are wrung dry, 

and may be employed, after careful recleans- 

ing, throughout the operation. If sponges be 

used they should be prepared as follows : 

Immediately after nsc they should he 

thoroughly cleansed till the water remains 

nnthited, and then BOaked for from two to 

four hours in four pints of warm water (for, 

say, 25 sponges), in which a handful of wash- 
ing soda has been dissolved. The sponges 

are then removed and well washed in three 

or four waters to remove Blindness, ami finally 

SOalted for twenty four hours in a mrrml 

howl, containing a 1 in 500 BUlphUTOUS 

acid 'solution, which bleaches them. After 

being well dried they are wrapped in a sterilised towel, or put away 

a large hermetically closed glass jar (Fig. 64), with a small quantity of 






' 






-H3SB1 






Flo. 64. 



-Glass jar for >poB| 
rool-pad 



GYNAECOLOGICAL THERAPEUTICS 



269 




Fig. 65. -Steriliser for 
ligatures. 



alcohol. For some hours before the operation they should be soaked in 
a 1 in 20 solution of carbolic acid, which should be diluted with equal 
parts of boiling water at the time of the operation. The nurse who 
has charge of the sponges should squeeze them thoroughly before handing 
them to the assistant operator, and during the operation they should be 
thoroughly rinsed in hot carbolic solution till free from all blood, etc., 
and then kept in the 1 in 40 carbolic solution till 
required for further use. .. , i% 

(c) Antisepsis as regards Ligatures and Sutures. 
Silk when used for ligatures may either be 
left long, as in vaginal hysterectomy, to come 
away in from five to twenty days ; or may be cut 
short and so gradually destroyed by the action of 
leucocytes after a much longer period, sixty-four 
days, according to Thomson of Dorpat. If in the 
peritoneum, they may require, according to Ball- 
ance and Edmunds, at least 500 days for their 
complete absorption. 

The best silk for internal ligation or suturing 
is China twist ; though when it gets dry, as it 
would if used externally, it tends to kink and coil. 
Floss silk is more apt to slip when being knotted. 
Silk must be used sufficiently thick to be firmly 
tied, but must not be too thick to make a deep groove in the part 
ligatured. It will also be noted that the thinner the silk the more 
rapidly does it come away or get absorbed. 

In using silk ligatures be sure that they have been efficiently 
sterilised (Fig. 65), and that they remain antiseptic. As boiling per- 
ceptibly weakens silk, after being so treated its strength should be always 
tested before use. Previous to the operation the silk should be well 

soaked in a 1 per 1000 
corrosive sublimate solu- 
tion, or in a 1 in 20 
carbolic acid solution. 
When not being used it 
may be wound on glass 
reels, and kept in air- 
tight glass bottles (Fig. 
66). 

Every operator has 
his own way of prepar- 
ing catgut and rendering 
it antiseptic. It seems 

GG.-Catgut or silk sterilised in alcohol. begt %Q g()ak {t {r ether 

(Pozzi) to remove any grease, and so allow antiseptics to enter freely 
among its fibres. Then it may be immersed for one hour in a 1 per 
1000 solution of corrosive sublimate, and afterwards rolled on glass plates 




270 SYSTEM OF GYNECOLOGY 

or cylinders, and steeped iii oleum ligni juniperj for a week, to render 

it supple and flexible; it should then be kept in a mixture of rectified 
spirit and juniper oil (10 per cent) in an air-tight bottle till wanted. 
Immediately befori being used it should be immersed in the sublimate 
solution Catgut is usually absorbed in about ten days. 

Silkworm gut 18 the most imperishable organic ligature known. It is 
bought in hunches of 50 or LOO strands, the curly ends of which should he 
cut off, and the straight intervening portions only used. These should 
be rendered antiseptic by boiling in a 1 in 20 carbolic acid solution, and 
should then he kept in long glass bottles, containing absolute alcohol, for 
preservation. Before being used they should be placed in boiling water 
to make them supple and pliable. 

Silver wire should be kept in a 1 in 20 carbolic acid solution, and 
before being used should be well polished by friction with wash leather] 
then boiled, and replaced in the carbolic solution. 

Glass drainage tubes should be boiled in sublimate or carbolic acid 
solution, and india-rubber tubing may be similarly treated for not more 
than fifteen minutes, being subsequently kept rolled up in antiseptic 
gauze, or in stoppered bottles containing weak sublimate or carbolic 
solution. To preserve india-rubber tubing, oil of all sorts, iodine, and a. 
temperature higher than 120 C. should lie avoided. 

(d) Antisepsis as regards the Patient. Although the patient is pre- 
pared for some days previous to the operation by baths, yet much remains 
to be done before the skin and other parts are really aseptic. 

.. Before Abdominal Section. There is probably far more danger to 
the patient from infection from her own skin, sweat glands, and so 
forth, than from the germs which may and do enter from the atmosphere. 
The glands open so freely on its surface that it is doubtful whether it be 
possible to purify the skin perfectly. The permanganate and oxalic acid 
method is one .if the best methods for aiming at perfection. 

After freely washing the skin, and especially the umbilicus, with 
soap and water, and subsequently with ether, to remove any fatty 
material, the surfaces should be washed several times with strong per- 
manganate of potash solution, which stains the skin of a deep mahogany 
colour. This discoloration can be removed by a 1 in 20 sulphurous acid 

solution, by a Concentrated oxalic acid solution. Or to a less perfect extent 

ftitas or turpentine. This should be done some hours before the 

Operation, and the abdomen should then he covered by a wool <>r gauze 

pad wrung out of a 1 in 10 carbolic acid solution: when this is removed 

immediately before the operation the skin should be carefully washed 
with a 1 in 1000 sublimate solution. 

fj. Before operation- on the perineum or per vaginam, the nurse 

will douche the Vagina twice daily tor two or three days with hot 

water containing tincture of iodine (1 in 150), or carbolic acid (1 in 60), 

or C01T08ive Sublimate (I in 2600); and after carefully washing the 

external genitals' and perineum, will foment them with the same sub 

limate solution. If so directed, she will also shave the vulva and peri- 






GYNAECOLOGICAL THERAPEUTICS 271 

neuni before the operation. Three hours before the operation the last 
toilet should be effected, by douching the vagina and washing the 
genitals either with sublimate, or as indicated for abdominal section ; 
and when so instructed she should clean the vagina more thoroughly by 
Manipulation and swabbing, and pack it lightly with antiseptic gauze. 

At the operation the gauze should be removed, and the vagina 
vigorously douched and well swabbed out with cotton-wool pads satu- 
rated with 1 per 1000 sublimate solution; the cervical cavity should be 
similarly treated. 

In some vaginal operations a continuous stream of antiseptic (carbolic 
or iodine) lotion may be kept running over the parts, either by using 
instruments hollowed out like a flushing curette, or by special arrangement. 
After the operation a douche should, as a rule, be given, antiseptic dry 
Bads applied to the perineum, and possibly a vaginal antiseptic gauze 
tampon also employed. Subsequent contamination by urine and faeces 
must be prevented for some days by catheterisation and careful 
cleanliness. 

(e) The Surroundings of the Patient. From the antiseptic point of view 
the room in which the operation is to be performed should be scrupu- 
lously clean ; and as a rule, whatever the nature of the operation, it is 
desirable to operate in a room apart from the ward in which the patient 
has previously been sleeping. After abdominal section the patient should, 
if possible, be in a room isolated from other wards for some days. 

The operation room should be well lighted by windows, and should 
also be provided with electric light. The walls of the room and the 
ceiling should be distempered, and its floor made of concrete or polished 
wood-blocks. For abdominal operations a room on the top floor, with a 
skylight, is very advantageous. The furniture should be scanty, and 
made of glass and enamelled iron, so as to be easily cleaned. 

If a case have shown any evidence of a septic process the ward must 
lie thoroughly disinfected, before another case is admitted, by having the 
floor and furniture washed w T ith sublimate lotion, by having sulphur 
burnt in the room with all its outlets closed, and by having its walls and 
ceilings freshly distempered. The bed-furniture should be sterilised, and 
the mattress should be destroyed. 

It is almost superfluous to add that the drainage of the house must be 
absolutely perfect, and that the water-supply, both hot and cold, must 
be pure and ample. 

(ii) Preparation of the Patient, apart from Antiseptics. When it is 
known that a patient is to be operated upon in a few days, everything 
should be done to promote the functional activity of her organs so that 
she may better withstand the ordeal of the operation, and perhaps avoid 
a tedious convalescence. 

Her diet should be light and nutritious, with plenty of non-alcoholic 
fluid to encourage the skin and kidneys to act freely. Warm baths at 
bedtime, with free use of soft soap and a brisk towelling, should be 
ordered, and the bowels should be regulated by some such mild pill as 



272 SYSTEM OF GYNAECOLOGY 

])il. coloc. cum hyoscyam. gr. iv., piL hydrarg. gr. j.. at bedtime, followed 
by a Beidlitz powder in the morning; On the morning of the operation 
the larger bowel should be emptied by an enema ; and if it be evident 
that tlu' rectum will, after all, be active during the operation, it may bf 
advisable to pass a suppository of pil. plumbi cum opio, gr. v., two hours 
beforehand 

Before the operation a good night's sleep should, if necessary, be 
ensured by means of a harmless drug, such as 30 or 45 grains of 
bromide of ammonium. 

No solid food should be administered for at least eight hours bi 
the operation, though some diluted milk, or egg and milk, or peptonisei 
raw beef juice may be given three hours beforehand. 

Immediately before the operation the patient should either pass 
water, or have the catheter passed by the nurse. 

At the time of the operation the patient should be warmly but 
loosely clothed, the exact details varying necessarily with the nature ol 
the operation. 

The bed into which the patient will be put after the operation should 
be warmed by a hot bottle, which should lie at the foot; and an extra 
blanket should be provided till the skin acts freely. 

(iii) Ancesthesia, Local and General. (a) Local Ancesthesia. Coca!' 
the agent mostly used as a local anaesthetic, both for the relief of sever| 
pain, pruritus, or other form of local hyperesthesia, and also prior 
operation, where, for any reason, general anaesthesia is contra-indicated 

Cocaine (10 to 20 per cent) may be painted on the skin or muco 
membrane, or may be rubbed on as a lanolinated ointment ; after a fa 
minutes the tissue loses all sense of contact, and becomes "wooden," 
the patient generally describes it. Minor operations, such as opening 
superficial abscess, or cutting or burning off a wart or a mole, can then 
painlessly performed ; but if the operation involve deeper incisions, coram 
should be injected hypodermic-ally, or better still, both endermically anj 
hypodermieally. To do this, three or four drops of a 2 or even a 1 
(nt solution should be used for injection in several places, at distan 
of slightly over an inch half an inch radius from each puncture being 
the /one of absolute anaesthesia produced by such an injection. This 
anaesthesia is produced in three minutes, and lasts about twenty -live 
minutes, and provided not more than twenty drops are used at one 
time, the cocaine is not likely to produce any syncope or other ill effect* 
Schleich finds that ,i '02 per cent solution produces anaesthesia ;iticr 
injection, and even distilled water has some anaesthetic effect. 

After such an injection of cocaine, operations like trachelorrhaphy 
perineorrhaphy, excision of a retention -cyst of Bartholini's gland, <> 
burning off B vascular urethral caruncle, may be performed withou 
Buffering. It has been asserted, however, that union is often less com 
plete, and repair less rapid, after operation performed with locally 
induced anaesthi 

If a caruncle be present^ anaesthesia may be desired before cat 



he- 



GYNAECOLOGICAL THERAPEUTICS 



273 



terisation, and an ointment (8 per cent) may then be gently applied ten 
minutes beforehand. A similar ointment may be useful in cases of 
vaginismus or dyspareunia from a local hyperesthesia, coitus being thus 
rendered possible. For this purpose, as also for the relief of pruritus, 
as in kraurosis vulvae, its use is, as a rule, but a temporary expedient, 
operative measures being generally needed to effect a cure. 

(b) General Anaesthesia. The choice of the anaesthetic is a subject which 
should not be solely in the hands either of the operator or of the 
anaesthetist, but the operator should state which anaesthetic he prefers. If 
the anaesthetist, after noting the type of patient, and listening to the 
heart and lungs, be satisfied that that particular anaesthetic is not contra- 
indicated, he will acquiesce ; if, however, he consider another form of 
anaesthesia to be more suitable for the particular patient, a friendly con- 
sultation would no doubt lead to the adoption of his advice. Some 
operators pin their faith to a certain form of anaesthesia as the best for 




Fig. 67. Junker's Inhale 



certain . operations ; but inasmuch as patients vary greatly, the choice 
must ultimately be . made after a consideration of the patient's state, and 
i as the responsibility finally rests with the anaesthetist, it is right that he 
1 should be always consulted and his views upheld. 

Although much depends on the skill of the administrator, it is 

: probably true that there is more bleeding during ether anaesthesia, and 

I thus, cceteris paribus, such operations as perineorrhaphy or vesico-vaginal 

' fistula are easier to perform under chloroform or A. C. E. mixture ; 

I sickness is usually more marked after ether, and spasmodic, laboured, 

: or jerky breathing is apt to be present during its administration : for 

! this reason many prefer chloroform for abdominal operations, especially 

when administered by means of a Junker's inhaler (Fig. 67), but it is 

fair to say that in the administration of ether by a few anaesthetists these 

objections are not experienced. Ether should not be used where the 

i abdomen is much distended, or where, from other, especially pulmonary 

! conditions, the respiration is laboured. In operations requiring very 

deep anaesthesia as in rapid dilatation of the cervix uteri for digital 

exploration of the uterine cavity there is no doubt that ether is safer 

T 



274 SYSTEM OF GYNECOLOGY 

than chloroform, as it can be "pushed" to a further degree without 
risk. 

After loss of large quantities of blood ether is safer than chloroform. 

The scope of this work forbids further reference to the details of the 
administration of the various anaesthetics. 

8. Therapeutical Operations. (i) Dilatation of the Uterus. This 
operation was introduced by Simpson in 1844, and may be required foj 
various purposes. Dilatation may be complete so as to admit the finger] 
or merely partial, to facilitate curetting or intra-uterine medication. 

Complete dilatation is mainly effected for diagnosis by digital 
exploration, or for treatment of some condition otherwise diagnosed. It 
ia most frequently employed for the purpose of discovering the cause 01 
an intra-uterine haemorrhage; and the dilatation must, for that object, 
be sufficient to admit the introduction of the little, or if need be, of the 
index finger of the operator. 

Partial dilatation is practised for the treatment of some cases of 
dysmenorrhea and sterility ; or prior to the application of some caustic 
or counter-irritant to the endometrium; or for the purpose of curettinl 
in cases of haemorrhage or chronic purulent endometritis, where the 
uterus is not much enlarged and digital exploration not needed. 

In all cases, however, where a diagnosis cannot be made by the 
examination of portions of the endometrium detached by the curette or 
other instrument, or where polypus, carcinoma, or other disease cannot 
be excluded by other evidences, it is far wiser to make sure of the nature 
of the case by dilating so as to admit the finger. 

Both degrees of dilatation should preferably be performed immediately 
after the cessation of a period; then the cervix is softest, and is also 
somewhat patent. This softness (p. 281) and relaxation are greatlj 
increased by the introduction of a glycerine tampon two hours beforehand 
by the nurse ; and dilatation becomes still more easy if the physician 
insert into the cervix, as described hereafter, a piece of gauze saturated 
with glycerine and iodoform about six hours before the operation. 

Methods of dilatation : 

A. (Iradual dilatation: a. By antiseptic wool or gauze, ji. By ti'iit 

B. Rapid dilatation : a. By graduate* I bougies. f3. By two or thrcl 
bladed dilators, y. By miscellaneous methods. 

C. Combined gradual and rapid methods. 

D. I )ilatation with incision. 
A. Gradual Dilatation: a. By Antiseptic Wool or Gauze. Thi 

method wras introduced by Vulliel in 1886, and is easy of execution 

if antiseptics an rigorously used, and suitable cases selected, no dang( 
should a i 

The vagina and vulva should be previously rendered antiseptic 1>\ 

douching and trashing, and the vagina temporarily distended with ai 
iodoform gauze tampon. The cervix should be exposed by a Sims' or n 
a diverging speculum, such as Griffin's (Fig. 68), disco's (Fig. 69), 
NTeugebauer's (Fig. 58, p. 263), and the anterior lip should be seized by 



GYNAECOLOGICAL THERAPEUTICS 



275 



jrolsella and held steady at a somewhat lower level than normal. The 
endocervix should then be cleansed, and the direction of the uterine canal 
ascertained by a sound ; if the os internum be found to be small, a few 
bougies may be passed. A strip of gauze, a quarter to one inch wide 




Fig. 68. Griffin's speculum. 



Fig. 



-Cusco's speculum. 



(according to the estimated size of the canal), is then dipped in carbolised 
or iodised glycerine, and is introduced by doubling it over the end of a 
uterine gauze applicator (Fig. 70). This instrument should taper some- 






Fig. 70. Gauze applicator (whalebone). 



jwhat towards the end, which should be blunt-pointed, and not so fine 
as to penetrate the gauze. Gauze may also be introduced on long, 
Inarrow-bladed forceps (Fig. 71). 




Fig. 71. Forceps to introduce gauze. 



After the cervix has been completely or even partially dilated, some 
operators prefer to tampon its cavity through a cervical speculum (Fig. 72). 
The gauze should be carried up to the fundus and the probe withdrawn, 
md more gauze similarly introduced, till the cavity is somewhat tightly 



276 SYSTEM OF GYNAECOLOGY 

packed. Vulliet preferred to dilate by wool tampons, varying in size 
from a pea to an almond, rendered antiseptic by dipping in a 10 per cent 
ethereal solution of iodoform. 

Whether gauze or wool have been used it is withdrawn after twenty- 
four hours, and the cavity carefully cleansed with sublimate swabs] 
Fresh gauze is then similarly introduced, and, after the third introduc- 
tion, the cervix will be so softened and dilated as to admit the finger. 

The advantage of this method is that it is nearly painless, but 
unless great care be taken not to injure the endometrium, it is certainly 
not free from the risk of septic absorption. As a preliminary accelerant 
of rapid dilatation it is excellent, but even then great care has to be taken 
to avoid rough introduction of the gauze. To lessen this risk of septic 
absorption through lesions accidentally made, gauze should never be thus 
used if the uterine discharges be offensive. 

If it be desired to keep the uterus patent after either rapid or slow 




Fig. 72. Cervical speculum (Bantock's). 

dilatation, as, for instance, when it is hoped to obtain the extrusion of a 
submucous fibroid whose capsule has been incised, continuous packing of 
the endometrium will usually ensure the safety of the patient in the 
frequent case of danger from sloughing of the fibroid. Such packing 
will further dilate the uterus and render any subsequent manipulation* 
easier. 

In some cases of chronic endometritis a partial dilatation and draina< 
by gauze, with the application of iodine liniment or paint twice weeklj 
whilst drainage is continued, will often cure the condition in a fortnight, 
the patient meanwhile keeping to her room. Curetting is, however, in 
most cases far preferable. 

/3. Gradual Dilatation by Tents. According to More Madden sponge 
tents were invented by Phillip Barrow in 1539 ; but the method was so 
Ear forgotten that when Sir James Simpson revived their use, in 184 I, he 
Mated that "intrauterine disease was generally considered beyond the 
pale of any certain means of detection or possibility of removal." 

The tents mostly used are laminaria (introduced by C. F. Sloan of 
Ayr in 1862), sponge, and tupelo. Gentian root and decalcified ivory 
are also used by Pprak. Laminaria tents, as sold by instrument 
makers, are unreliable as regards antisepsis; and it would he worth 
while for any gynaecologist who uses them much to collect and prepare 
his own, an easy undertaking. Sponge tents are even more difficult 
get antiseptically clean. The results of using tents not absolute! 
aseptic are most disastrous, and have caused many a death; in the pit 



GYNECOLOGICAL THERAPEUTICS 



277 



antiseptic days, acute metritis, salpingitis, peri- and para-metritis and 
septic fever were frequent consequences. 

Laminaria and tupelo tents should be steeped in a saturated solution 
of alcohol and corrosive sublimate for two or three hours, and then 
allowed to dry before being used ; sponge tents may be dipped in an 
ethereal solution of iodoform (10 per cent), and then dried by swinging 
them round by the attached string. 

Tents are mainly used as a preparatory step to rapid dilatation ; but 
they are still used sometimes for completing dilatation, and must then be 
repeatedly introduced till the finger can be inserted. I have not used a 
tent for several years, as I find rapid dilatation answers all purposes when 




Duckbill speculum (Sims'). 

used with the aids described on pp. 280, 281, but, as it is evident that tents 
are still frequently used, full details of their introduction are here given. 
After the tents and the vagina have been prepared, and the patient 
put into the Sims or lithotomy position, a duckbill speculum (Fig. 73) 
is introduced, and the cervix somewhat lowered by a sharp hook, so as 
to fix the uterus and straighten its canal. The actual length and curve 




Fig. 74. Barnes' tent-introducer. 

of the cavity is then ascertained by the sound, and the size of the tent 
which can probably be introduced is roughly gauged. A laminaria tent 
can be curved by holding it over a spirit lamp till hot. The cervix should 
then be cleansed with sublimate solution, and the tent passed either on a 
pointed introducer provided with a cannula, such as Barnes' (Fig. 74), or 
held in a suitable pair of forceps, such as Chambers' (Fig. 75). It is a 
good plan to dip the tent into pure liquid carbolic acid before inserting it. 



-s 



SYSTEM OF GYNAECOLOGY 



As large a tent, or as many small ones, as can be passed beyond the od 

internum should be inserted at once. The ends should slightly project 
into the vagina. A vaginal antiseptic tampon soaked in glycerine should 
then be inserted. The tents should be left in from eight to twelve hours 
especially the hollow laminaria ones, as they do not readily dilate to their 
full extent at the os internum, where there is greatest resistance. To 
extract a tent, all that is necessary is to draw upon the string attache* 1 to 
the vaginal end; but if the tent has not dilated well at the level of the os 
internum, forceps must be used to pull and lever it out, whilst counter- 
pressure is exerted upon the cervix by the finger. 

To admit the exploring finger into the uterus, one or often two 
repetitions have to be made. This should only be done after careful 
antiseptic cleansing both of the vagina and uterine cavity; and then as 
many fresh tents as can be introduced should be simultaneously inserted. 




Fig. 75. Chambers' tent-introducing forcepi 



If only a slight further dilatation be necessary, and rapid dilatatioi 
be not available, a tupelo tent is better than another series of laminari 
as it dilates more rapidly and more evenly, can be obtained of largej 
size, and be more efficiently rendered antiseptic. By this time, especially 
if a third series of tents have been introduced, the temperature may hav< 
risen, the patient will be irritable and restless and sometimes nauseate( 
and not in the best condition to undergo a prolonged examination for tin 
purpose of treating whatever conditions may be found. 

In the old days, when the uterus Avas always dilated with tents, it was 
not often that any condition was found which required, or at all event! 
was treated by curetting; this is to be explained by the fact that the 
prolonged pressure of three series of tents, with the application of the 
intra-uterine counter-irritants subsequently used, would destroy any ol 
the more ordinary hypertrophic fungosities found in so-called "fungoui 
endometritis,'' and would, if no accidents followed, tend to promote 
absorption of inflammatory exudations in the parenchyma of the organ 
in curetting we have now, however, a much more rapid and effectual 
method of dealing with these conditions. 

Tents should never be used if the uterine discharges are offensiv< 
the absorption of pent up putrescenl secretions may lead both to local 
septic inflammation and to ;i general septicaemia; and, even recently, 
deaths have been described as having occurred under these conditions. 
refer to such cases as cancer of the body of the uterus, sloughing polypul 
and even to some I Fungous endometritis in which the polypoid 



GYNAECOLOGICAL THERAPEUTICS 279 

villous processes of gland tissue have either become ulcerated or have 
superficially sloughed. No tent should ever be used twice. 

It must be remembered that the danger of sepsis is not over when the 
tents have been removed, as, especially with sponge tents, small pieces 
are apt to remain in the folds of the lining membrane, and will there 
decompose and cause a local absorption. It is therefore most important 
that after the withdrawal of tents some strong antiseptic should be 
carried up into the uterine cavity, such, for instance, as iodine liniment or 
iodised phenol ; and that drainage should, for twenty -four hours, be 
maintained by passing up into the uterus a thin strip of iodoform gauze 
soaked in iodised glycerine. 

Every now and again it is found that the effect of the introduction of 
a tent upon the nervous system is considerable ; the patient becomes 
extremely restless, or vomits incessantly, or the temperature rises imme- 
diately, or at all events too soon for it to have a septic origin ; a few 
cases of convulsions have been described, and one or two of tetanus. In 
one case, treated by myself, the temperature rose to 107 F. within 
thirty minutes of the insertion of the tent ; but under the influence of a 
hypodermic injection of morphia it gradually fell, and by the next 
morning, on removal of the tent, it was 99 F. ; the patient recovered 
without further trouble. Bromide of potassium is very useful to control 
this hyperesthesia and excitement. 

B. Rapid Dilatation. Dilatation by tents, except as a preliminary 
step, having now been almost universally given up, all the exploratory 
and therapeutical dilatations are performed either entirely, or in the 
main, by one or other of the rapid methods. Whereas it used to take 
from twenty-four to forty-eight hours to dilate the uterus sufficiently to 
admit the exploring finger, it is now done with far less risk in from 
twenty to sixty minutes. 

Indications for Rapid Dilatation. Rapid dilatation may have to be 
done for the treatment of some forms of dysmenorrhea, as for instance in 
some cases of the spasmodic or of the obstructive type, and especially in 
cases of membranous dysmenorrhea ; as a preliminary step to a thorough 
application of some medicament to the endometrium, or antecedent to a 
subsequent curettage ; or in some of those rare cases where, according to 
Schultze, it is advisable to dilate the uterus sufficiently to admit the 
finger, with a view to breaking down retro-uterine adhesions by manipu- 
lation, and so to perform " intra-uterine reposition." The main object of 
rapid dilatation, however, is to enable the finger to be introduced for the 
purpose of making a diagnosis of the intra-uterine condition in cases of 
uterine haemorrhage, where, in the absence of any constitutional cause or 
obvious local extra-uterine disease, a further examination is indicated. 

Assuming, then, that a woman comes for treatment, one of whose 
chief symptoms is menorrhagia or metrorrhagia, inquiries would be made 
as to any constitutional cause, and a vaginal examination would be made, 
unless contra-indicated by virginity or youth. In all cases of haemorrhage 
after the menopause, or even in cases of severe haemorrhage before that 



2 So SYSTEM OF GYNAECOLOGY 

time of life, a vaginal examination should he insisted upon to make the 
diagnosis sure. Possibly some obvious cause of haemorrhage would thus 
be discovered, such as cancer or adenoma of the cervix or vagina, adhesive 
ulcerative vaginitis, severe erosion of the vaginal portion, ulceration from 
foreign bodies, an extruding fibroid, a cervical mucous polypus, ulcerating 
procidentia, or inversion of the uterus. The possibility of a molar pregj 
nancy, a threatened, incomplete, or missed abortion, or the existence of 
a mole or an endometritis of the gravid uterus, must not he overlooked. 

A bimanual examination would further serve to limit the diagnosis, 
when the uterus might be found uniformly enlarged by subinvolution, or 
irregularly so by intramural fibroid; or some tubal or other perimetric 
disease might be found to account for the haemorrhage. If none of these 
obvious causes were discovered, the sound might be passed, whereby the 
size and shape and any considerable roughness and vascularity of the 
endometrium would be discovered. If the uterus be not enlarged, con- 
stitutional treatment may be tried; or if an ordinary endometritis be 
diagnosed in a small uterus, a partial dilatation, prior to the use of some 
counter-irritant, may be effected without anaesthesia, or after the local 
application* of a 10 per cent solution of cocaine. Even if the uterus he 
irregularly enlarged, and intra-mural fibroids be diagnosed, it must not be 
assumed that the haemorrhage, which is probably the main symptom, is 
to be dealt with by a serious operation like oophorectomy or hysterectomy, 
for, as I (25) have elsewhere shown in a series of consecutive easel 
dilated for haemorrhage 88 per cent of the cases of fibroid uterus thus 
treated contained a removable cause; that is, they were found compli- 
cated with fungous endometritis, polypus, or the two combined, and wen 
thus capable of immediate relief, so far, at least, as the immediate symptoi 
of haemorrhage was concerned. By this means the patient would oftei 
be steered safely over the menopause. 

Many cases are now on record, and others are within the knowledge of 
all gynaecologists, where haemorrhage has persisted after oophorectomy, am 
has been subsequently cured by the removal of an intra-uterine polypus 
after exploratory dilatation. 

Aids to Rapid Dilatation. There are many uteri which are difficult to 
dilate sufficiently to admit the linger, and it is impossible to decide 

beforehand which cases will prove so resistant. It used to be said that 
if it were impossible to dilate ;i cervix, this was a fair proof that il was 
affected by malignanl disease. As a rule a cervix is only materially 

resistanl if there be an intramural fibroid involving part of its circumfew 

ence, and also in some nulliparous women, but only twice in my experience 

baa this been sufficient to prevent digital exploration. There are aids to 

dilatation, rendering il easier, quicker, and less dangerous, which it is 

desirable to emphasise ; for it is rare to find that anything has been done 

to prepare the patient before tin- actual operation, except perhaps from 
the antiseptic point of view. First of all, it is infinitely easier to dilate a 
Cervix if the day following the cessation <>f a period is chosen. The 
tissues are softer, and the cervii i> somewhat patent. This was 






GYNECOLOGICAL THERAPEUTICS 281 

noted by Dr. C. H. F. Routh in 1864; recently Dr. Braithwaite has 
drawn special attention to this fact, and Dr. Herman has shown that 
this relaxation is most marked on the third and fourth days of ordi- 
nary periods ; but it is better to await the cessation of the period 
before attempting dilatation. Secondly, the cervical glands should be 
encouraged to secrete, for, as Dr. Champneys has said, dilatation is 
physiological, and the cervix has to be induced to yield. When it yields 
it also secretes, as in pregnancy and labour. When the cervix is moist it 
is dilatable ; when dry it is rigid ; and, in this latter condition, any 
attempt at rapid dilatation is generally a failure, and might cause exten- 
sive tearing. Many writers consider the best way to overcome this rigidity 
is by preliminary partial dilatation by tents ; but it is evident that there 
may be danger in this also, as well as several hours' discomfort to the 
patient. 

The cervix can be induced to secrete freely by inserting into the 
vagina, two or three hours before the operation, a wool tampon soaked in 
glycerine, or less effectually by a gelatine and glycerine pessary. The 
effect of the glycerine is enhanced by the addition of a little cocaine, 
which serves to relax local spasm, as it does in rigid cervix in the first 
stage of labour. In either case the glycerine should be applied close up 
to the external os uteri. Secretion is further helped by giving a warm 
vaginal douche of borax or creolin solution before introducing the gly- 
cerine tampon. 

If unusual difficulty be anticipated, owing to nulliparity, advanced age, 
or the presence of fibroids, additional help is afforded by passing into the 
cervical cavity, and if possible through the os internum, some gauze 
saturated with glycerine and iodoform. This may be introduced from six 
to twelve hours before the operation, which it greatly facilitates by relax- 
ing the muscular fibres, and partly dilating the canal. As has been 
stated this preliminary gauze packing should not be adopted when there 
is an offensive discharge. These " aids " practically obviate the need for 
a preliminary dilatation by tents in all but very exceptional cases. 

Methods of Rapid Dilatation. Assuming, however, that rapid dilata- 
tion has been decided upon for the purpose of making a diagnosis of the 
intra-uterine condition to which is due the hemorrhagic, purulent, and 
possibly offensive discharge, there are several ways by which this can be 
effected, namely : i. By graduated bougies j ii. By two, three, or four- 
bladed dilators with or without attached screws; iii. By miscellaneous 
instruments. 

a. Rapid Dilatation by Graduated Bougies. In England dilatation by 
bougies is preferred ; and when carefully and antiseptically conducted, it 
is free from risk, sufficiently speedy in its performance, and effectual in its 
results. Hegar's bougies were first introduced to the profession in 1881, 
but were not in general use in this country till eight or ten years later ; 
when amongst others Drs. Lewers and Phillips drew special atten- 
tion to their value. Hegar's original dilators were rather short, and 
made of polished wood or ebony ; they consequently gave rise to a good 



282 



5 YSTEM OF G YN. K CO LOG Y 



leal of friction, and were if anything too sharply pointed. To overcome 
these disadvantages Hegar's dilators (Fig. 7(1) are now made longer, and 

the metallic bougies now 
used are often made about 
the same length as a male 
catheter, with a sharper 
curve than Hegar's, and 
are constructed of hollow 
metal tubes, with ends 
somewhat less pointed. 

There are numerous 
varieties of metallicbougies, 
with varied details in the 
length, the shape of the point, the curve, the weight, and the handle. 
Among these may be mentioned those of Matthews Duncan, Galabin, 
Macnaughton Jones, Hey wood Smith, Peaslee, Godson, John Phillips, 
and Hayes. Those of the last type (Fig. 77) and Matthews Duncan's 
(Fig. 78) are probably the best. 

The best size to begin with is one with a diameter of four milli- 





KROHNE &. C LONDON 



Yu,. 



-Uterine dilators (Hayes'). 



= 



metres, and each succeeding size should vary in diameter not more thai 
one millimetre. These bougies should be numbered according to the! 
diameters. A case is occasionally met with where one millimetre seemi 
too large a difference; and it is therefore advisable for hospital use t< 
have some made with half a millimetre difference. In private, the di Hi 
culty i> overcome by giving more time, or by having always in the baj 




i-'i'.. 78. - Uterine dilator (Matthewi Duncan's). 

odelPa two-bladed parallel dilator (Fig. 83), which will speedily ovei] 
come the resistance; so that the next-sized bougie may be used. Such 
metal bou these involve very little friction, follow the pelvic ani 

uterine curve easier, and. owing to their greater length, allow greats^ 
facility of manipulation. Their points being less tapering, they also dilal 
the uterus right up to the fundus. 

With these bougies, and with accelerants to dilatation as suggests 
the usual time taken to dilate the uterus so as to admit the finger % 
about fifteen or twenty minutes. Thus I myself dilated and digitally 



GYNAECOLOGICAL THERAPEUTICS 



2S3 



explored the uterus in two patients for hemorrhage ; curetted both for 
fungous endometritis ; dilated another uterus for dysmenorrhoea, all under 
ether ; and performed another small operation under gas, in exactly sixty 
minutes, without unusual haste. 

The Operation. The patient having been duly prepared by previous 
purgation, the vagina having been douched, and all antiseptic precautions 
having been taken as already described, the patient is anaesthetised, with 
ether for choice, and is placed either in the lithotomy position Clover's 
crutch (Fig. 79) being employed to keep the legs up or else, as some 
prefer, in the Sims position. 




Clover's crutch. 



The vagina is then again cleansed with a 1 in 2000 sublimate solution, 
and the operator's hands and the instruments being prepared as stated, 
the anterior lip (the uterus being assumed to be anteverted) is seized with 
a volsella forceps, drawn downwards, and held steady. This straightens 
the uterine curve, and prevents the strain on the ligaments which must 
occur if the bougies are passed without the uterus being thus fixed. A 
uterine sound is next introduced to ascertain the exact curve of the 
uterine cavity when thus drawn down ; and then the smallest-sized bougie 
is steadily passed, so that it may not be jerked through the internal os 
uteri as its spasm passes off, and perhaps made to impinge roughly 
against the fundus. 

Some recommend that the operator should hold the volsella forceps 
whilst passing in the bougie so as to estimate the amount of force being 
used, but this is not advisable. An assistant should hold the cervix 



284 



SYSTEM OF GYNECOLOGY 



immovably, and the operator should then pass up two fingers (a speculum 
should not as a rule be used) to the cervix, and introduce the bougie along 
them; with some experience, the operator can estimate very accural dv 
how much force hi' is employing. It is important to use a volsella 
forceps which will not readily tear or cut its way out, and for this reason 
Teale's forceps (Fig. 80), which has several blunt teeth on each face, is the 
best, as it seizes the anterior lip bodily, and if the racket on its handle 
is efficient it practically never slips off. 

The time which should elapse between the passage of succeeding 
bougies varies greatly. If a bougie has been introduced with difficulty, 
time should be allowed for it to get loose by relaxation of the cer- 
vical fibres ; this can be tested by partially withdrawing it and 
feeling whether it has become looser in the grip of the os intern inn. 
Perhaps one to three minutes may be needed for this relaxation to occur, 
but as a rule a few seconds suffice. An assistant should remove the 
bougies, when the operator has ascertained that they are ready for 




forceps. 



removal, and should dip them in warm carbolic solution in case 
operator should find that the next size will not enter, and the previoj 
size be again required. By allowing an assistant to remove each bougiej 
the operator is enabled to have in his hand the next-sized bougie, ready! 
warmed and oiled, for immediate insertion. This is an important detail] 
as the spasmodic contraction of the cervix, even under deep anaesthesia^ 
is remarkably persistent, the pelvic reflexes not being annulled till aftel 
the conjunctiva] reflexes are quite absent. 

The extent of the dilatation required will vary according to the nature 
of the case. If a digital exploration be required, it is usually sufficient 
dilate so as to admit the little finger, especially if the cervix can 
drawn well down. This will enable the operator to diagnose a polypus, 
malignant disease, or fungous endometritis; bul he must not be satisfied 
till he has succeeded in feeling, if possible, the whole of the endometrium] 
including the two corona, which are favourite spots for placental polypi 
and hypertrophic endometritis. The finger can explore uteri which ;i\\ 
considerably longer than the examining finger if the other hand be us< 
to press down the fundus from over the pubes ; care being taken that th< 



be 



GYNECOLOGICAL THERAPEUTICS 285 

bladder is empty. If malignant disease be diagnosed, no further dilatation 
is required, hysterectomy being needed if otherwise indicated ; or if the 
diagnosis be uncertain, the curette or scissors will be wanted to remove a 
piece for microscopical examination. If a fibroid polypus be found, 
further dilatation may be needed to admit the scissors, forceps, or wire 
ecraseur along the finger. If fungous endometritis be detected, a curette 
can be at once used. If a bit of placenta be found, it may usually be 
detached by the finger-tip. 

Sometimes the diagnosis of fungous endometritis is made after the 
passage of a few bougies, by pieces of characteristic material coming away ; 
but it is only safe to accept this as the sole condition in small uteri, as it 
is not unusual to find this state of the endometrium complicating both 
submucous fibroid and polypus. 

It is evident that the amount of dilatation for exploratory pur- 
poses really depends upon the size of the operator's little finger, or 
rather upon the size of the second joint of that digit ; and this is a matter 
of considerable moment, as fingers vary several millimetres in diameter, 




Fig. 81. Budin's tube. 



and any risk to the patient is necessarily proportional to the amount of 
dilatation required. It is for this reason that diagnosis should be made 
by the little finger, and not, in cases of rigid cervix at all events, by the 
index finger. Usually the fingers of the left hand are smaller than those 
of the right. 

Whatever be the object of the dilatation, and whatever be the subse- 
quent procedure (curetting, removal of polypus, etc.), it is advisable to 
apply to the endometrium some strong antiseptic counter-irritant, such as 
iodine liniment or iodised phenol, on a Playfair's probe, which should be 
covered with as much wool as will easily enter the dilated cervix. 

To permit free drainage, and prevent uterine colic following the 
application of the iodine, a piece of iodoform gauze should be passed up 
to the fundus in the manner previously described, and should not be 
removed till next morning when the vagina will also be douched. 

Some operators prefer not to apply any antiseptic after dilatation, 
unless purulent endometritis is present, or the discharge indicates the 
existence of a septic intra-uterine condition. It is advisable, however, if 
this be not done, and if a flushing curette be not subsequently used, to 
wash out the uterus thoroughly with iodised or carbolised water at a 
temperature of about 118 F., by means of a double-channelled tube of glass 



286 SYS TEM OF G } \Y. & OOLOGY 

or celluloid, such as Budin's (Fig. 81), or Graily Hewitt's glass tube 
(Fig. 82), or a metallic one, such as Bozeman-Fritsch's. 

The Dangers of Rapid Dilatation. The risk of rapid dilatation is very 
small if carried out thus. There is hardly ever any subsequent pyrexia! 

if there be, it is almost always in cases where malignant disease has 




Fia. 82. Graily Hewitt's uterine tube. 

been diagnosed, and then probably arises from septic absorption. In 
cases of tubal disease there is sometimes a little inflammatory reaction ; 
but if free drainage be provided this soon passes off, and any chronic 
salpingitis, which existed as a sequence to the concurrent endometritis. 
often disappears within a few weeks (C. H. F. Eouth, Doleris, Trelat). 
"Lumps in the pelvis," such as are due to ovarian congestion or swollen 
tubes, are not necessarily contra-indications to rapid dilatation, for slow 
dilatation by tents would be more risky (see curetting). 

If by some accident such as roughness on the part of the operator. 
or, as more often happens, in extreme softness of the uterine tissues. 
as in some cases of subinvolution, or where the tissues are friable as 
in carcinoma perforation of the uterus has occurred, serious results 
may not follow, provided that antisepsis has been thorough, and 
recognition of the accident immediate. The proper treatment in such 
cases is to cease further dilatation, and after cleansing the vagina and 
endocervix, lightly to pack the uterine cavity with gauze. In a few 
hours lymph will have covered over the perforation, and probably no 
symptoms beyond some sickness will ensue. All cases of perforation do 
not terminate thus satisfactorily, but these are either in themselves septic 
or antiseptics have been neglected j or the accident has not been recognised, 
and more bougies have been passed, possibly even a curette used, and the 
bowel injured. Fortunately such accidents are very rare, but the possi- 
bility of the uterine tissue being extremely soft must be kept in mind. 
If it he realised that the perforation through the uterus is extensive, or 

the Uterine contents Septic, Or that the bowel have Come down into the 
uterine cavity, the abdomen may he opened ; and if the rent cannot he 

sutured, hysterectomy should be performed : some operators would at 
once proceed to perform vaginal hysterectomy, being particularly careful 
to ensure subsequent good drainage by gauze. 

If the cervix he rigid, slighl laceral ions of the mucous membrane 
usually occur, and occasionally when the exploring finger is introduced 

rather deep splits are found, usually on the left side: but in a series of 

several hundred oases I have never seen permanent mischief result, or 

even inflammatory troubles follow. Such tears seem to commence at the 









GYNECOLOGICAL THERAPEUTICS 



287 



level of the os internum, and may be suspected if a bougie pass easily 
after the preceding smaller size entered with difficulty. 

Occasionally haemorrhage suddenly arises during a dilatation, as for 
instance when a piece of placental polypus becomes detached, appearing, it 
may be, at the os externum when the bougie is withdrawn. In such a case 
the haemorrhage is sometimes alarming, and time cannot be wasted by 
attempting further dilatation with a view to explore with the finger 
though it may be worth while to pass in the curette and rapidly scrape 
the endometrium -to remove any more placental tissue, and thus encourage 
retraction : but if the haemorrhage persist, as it probably will, the uterus 
should be plugged at once with antiseptic gauze, and the plugs retained 
in utero for twenty-four hours, by which time the uterus will be sufficiently 
dilated to admit the finger if necessary. The haemorrhage appears to be 




Fig. 



-Goodell's two parallel-bladed dilator. 



arrested by pressure and by the blood coagulating readily upon the gauze 

j fibres, and not, at all events, solely by the uterus being excited to con- 

I tract by the presence of a foreign body : for it is evident that even if 

contraction and retraction of the muscles at the site of the haemorrhage 

be the immediate effect of the gauze -packing, a secondary effect is a 

further passive dilatation and relaxation, and yet haemorrhage does not 

i then recur. 

[3. Kapid Dilatation by Two or Three-Bladed Dilators. There are 

j some who prefer this type of dilator, but none of these instruments has 

met with universal approval, owing to the irregular way in which they 

dilate, the time occupied by the process, the more frequent failure, and 

j the greater tendency to tearing of the cervix. There is, however, a great 

1 advantage in having one of these instruments at hand when dilating with 

bougies, as it occasionally happens that the operator finds it difficult to 

pass the next-sized bougie, or possibly a particular bougie may have been 

forgotten. The possession of a dilator of this type, like Goodell's, is then 



2SS 



SYSTEM OF GYNAECOLOGY 



most opportune, and its employment will enable the further dilatation to 
be made with the other bougies. 

The preliminary steps are identical with those required for dilatation 
by bougies, both as regards antiseptics, anaesthesia, and the position of 




Pio. 84. Uterine dilator (Ellinger's). 

the patient. The cervix must also be seized and steadied, and the uterus 
drawn down ; it is advisable to use a duckbill speculum, so as to introduce 
and screw up the dilator by the aid of inspection. The best instrument! 
are Goodell's (Fig. 83), or Ellinger's two-bladed dilators (Fig. 84), or 
Sims' three-bladed dilator (Fig. 85). The two former are the best, as 
they dilate by parallel blades. 



x#H 




Pick 85. Sims' three-bladed dilator. 

For the employment of all these instruments the cervix should 
somewhat patent; and if it be found that they cannot enter the cen 
above the os internum, a smaller-sized dilator, such as Palmer's two blad 
dilator (Fig. 86), should be first used, or a few bougies passed The m 
important precaution in dilating by these instruments is to avoid sere 
ing n|) the blades in one diameter of the cervix only. They should 
opened rery gradually in the transverse diameter first, then unscrew 
and rotated, and again opened in another diameter, and so on till disten- 
tion of the muscle fibres has been uniformly effected all round. In a sol 
relaxed cervix dilatation can be easily effected by this means; but in t 
rtulliparoua rigid cervix complete dilatation is often impossible, or, i 

ible, open to serious risk. 

Iii cases of dysmenorrheas^ where moderate stretching is to be effee 
as a method of treatment, dilatation by these instruments is fairly satis- 
factory; and if it be desired to attempt a partial dilatation without 
anaesthesia, a small-bladed instrument like Palmer's, Priestley's (Fig. 8 






GYNAECOLOGICAL THERAPEUTICS 



289 



or Collins' may be passed in, and a few turns given to the screw. Some- 
times great improvement follows as regards the pain and sickness usually 
accompanying the period, which should not be more than two or three 




//E.scalc 

Fig. 86. Palmer's two-bladed dilator. 



Fig. 87. Dilator 
(Priestley's). 




F10. 88. Uterine dilators 
(Reid's). 



days distant. The danger of such a partial proceeding is that there is a 
risk of neglecting complete antisepsis, and serious inflammation might 
then follow. There are many instruments on the same principle, such as 

u 



igo SYSTEM OF GYNECOLOGY 



Gardner's, Wathen's, Buck's, Simpson's, Pearson's. Some of these ari 
worked by hand-pressure, some by screws. 

y. Rapid Dilatation by Miscellaneous Instruments. Such instruments 
are numerous. A tew will suffice as types. Dr. Keid of Glasgow has 
invented a conical screw dilator, with different - sized screws. They 
answer well in the inventor's hands, or when his instructions are 
followed ; but his method is not satisfactory in cases of rigid or indurate! 
cervix, as unless the tissues yield readily the biting of the conical screws 
causes abrasion <>f the lining membrane. Mr. Lawson Tait, again, lias some 
conical dilators, which are, however, only "rapid" when compared with 
tents, for two or three hours at least are required for each sized conical 
wedge to do its "work. They are cones fixed to a vaginal stem or holder 
attached to elastic hands, which pass up, two in front and two behind, to 
he fastened to a belt or waistband. By regulating the tension of these 
bands the direction and amount of pressure can be arranged ; but inasmuch 
.is these details require careful watching and readjustment, the method is 
only suitable for hospital work, and it is clearly capable of causing 
dangerous upward pressure if by any accident the bands are not loosened 
when the dilatation of the cervix is completed. Fritsch has also in- 
vented some conical dilators, to be used manually just as the graduated 
bougies are used. 

More Madden's dilator is two-bladed, but instead of dilating equally 
along the cervix, it dilates from its upper end, where the ends moa 
diverge; so that the uterus is dilated first, then the os internum, ail 
gradually, as the instrument is drawn out, the endocervical canal beconou 
stretched. It is no improvement upon such instruments as Goodellj 
two-bladed dilator. 

Duke's two-bladed dilator has a more decided curve, and its blades 
which open by a powerful screw, are conical in shape. 

Reverdin uses a two-bladed dilator with one blade hollowed out f< 
flushing, and he states that dilatation is accelerated by the continuoi 
flow of a warm antiseptic solution. 

C. Combined Gradual and Rapid Dilatation. After failing to dilat 
the cervix to the "exploratory" size by rapid dilatation, it is uol safe to 
continue the dilatation with tents until the abrasions have healed. The 
mucous membrane Is necessarily torn here and there after such a trial, 
and septic absorption is very prone to occur. In such a case the best 
plan is to antisepticise the endometrium thoroughly, and then to pack the 
cavity gently but firmly with 10 per cent iodoform gauze, as before 
described. This will efficiently dilate the uterus in twenty four hours 
without any appreciable risk. 

Previous to rapid dilatation in nulliparous women, it is the routine 
custom of some operators to dilate the cervix partially overnighl by meai 
of tents, preferably laminaria. This undoubtedly softens, and begins 
dilate the cervix, but is rarely necessary, as it usually gives the patiei 
;i \.-ry uncomfortable night ; and if the aids to rapid dilatation describe 
on page 280 be made use of, this preliminary dilatation can be dispense! 



GYNECOLOGICAL THERAPEUTICS 291 

with, or accomplished much more safely, with far less discomfort and 
quite as effectually, by stuffing the endocervix with gauze, as described 
on page 274. 

D. Dilatation with Incision. Occasionally the os uteri externum 
remains rigid, while the rest of the cervix has become relaxed and 
dilatable ; it may then become necessary to divide the rigid rim bilater- 
ally. A common instance of this is where an intrauterine polypus has 
partly extruded, and has fully dilated the whole cervix, except a 
rim of rigid tissue at the os externum. Here a slight notch on each side, 
the loss of a little blood, and the yielding of the rigidity, will afford suffi- 
cient space, and dilatation can then be proceeded with. 

Incisions for this purpose, and for the division of the os externum in 

of pinhole os and conical cervix, may need to be somewhat more 

than mere notches. Then Kiichenmeisters scissors (Fig. 89) should be 




FlG. 89. Scissors, uterine (Kiichenmeister's). 



used instead of ordinary scissors or bistouries. Kiichenmeister's scissors 
have a probe-pointed blade which is passed into the cervical canal, and a 

I hooked blade which grips the cervix on its vaginal aspect and prevents 

; its slipping, and so dispenses with the use of sharp hook or volsella 
forceps. The extent of the desired incision is regulated by the distance 
of the hooked blade from the external os uteri, as this blade is the 

, cutting one. 

In all cases where a mere temporary dilatation is needed, the incision 
should be sewn up at once with wire or silk-worm gut, lest ectropion and 

i chronic endocervicitis may ensue. 

Incision by means of a Paquelin's cautery, or the galvanic cautery with 
the platinum terminals brought to a dull red heat, is very efficacious in 
preventing haemorrhage ; and it may advantageously be used when it is 
desired to prevent rapid reunion of the incised cervix, as, for instance, 
when the os uteri externum has been divided for "pinhole os." The 
cautery, however, should never be used to incise the internal os uteri or 

j the cervix high up, where the branches of the uterine artery may be 
found, as, even if it prevent haemorrhage at the time, secondary haemor- 
rhage is very likely to occur ; and owing to the necessary sloughing, 
perfect asepsis at that level is very difficult to maintain. If it is desired 
to prevent closure of the incision, and the cautery has not been employed, 



292 SYSTEM OF GYNAECOLOGY 

the raw surfaces should be touched with iodine liniment; and a piece ol 

gauze, soaked in iodised glycerine, should be kept in the cervix for some 
days, beyond the upper limit of the cut, being changed of course daily, 
and a vaginal douche given at the intervals. 

If haemorrhage be severe, it may usually be arrested by plugging the 
cervical cavity with gauze ; or the bleeding point may be touched with the 
actual cautery, though, as has just been stated, this lias its disadvantage^ 
If this do not arrest the bleeding, the uterine artery, or the branch going 
to the cervix, must be tied. 

In those very rare cases where, owing to the failure of a rapid dilata- 
tion, hysterotomy to the level of the os internum has been decided upon, 
it has been very strongly recommended by such authorities as Schroeder, 
Martin, and Pozzi that the uterine artery, or rather the large branch 
which enters the cervix at the base of the broad ligament, should be tied. 
This can be done by a curved needle, which should be entered precisely 
as when the artery is tied for vaginal hysterectomy, except that there i> 
no need to divide any mucous membrane before passing the needle. After 
reuniting the incisions in the cervix, or at all events after the lapse of 
twelve hours, the ligatures should be removed to prevent ulceration of the 
mucous membrane where it was included in the knot. If this preliminary 
ligation of the arteries were efficiently performed, the greatest danger of 
the operation, that of death from primary haemorrhage, would be entirely 
obviated. The danger from sepsis has, of course, to be otherwise combated. 

After such an "high" operation it may be advisable to introduce a 
stem pessary, such as Meadows' glass stem, till healing is completed 
With rest in bed and perfect antisepsis this ensures free drainage. Fo 
this "high" operation Kiichenmeister's scissors, which can only cut to the 
level of the vaginal vault, are not suitable; for the cervix need not be cu 
through from its cavity into the vagina except at the os externum 
Practically the simplest plan is to dilate the cervix partially, and then 
to incise the neck of the uterus at the desired level, and to the desire* 
extent, by means of a Sims' knife (Fig. 90) set at a suitable angle, or bj 




Fk.. DO. Sims' metrotome. 

light probe pointed bistoury, whieh can be easily introduced if I he 
uterus be drawn down by a vulsella. 

Formerly single hysterotomes, such as Simpson's or Priestley's, were 

Used, but they have no advantage Over ;i probe-pointed bistoury, which is 

ifer than the double hysterotomes, such as Greenhalgh's and its 
modifications (fi or Peaslee's), all of which are apt to cut mod 

deeply OU the side where there is leflS resistance, and have been the caua 

of most of the disasters to which the operation has led. 

ii. Curettin<! tin- Uterus.- Curetting was introduced by Re'camier it 
1843. and was so vehemently opposed that it fell immediately into di 



G YNsE COL GICAL THE RAPE UTICS 



293 



repute, though in 1850 Recamier was still advocating his curette for the 
"removal of intra-uterine fungosities," which he had discovered to be 
often the cause of obstinate metrorrhagia. In 1846 Sir Charles Locock 
described his scoop for the removal of malignant nodules, and soon after- 
wards Simon's scoop was also recommended. In 1861 C. H. F. Eouth 



Fio. 91. Simon's uterine scoop. 



somewhat modified Recamier's curette, and read a paper to the Obstetrical 
Society of London, giving three cases of metrorrhagia cured by its use after 
a diagnosis had been made by slow dilatation and digital exploration. In 
1866 Sims introduced his sharp curette with a malleable handle. This 



Fig. 92. Sims' pliable curette. 

continued to be the favourite curette till about 1874, when Thomas intro- 
duced, and Munde strongly advocated, a "dull curette of flexible copper 
wire," and this was used almost universally in America for some years. 
In the same year Hegar, Kaltenbach, and Olshausen brought its use 
prominently into notice in Germany ; and in France, Trousseau, Nelaton 
(1861), Maisonneuve, and Nonat (1869) had occasionally made use of it. 
In England it was long in coming into favour, for in spite of its occasional 
use, as stated above, it was opposed at first by such men as Barnes and 
Atthill, though in 1873 the former, and somewhat later the latter, advised 
its use in serious cases. 

With such well-known gynaecologists as Courty (1866), Scanzoni 
(1861 to 1865), Thomas (up to 1871), Schroeder, and Colucci (1877) 
writing against the use of the curette, it is not surprising that very 
little progress was made ; and in spite of the recommendation of many 
strong advocates, it is probable that it would never have become so uni- 
versally employed as it is now if the era of antiseptics and of anaesthetics 
had not made it both safe and easy of execution. 

Indications for Curetting. This operation may be used merely to 
make a diagnosis of the state of the endometrium, by scraping off a small 
piece of the mucosa for microscopic examination. For such a purpose 
a small exploratory curette can be used without previous dilatation. 
Curetting is done both for hypertrophic and atrophic endometritis. It 
is done also for cases of septic or infective endometritis, with their resulting 
purulent discharges, in order to prevent sequential tubal and periuterine 
complications from extension of the inflammation. Whether the process 
advance through the tubes, or through the lymphatics of the uterine 
tissues, the result is very serious, and a timely curetting may prevent 
such disaster. 



294 6" YSTEM OF G i \W E COL OG Y 

I.' I'M if the periuterine tissues be already involved, it is good practice 
to remove the infective focus in utero by an efficient curetting \ and if it 

be considered necessary to open the abdomen and deal with some serious 
condition there which has followed the endometritis, it is right to curette 
the uterus beforehand or simultaneously. In many cases the perl 
uterine exudation, whether in tubes or peritoneum or as phlegmon in 
the cellular tissue, will disappear after a careful curetting and packing of 
the uterus with gauze to ensure tree drainage ; and unless an abdominJ 
section be clearly necessary, this minor operation should be first tried 
The time will almost surely come when the practice will be to curette 
the uterus, or otherwise cure the endometritis, in all cases of tubal or 
peritoneal inflammation of uterine origin, in which there is no absci 

Sometimes an endometritis exists with haemorrhage as its chief 
symptom. This is usually hypertrophic and adenomatous in nature. Foj 
this state also curetting is indicated. 

Curetting is also needed for the removal of placental or membranous 
debris retained after labour or abortion. Such a condition is almost the 
only indication for a blunt curette, for the uterus may be \cvy soft : but 
in such cases the cervix is generally so patent, or so easily dilated, that 
the insertion of the finger involves no difficulty, and the piece of retained 
placenta or other matter can almost certainly be removed by the finger- 
tip alone. If, however, the discharge be septic, and especially if genera 
septicaemia be setting in. a deep and thorough curetting of the whole 
endometrium is imperatively necessary if the patient's life is to be saved 

Varieties of Curettes. Curettes should be provided with soi 
arrangement of the handle or shaft to prevent rotation, and to enabj 
the operator to know which is the sharp and which the blunt n\^v 
the end. Some curettes have a sharp loop at one end, and a blunt 
the other; and as these loops are on opposite faces of the shaft, tin 
outside end gives sufficient indication of the direction of the intra-uteriia 
end. Some curettes have loops of different sizes or curves at the tw] 
ends. Amongst such are Gervis' (Fig. 93), Kecaniiers (Fig. 94), an< 

^ APNOLDASONS LGNDUN 

Fio. 08. Doable uterine curette (Gervi**). 

that used at St. Bartholomew's Hospital. The firsl is sharp-edged, 
the Becond is blunted : all are excellent instruments, but it is desirable 




in ., 

I H imier'a curette 



to have at least one end of the Recamier's curette sharpened forded 
curetting. For scraping a way the friable tissues of a malignant growth- 
as a palliative measure, or preparatory to a radical operation Volkmannl 



G YNsECOL OGICAL THERAPE UTICS 



295 



or Thomas's uterine scoops (Fig. 95) are better than ordinary curettes. 
Bell's dredging curette (Fig. 96) is also very useful in malignant cases, 



*E.- 



"""- 







ARNOLn 8 SDKS LONDON 

Fig. 95. Uterine scoop, or spoon saw (Thomas's). 

especially where the cervix is too friable to be grasped with the vol- 
sella forceps, and an intra-uterine diverging tenaculum has to be used. 
In such a case Bell's curette will clear a way along the uterine cavity, 
so as to admit the tenaculum, better than any other instrument. It 
is not so suitable for ordinary curetting unless the uterine cavity be 
normally regular in outline ; though much may be done, by outside supra- 



Pio. 96. Dredging curette (Bell's). 



pubic pressure, to bring the different parts of the endometrium in contact 
with the instrument, which has other advantages, and can be constructed 
with a hollow shaft for flushing purposes. Jessett's watch-spring dredg- 
ing curette is more dangerous, but is otherwise on the same lines. Both 
these instruments leave too much to chance, and most operators would 
therefore prefer an ordinary looped . curette, which is more generally 
useful. 

Flushing curettes that is, curettes with the shaft hollowed out from 
the end of the handle to the space within the loop of the scraping end 
are very useful, and may be made like Duke's, with the shaft only partly 




p IG . 97. Uterine flushing curette (Auvard's) 



hollowed; or like Auvard's (Fig. 97), with a place on the shaft in which 
to dip the pulp of the index finger to secure steadiness ; or like Routh's 



C^ 



^p^ 




^y=& 



Fig. 9S. Routh s flushing curette. 



(Fig. 98), which is longer in the shaft, has the tubing attached to the 
extreme end of the handle, and, half-way along the shaft, has a flat plate 



296 SYSTEM OF GYNECOLOGY 

to lie in the palm of the hand to steady the instrument and prevent 
rotation. 

The Operation of Curetting. It may be assumed that dilatation has 
been performed, that sufficient exploration of the uterus, by sound, 
exploratory scraping, or insertion of the finger, has been made, and that 
curetting is indicated. 

The patient should be in the lithotomy position, both to facilitate the 
operation and to permit a perfect irrigation. The cervix is steadied and 
lowered as in rapid dilatation, and the largest-sized curette which will 
readily enter is passed up to the fundus, and then withdrawn with the 
sharp edge against the mucosa. This is repeated all over the intra] 
uterine surface. Special care is taken at the two cornua, as clumps of 
hypertrophic tissue are apt to collect there; to get at them it may bj 
necessary to use a smaller curette, or one with the end set at a dine rent 
angle. The cervix also should be subsequently curetted. In curetting 
pressure with the sharp end should be firm and equal ; and in going <> wi- 
the surface again to make sure (if possible) that all of the mucosa lias 
been removed, it will be noted that if the curette cause a grating feeling 
or sound, it indicates that the mucosa has already been removed ; I nit if 
no such sensation is produced, the lining membrane is still intact at that 
spot, and needs further attention. 

After Treatment. The uterus should be washed out with an antiseptic 
douche at about 118 F., if no flushing curette has been used ; and then 
its rawed surface should be painted freely with iodine liniment, carried 
up through a speculum on a probe armed with plenty of wool. In any 
case where septic or infective endometritis exists, the uterus should then 
be packed with iodoform gauze to encourage free drainage; if further 
intra-uterine treatment be indicated, the gauze, which should be removed 
in twelve hours, should be replaced, and the uterus kept patent. If there 
should be severe haemorrhage this packing should also be resorted to, 
done however more tightly, with a firm vaginal tampon below. In this 
latter case the uterine tampon may be left in for twenty-four bonis. In 
most cases antiseptic douches are advisable for the first week, after which 
time the patient may get up and may resume her ordinary duties in 1 
fortnight. 

iii. Alternatives to Curetting. Excluding serious operations like hyster- 
ectomy, always unjustifiable in cases where curetting is an alternative, 
these cases of endometritis must either be treated palliatively by < met ting 
or by some escharotic. 

Minor palliative methods have been described under the head 
intra-uterine medication, and dilatation by gauze-packing, and need not 
here be again referred to, except to say that, as stated on page 276, 
of the mild and uncomplicated cases of endometritis will yield to them. 

Treatment by BScharotios, such as chloride of zinc nitric acid, oi 
electricity with strong currents, involves the formation of extensive 
sloughs, the depth of which cannot be regulated. Such a slough is 
a danger, and, as the surface of repair which is left has very litth 



GYNECOLOGICAL THERAPEUTICS 



297 



protective epithelium to defend it against the passage of pathogenetic 
germs, the slough is thrown off by suppuration, and an atrophic endo- 
metritis results. Curetting, therefore, preceded by dilatation and followed 
by gauze-packing, is by far the safest method of treating these cases ; 
and when repair begins, the uterus is relieved of the septic process. 
As Baldy says, " new leucocytes and plasma cells are not forced to exercise 
their phagocytic properties by battling with pathogenic germs, but the 
plasma cells have a healthy pabulum, and devote their entire energy to 
the work of regeneration, which is not merely non-suppurative repair, 
but is histological growth." 

Reproduction of the Endometrium. After a thoroughly antiseptic 
curetting the endometrium is reproduced in about two months, that is, 
between the second and third catamenial periods following the operation. 
After destruction of the endometrium by acids or other escharotics, 



a 



h 



c 




Fig. 



99. Vertical section three months after curetting, a, Epithelium ; b, new-formed glands ; c, 
connective tissue ; d, muscular tissue of the uterine walls ; v v, blood-vessels. (From Baldy's Text- 
Book of Gyncecology by kind permission of the editor of the Nouv. Archiv. d'obstet. et de gynecol.) 



suppuration ensues, with the formation and separation of a slough ; and 
the endometrium is very imperfectly re-formed after the lapse of three or 
four months. In both cases the mucous membrane is re-formed mainly 
from the cells of the connective tissue which covers the muscle layers of 
the uterus ; but there is an essential difference in the new membrane 
formed under these circumstances. After chloride of zinc paste has been 
used the connective tissue layer is much injured, and may be destroyed ; 
for the action of this caustic is very uncertain, and may, as is desired by 
those who use this agent for cancer of the uterine body, lead to destruc- 
tion of the muscle also. 

After curetting, the connective tissue is rarely injured ; and in addition 
to this, it is more than probable that the most skilful operator would 
almost invariably leave islets of mucosa from the edges of which new 
epithelium would spring. The bases of many of the uterine glands also 
dip down so far, some even into the muscular layer, that they certainly 



298 



SYSTEM OF GYN. ECOLOGY 



would not be reached even with a sharp curette, and they may therefore 
be additional Bourcefl of epithelial regeneration. 

Sections of a uterus taken three months after curetting show 

99) under the microscope healthy ciliated epithelium, with newly] 

formed glands dipping down into the connective tissue, which is richly 










1 v rtical flection of the uterine macoiu membrane fifty-five days after the application of I 
I Ithellum ; b. connective tissue; c c, section of the -lands which have undi 
aeration; </, tabular glands enormously dilated; m, musculai tissue of the uterine 
wall. (From Bftl of Gynecology by kind permission of tl litor of the Nnuv. Archiv. 

d'obsfit, it ill /;/). 

supplied with blood vessels. In other words, the endometrium is 

absolutely normal. This happy result can only be expected when no fivdi 

infection of the parts baa meanwhile occurred, and when suppuration has 
been absent. On the other hand, microscopical sections of the uteri 
following the use of chloride of zinc (Fig. 100) show an imperfect non- 
ciliated epithelium, greatly exaggerated connective tissue, and a fei 
partially -formed glands, which do not open on to the surface of On 
endometrium, but ar.- mostly distended into small cysts from blockin| 



G YN.EC0L0G1CAL THE RAPE UTICS 



299 



of their surface orifices. The condition is, in fact, one of chronic inter- 
stitial endometritis, with its accompanying atrophy of the epithelial 
elements. 

Pregnancy after the use of an escharotic, used as assumed above, is 
very rare. After curetting it is, however, very common, and indeed, in 
suitable cases, this operation has cured many women of an obstinate 
sterility. Heinricius collected statistics of this, and showed that out of 
52 patients, whose history after curetting he was able to learn, 16, or 30 
per cent, conceived ; he states that pregnancy commenced in two cases 
five weeks, and in one case eight weeks after the operation. 



Amand Kouth. 



REFERENCES 



1. Allbutt, T. Clifford. Goulstonian Lectures, 1884. 2. Auvard, A. Traite 
Prutiqw de Gyncec. 1894. 3. BALLANCE and Edmunds. Treat, on the Ligation of 
Artrrirs, 1891, pp. 259 and 271. 4. Baldy, J. M. Text-Book of Gyneec. 1894, p. 227. 
5. Barnes, Robert. Disease's of Women, etc. 6. Bbaithwaite, James. Brit. 
Bled. Jour. June 29, 1895, p. 1438. 7. Champneys, F. H. Med. Soc. Trans, vol. xv. 
1892, p. 374. 8. Dickenson, Dr. R. L. Amer. Jour, of Obstet. Jan. 1895. 9. Doleris. 
Nouv. Archiv. (V obstet. et de gyn. vol. vi. p. 401. 10. Ferria. Gazetta Mcclica di 
Torino, Dec. 13, 1894. 11. Goodell, William. Lessons in Gyncec. p. 98 ; Med. 
Gyncec. 1895. 12. Head, Henry. Brain, vol. xvi. 1893, pp. 1 to 134. 13. Hein- 
fcicius. Gyncec. og Obstet. Med. vol. vi. Xo. iii. p. 134. 14. Herman, G. E. Obstet. 
Woe. Trans, vol. xxxvi. 1894, p. 250. 15. Lewers, A. H. N. Lancet, 1891, p. 1119. 
16. Malcolm, J. D. Med. Chir. Trans, vol. lxxi. 1888, p. 43. 17. Martin, A. 
Path, und Ther. der Fraucnkr. 1887, p. 26. 18. More, Madden. Brit. Med. Jour. 
1884, vol. ii. p. 1068. 19. Olshausen. Cent, fur Gynaec. July 1888. 20. Pesbeb, 
De. Annal. de Maladies des Org. Oen.-urin. Jan. 1894. 21. Phillips, John. Lane. 
1887, vol. ii. p. 507. 22. Pozzi, S. (Syd. Soc.) Treat, on Gijncec. 1888, pp. 31 and 141. 
23. Rousing, Theodore. Hosp. Tidcnde, Feb. 7, 1894. 24. Routh, Amand. "Rapid 
Dilat. of Uterus," Med. Soc. Trans. 1892, p. 347.-25. Routh, C. H. F. " Conserv. Surg. 
in Pelv. Dis.," Med. Press and Circ. May 1894. 26. Ibid. "Cases of Menorrhag. 
treated by the Gouge," Obstet. Soc. Trans, vol. ii. 1860, p. 117. 27. Schroeder. 
Keitsch. f. Geb. mid Gynak. 1881, vol. vi. p. 29. 28. Schultze, B. S. Displace- 
ments of Uterus (trans, by Dr. Macan), p. 222. 29. Sloan, C. F., of Ayr. Glasg. Med. 
Jour. vol. x. 1862, p. 281. 30. Tait, Lawson. Bis. of Ovaries, 4th ed. p. 309; 
Brit. Med. Jour. May 15, 1886, p. 921. 31. Thomson, H. F., of Dorpat. Cent, f 
Gyncec. vol. xiii. 1889, p. 409. 32. Trelat. Annal. de gyn. et d' obstet. Paris, May 
1891. 33. Treves, F. Lcttsom : Led. Med. Soc. Trans, vol. xvii. 1894. 34. Vulliet. 
Wouv. Archiv. cVobstel. et de gyn. 1886, p. 693. 35. Ibid. Lecons de gyn. operatoire, 
1890, p. 78. 36. Wright, A. E. "Methods of Increasing the Coagulability of the 
Blood," Brit. Med. Jour. July 14, 1894. 

A. E, 



300 S YSTEM OF G YN.-ECOLOG Y 



THE ELECTRICAL TREATMENT OF DISEASES 
OF WOMEN 

THE successful employment of electricity in the treatment of the diseases 
of women is of very recent date. General attention was drawn to it in 
1886, when Dr. Georges Apostoli of Paris published the results of five 
years' experience of its use in this class of cases, and at the same time 
gave a full account of the method by which he carried it out. That the 
method was new admits of no discussion. No doubt many attempts had 
been made in previous years to utilise electric energy in some form or 
other for this purpose ; but the knowledge of these attempts was of value 
to Apostoli only in so far as it showed him what to avoid. 

The limits of this article do not permit me to review the efforts of 
earlier workers in this field ; and, indeed, but little purpose would be 
served by such a review. We may take it that the present position of 
electricity in gynaecology is simply this, that it consists of the application 
of Apostolus methods with such slight modification of details as ha- been 
suggested by the experience of workers following on his lines. 

I purpose in the following pages to consider this subject under t ! 
heads: 1. The armamentarium, or instrumental equipment, required in 
gynaecological electro- therapeutics. 2. The modes of making the appli ca- 
tions. 3. The modes of action of the current. 4. The diseased con- 
ditions in women which can be treated by electricity, and an account of 
the modes of procedure in each. 

1. The Armamentarium. The suitable instrumental equipment of 
the gynaecologist for electrical treatment is a matter of the first importance] 
and deserves careful consideration. Much of the disappointment and 
failure which have ensued on attempts to carry out electrical treatment 
with currents of relatively considerable strength have resulted from the 
unsuitable nature or mismanagement of the battery and other instruj 
I means employed It is essential, then, that the apparatus should 
be suitable and well cared for, otherwise vexation and disappointment 
are inevitable. It is sometimes forgotten that a battery is capable of 
giving out only an amount of energy corresponding to its size. When 
an ordinary portable "constant current " battery of thirty or forty small 
cells is found exhausted after a small number of sittings the practitioner 
is annoyed, and this method of treatment is called impracticable. Hut 
the failure i> due to the employment of an unsuitable and inadequat 
source of energy. 

We -hull consider first, then, the most convenient and suitable form of 
battery. The current from th< electric lighting mains of a continuoi 
low pressure supply is the most convenient source of energy for tin 
purpose in new : hut this source is not as yet generally available. Com 



THE ELECTRICAL TREATMENT OF DLSEASES OF WOMEN 301 



sequently the majority of practitioners must fall back upon some form of 
primary battery. The form of battery will depend on whether the 
treatment is to be carried out in the physician's rooms or at the patient's 
residence in other words, whether the patient is to come to the battery, 
or the battery is to go to the patient. There can be no doubt that the 
former arrangement is much the more satisfactory ; it permits the use 
of a large-celled stationary battery, and avoids the inevitable inconvenience 
associated with the carriage of a portable one. I shall consider first the 
most convenient kind of stationary battery. 

Experience has shown that some form of Leclanche cell is the most 
suitable. The simplicity of its construction and the harmless fluid used 
are matters of great advantage. Any good form of cell, such as is 
used for electrical bells or telegraph work, will suffice. An excellent 
type of cell is sold by Mr. K. Schall (Fig. 101). The carbon element is 
a cylinder about 2 inches in diameter, pierced 
by a central channel \\ inch in diameter.. 
The mouth of the glass jar is surrounded by 
an india-rubber collar, which supports a lead 
flange attached to the carbon cylinder ; the 
carbon thus hangs in the liquid, being half 
an inch clear of the bottom of the jar. This 
Bpace prevents the formation of crystals on 
the lower end of the carbon. In the central 
channel hangs the zinc rod ; this rod is attached 
to a china disc which rests on the top of the 
carbon cylinder in such a way as to prevent 
its shifting or coming in contact with the 
Carbon. An india-rubber ring is slipped over 
the lower end of the zinc rod, which effectually 
prevents its touching the carbon cylinder at 
that point. The cell is thus of a simple and workmanlike construction, 
and has a very low internal resistance a matter of some consequence. 
Whatever kind of cell is used it should be of at least a quart capacity. 
From thirty to forty of such cells will be required. 

The efficiency and length of life of such a battery will depend largely 
on the manner in which it is charged and set up ; and the following 
instructions may be found of use : The glass jars after being unpacked 
should be wiped inside and out with a dry cloth so as carefully to free 
them from straw and dust. Care should be taken not to damage in any 
way the coating of paraffin round the outer edge ; the object of the 
paraffin is to prevent " creeping," and if it should be deficient or cracked 
it should be repaired by brushing a little melted paraffin over it. 
The jar should then be rather more than half filled with a saturated 
solution of sal ammoniac. The salt used should be nearly pure ; the 
common or commercial form gives very unsatisfactory results. The 
rubber collars are then to be fitted, and the carbon cylinders put in. 
Great care should be taken that the outside of the jars be not wetted by 




Fig. 101. Leclanche cell. 



3 o2 S ) S 7 EM OF G\ \\ r . / CO LOGY 

sparking of the fluid. The introduction of the carbon will raise the fluid 

within 2 inches of the shoulder of the cell. The cell should be allowed 

and for twenty-four hours, at the end of which time the fluid will 

haw sunk a little owing to the absorption of some of it by the porous 

carbon. The cells aiv now to be filled with plain water to a level of one 
inch below the shoulder ; this will reduce the saturation somewhat, and 
avoid the risk of any part of the salt crystallising out. If the fluid used 
he fully saturated this change is apt to occur in cold weather, and crystals 
tunning in the space round the zinc rod, may ultimately make a bridgi 
between the elements, an accident which will rapidly destroy the cell. 
The zinc rods may then be placed in position, and the cells arranged in 
their permanent places. The most convenient place is a dry roomy cup- 
board, the shelves of which should he varnished or covered with thick 
brown glazed paper. If a cupboard be not available, stout shelves must 
be provided. If forty cells are employed they should he arranged in two 
sets of twenty cells each on two shelves, each set consisting of two rows 
of ten cells. A clear inch should be allowed between each cell, and two 
or three between each row. In this way any cell can readily he removed 
for any purpose, and the cells periodically tested as to efficiency. Beforl 
being placed on the shelf each cell must be carefully dried from any stray 
drops of solution or moisture which may have been deposited on it. This 
precaution should not he omitted, as the efficiency and durability of tin; 
battery greatly depend on keeping the cells thoroughly dry on then 
external surface. The cells may now he connected up; the carbon of 
each should be joined to the zinc of the next by a piece of clean No. 1 
COpper wire, care being taken that the binding screws are well serewe 
up and the wires firmly held by them. This will leave a free carbon au 
a free zinc at the end of the battery ; from these, pieces of insulated w 
should run to a couple of stout binding screws fixed to one of the shelv 
The binding screw connected with the last carbon will be the positive, an 
that connected with the last zinc will be the negative pole of the battery 
A battery consisting, say, of forty cells, if tested by a volt meter, shoul 
give an electromotive force of about 58 volts; and as the resistance o 
each cell, when in good condition, is about 0*5 ohm, the total resistance 

f the battery will be about 20 ohms. On short circuit, then, the batterj 
will give, for a shorl time, nearly l' - "> amperes. With a good abdominal 
electrode properly applied, and a sound in the uterus, the resistance of 
the human body averages about 150 ohms; thus the battery will he 
capable of transmitting a current of about one-third of an ampere through 
the tissues <f the patient. This is more than sufficient for all ordinari 
purposes; but as the electromotive force tends to fall and the internal 
resistance to rise, it is well to be provided at the outset with a certain 
.imoiiiit of surplus energy. If properly used and cared for, such a battery 
will prove efficient tor ;i wry long time. The following matters must 
be attended to if disappointment is to be avoided: 1st, The battery 
should not be allowed to rmiiiiii idle for long intervals: if it happeii 
not to be nied for a tew weeks at a time, crystals tend to form on 






THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 303 

the zincs, and when next examined the internal resistance will be found 
greatly increased. If the battery is not to be used for a week or two, the 
terminals ought to be connected to a resistance, and a current of 50 or 60 
milliamperes allowed to flow for five or six minutes at least once a fort- 
night. Attention to this will do much to prolong the life of a battery ; 
nothing is worse for it than long periods of idleness. 2nd, From time to 
time the evaporation from the vessels should be made good by the addition 
of a little water. 3rd, Once a month each cell should be tested with a 
galvanometer to see that it is giving its proper quota of energy. This 
can be done without disconnecting the cells, by having two stiff copper 
wires attached to flexible leads connected with the galvanometer, with 
which the terminals of each cell may be touched. If any cell gives a 
smaller deflection than it should do, it should be removed and examined 
for the cause of the defect. This may be creeping of the fluid over the 
edge of the cell, or accidental contact of the plates in the fluid. The 
defect should be rectified, and the cell tested and returned to its place ; 
but the battery may, of course, be used without the defective cell if those 
on each side of it be connected by a piece of stout copper wire. 4th, 



Fig. 102. Carbon rheostat. 

Any fluid accidentally spilt on or about the cells should be carefully dried 
up at once. 

When such a battery has been in use for two or three years it will 
show signs of exhaustion ; it should then be taken apart, the solution 
replaced by a fresh quantity, and the zincs reamalgamated. Any of the 
latter which are much worn should be replaced by new ones : this 
may be done at the cost of a few pence for each rod. With careful and 
regular use, and an overhaul now and then, a battery of this sort may 
remain in good working order for an indefinite time. 

The Current Regulator. For the control of this or any other battery 
some form of current regulator is necessary. For portable batteries the 
cell collector is probably the most convenient means ; but for a fixed 
installation such an arrangement is impracticable. The regulation in this 
case is best effected by some form of rheostat or adjustable resistance. 
The most convenient form of rheostat at present available is one made 
of filaments or thin rods of carbon, which can be cut out or introduced 
into the circuit gradually by means of sliding metal pieces (Fig. 102). 
This arrangement permits of increase or diminution of the current to any 
extent without the least interruption or shock a matter of essential 
cm sequence in the use of strong currents. Four of these rheostats, 



3<H 



SYSTEM OF GYNAECOLOGY 



mounted in series, will be found a convenient combination ; and the 
following approximate values will be suitable : No. 1 of 200 ohms ; 
No. 2 of 1000 ohms; No. 3 of 10,000 ohms; No. 4 of 100,000 ohms. 
With such a combination inserted into the circuit between the battery 
and the patient about 2 milliamperes of current will pass, so that the 
patient may be connected to the terminals without any appreciable 
shock. 

Liquid rheostats have been devised for this purpose ; but, although 
they are cheaper than those just described, they are very apt to get out 
of order, and seldom can be regulated through the necessary range; 
They are thus very unsatisfactory. Rheostats consisting of graduated 
coils of wire, which can be switched in or out of the circuit, have been 
employed ; they are costly, and they are also unsatisfactory, because the 
passage from one coil to another means a more or less abrupt drop in the 
resistance with a corresponding abrupt rise in the current. The patient 
is thus subjected to a series of unpleasant shocks, and this defect alone 
is enough to condemn them. 

The Galvanometer. A galvanometer calibrated to read directly in 
milliamperes (hence termed a milliampere meter) is an essential pari 
of the apparatus. These are now comparatively cheap, and are so 
constructed as to be readily portable. Probably the most con- 
venient form is that made by Dr. Edelmann of Munich. These 
instruments are fairly accurate, wear well, and can be readily transportec 
if need be. The best form is that in which the needle is suspended by 
silk fibre ; for, however satisfactory the pivoted form of magnet may be 
at first, it becomes less so by use on account of the blunting of the pivot 
by continued swinging. Edelmann's instruments are nearly dead beat, 
that is, after the passage of a current the needle assumes its proper 

position, with one or two small oscilla- 
tions only. This is an undoubte 
advantage, as the current can Ik 
quickly adjusted and read offi 

A convenient instrument sole 
by Mr. Schall is shown in Fig. 103. 
The dial of this instrument is divided 
into fifty divisions : with both shunts 
withdrawn, each division represent! 
0*1 in. a. : with the 10 shunt scr< 
in, each division represents 1 in. a. ; 
with the 100 shunt screwed in, each 
division indicates 10 m.a. : thus the 
total range is from 0*1 m.a. to "' (,(l 
m.a. For those who desire an in- 
strument of the highest class, the milliampere meter, made specially for 
Ihv>icians' use by the Weston Electrical Company of America, may be 
strongly recommended (Fig. 104). These instruments are beautifully 
constructed, accurately adjusted, and absolutely dead beat. More 




iniaiiii galvanometer. 




THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 305 

they are quite portable, require no levelling, and seem to undergo no 
change by continued use ; they are, however, somewhat costly. They 
may be obtained from Elliott Brothers, of 
101 St. Martin's Lane. 

When any of the swinging magnet 
galvanometers are used they must be set up 
on a level surface or adjusted by levelling 
screws ; the instrument must then be so 
turned that the needle points to zero on the 
scale. These galvanometers should be kept 
as far away as possible from anything made 
of iron, such as a grate, stove, or iron 
bracket. With the Weston instrument ^ ^-Weston mffliampke meter. 
such a precaution is unnecessary ; they may be set down on any 
surface, and the vicinity of iron does not influence them. 

Connecting wires must be provided to convey the current from the 
battery to the patient. These may conveniently be made of copper wire 
(No. 18) insulated with india-rubber covered with cotton or silk ; or they 
may be made of the stranded flexible cord used for pendent electric lights. 
They should be at least 4 feet in length, and of different colours, so that 
they can be readily distinguished. 

Electrodes. By electrodes we mean the special appliances by which 
we bring the current into contact with the patient. In gynaecological 
therapeutics we distinguish them by the terms internal and external, 
according as they are to be introduced into the interior of the body or 
applied to the skin. They are of course electrically distinguished by the 
pole with Avhich they are connected. 

Internal electrodes may be introduced into the uterus or simply into 
the vagina. The intra-uterine electrode usually takes the form of a sound. 
The most generally convenient form is one made like an ordinary uterine 
sound, the three or four inches at the point being made of platinum (Fig. 
105). To the handle is fixed a binding screw for attachment of the flexible 




Fig. 105. Intra-uterine electrode. 



conductor. A gum elastic or celluloid sheath slides on the sound and 
can be clamped at any point, so as to expose more or less of the platinum 
end. In this way a greater or a smaller part of the uterine surface is 
brought directly in contact with the metallic surface of the electrode, 
and so with the current. In certain cases, as we shall see later, the best 
results are obtained by limiting the area of contact to a considerable 
extent. For this purpose Apostoli uses electrodes having carbon ends 
about 0*75 inch in length (Fig. 106). By moving this along the uterine 

x 



306 SYSTEM OF G YN* ECOLOG Y 

canal successive portions may be treated at will. These electrodes 
however. Btraight and often difficult if not impossible to introduce. I 



i H \X"? 



Pio. L06. Apostoli's carbon electrode. 

have used a sound which is about the diameter of a No. 10 bougie 
L07). This is insulated up to half an inch from the point. This half-inch 
consists of platinum of the same diameter as the rest of the sound, and is 
screwed to a copper rod passing down to the handle and ending in I 
binding screw. The position of the platinum tip can be regulated and 
adjusted in the uterus by means of the sliding collar which is conn 
to a gauge on the handle. This electrode can be readily passed into any 
uterus the cervical canal of which is sufficiently wide to admit it ; and in 
the cases where the treatment is specially useful this condition is generally 




Fio. 107. Adjustable platinum electrode. 

present. In cases where the cervix is so displaced by a fibroid that it 
not be reached, or in case it be impossible to introduce the sounds descri 
it will be necessary to puncture the tumour at its most prominent point, 
as to carry the current directly into its substance ; for this purpose so 
form of pointed electrode must be used. Apostoli recommends th 
of an instrument constructed like the ordinary sound electrode, but ending 
in a -harp point: this is inserted into the mass for about 1 cm., and the 
sheath i< then pushed up to the vaginal roof. The objection to tin's 
method is that the tissue of the roof is electrolysed, and an open sinus 
formed leading from the vagina to the deepest part of the punctt 
This lesion is obviously not free from risk of septic infection passing fro 
the vagina into the tissue of the tumour. A better plan is to tise a needle 
Bimilar to thai employed for the electrolysis of aneurysms or nsevi, but 
iurse much larger (Fig. 108). The rubber insulation of this 



rem 



Pio. I"- for puncture. 



aboul \ inch from the point, which is of course sharp; thus the nee* 
can be plunged well into the tumour, the rubber sheath passing throt 
the vaginal roof, which is thus merely punctured, not electrolysed ; 
on the withdrawal of the needle the puncture closes up again. Tl 
electrolysis [g thus confined to the tissue of the tumour. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 307 



Vaginal electrodes may be made of plain metal bulbs carried on an 
insulated stem, or the bulb may be covered by a piece of cotton soaked 
in salt solution (Fig. 109). 

The External Electrode. The purpose of the external electrode is to 
distribute the current, as it enters or leaves the body, over as large an 
area of skin surface as practicable. The result is so to diminish the 
cutaneous resistance as to permit the passage of a current of considerable 
strength by means of a moderate electromotive force ; and this without 
the production of much pain. The main points in the selection of the 
electrode, then, are these : 1st, it must be a good conductor; 2nd, it must 
cover as much of the abdomen as practicable ; and, 3rd, it must make good 
contact with the moistened skin. 




Fig. 109. Vaginal electrodes. 

The external electrode first recommended by Apostoli, and still 
used by him and others, is made of moistened sculptor's clay rolled 
into a suitable thickness, and sufficiently large to cover the greater part 
of the anterior abdominal wall. The clay is moistened with water and 
a little glycerine, and rolled to a stiff consistence with a rolling-pin. It 
should be about half an inch in thickness, and about 10 by 8 inches in 
area. The clay should then be placed on a piece of muslin large enough 
to extend about 3 inches beyond the electrode all round ; by this edge 
the electrode can be readily lifted and placed on the abdomen, the 
muslin being next the skin. A thin sheet of lead, about 6 inches 
square, is then placed on the clay arid pressed into it, and to this one 
of the connecting cords is attached. The undoubted advantage of this 
electrode is that it forms an excellent contact with the skin, moulding 
itself to all the elevations and hollows, and so reducing the resistance to 
a minimum. It is certainly easier to transmit heavy currents by this 
electrode than by any other. Its disadvantages are, that in spite of every 
care it is troublesome to make ready, and apt to be very dirty ; 
and as it is most effective when applied cold, it is unpleasant to the 
patient. If warmed it is apt to become dry on the surface, and thus to 
lose its efficiency. There are, however, a number of external electrodes 
which make good substitutes for the clay ; and experience has shown 
that in most cases it is not necessary to employ the very high currents 
first recommended, which can certainly be best transmitted by means of 
the clay. For most cases a simpler and pleasanter form of electrode 



30S SYSTEM OF GYNAECOLOGY 

may be employed: thus a double fold of thick flannel, about 10 inches 
square, soaked in a warm solution of salt in water, and laid carefully on 
the abdomen, makes a good contact; upon this a plate of lead or zinc, 
about -i inches square, should be laid, and connected by a binding 
with one of the connecting cords. A piece of mackintosh laid on the 
whole will prevent the moisture from escaping or wetting the dress, 
Again, a piece of sheet lead of sufficient size may be thickly padded 
with cotton wool on one side ; when this is soaked in salt water it 
makes a good conductor, and will make close contact with the skin. 

One of the best of these electrodes, according to my own expel 
ence, is supplied by Mr. Coxeter. It is made of a sheet of brass wire 
cloth on which a composition, consisting mainly of gelatine, has 
poured. The surface of the gelatine is made very smooth. This i> 
sponged over with plain warm water until it is slightly softened, and it 
is then carefully laid on the abdomen : if pressed down all round it 
will adhere slightly to the skin, making very intimate contact, and offering 
slight resistance. Currents of considerable intensity 150 to 200 m.a. 
may be transmitted by means of this electrode ; and if carefully 
made so as to be free from air spaces, it will last for a long time. When 
it has become rough on the surface it may be smoothed by means of a 
hot knife passed carefully over it. Several other materials hav< 
recommended, but one or other of these described will be found sufficienl 
for all purposes. 

With such an equipment the gynaecologist is in a position to in. 
all the applications of the continuous current which experience has sh<.\ 
to be of practical use. It is, of course, presumed that the patients 
to attend for treatment ; and there can be no doubt that the best rest 
are obtained when this can be arranged. The stationary battery 
with reasonable care be relied on to do its work in a way which nei 
can be expected from any form of portable battery, all of which 
liable to disorganisation from a variety of conditions which cannot alwaj 
be foreseen or provided against. 

Nevertheless it may be convenient or necessary on occasion to << 
duct the treatment by electricity at the residence of a patient ; in 

<>f course, a portable battery must be employed. Hence it will 
advisable to say a word or two about the most suitable instrument 
this purpose. A battery of thirty or forty cells will be required 
Ia-elaii<-Iie element is again the most suitable. A very convi 

ery is made by Schall (Fig. 110). This contains the requisite num 
ber of element-, and i- fitted with a double collector, by which not onl} 
can the cells be introduced into the circuit one by one, but any si 
group of cells can be selected, so thai the battery can be evenly and thu 
economically used In place of the "collector" a rheostal may be 
similar to the one already described. This will be found convenient, bit 
it is more costly. A galvanometer is fitted to this instrument, so tha 
nothing in addition but the electrodes is required. Such a battery is no 
unduly heavy about 38 lbs. and is thus fairly portable. It is, how 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 



39 



ever, liable to accident by careless use, and if violently jolted may be 
damaged by the cracking of a cell. If kept in good order it may give 
from sixty to seventy applications of average strength and duration, 
after which its electromotive force will begin to fall and its internal 
resistance to rise, so that the available current will be greatly reduced. 
Iln these batteries the cells should be tested from time to time, and any 
defective one at once removed and replaced by another until it can be 
[repaired. For this reason it is advisable to have a few spare cells at hand. 




Fig. 110. Portable battery with collector and galvanometer. 

Induced, alternating, or "faradic " currents are frequently employed in 
gynaecology, and for the production of these many convenient appliances 
are available. The most convenient portable faradic apparatus is that 
known as Spamer's ; the whole apparatus is contained in a box 5 inches 
square, and includes a bichromate cell and coil with the necessary con- 
nections. For use in the consulting-room Mr. Coxeter and Mr. Schall 
both supply very excellent coils of the Dubois Reymond pattern, which 
can be excited by two large Leclanche cells, or by a bichromate cell. 
In these the rate of interruption can be widely varied, and the strength 
adjusted by the sliding of the secondary on or away from the primary. 
It is advisable in these last patterns to have two secondary coils, one of 
many turns of thin wire, say 5000, and the other of a smaller number 



3io 



S 3 'STEM ( )F G 3 \Y. 7X0 LOG Y 



of turns of thick wire say 200. The electromotive} force of the two 
differs in proportion to the turns on the coil. Convenient forms of such 
instruments arc shown in Figs. Ill and 112. 




Fig. 111. spainer - * Induction coil. 




Pro. 1 12. Sledge Induction coil. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 



3" 



It is now necessary to consider the way in which the pieces of apparatus 
described above are to be connected up for use. We shall presume that a 
stationary battery of the kind described is to be employed. A level 
table or shelf must be provided close to the couch on which the patient 
is to lie. The rheostat and galvanometer are arranged on this shelf or 
table, and an insulated flexible wire is to be brought from, say, the 
positive terminal, and firmly connected to one of the binding screws of 
the rheostat. A similar wire is brought from the 



negative terminal of 




Fig. 113. Regulator switch-board for continuous and induced currents. 

the battery and connected to one of the binding screws of the galvano- 
meter. The slides of the rheostat must be so arranged that the full 
resistance is in circuit, while the galvanometer must be so adjusted that 
the needle points to zero. If it is proposed to use a current of more 
than 50 m.a. the 100 shunt must be screwed in; if less than 50 m.a. 
the 100 shunt must be withdrawn and the 10 shunt screwed in. The 
flexible connecting cords must then be attached to the rheostat and the 
galvanometer, the one attached to the former being now the positive 
pole, and that to the latter being the negative. These are now ready to 
be attached to the respective electrodes, after the latter have been 
adapted to the patient. 



312 



SYSTEM OF GYNAECOLOGY 



When a number of patients are under regular treatment it is advis- 
able and most convenient to have the various instruments permanently 
connected up on a kind of switch-board ; so that, after applying the elec- 
trodes to the patient, it is only necessary to connect the electrodes to the 
conducting cords and turn on the current. Such an arrangement is 
shown in the accompanying figure, which illustrates the switch -board 
(Fig. 113) employed by myself for a number of years, and which I have 
found exceedingly convenient. 

As already mentioned, there is no doubt that the most convenient 
source of energy for electrical treatment is the lighting mains of a con- 
tinuous low pressure supply. There are two ways in which the current 
strength may be regulated. 1st, The patient may be put in the main 
circuit with a resistance interpolated, sufficient to reduce the current, so 
that not more than one or two m.a. -will pass. One hundred thousand 
ohms will be required to do this. The switch -board shown in the pre- 
ceding figure will serve the purpose very well, and another made by 

Schall is shown in Fig. 11-4. The 
objection to this method is that 
at the moment of making and 
also at breaking contact the 
patient experiences a somewhaj 
sharp and disagreeable shod 
owing to the high voltage. 2n< 
The patient may be in a shunt 
circuit. This arrangement 
shown diagrammatically in Fi^ 
115. The current from the m.iii 
passes to the resistance R. Tl 
patient is in a shunt circuit 
nected with one end of the 
ance and the slider M. By shii 
ing the position of the latter th< 
voltage of this shunt circuit caj 
be raised from 0*1 volt to 50 or 
60 volts ; and in this way, with- 
out shock oi- interruption of 
any kind, the current can be 
varied from a fraction of a 
milliampere to the required 
strength. A convenient switch- 
board fitted on this principli 
by Schall is shown in Fig. 116. 
In all rases where current 
taken from the mains an eight 
or sixteen candle power lamp should be interpolated. This acts as 
ty resistance, and prevents the passage of more than 250 m.a. 




FlO. 114. 



julating lighting en 
by m< 



the former case, or 500 m.a. in the latter. 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 313 

II. Mode of Making the Applications. We may now consider the 
details of the procedure for administration of the current. Careful attention 




Fig. 115. Diagram of switch-board for regulating lighting currents by means of shunt. 



to these details is essential to success and to the avoidance of serious 

accidents. It must be carefully kept in mind that the use of currents of 

100 m.a. and upwards is not free from 

danger, and that serious mischief may 

result from carelessness in their use. 

The patient should be directed before 

attending to take a vaginal douche of 

warm (105 F.) water made antiseptic 

by carbolic acid 1-40. This should be 

copious, two quarts at least. On arrival 

she should remove her ordinary clothes, 

and put on a night and a dressing 

gown, the latter made so as to open 

completely down the front. She wears 

her stockings of course, and should 

also put on warm slippers. She should 

now lie down on the couch, which 

should be moderately high and firm, 

and should be covered with a rug or 

blanket. In cold weather her feet 

should rest on a hot-water bottle. 

Let us suppose that a continuous 
current is to be applied to the interior 
of the uterus for the treatment of 
haemorrhage, endometritis, and so forth. 
A suitable sound-electrode having been 
chosen, it must now be passed into the uterus. This may be done with the 
patient on her back : if, however, as is usual in this country, the gynaecologist 




Fig. 116. Switch-board for shunt regulation. 



3 14 SYSTEM OF GYNAECOLOGY 

is in the habit of passing the sound with the patient on her left side, there 
is no reason why this position should not be retained When the sound is 
i. the finger is still kept against the cervix in order to keep the sound 
in position, and the patient is asked to roll slowly round on to her hack, and 
while she is doing this care must be taken that the sound does not slip. 
When the patient is comfortably settled on her back the connecting cord 
from the proper pole must be attached, and the handle of the sound given 
to the nurse or attendant, whose duty it is to be by the side of the couch 
and to hold the sound steadily all through the sitting. The dressing- 
gown is now to be opened, and the night-gown drawn up so as to expose 
the abdomen up to the pit of the stomach. The abdomen should be 
sponged with warm salt solution, and any abrasion, scratch, or pimple 
must be protected by a small piece of pink mackintosh or oiled silk. 
The properly prepared electrode, whether clay, flannel, or gelatine, is 
now to be carefully laid on the abdominal surface so that, in the 
case of flannel, there are no creases, and that no part of it rests on 
the bony edge of the ilium. The pad must then be pressed firmly 
down, the connection to the other electrode made, and the blanket drawn 
up over the body. The patient is then requested to place both hands on 
the pad, and to press evenly and gently, so as to ensure good contact. 
The galvanometer will now indicate 2 to 5 m.a. according to the electro- 
motive force of the battery and the resistance of the rheostat. This current 
is of course not appreciable by the patient. The various binding screws 
should now be examined and tested to make certain of their being firmly 
adjusted. The slide of the highest rheostat is now slowly moved so as 
to reduce the resistance, the patient's face and the galvanometer being 
carefully watched. Then the next slide is even more slowly moved, and. 
if need be, the third, until the limit of tolerance is reached, or until the 
galvanometer shows that the necessary current strength is passing. If 
great pain is complained of before this degree is reached, inquiry should be 
made if it is general all under the pad, or concentrated at one or more 
points. If the former, the current should be reduced for a little, when it 
will generally be found that the sensation of burning disappears, and the 
current may again he gradually increased If the pain be confined to one 
or more spots it is probably due to some tender area of skin, or to some 
irregularity in the application of the pad ; in tin's case the current 
mii-t be reduced by introducing the full resistance of the rheostat, and 
the pad removed and examined. A particle of salt which has escaped 
solution may be the cause of very severe local pain. If this be over- 
looked, and the current kept on. a small liit wry painful ulcer may be 
formed, which will take months to heal. The duration of the applica- 
tion is reckoned from the moment at which the proper current strength 
i- attained : it is generally continued for 5 to 10 minutes. At the 
conclusion of this time the current is to be gradually and slowly reducedj 

beginning with the lowest slide of the rheostat, and ending with the 
highest. When the full resistance has been introduced the internal 
electrode should be withdrawn, and the pad removed from the abdomen, 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 315 

which is sponged with warm water and dried. The patient should then 
remain lying on this or another couch for a quarter of an hour : after 
this she should put on her clothes. It is well to advise patients, 
after the first few applications, to keep to a couch for the rest of the 
day ; and also on any other occasion, if any pain or red discharge follow 
the application, she should be advised to go to bed, or at least to lie 
down for the evening. It is also very important that in the course of 
an hour or two after each application the vagina should be douched 
with carbolic lotion. When puncture of a fibroid tumour or of an 
inflammatory deposit has been practised, special precautions are necessary. 
These will be discussed later. 

III. The Mode of Action of the Continuous Current. It will now 
be convenient to consider shortly the effects on the tissues produced by 
the transmissions of continuous currents through them by means of 
metallic electrodes. This will be best understood if we study, in the 
first place, the effect of the passage of the current through a piece of 
dead tissue say a piece of beef. A small block of fresh beef is placed 
on a dish, and into it two steel sewing needles are inserted at a distance 
of an inch from each other. One of these is connected to the positive 
and the other to the negative pole of a battery, and a current of, say, 50 
m.a. is transmitted. The following things will be observed. 1st, In a 
few seconds a frothy effervescence will appear round the negative needle, 
while the tissue will shrink and condense round the positive needle. 2nd, 
If, at the end of a few minutes, the negative needle be gently pulled, it 
will come away without difficulty, leaving an aperture a good deal wider 
than its own thickness ; this aperture opens into a sinus which is filled 
with a soft frothy scum. 3rd, If the positive needle be similarly pulled, 
it will not come away without considerable traction, and will leave a 
small orifice with a dense, firm outline. 4th, On examination, the 
negative needle will be found quite bright, Avhile the positive needle will 
be dulled and slightly corroded. 5th, If the piece of meat be now care- 
fully cut open, so as to expose the channels formed by the needles, it will 
be found that the tract of the negative needle is surrounded by a softened 
loose area of disorganised tissue, while the tract of the positive is 
surrounded by a condensed area much smaller than that round the 
negative needle ; it is, moreover, paler in colour, and cuts with a some- 
what gritty sensation. 6th, If the surfaces so exposed are tested with 
litmus paper, it will be found that on the negative side an alkaline and 
on the positive side an acid reaction is given. 

Similar phenomena are seen as the result of the action of such 
a current on the albumin of an egg. If the whites of two eggs be 
placed in a glass beaker, and a current of 20-30 m.a. be passed 
through them by means of steel needles, a loose flocculent coagulum 
will form round the negative needle. After a time this disintegrates and 
floats through the rest of the fluid, leaving the needle quite clean and 
bright. Round the positive needle a dense compact clot is formed which 
firmly adheres to it, and can be lifted out of the vessel by means of it. 



3 1 6 SYS TEM OF G) \Y. K CO LOG Y 

On examination by test-paper the positive clot will be found markedly 
acid, and the negative markedly alkaline. 

These changes constitute part of the phenomena of electrolysis ; and 
experiment has shown that under similar conditions identical results are 
produced in the tissues of the living body. Briefly stated, we find then 
that round the metallic surface of the negative pole physical disintegration 
suits with a chemical alkaline reaction, while round the positive pole 
a physical condensation of tissue results with a chemical acid reaction. 

So far as the quantitative aspects of the case are concerned, we must 
keep in mind that the amount of tissue broken up at the two poles is, 
chemically speaking, identical. The basic products set free at the negative 
are chemically equivalent to the acid products set free at the positive 
electrode. 

In the present state of our knowledge it is impossible to state 
precisely the chemical nature of the products of electrolytic decom- 
position at either pole : they are highly complex. Among them, 
however, we may readily detect a certain amount of caustic soda 
and potash at the negative, and of chlorine at the positive pole. To 
what extent the influence of these chemical substances may be credited 
with the production of the peculiar coagula found at the respective 
poles is a matter of some doubt, in spite of the fact that Apostoli and his 
immediate followers hold that they explain the wide difference of the 
condition of the tissues observed. On this account Apostoli terms the 
action of the positive pole "acid galvano-caustic," and of the negative 
"alkaline gal vano-caus tic." Our ignorance of the precise nature of the 
chemical and vital changes induced by electrolysis of these complex bodies 
scarcely justifies this assumption ; and further investigation is necessary t<> 
explain the marked difference between the influence of these poles. 

It seems safer in the meantime to accept simply that the difference in 
the action exists; and, in cases where we seem to require a loose disin- 
tegration of tissue, to employ the negative pole j and in others, where we 
seem to require an "astringent" or condensing effect, to resorl to the 
positive pole. In other words, it is better at present in our employment 
of these currents to trust to an empirical knowledge of the effects pro 
duced, than to attempt to guide our methods by an assumed knowledge 
of the way in which those effects are produced. 

In addition to the electrolytic effect another influence of the con- 
tinuous current La claimed by certain authors; 'his is termed t lie 
"interpolar effect." By this is meant an assumed influence of the 
currenl upon the tissues lying between the electrodes. It is practically 
assumed that the passage of the current produces a certain influence, 
disintegrating or otherwise, upon the molecules of the tissue which lie in its 
path between one electrode and another. To this supposed interpolar 
effect is attributed part of the diminution in the bulk of fibroid 

tumours and cellulitic deposits which is occasionally met with in our 
experience. Xow, it is admitted that there is no physical evidence for 
the decomposition of the solution of a sail by a galvanic current save in 






THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 317 

the vicinity of the electrodes. The products of the decomposition appear 
round the electrodes, and so far as any direct evidence is concerned there 
is no proof that any change occurs in the fluids between these regions. 
Still less is there any evidence that electrolytic decomposition takes 
place in such a mass as that of a fibroid tumour away from the seat of the 
electrodes in contact with it. Any so-called experimental proof which 
has been advanced in favour of the existence of interpolar decomposition 
can be readily explained on other grounds ; and we may take it that there 
is no proof of any electrolytic decomposition occurring anywhere except 
round the metallic electrodes. 

There is abundant clinical evidence, however, that the passage of a 
current through the pelvis may have other than directly electrolytic 
effects. For example, it is a matter of common experience that, after 
two or three applications of a fairly powerful current to a uterine fibroid, 
the bulk of it will be appreciably diminished. This immediate but in 
many cases temporary eft'ect is oftenest produced when the positive pole 
is applied to the interior of the uterus ; and it appears to be due to a 
stimulation of the muscular fibres of the uterus and tumour by the 
current, which results in a vigorous contraction and expulsion of a large 
amount of the blood contained in these structures, and a consequent 
diminution of their bulk. That this may have an important effect on the 
nutrition and growth of such a tumour seems very likely, and that its 
repeated reproduction may ultimately induce a progressive atrophy of 
such a neoplasm is no less probable. That this is the action of the 
current in many of these cases is also borne out by the fact that bulky 
and somewhat soft fibroids, after a few applications, often show a marked 
diminution in bulk ; while at the same time they become firm and con- 
densed to external manipulation. Further, during this process of shrink- 
age we may notice that large quantities of watery discharge are constantly 
escaping from the uterine cavity. 

A second effect, which one may often observe in cases under treatment, 
is the production of a sense of improved well-being which frequently is 
felt almost from the first. Every one who has had an experience of any 
extent in the treatment of pelvic diseases by electricity must have 
noticed how often the patient expresses herself as greatly benefited by 
the treatment long before any definite change can be detected in the local 
condition. So manifest and constant is this effect, that it would almost 
appear that these electric currents in some way induce an improved 
nutrition and a general exaltation of function in which the nervous 
system especially participates. 

4. The therapeutic application of electricity to those diseases of the 
female pelvic organs in which experience has shown that beneficial results 
have followed its use, is now to be considered. 

Stenosis. A contracted state of the os externum or of the cervical 
canal, whether congenital or acquired, can be successfully treated by 
electricity. The symptoms associated with this condition are usually 
dysmenorrhcea and sterility. In congenital conditions there is often, 



ji 8 SYSTEM OF GYNECOLOGY 

though by DO means always, an imperfect development of the uterus and 

ovaries; and in these cases, of course, the main object is to relieve the 
dysmenorrhosa. These conditions can no doubt be treated in most cases 
by dilatation on one or other of the well-known methods. This, to bi 
satisfactory, involves the use of an anaesthetic, for when the dilatation is 
carried to the necessary extent the pain produced is very great. Further] 
it is a matter of common experience that there is a tendency for the pain 
to recur after several months of painless menstruation : so that, in order 
to relieve the menstrual pain, the repetition of the operation to a certain 
degree is required from time to time. 

Considerable experience with both methods seems, however, to show a 
distinct advantage in favour of the electrical treatment for these conditions. 
This treatment is practically painless ; it involves no interference with 
ordinary duties or occupations, and its results in my experience have 
been more permanent and more completely satisfactory than those of 
forcible dilatation. 

The mode of treatment is as follows : The ordinary platinum sound 
is employed as the internal electrode. With a little care this can be 
introduced into the canal without any previous dilatation ; but, if need 
lie, a No. 1 or Xo. 2 Hegar dilator may be passed first. 

The sheath is carefully pushed up against the os, and this electrode is 
connected to the negative pole: the abdominal pad is now applied and 
connected to the positive pole, and a current of from 50 to < s <> m.a. i 
slowly turned on. This should be continued for five minutes, and the 
taken off gradually. This application should be made twice a week fo 
eight or ten times. Unless an application takes place very near th 
expected time of menstruation there is no need of any special restrictio 
on the patient's movements. If it happens within a day or two of th 
menstrual onset she should rest for some time afterwards. 

After two or three sittings it will be found that the canal is nine 
more patent. It is advisable then to employ the thick sound, taking 
always that it is not inserted too far into the cavity : its point shoul 
just pass through the os internum. 

The relief given to the dysmenorrhosa is almost always immediate; if 

Only two or three applications have been made before a period sets in 

this period will be almost painless. As a rule, ten application 

of the strength indicated are enough. When the cervix is at firs 

v.-ry sensitive, owing to th.- presence of an endocervicitis or an end 

metritis, the patient may qoI be able to bear such current strengths; in 

these cases it ifl better to begin with the use of the anode internally, 

using a current strength well within toleration. After a few applications 

it will be found that the full kathodal strength can lie used without 

Inconvenience. 

Endometritis. The great majority of cases of chronic endometritis 
undoubtedly yield to the various means, other than electrical, at the 
disposal of the gynaecologist. These have the advantage of occupying 

less time, a matter of Considerable importance to many patients. The 









THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 319 

simpler measures, such as the application of caustics like carbolic acid or 
iodine, to the endometrium, if done with reasonable skill and care, are 
practically devoid of danger. But it is only in the milder cases that we 
can expect such measures to effect a cure. The more efficient and more 
drastic procedure of curettage is now found necessary in a large number 
of cases ; and it is useless to deny that this method, even in experienced 
hands, is associated with very considerable danger : the danger may be 
minimised by skill and care, but it cannot be entirely eliminated. It is, 
accordingly, as an alternative to curettage that the advantage of electrical 
treatment appears ; for, with the simplest precautions, this method is 
free from danger. Not only so, but the experience of a very considerable 
number of cases has shown that it will often cure when repeated curetting 
has failed to produce any permanent benefit. I am convinced that 
electrical treatment will cure any case curable by curetting, and will also 
cure many cases that curetting cannot cure. Against the length of time 
that it occupies we may confidently put the entire freedom from danger. 
Still, I do not advocate its use in all cases of endometritis. The time 
occupied by it, which is not less than two and often as long as three or 
four months, is a serious difficulty, and one which renders the method im- 
practicable for a considerable number of patients. In the simpler and 
more recent cases the cauterisation of the endometrium is easy and effective; 
in the more chronic and persistent cases I should certainly advise thorough 
curetting. If this is to be effective the result will show itself in a short 
time ; but if not, and if any of the symptoms return, I do not hesitate to 
advise electrical treatment as being much more likely to produce a per- 
manent cure than any number of subsequent applications of the curette. 

The symptoms of chronic endometritis are chiefly leucorrhoea, 
haemorrhage, and local discomfort ; and the predominance of one or other 
of these in any given case forms a sound guide to the proper mode of 
electrical treatment. 

Without going into a detailed consideration of the pathological 
changes in the endometrium in the various kinds of this disorder, it may 
be advisable to recall the fact that, in the glandular variety, we have a 
characteristic increase of the gland elements of the endometrium, accom- 
panied by thickening of the whole membrane, and characterised by a 
more or less profuse flow of a discharge which may be watery, creamy, or 
greenish : in the hemorrhagic variety the membrane is greatly thickened, 
thrown into elevations, and especially characterised by a great increase of 
the vascular constituents of the structure. A third variety, characterised 
by a profuse flow of muco-pus, is distinguished by the development of 
granulations composed of an embryonic tissue. This last variety seems 
to be somewhat rare ; the great majority of the cases fall in the first 
two classes. It should be kept in mind that practically in every case of 
endometritis the uterus is enlarged ; the tissues of the wall seem swollen, 
soft, and boggy, and the organ is usually mobile, readily falling to one or 
other side of the pelvis with the inclination of the body. 

Very often the os is patulous ; this is generally the case with the os 



320 SYSTEM OF GYNECOLOGY 

externum, but in a certain number of eases the os internum is not larger 
than usual, and admits nothing thicker than the ordinary sound without 
being stretched. 

The amount and kind of the pelvic distress are very variable. In 

some cases there may be little or none ; in others there may be more or 

onstant discomfort, amounting at times to severe pelvic pain. In 

most there is an unpleasant backache or feeling of weariness and fatigue 

which greatly interferes with the performance of ordinary duties. 

The details of the treatment of chronic endometritis vary with the 
nature of the conditions to be dealt with. Attention must be given to 
the special symptoms present in each case ; as we have seen, thesi 
generally pain, leucorrhcea, and haemorrhage. It is generally laid down as 
a guiding rule that if haemorrhage be a prominent feature the positive pole 
should be used internally, and when this is not the case that the internal 
electrode should be negative. There seems no doubt at all as to the 
propriety of the use of the positive pole in hemorrhagic cases ; the 
tringent" and haemostatic influence of it is well known, and the result! 
on the first menstrual period after the beginning of treatment are usually 
very striking. Not only does it seem effectually to destroy the hemor- 
rhagic endometrium, but it seems in a very definite way to diminish the 
bulk of the whole organ, during and for some time after each application 
as if it caused an emptying of the distended vessels in its walls. On the 
other hand, the wisdom of the routine use of the negative pole internally, 
in all cases of a marked leucorrhoeal type, is by no means so evident. L 
these cases the endometrium is no doubt thickened by an increase of the 
glandular or connective tissue elements of the structure, and according]] 
the negative pole is employed on account of its supposed destruetivi 
action on the tissues. It is assumed, in fact, that "electrical curettage 
18 more effectually performed by the negative pole. This, however, is bj 
no means clearly proved. No doubt the electrolytic results of the kathode 
are more bulky, because more loosely held together ; bul the actui 
amount of tissue destroyed is not necessarily greater. The affected art 
round the anode seems less than that around the kathode, because the 
affected tissue in the former case shrinks more than in the latter; hut 
the tissue round the anode is as thoroughly devitalised as that round the 
kathode. As a matter of fact the influence of both poles is, chemically 
and quantitatively speaking, equivalent; but the anodal application has this 
advantage over the kathodal, that it tends mosl effectively to restrain 
liMtnorrhage. The destruction of the diseased endometrium must often 
result in the exposure of .-i more or less vascular surface. Every one 
knows how some of these leucorrhcea] wombs bleed during the use of an 
ordinary curette. Accordingly, after the use of the negative electrode it 
i- ool uncommon to find patients Losing blond for some days in greater 
less amount; and if a period comes on after but one or two application 
the monorrhagia u often considerable, and this in patients in whoi 
hsemorrluig.' had not previously been a prominent symptom. Now wit! 
the anode used internally thia i- very seldom the case. As ;i rule in 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 321 

these cases there is a little red or reddish discharge on the evening of the 
sitting, or perhaps for an hour or two next day ; but the quantity is incon- 
siderable, and never amounts to haemorrhage. When I first began to 
employ electricity for the treatment of endometritis I always employed 
the negative pole ; and to combat the haemorrhage, used to enjoin on the 
patient the necessity of going to bed and using a hot douche, or taking 
some ergot every day while the early part of the treatment lasted : but 
in spite of this the exhaustion of the patient by persistent blood loss was 
a serious matter. Such complications are entirely avoided by the use of 
the anode. 

Moreover, the anode has another advantage in the treatment of these 
cases. A painful condition of the pelvic organs constitutes a marked 
feature in many cases of endometritis, which pain may be due to the 
inflamed state of the uterus or to altered conditions of the tubes, 
ovaries, peritoneum, or parts around ; in these cases the negative pole is 
very badly borne. The kathode, when applied to normal surfaces such 
as the healthy skin, is far more irritating to sensory nerves than the 
anode. This sensory effect is greatly exaggerated in inflamed structures, 
and accordingly it is difficult or impossible for many patients to tolerate 
a current of sufficient strength for any length of time if the kathode is 
used internally. On these grounds, then, I should strongly advise that, 
in all cases of endometritis, whatever the prominent symptoms may be, 
the internal pole should be anodal, at any rate at the commencement of 
treatment. In this way haemorrhage will be checked, and larger and 
therefore more efficient currents will be more easily borne. 

The mode of making the application does not materially differ from 
that of which a general description has been already given. One or two 
i points, however, require notice. For the first four or five applications it 
is advisable to employ the ordinary platinum sound-electrode, exposing 
as much of the metal as corresponds to the length of the uterine 
canal. In this way the whole cavity is brought under the influence of 
the current. The handle of the sound may be moved slightly now and 
then during the sitting in order to bring the platinum in contact with 
different parts of the endometrium. After four or five applications have 
been made by this instrument the thick, short platinum sound or 
Apostolus carbon electrode should be used, the active part being shifted 
down the cavity length by length, either at each sitting or on consecutive 
sittings. In this way the current density is greatly increased, and is 
brought to bear on each segment of the cavity in succession. 

A very careful preliminary bimanual examination should be made 
in order to determine the exact position of the os and the lie of the 
uterine body ; and in passing the electrode the greatest care should be 
exercised so as to excite as little pain as possible. If pain be caused at 
this stage it will seriously interfere with the toleration of a suitable 
current strength. When the sound is fully introduced, the sheath should 
be pushed well up into the cervix to protect it from the action of the 
current : the cervix is sometimes highly sensitive, and it is better, at first 

Y 



322 SYSTEM OF GYNAECOLOGY 

at any rate, to concentrate the action on the endometrium properi 
When the sound is properly placed and connected, the application of the 
abdominal pad requires some attention. It should be large, so as to 
diminish the skin resistance as much as possible: if, however, it is 
known that one ovary is inflamed, or that one side of the pelvis is more 
sensitive than another, the pad must be shaped so as to avoid this region] 
To do this, and yet to obtain a sufficient surface, it may be advisable to 
shift the pad well on to the epigastrium, or as high up on the thorax ai 
the mamma will permit. Some have recommended that the pad be 
placed on the back, or that an auxiliary pad be used there ; but it is 
difficult to get good contact on the back with the patient in the dorsal 
position, and a little management will enable us to get all the surface wi 
want on the anterior aspect of the body. The current employed should 
be moderate at first; if 50 m.a. can be borne on the first occasion we 
should rest content. This may be kept up for eight minutes or so and 
then gradually reduced. On subsequent occasions t lie current must be in] 
leased ; this can be done without difficulty if care be taken, until by 
the eighth or ninth sitting as much as 150 or 170 m.a. can be borne. I 
am of opinion that in this group of cases a much stronger current is 
required than in some other groups bleeding fibroids, for example. To 
judge from the recent writings on this subject, most operators have aban- 
doned the use of the very powerful currents 250 m.a. and upwards firs] 
recommended by Apostoli ; and in this decision I quite agree with them. 
But, while excellent results can be obtained in the treatment of bleedinf 
fibroids by the use of currents of only 100 m.a. or even less, I believe 
the best results in cases of endometritis, whether haBmorrhagic 
leucorrhceal, can be got only by the use of currents a good deal strong* 
than this. Hence the importance of taking all the precautions possibl 
to favour the toleration of a high current, these being, as 1 have sai( 
the use of the anode, great care in hit reducing t he sound, t he protect ion 
the cervix, and the proper application of the external electrode, 
douche, both before and after the application, must be insisted on ; am 
if pain persist, the patient should go to bed and repeal the douche (; 
I in the course of the evening. If there be no pain, the avoidant 
of any undue exertion is all th.it need be exacted. The application 
should be made twice a week. The first three days of the menses should 
oided, but after that treatment should be resumed. As to the 
number of applications required, much will depend on the circumstance! 
of each case. If the patient is regular in attendance and can bear a 
medium current* fifteen to twenty five sittings will suffice; but more will 
be required in cases' where these conditions cannot be obtained. After 
twenty-five applications have been made it is advisable to stop for a 
month, watching the symptoms ; if they seem then to increase, a few more 
applications should be made, but I have not met with any case in which 
twenty-five consecutive applications of average strength failed to effect 
a cure. In case- in which pain is a prominent feature, and in which the 
pain is increased by the application of the continuous current and continue 



in lies 



THE ELECTRICAL TREATMENT OF DLS EASES OF WOMEN 323 

for some time afterwards, great advantage will be gained by the use of 
the " faradic " or induced current. This application is made as follows : 

1 The continuous current having been applied, as above directed, to the 
full tolerance of the patient for, say, five or six minutes, the current is 
slowly reduced, and when zero has been reached, the electrodes are con- 
nected to the terminals of the secondary coil, which should have as many 
turns as are available. The hammer should be set to give the most rapid 
interruptions possible. The apparatus is started with the current at its 
weakest, and gradually increased until the patient begins to feel 
a sensation of numbness in the pelvis ; after which time it may be con- 
tinued for three or four minutes and then stopped. In most cases this 
completely removes any pain which may have been caused by the con- 
tinuous current. 

During a course of treatment such as this the patient should be 
advised as to the regulation of her diet and the action of the bowels ; and 
she should be encouraged in the use of reasonable exercise. As was 
previously noticed, nothing is more remarkable in these cases than the 
almost immediate effect this treatment seems to have on the general well- 
being of the patient. From the first the sense of depression, which is so 
common in this disorder, begins to lighten. Exercise becomes less and 
less a burden, appetite and circulation manifestly improve, and the bowels 
either begin to act regularly and spontaneously, or do so under much 
less artificial stimuli than they have previously required. This sense of 
improvement greatly lightens the tedium of the treatment, encourages 
the patient, and enables her to tolerate increasing and hence more effec- 
tive current strengths. 

One word by way of caution. During the whole course of treatment, 
but especially towards the end of it, sexual intercourse must be forbidden. 
As the patient improves conception may occur, say after a menstrual 
period, during and subsequent to which there may, for some reason, have 

j been a somewhat longer cessation of the applications than usual. When 
these are resumed it is more than likely that abortion may be induced by 
the first application of the current. I have in my records two cases 
where profuse and persistent haemorrhage, which I can account for in 
no other way, followed an application. Indeed in one case decidual 
shreds came away for a long time afterwards. In this case, owing to 
special circumstances, the application had been in abeyance for nearly a 
month. 

Subinvolution. A group of cases in which excellent results are 

I obtained by the use of electricity are those in which, after a compara- 
tively recent pregnancy, the normal involution of the uterus has, by 
some cause or other, been checked, and it remains large, congested, and 
soft. This is, of course, most frequently seen after neglected or badly 
managed abortions occurring in the early months ; and the condition is one 
which, as every gynaecologist well knows, is often the precursor of a 
whole train of morbid phenomena, organic as well as functional. Let us 
take a typical case : an abortion has occurred at, say, the third or fourth 



324 SYSTEM OF GYNAECOLOGY 

month ; a few days afterwards the patient gets up, the hsemorrhagi 
having barely ceased; the next period comes on in about three weeks 
and is so profuse that the woman may be compelled to return to bed for 
a while : the haemorrhage ceases, she resumes her duties with the same 
result a premature and profuse menstruation. Such a condition a] 
this may continue for some months, the patient suffering seriously from 
the losses, from an intermenstrual leucorrhceal discharge, and fron 
constant and increasing pelvic distress. If the patient now comes 
under observation we find a large, soft uterus, often retroflexed and re- 
troverted, with a patulous os and some tenderness on pressure. The 
sound may pass 3^ to 5 inches, and it is felt also that the walls are con- 
siderably thickened. With every care it may be impossible to avoid pro- 
ducing some haemorrhage on passing the sound. The uterus may be found 
tender, and not unfrequently the ovary on one or other side is prolapsed] 
Usually the rectum is loaded, or at any rate large doses of purgative! 
are required to produce an evacuation. We have to deal here with the 
first or congestive stage of a chronic metritis, which may be associated 
ultimately with the local and general conditions only too familiar to us 
in such cases. No doubt this condition is amenable to ordinary modes 
of treatment, but to nothing does it yield so thoroughly and so expedi- 
tiously as, in my experience, it has done to electrical treatment. 

The treatment may best be begun by a few applications of the 
induced current. For this purpose Apostoli's bipolar intra - uterhn 
electrode, or the ordinary sound-electrode, and a small abdominal pa 
may be used. The coil, w r ith somewhat slow interruptions, is connected 
and a current as strong as can be borne is applied for ten or fifteei 
minutes. This may be repeated three or four times a week for a fort 
night or three weeks. The effect of this seems to be to increase the toi 
of the uterine muscle, and materially to diminish the congestion. 
the end of this time it will be found that, although the cavity is n< 
appreciably shortened, the walls are less flabby, certainly less thick ail 
swollen; and there is far less tendency to backward flexion. The genei 
feeling of pelvic distress is also greatly relieved. The application of tl 
continuous current may now be commenced. Here again the anode 
used internally, the full Length of the platinum electrode being employed* 
and the treatment carried out in the way indicated for endometritis 
Smaller currents up to 100 m.a. will suffice. After ten or twelve app] 
cations the uterus will be found markedly diminished in length, 
white discharge almost gone, and the periods norma] in amount and di 
tion. Fifteen to twenty applications will be sufficient. If at the end 
this time there be any tendency to displacement, a pessary should be 
fitted and worn for a few wrecks. The same precaution as to the avoi< 
anee of a risk of conception musi be insisted on as in the treatment 
endometritis 

Fibroid Tumour* of tfk Uterus. The great interest which in recej 
years has been aroused in the application of electricity to the treatmei 
of pelvic diseases in women is undoubtedly due to the work of Apostoi 






THE ELECTRICAL TREA TMENT OF DISEASES OF WOMEN 325 

of Paris ; it began when the account of his results in the treatment of 
fibroid tumours was published in 1886. His methods were a complete 
departure from anything which had been attempted previously, and the 
results were in themselves so striking that attention was at once arrested. 
To him, then, is due any credit which is associated with this form of treat- 
ment. No doubt a considerable number of attempts had been made to 
utilise this form of energy for the purpose of treating various forms of 
gynaecological diseases by previous workers, but the methods were crude 
and the results insignificant. A strong claim of precedence was made by 
Cutter, and by others on his behalf, in America ; but it has been shown 
again and again that the apparatus used by Cutter was quite incapable of 
giving anything like an appreciable current, and that the effects produced 
must have been due to other than electrical agency. Apostoli's position 
rests on the fact that he employed strong currents which were accurately 
measured, and which were applied on a definite principle, depending on 
the characteristic action of the different poles. He certainly was the first 
to show how the currents might be obtained, how they should be 
measured, and especially how they could be brought to bear on the 
tissues to be dealt with. Until he did it no current approaching 200 m.a, 
had ever been transmitted through the human body for therapeutic 
purposes ; he showed very clearly how this could be done, and he also 
demonstrated, to a great extent, the result of such an application. 
Apostoli's communication aroused great interest all over the world, and 
very speedily a number of gynaecologists were engaged in an extensive 
series of clinical experiments to verify or disprove the results alleged by the 
originator of the treatment. Many of these experiments were of the crudest 
kind, and in some cases were attempted by men who knew little or nothing 
of the nature of the energy they were endeavouring to use, and with 
apparatus quite incapable of providing or applying that energy. Not 
only so, but Apostoli's statements were misread, and he was credited with 
alleging results which he never did allege. Because he said that some 
tumours diminished or disappeared, it seemed to be assumed by some of 
his critics that all tumours should disappear under this form of treatment ; 
and as they did not do so his assertions were regarded as unfounded. It 
is probable, too, that a misapprehension of the scope of the treatment 
arose from the unreasonable claims which were made for it by some of its 
upholders ; thus again a certain disappointment and sense of failure arose 
in the minds of those who were endeavouring to obtain results which should 
never have been claimed. For a time the discussion was keen, not to say 
acrimonious ; and extreme opinions were freely expressed. Time has 
allayed the turmoil of the debate, and the method, if practised by a 
smaller number, is receiving a fairer trial and is being placed on a 
sounder basis. " Apostoli's method " is now generally regarded by 
those who have given it a fair and intelligent trial as fulfilling a 
certain well-defined but highly important function in gynaecological 
therapeutics ; and those who have not given it such a trial have no right 
to an opinion one way or the other. 



326 SYSTEM OF GYNECOLOGY 

The symptoms arising from the presence of a fibroid tumour of the 
uterus are the following: (i.) Hemorrhage ; (ii.) Pain; (iii.) Pressure 
symptoms. These may, however, be entirely absent in some cases of 
fibroids even of considerable size. On the other hand, they are often all 
present together in one subject. 

The cause of the haemorrhage is undoubtedly the great vascularity 
induced by the growth; and the blood seems to come not only from that 
portion of the mucous membrane which lies on the surface of the neoplasm! 
but from the whole endometrium as well. It may show itself at the 
menstrual periods only, or it may occur also during the intermenstrual time. 
The pain may arise from various causes. It may be due to the growing 
fibroid pressing upon and straining the uterine nerves, to irregular uterine 
contractions set up by the presence of the tumour, to the production or 
straining of peritoneal adhesions, and to the compression of nerves with 
which it comes into contact. 

The pressure symptoms chiefly affect the bladder and rectum, and 
often disturb their functions to a very great extent. They may also act 
on the pelvic veins, causing haemorrhoids and varicose veins of the lower 
limbs. In large tumours the effect of pressure may manifest itself on 
organs so remote from the pelvis as the stomach and heart. The most 
acute form of pressure effect is seen in the case of growing fibroids which 
have become incarcerated in the pelvis. In these cases the suffering at 
times becomes intense. 

To the relief of these symptoms, pain, hemorrhage, and pressure, tin 
electric treatment of fibroids is directed. If it succeeds in relieving 
these it not only removes the danger of death (which, though coi 
paratively rare from a fibroid tumour, yet may result from sudden 01 
continuous haemorrhage, or from gangrene during spontaneous enuclei 
tion), but it also removes or greatly ameliorates all those consequence! 
of the presence of the tumour which tend to interfere with the dil 
charge of ordinary duties and in many cases render lite a daily increasing 
burden. The aim of the gynaecologist is not to remove the tumour, 
nor greatly to diminish its bulk ; it is simply to abolish those conditions 
which impair the activity of the subject of it, render her life a burden, or 
even menace her existence. 

It is to this relief of the symptoms of fibroid tumours thai those who 
have systematically and carefully carried out Apostolus method are prepared 

to lay claim J and when we consider that, in the great majority of cases 
of this exceedingly common disorder, these symptoms are the only serious 
ones, it must be admitted that the claim is no insignificant one. 

I repeat it is not alleged that tumours are necessarily dispersed 
or materially diminished in hulk by electrical treatment, however long 
or energetically carried out ; that both these events happen from time 
to time is no doubt, true, hut the symptomatic cure which is clainie< 

as the aim and result of this treatment does not depend on the disappear- 
ance or even on a considerable diminution of the tumour. To those win 
have had even a moderate experience of this met hod, it is known that 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 327 

tumour which was a menace to life may cease to give any inconvenience 
without undergoing any appreciable diminution in size. 

The question, then, naturally arises how these symptomatic ameliora- 
tions are brought about. How are the haemorrhage, the dysmenorrhea, 
and the general pelvic distress relieved by electrical treatment? 
The answer to this question is by no means clear. That the results are 
such as I have stated is certain ; the explanation of the results is a 
matter of some doubt. One or two considerations may, however, help 
to throw light on this subject : first, as regards the arrest of haemorrhage, 
we know that the source of it is the congested endometrium ; we have 
seen that electricity will cure ordinary haemorrhagic endometritis, and it is 
not unlikely that if a fibroid be present in the uterus the endometrium is in 
a state not unlike that found in endometritis. It is probable, then, that 
the action of the intra-uterine pole is such as to change the state of the 
endometrium and so to diminish its tendency to bleed. But it is not 
always necessary, in order to produce this control of haemorrhage, that the 
metallic electrode should come in contact with the endometrium. There 
are some cases of haemorrhagic fibroid in which, on account of the displace- 
ment of the uterus, it is impossible to introduce a sound. In these cases 
electro-puncture of the projecting mass of the fibroid may be resorted to ; 
and though, in such a case, the endometrium is never reached, the 
haemorrhage comes very soon under control. This clearly shows that, 
while electrolytic effects on the mucous membrane may be part of the 
explanation of electro - haemostasis, it is not the whole explanation. 
Other and more obscure effects of the electric application must play 
an important part in the process. One of these effects seems to be 
the distinct, though limited and probably temporary, shrinkage of 
the tumour, which is probably due to the stimulation of the muscular 
tissue of the uterus and tumour ; for there seems no doubt that those 
tumours which contain most muscular tissue are most susceptible to treat- 
ment. This shrinkage can be inferred from these two facts : firstly, after 
a sitting in which the positive pole has been used, bimanual examination 
will give a distinct impression that the tumour has become more firm and 
condensed than before ; and, secondly, in cases of tumour threatening 
impaction, although before a sitting it may often be found quite im- 
possible to raise the mass out of the pelvis, or even to shift its position, 
and that the attempt to do so causes intense pain, yet immediately after 
the sitting it can be pushed well up into the abdomen, with very little 
inconvenience to the patient. Such a change can only be explained by 
a change in the bulk of the tumour. It seems, then, quite likely that the 
haemostatic effect may, to some extent at any rate, be a secondary result 
of muscular contraction. 

It is well recognised, of course, that the continuous current has a 
marked effect in producing powerful contractions of the uterus. This can 
be demonstrated experimentally ; and it is shown clinically by the consider- 
able number of intra-uterine fibroids which have been expelled during 
electrical treatment, in some cases after a very few applications. It is 



328 SYSTEM OF GYNECOLOGY 

farther quite probable that we must look to this contraction-producing 
effect for an explanation, not only of the haemostatic results, but also of 
the alteration of nutrition and consequent diminution in size which 
not infrequently result from electrical treatment. 

The pathology of fibroid tumours and their clinical classification have 
been dealt with in another part of this work. 

The indications for electrical treatment must now be considered, and 
on the other hand the conditions, whether in the tumour itself or its sur- 
roundings, which forbid its use. To take the latter first, we may enumerate 
the following conditions : (a) Tumours which give rise to no symptoms of 
haemorrhage or pain, and which are either small enough to lie comfortably 
in the pelvis, or are large enough to occupy part of the abdominal 
cavity, are generally subserous, and in many cases are connected to the 
uterus by a more or less defined pedicle. Little benefit will accrue from 
electrical treatment in these cases, however long it may be carried out I 
they are best left alone, (b) Tumours belonging to the fibro-cystic type 
are not amenable to electrical treatment. These often grow rapidly, and 
are usually associated with a sero-sanguinolent discharge, often profuse in 
amount : it is almost universally admitted that electricity has little 
influence on them, and prolonged attempts may tend rather to increase tho 
amount and frequency of the haemorrhage. Moreover, the electrical 
application seems to have no influence in controlling the growth of these 
tumours, probably owing to their scanty and disorganised muscularity. 
(c) The soft, gelatin-like fibroid (the " cedematous " fibroid of Tait) has 
many clinical characters in common with the fibro-cystic variety. It seems 
in all cases to resist electrical treatment, and is indeed apt to undergo 
reactions of an unsatisfactory and undesirable kind on persistent attempts 
at treatment, (d) The presence of any degree of purulent salpingitis 
ought to be regarded as an absolute contra-indication. In the first place, 
this complication renders the tolerance of an effective current impossible 
and, secondly, it has been found that even small currents (20-30 m.a.), ii 
administered in such cases, are always followed by an increase in the loc 
pain, sometimes by rigors and by a rise of temperature. Such sequel* 
must be regarded in any case in which they occur as an absolute contra- 
indication, (e) A chronic peritonitis in connection with a fibroid, which 
has set up firm adhesions of the tumour either to the parietal peri 
tom-iim or to adjacent viscera, must be approached with much caution) 
It is undoubtedly a fact that some of these cases of peritoneal adhesions 
yield in a remarkable way to the use of electrical treatment, and in them 
the procedure IS more than justified. In others, however, the saml 
reactions ai those noted under (d) appear, and in them further attempt 
must be abandoned. Accordingly, in such cases tentative measures 
with a very weak current at first maybe tried, the results being carefullj 
noted and subsequent procedure thereby regulated. 

Turning now to the indications for the electrical treatment of uterim 
fibroids, we may make the general statement that all fibroids whether 
submucous, interstitial, or even subperitoneal which give rise to hsemol 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 329 

rhage or pain, which do not belong to the pathological varieties above 
noted, and which are not complicated with suppurative or inflammatory 
i conditions in the uterine annexa, are fit for treatment by electricity. 

It is almost unnecessary to say that no one supposes that the 
symptoms will be cured in every such case ; but under fair and reasonable 
conditions the pain and haemorrhage will be so completely relieved in the 
great majority of them as to remove the burden from life, and render 
existence not only tolerable, but enjoyable. 

Of the various clinical types which yield to treatment one may single 
out as specially amenable submucous tumours of moderate size, of fairly 
soft consistency, in which growth is fairly rapid, and in which the periods 
and intermenstrual haemorrhage are fairly profuse. Under this treat- 
ment the growth is distinctly arrested, the haemorrhage is reduced to that 
of a normal period, the pain, if it exists, is abolished or greatly relieved, 
and the sense of well-being is enormously exalted. And these are just the 
groups of tumours, occurring as they do most frequently between the 
ages of thirty and forty, which, by their continued and recurring 
haemorrhages, reduce activity to the lowest point, and vitality to the 
narrowest verge of existence. 

Method of Treatment. We may now consider the special details of 
procedure in dealing with these cases. It cannot be too strongly kept in 
mind that success entirely depends on close attention to these details, to 
the general care of the patient, and on watchfulness in regulating the 
manner, frequency, and vigour of the applications. 

Before the sitting the patient should take a copious douche, containing 
boric or carbolic acid, or some other suitable antiseptic ; the temperature of 
which should be between 115 and 120 F. The high temperature seems 
to check any haemorrhage which may be going on, and also acts usefully as 
a stimulant. After being placed on the couch the first step should be the 
introduction of the sound. Apostoli and some others recommend that the 
abdominal pad be placed in position first, the object of this being to give 
it time thoroughly to saturate the skin and to get into good contact with 
it before the current is turned on. My objection to this, however, is that 
it necessitates the introduction of the sound while the patient is on her 
back. Most people in this country are far more expert in passing the 
sound with the patient on her side ; and as it is of the first importance 
that the sound be passed with as little effort and with as little disturbance 
of parts as possible, it is obviously better that it should be done in that 
attitude in which the greatest skill and dexterity are available. More- 
over, the time occupied by adapting the pad is well spent in allowing any 
pain set up by the introduction of the sound to subside ; so that it may 
not in any way interfere with the tolerance of the maximum current. 
The introduction of the sound is a matter of varying difficulty in these 
cases. Sometimes it is quite simple, sometimes it is a matter of extreme 
difficulty, involving no little dexterity and patience. A careful bimanual 
examination will often help us much in indicating the relations of the uterus 
and tumour, and the probable lie of the uterine canal. If any difficulty 



33Q SYSTEM OF GYNAECOLOGY 

is anticipated it is often wisest to use first the ordinary Simpson sound, 
with which one is most familiar, to determine the direction of the canal 
and the presence of any projection which may cause difficulty. When 
this is withdrawn, and the various movements required to insert it are 
carefully borne in mind, the electric sound may often he passed with ease. 
The most troublesome cases are those in which the cervix is tilted very 
high up, either in front or behind, by the retroversion or anteversion of 
the tumour : and of these two the former is the more objectionable. The 
annoying thing about these eases is that when the tumour is moderate in 
size the direction of the canal varies from time to time, so that each sitting 
is complicated with the trouble and time spent in introducing the sound. 
In eases where the uterus is lying forward the tendency to shift is not so 
marked, and the direction once determined makes it easy to pass the 
electrode subsequently. 

The sound having been inserted, the patient turns on her back, the 
sound being held with the finger in the vagina to make sure that it does 
not shift in any way. The close contact of the abdominal pad is quickly 
assured by sponging the skin of the abdomen with hot water previous to 
its application; and by the time it is adjusted any pain setup by the 
introduction of the sound has had time to subside. The current is now 
slowly turned on, with the precautions already indicated. At the lirst 
sitting Ave should be content with a current strength of 60 m.a.. or even 
less. This is usually well borne, and the patient gains confidence bj 
discovering that any discomfort produced is moderate and easily supported. 
A duration of five minutes after this current strength has been attain e 
should suffice. The positive pole should always be employed internally 
in 1 deeding fibroids this rule admits of no exception : the negative pol 
causes more pain, and is apt to be followed by free haemorrhage. Afte 
the current is Stopped, and the apparatus removed, the patient should li 
down on a comfortable couch for twenty or thirty minutes ; and on goin 
home Bhe should either go to bed at once, or keep to a COUch for the res 
of the evening, Before retiring for the night another hot douche shoul 
l>e taken. The application should be made twice a week, and the curren 
gradually strengthened until 100 to 150 m.a. are reached. 1 am cool 
rinced that there La nothing to be gained from the use of higher strengths! 

they exhausl the patient more, and have no countervailing advantage] 
Until al Least Bight applications have been made (that is. for about the lirst 

month) the patient must be cautioned against any undue exertion ; indeed 
she should rest as much as possible. Scrupulous attention must be paid to 

the action of the bowels, a- troubles of Various kinds may follow constipa- 
tion even of a day's duration. The management at the periods is a mattes 
of prime importance. It is commonly found that, at the first period 
after treatment has begun after, gay, four or five applications have bees 

given the How begins ly a slight Bero-Sanguinolent discharge, which nia 

last for three days or so before the establishment of the period propeii 

At one time I was in the habit of ignoring this flux and making the 
application as usual. This, I now think, is a mistake; for 1 hav 






THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 331 

frequently found that it was immediately followed by a very profuse 
haemorrhage, often of a most exhausting and sometimes, of an alarming 
kind. It is better to refrain from electrical treatment under these 
circumstances, to order a hot douche twice a day until the full dis- 
charge commences, and then to advise the patient to lay up for 
three or four days. At this time that is, three or four days after the 
discharge has fairly set in the applications may be resumed, and it will 
generally be found that the amount at once diminishes, and that in forty- 
eight hours it has entirely ceased. 

At first the long sound should be used, exposing as much of the 
platinum as will lie in the canal. When ten or twelve applications have 
been made, the short, thick sound may be used, if it can be passed, and 
the cavity treated in successive segments. This is, however, of less 
consequence in the treatment of fibroids than of endometritis, under which 
head its use has been described. The number of applications will vary ; 
in most cases where the patient attends to instructions it will be found 
that twenty sittings will be enough. After the treatment is stopped the 
first period is usually somewhat profuse, but the succeeding ones approach 
more and more to the normal. In others ten more applications may be 
required, but this is exceptional. In any case it is advisable, after giving 
about twenty applications, to cease for a time and to watch one or two 
periods, and then to give a few more if this course seems to be indicated. 
Almost from the very first the improvement in general tone and vigour 
is remarkable ; the patient feels stronger, eats better, and especially 
sleeps sounder. It is, indeed, in many cases necessary to caution her 
against the too free indulgence in exercise, to which she may be tempted 
by her increased sense of well-being. 

Next we may consider the cases in which pain is the special 
symptom. In a certain number of these the pain is chiefly dysmenor- 
rhoeal, and in them it is usually accompanied by a considerable amount of 
monorrhagia. The tumour in such cases is either situated low down 
near the cervix, the uterus being usually markedly flexed ; or the condition 
is accompanied by a considerable amount of endometritis, and is charac- 
terised by the profusion of leucorrhcea between the periods. 

In such cases the treatment should be conducted on much the same 
lines as in the group already discussed. The pain at the onset of the 
period will be very greatly relieved if, at the sitting just before the period 
is due, the short sound be so introduced that the active part lies just 
beyond the os internum, and a positive application be made of the 
maximum strength which can be borne. Many cases seem to be further 
benefited by the use of the induced current applied at the same spot at 
this sitting. Indeed I am in the habit of using both currents simul- 
taneously during the sitting previous to the period. This can be done 
most conveniently by the arrangement known as the De Watteville key, 
which is fitted to properly-arranged batteries and switch-boards. The 
strength of both currents should be as much as the patient can bear. 

In other cases the pain is a more constant element ; and where it is 



332 SYSTEM OF GYNECOLOGY 

n<>t due to inflammatory conditions of the annexa, it is usually caused by 
the tendency <>f the tumour to become impacted in the pelvis, either as 
the result of its steady growth, or from the vascular flushing which 
precedes the period or sometimes arises from external causes, such as 
constipation. In these cases examination will show that the tumour 
nearly fills the pelvis, or else grows from the wall of a very much 
retroverted uterus. In either case it resists any attempt at displacement 
upwards ; and such attempts are always the cause of much pain. In 
many of the subjects of this condition rectal and vesical tenesmus give 
rise to added distress, the latter especially being the source of muefi 
misery. It is well known that many of these cases can be greatly 
relieved for long periods by a course of hot douches extending over two 
or more months. This no doubt acts by stimulating the muscular 
fibres, and so diminishing the congestion of the organ ; and this some- 
times even to such an extent that the tumour may be pushed clear of 
the pelvis, and prevented from returning to it by means of a ring or 
other pessary. In most cases, however, it will be found that a quicken 
and in the end a much more satisfactory result may be obtained by the 
judicious use of electricity. It is more speedy, for after two or three 
applications very violent tenesmus may disappear, and it is often 
immensely relieved after a single application. But more than this, the 
influence of electricity is to check the further growth of the tumour, and 
in many cases it will actually produce a diminution of it ; to lift i 
into the abdomen has no such effect, but simply gives it room to gro 
M'ithout the production of painful pressure symptoms. Take, then 
case in which the tumour is nearly filling the pelvis, and is causing son 
degree of vesical or rectal tenesmus. The long sound should be intn 
duced into the uterus, special care being taken to avoid the product ion o 
all undue pain. If, in spite of this, great pain is complained of by th 
time the abdominal pad is applied, the electrodes should be connected t 
the induction coil, and an induced current administered, of gradually in 
creasing strength, with the interruptions as rapid as possible, and ken 
op until a feeling of numbness is induced in the pelvis generally^ 
With the large pad the current can be borne nearly as strong as th 
instrument can give, and generally the numb sensation comes on 
within ten minutes. When this is fairly established the coil may he 
disconnected and the continuous current applied, the sound being 
positive, This Bhould be increased until 60 to 80 m.a. are reached, and 

the current should then be maintained for about ten minutes. The sum' 

care a I ami the use of the hot douche must be exacted. The 

sense of relief which follows even one application of this nature is oftei 
very remarkable ; and after five or six sittings the patient will usually 
express herself as being quite comfortable. It is not, wise, however, to 
stop at this point. Fifteen to twenty applications should be given, an 
it will usually he found long before tin's that the uterus is free! 
movable, and that, in the case of a retroversion, a pessary can he worn 
with perfect comfort. Of course in many cases the passing of the sound 



: 






THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 333 

gives rise to no great pain, and in these the preliminary faradisation is 
not necessary. In none need the current ever exceed 150 m.a. ; and 100 
in. a. will usually be found sufficient. 

It is, however, of the greatest consequence in connection with this 
group of cases to bear in mind that some of the symptoms may be due 
to the presence of conditions in the annexa such as pyosalpingitis 
which absolutely contra-indicate electrical treatment. Where there is 
the slightest suspicion of the presence of such elements in the case, great 
care must be employed in beginning the treatment a small current being 
used, and any febrile reaction carefully watched for. If this occur, or if 
the pain seem in any way aggravated by the treatment, further procedure 
in this direction should be abandoned. 

The Use of Eleetro-puneture. All authors seem to be agreed that 
whenever the current can be passed by the endometrium, it is better so to 
pass it. Consequently whenever the sound-electrode can be introduced 
into the uterus Avithout resort to violent measures, this method of apply- 
ing the internal electrode should be adopted. There is, however, a certain 
group of cases in which it is impossible to pass the sound. This state of 
things is brought about by so great a displacement of the uterus, back- 
wards or forwards, by the tumour as to tilt the cervix and so put it out 
of reach ; or it may arise from the downward growth of a lobule of a 
large tumour, or of one mass of a multiple tumour, the main body of 
which is in the abdomen. In these cases the roof of the vagina is gener- 
ally occupied by a hard, solid mass of spherical outline, the cervix being 
just within or altogether beyond reach. In such cases pain is usually 
the chief complaint though, of course, haemorrhage is often present as 
well. The passage of the sound being out of the question, the only 
means of dealing with the tumour electrically is by means of electro- 
puncture. Now, while admitting the obviously greater risk involved in 
this procedure, I do not for a moment admit that the risk is in any sense 
sufficient to forbid it, if it be carried out with certain simple precautions. 
The marvellous relief which may follow the practice of puncture in 
cases in which hysterectomy is positively the only alternative, is, to my 
mind, an ample reason for its use in properly selected cases. I have used 
it many times, and I have had only one case in which its results gave rise 
to any anxiety ; in that case conditions were present which can be easily 
excluded in any other. 

The instrument employed for the puncture has been already described ; 
it is simply an enlarged electrolysis needle (see Fig. 108) ; and the special 
condition of its introduction is that it be buried at least deeply enough 
to allow the sheathing to pass through the mucous membrane of the 
vaginal roof. In this way the formation of a sinus or sinuses in the roof 
is avoided. On the other hand, if, as is advised by Apostoli and others, 
a bare steel or platinum needle or trocar be used, with the insulating 
sheath up to the vaginal roof, but not through it, the latter is acted upon 
by the current as well as the deeper parts, and an open channel is formed 
from the vagina to the deepest part of the puncture. 



334 SYSTEM OF GYNAECOLOGY 

For purposes of description Let us take a case where the roof of the 
vagina or posterior wall is blocked by a fibroid mass causing pain and 
pressure symptoms, and where it is impossible to pass the sound. Im- 
mediately before the operation a strong corrosive or carbolic douche, 

copious enough to remove any trace of discharge of any sort from the 

vagina, must be given. The patient should then be placed on the conch 
in the dorsal position. If a bed be used it must he firm, and she must 
lie as near the edge of it as possible : the knees must he drawn up and 
widely separated, and the feet firmly planted. As the patient must not 
he disturbed after the puncture is made, the abdominal pad should now 
be applied and its connecting cord, the positive one. attached. The 
needle, which should have been standing in a 1-20 carbolic solution, is 
now attached to the negative connecting cord and taken in the right 
hand. Its point, protected by the pulp of the forefinger, is carried along 
the vagina until the most prominent part of the tumour is felt. The tip 
of the finger is used to determine if any pulsating vessel can be felt over 
this part ; if not, the point is presented to it and steadily held with the 
right hand, while the left is employed to press on the handle until the 
point passes .', or j of an inch through the mucous membrane. The 
length can be previously marked by tying a piece of silk thread firmly 
round the insulator at the proper distance from the point. As the needle 
tapers to the point, the thread, if properly tied, cannot slip up the stem, 
and an accurate guide to the depth of puncture is thus secured. 

The pain caused is very slight ; it is usually confined to that produced 
by the puncture of the vaginal roof, and is but momentary. In con- 
nection with this electro-puncture a good deal lias been made of the 
supposed risk of injuring the bladder or other organs in introducing the 
needle. I have never seen a case where there was the slightest risk of 
BUch an injury. In cases suitable for puncture the pelvic roof is so com- 
pletely occupied by the tumour that no other organ can encroach upon it, 
and it is quite safe to select the most prominent part of the tumour for 
the puncture. This will usually be found well behind the middle point of 
the pelvis, where we are a good deal nearer the rectum than the bladder. 
Everything now being in position, the needle is handed to the muse, the 
forefinger being kept in position against the roof of the vagina to make 

sure that there is no displacement as she takes charge of it. The current 

is now carefully turned On, the same precautions being observed as were 
previously described. A strength of 1(H) ni.a. is usually borne with ease, 
and this may be continued for from five to eight minutes. Asa matter 

of fact these negative electro punctures are rather more easily home than 

intra uterine applications ; and, after two or three sittings, one may safely 
OSS currents of L50 to 200 ni.a. When the current is taken oil' the 

needle is withdrawn, the pad removed, and absolute quiet enjoined for 

half an hour. The patient may then dies- and go home, but should go to 
bed at once. A douche mUBt be given ;it night, and repeated regularly 

once a day at least. There is often a little \^\ discharge for a day or 

two after the operation, but I ha\e never seen any serious haanorrhage 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 335 

follow it. It is wise to allow a week between each sitting. The same 
precautions and procedure must be rigorously observed at the subsequent 
sittings, and it is well to avoid puncturing again in the same spot until 
several weeks have intervened. For ten days or more the site of the 
puncture can be recognised by the presence of a little dimple or pucker ; 
after that time it should leave no trace. 

Apostoli and most other authors enjoin the use of the negative pole 
for electro-puncture. This has two advantages : 1st, it permits the use 
of a steel needle for an electrode ; and, 2nd, the needle is easily withdrawn 
at the end of the operation on account of the looseness of the disintegrated 
tissue. It is also supposed to have the advantage of breaking up more 
tissue than the positive. This difference is, however, rather apparent 
than real, as we have already seen. It has the disadvantage that it might 
favour haemorrhage through the puncture, if by any chance there were a 
tendency to this accident ; and it has the distinct and much more serious 
disadvantage of tending to cause a congestion of the tissues in the region 
of the puncture. In this case we should hardly expect the same im- 
mediate shrinkage which we certainly get in intra-uterine positive applica- 
tions, and we should miss to some extent the immediate and gratifying 
relief of pressure symptoms which usually follows a positive application. 
There is then, it seems to me, no objection whatever to the employment 
of the positive electro-puncture if the negative fail to give the desired 
relief. A platinum needle must be used, and if, as sometimes happens 
even with platinum, the needle does not come away of itself after stopping 
the current, a negative current of not more than 2 or 3 m.a. for a few 
seconds will free it. We thus get the soothing and congestion-reducing 
effects of the anode, with probably no diminution of the electrolytic in- 
fluence of the kathode. 

In concluding our consideration of the treatment of fibroid tumours 
of the uterus by " Apostoli's method" it will be well to summarise the 
claims made for it : 1 . In submucous and interstitial fibroids it controls 
haemorrhage, abolishes metrorrhagia, and restores the period to normal 
limits : 2. It relieves pain, both menstrual and intermenstrual : 3. It 
produces an immediate diminution in the congestion, and hence in the 
bulk, of an impacted tumour ; and, though this may be evanescent, it 
gives great relief to pressure symptoms, and may enable such a tumour 
to be freed : 4. The growth of submucous and interstitial tumours is 
almost always completely arrested : 5. In a certain number of cases the 
tumour is distinctly reduced in size : 6. In a very small number the 
tumour majr wholly or nearly disappear : 7. The effect of the treatment 
is a symptomatic, not a radical cure. 

Pelvic Exudations. The frequency with which perimetritic and para- 
metritic exudations occur in the female pelvis, the disorganisation of func- 
tion they cause, and the pain and distress they bring with them, are well 
known to every gynaecologist. Nor is he less well aware of the persistence 
of these deposits, and of their power of resistance to almost every form 
of treatment to which they can be subjected. 



336 SYSTEM OF GYNAECOLOGY 

These exudations may take the form of a bulging mass, in one or 
other or both sides of the uterus, of a dense, firm, and unyielding quality, 
fixing the uterus and displacing it to one or other side. This form is 
usually the result of a cellulitis beginning in the cellular tissue of the 
roof of the vagina on one side, sometimes being confined to that side, buf 
often finding its way to the other. Again, one may find a dense mass 
behind the uterus, occupying the pouch of Douglas; not bulging to any 
extent into the vagina, but binding the uterus to the posterior or lateral 
aspects of the pelvis. This is most frequently the result of a peritonitis, 
and, like the cellulitis, is generally septic in its origin. In other cases 
the whole pelvic viscera may be matted together, the pelvis being roofed 
in, as it were, by the inflammatory exudation, partly perimetritic, partly 
cellulitic. The tendency of these deposits in the early stage of their 
history to suppuration is well known ; but in many cases this does not 
occur, and the mass remains unchanged for months and years, a constant 
cause of pain and distress, of dysmenorrhea and monorrhagia, reducing 
the subject to a state of profound debility and misery. The treatment 
of these deposits is often one of the most tedious and disheartening ex- 
periences of gynaecological practice. Some of them, no doubt, become 
absorbed, either spontaneously or as the result of treatment; but in 
other cases, the treatment by blisters, iodine, ichthyol, hot water, glycerine, 
and other remedies, proves futile, and the condition remains unaltered 
for an indefinite time. 

It is in the treatment of some of these obstinate and previously hope- 
less conditions that electricity has achieved some of its most brilliant 
triumphs. However great may be the difference of opinion as to its 
efficiency in the treatment of fibroid tumours, few physicians who have 
given its virtues a fair trial in the present class of cases, or have watched 
the course of a case under treatment, are not compelled to admit that it 
beneficial results are most striking. I have seen an enormous exudativa 
mass, which was proved by an exploratory incision to have roofed in tin 
pelvis and tilled every fold of the peritoneum with a solid deposit, dis- 
appear after twenty-five applications of electricity; indeed it required 
careful examination by an expert to say that there was anything abnormal 
in the pelvis. And the patient, who had spent years in lied as a helplesl 
invalid, at the end of a few months' treatment was able to take a five 
miles 1 w.dk without discomfort or undue fatigue. 

The value of this treatment in these cases cannot well be overrated. 

Apostoli, Goelet of New fork, and others arc strongly in favour ol 
beginning the treatment ol this kind during the acute stage] 

when fever, pain, and the actual process of exudation are going 01 

They advise tin- OSe Of intra Vaginal faradisation with the fine wire coil 

asserting that this relieves the pain, calms the patient, and diminish* 
the amount of exudation. They recommend that a bulbous metallic 
electrode !' placed in the affected fornix, and gentle faradisation carria 
on until the pain is relieved, a process which occupies fifteen or twentj 
minutes, and that this process should be repeated once or twice dairj 



THE ELECTRICAL TREATMENT OF DISEASES OF WOMEN 337 

In the subacute stage the continuous current may be substituted, a cotton 
or clay covered vaginal electrode being used, and a pad on the abdomen. 
The current strength may vary from 20 to 30 m.a., the anode being 
used internally. This again is said to diminish the pain and to reduce 
the exudation. These applications may be made every second day. 
The only contra-indication to this line of treatment, according to these 
authors, is an intolerance of the application on account of increase of 
pain and rise of temperature. These events are probably indications of 
a change in the direction of suppuration which is generally regarded as 
being an absolute contra-indication. 

I have had no experience of this treatment at these stages of the 

disorder, and cannot therefore speak of it with any authority. But in 

the chronic condition, when all active change has ceased, and when the 

mass has assumed its firm, dense, immovable character, I can speak of 

the value of electrical treatment with every confidence. When the mass 

has the general character of a cellulitis when, that is to say, it is lateral 

to the uterus and bulges into the lateral fornix I believe the best results 

are to be obtained from electro-puncture ; and, following the general 

practice, I have always employed the kathode in these cases, though here 

again I should suggest that this rule need not be binding. The plan of 

procedure is precisely the same as in the puncture of a fibroid ; only, I 

should advise that the first few punctures be done at the patient's house 

so as to give her the benefit of complete rest after the sitting. The 

current strength should not exceed 50 m.a. on the first three or four 

occasions, but it may then be gradually increased until 100 or 150 m.a. 

1 are attained, provided no unfavourable reaction follow. After a variable 

number of applications, say three to six, it will be found that the bulging is 

; steadily diminishing, and that it becomes more and more difficult to 

j define a suitable spot for insertion of the needle. When this occurs, the 

I subsequent resolution is generally rapid. It seems undoubtedly to be 

; favoured, however, by a systematic pursuit of the treatment by intra- 

I uterine application, and this should now be substituted for the punctures. 

In a comparatively short space of time, varying from two to four months, 

I according to the extent of the deposit, the treatment may be completed. 

! This will be determined by the almost complete disappearance of the 

j mass, by the mobility of the uterus and ovaries, and by the nearly entire 

cessation of pain and pelvic distress. 

In retro-uterine perimetritic exudations, where a defined mass can be 
felt, a similar procedure may be resorted to. On account of the greater 
difficulty of securing this definition, the puncture should be made with 
great caution, and should never exceed half an inch in depth. The 
change in the mass of adhesions which follows necessitates an earlier 
resort to intra uterine applications than in the case of parametritic 
deposits. On account of the pain which the negative pole always sets 
up, these, at any rate, at first should be anodal. In my experience, 
perimetritic exudations are dispersed more slowly than parametritic ones ; 
one explanation probably being that the former can tolerate smaller 

z 



338 SYSTEM OF GYNECOLOGY 

current strengths than the latter. But the ultimate result in the 
majority of both cases is the same ; namely, an almost complete dispersion 
of the deposit, restored mobility of the pelvic organs, and an enormous 
relief from pain. 

R. Milne Murray. 

REFERENCES 

A complete bibliography of gynaecological electrotherapeutics will be found in 
Le Courant continu en gynecologic, by Dr. Albert Weil, Paris, 1895, embracing 
almost every paper bearing on the subject from 1857 to 1895. 

The following are some of the more important contributions with reference to 
Apostoli's method : 

1. Apostoli. " Nouveau traitement des fibromes de l'uterus; lecture faite de 20 
juillet a l'Academie des sciences," Comptes rendus, 1884. 2. Ibid. "Sur nouyeal 
traitement electrique des perimetrites," Comptes rendus Congres de Copenhague, ii. 
141. 3. Ibid. " Documents pour servir a l'histoire de relectrothirapie des fibroma 
uterins," Revue intern, d 'electrique, 1891. 4. Carlet. Traitement electrique des 
fibromes uterins. These de Paris, 1884. 5. Ibid. " Traitement electrique des tumeuil 
fibreuses de l'uterus d'apres la methode du Dr. Apostoli," Ann. Soc. de med. de Gandl 
1885. 6. Engelmann, F. "Die Elektricitat in der Gynakologie," Arch. f. GynaH 
xxxvi. p. 193. 7. Goelet. The Electrotherapeutics of Gynecology. Detroit, 1892. 
8. International System of Electrotherapeutics. Philadelphia, 1894. Sec variola 
articles by Grand and Famarque, Goelet, Kellogg, etc. 9. Keith, Thomas. "Dr. 
Apostoli's Treatment of Uterine Fibroids," Brit. Med. Journ. 14th July 1888. 10. 
Keith, Thomas and Skene. The Treatment of Uterine Tumours by Electricity 
Edinburgh, 1889. 11. Kellogg. "Summary of my Personal Experience with 
Electrolysis in the Treatment of Fibroid Tumours," Journ. Amer. Med. Assoc, vol 
xviii. 1892. 12. Martin, Franklin H. "Electrolysis in Gynaecology," Journey 
Amer. Med. Ass. Chicago, 1886, p. 61. 13. Ibid. Electricity in Diseases of Wome\ 
and Obstetrics. Chicago, 1893. 14. Massey, Betton. Electricity in Diseases \ 
Women. Philadelphia, 1889. 15. Munde. " My Recent Experience with Electricit 
in Gynaecology," Am. Journ. Obstet. June 1890. 16. Murray, Milne. i; The Treaj 
ment of Pelvic Disease by Electricity," Trans. Edin. Obstet. Soc. 1890. 17. N Loi El 
"Ueber die elektrische Behandlung der Franenkrankheiten, besonders der Myome, 
Zeit. f. Geburts. u. Gyne. Bd. xxii. Heft 3, 1893. 18. Pi.ayiam:. Electricity in th 
Treatment of Uterine Disease, 11th June 1887 and 14th January 1888. 19. Rkon i i i 
Traitement des maladies des Femmcs par VdectriciU. Paris, 1896. 20. Webb. "O 
the Treatment of Fibroid Tumours of the Uterus by Electricity," Brit. Md. Jour 
May to July 1887. 21. Wi.n.. Le Courant coat* 'mi en gynecologic. Paris, 1895. 

R. M. ML 



DISORDERS OF MENSTRUATION 



339 



DISORDERS OF MENSTRUATION 

The line of demarcation between menstruation which conforms to the 
normal order, and menstruation which presents features sufficiently 
abnormal to permit of its being considered disordered, is very difficult 
to draw. Menstruation which would be normal in one woman, might in 
another be regarded as painful, or profuse, or scanty ; even in the same 
subject, many deviations from the rule are perfectly consistent with 
health, and are not necessarily due to any local disease. In this 
article the various deviations from normal menstruation will be dis- 
cussed ; they are but symptoms, and when due to gross pathological 
lesions the description of these must be sought elsewhere. The prominent 
disorders are amenorrhcea, menorrhagia, and dysmenorrhoea, but before 
reaching a consideration of these, it will be well to discuss the questions 
of premature and protracted menstruation. 

Premature menstruation. Menstruation usually begins in the 
fifteenth year, and ends between forty-five and fifty ; thus menstrual life 
normally lasts from thirty to thirty-five years. But menstruation 
occasionally sets in at a much earlier age. One case was recorded by 
Campbell, in which a girl had menstruated regularly every three weeks 
since birth. In many of these cases of precocious menstruation the 
general and sexual development is premature ; the pubes becomes 
covered with hair, the mammae enlarge, and both the external and 
internal generative organs undergo rapid development. 

I have tabulated the cases found recorded under the following heads ; 
and, where the case seemed one of more outstanding peculiarity, I have 
shortly epitomised its history: 

1. Precocious menstruation with an early appearance of the external 
manifestations of puberty. 

2. Precocious sexual development without menstruation. 

3. Menstruation previous to development of the sexual organs. 

4. Early conception and pregnancy. 

5. Premature sexual development associated with tumours of the 
generative organs. 

1. One of the most striking cases illustrative of the first group is the 
oft -quoted one of De Beau, to the record of which he considered it 
advisable to append the signatures of four physicians, a mayor, and a 
British consul. 

The history is as follows: "Matilda H. was born on the 31st 
December 1829. She came into the world with her mammae perfectly 
formed, and the mons veneris covered with hairs, as much as a girl 
between thirteen and fourteen years old. When precisely three years old 
the catamenia made their appearance, and have continued to appear 
regularly every month until the present time (1832), and as copious as 
any woman might have them, each period taking four days. . . . Her 



34Q SYSTEM OF GYNAECOLOGY 

mammae are now of the size of a full-grown orange; and the dimensions 

of the pelvis are, in my opinion, such as to enable her to bear children 
when right years old, and very likely sooner." 

In Campbell's case (2) the catamenia set in a few days after birth, and 
occurred regularly at periods of three weeks and two or three days. 
This order continued until the patient died at the age of four years. 
Ber appearance was that of a girl of ten or eleven, the mammae and 
external genitals having the appearances proper to puberty. The 
development of the pelvis and of all the deep-seated genitals was found 
at the autopsy to be very considerable. 

R B. Smart gives a table of eight recorded cases, and describes in full 
detail a case which came under his own observation, with two accompany- 
ing photographs of the patient. The catamenia in this girl appeared at 
three years and six months, and the hair on the pubes shortly ante- 
cedent to that. 

Bouchart narrates the history of a girl, N. 0., and the appearance 
she presented at the age of four years. She had been born with the 
breasts notably enlarged, she began to menstruate at the age of twenty- 
two months, and at the time of examination she presented the appearance 
of puberty as regards her breasts and genitals. Menstruation in her case 
was very regular in its recurrence, it lasted four to six days, and was in 
quantity equal to that of an adult. 

Harris classifies precocious menstruation in two varieties : 1st, that 
occurring during infancy ; 2nd, that occurring between the ages of 
seven and thirteen years. He records the case of a girl who cann 
under his own observation, in whom menstruation appeared at the age <>t 
nine and a half years, and in whom the other evidences of puberty niani 
fested themselves. 

C. E. Harle records the result of a post-mortem examination on 
child who had begun to menstruate at the age of five months ; the 
menstruation returned regularly till the. fourteenth month, when the chile 
died of diarrhoea. The pudendum was large and clothed with hair; the 
uterus was large, the os patent and the lips congested, the vessels of th< 
broad ligament were injected, and both ovaries were cystic. 

The other cases I have noted under this category are the following : 



[TabJ 



DISORDERS OF MENSTRUATION 



34i 



Author. 


Menstruation 
began at age of 


External Appearances 
of Puberty. 


Astley Cooper in Med. - Chir. Trails. 
1813. 

Thomas Embling in Lancet, 1848. 

Aveling in Lancet, 1866, gives a refer- 
ence list of sixteen cases by different 
observers. 

Prochownick in Arch, fur GynaeJc. 1881. 

Berry in Medical Press for 1882. 

A. van Denver in Am. Journal of 

Obstet. 1883. 
Four of the following cases are cited 

by Pozzi in his Gynecologic : 
Cabade in Gaz. nUd. de Paris, 1883. 
W alien t in Dissert. Inauq., Breslau, 

1886. 
Casati in II. Raccoglitore, 1886. 

Diamant in Intern. Tclin. Rundschau, 

1888. 
Jagoe in New York Med. Joum. 1889. 


3 years. 
2 years. 

1 year. 

5 years and 4 

months. 

4 months. 

8 months. 

1 year and 3 

months. 

6 years. 

6 years. 

2 years. 


In breasts, axillae and 

on pubes. 
Mamma?, and pubes. 

In breasts, axillae and 
on pubes. Internal 
organs not enlarged. 

Breasts and genitals. 

Mamma? greatly enlarged. 

Rapid development. 

Rectal examination, 

" uUrus pubere." 
Extl. genitals. 

Extl. genitals. 



2. The indication of a sexual precocity, manifested by the outward signs 
on the breasts and pudenda, but unaccompanied by a menstrual discharge, 
is unusual. Few instances of this character have been noted, but that 
described by William Cook is distinctive enough. 

3. Menstruation occurring without any change in the genitals is not 
so unusual as the preceding, but it is rare for a child to have the 
catamenia established for a period of years without other associated 
phenomena presenting themselves. 

Pozzi cited Bernard's case of a girl who menstruated regularly 
from birth up to the age of twelve years without any development of 
her genital organs. 

In the same class may be included the cases noted by the following 
authors : 

Allbutt reports a case where the menstrual discharge occurred 
periodically until the youthful patient died of exhaustion. 

Clarence Harding reports that in a family of two daughters both 
suffered for a time from a periodic discharge, hemorrhagic in character, in 
the elder of whom the discharge vanished until puberty was established, 
when it recurred. 

4. Many remarkable instances of early pregnancy have been put 
on record by trustworthy authorities ; the majority of those in this 
country have occurred after the age of twelve. There is, however, in 
continental literature no great scarcity of reports of pregnancies at a much 
earlier age. 



342 



SYSTEM OF GYNAECOLOGY 



The following table of cases which I have collected from various 
sources has been arranged in order of age. The majority of the record*] 



bear evidence of being trustworthy : 



Author. 


Reference. 


Develop- 
ment. 


Menstrua- 
tion. 


Impregna- 
tion. 


Delivery. 


State Of 
Child. 


Miiller . 


of 
Obst. and 


Excessively 

* at birth. 


2nd year. 


8 years. 


Instrumental, 

8-9 months. 


Dead. 


Schmidt 


!-:: :::* ffisfcr 


Sexual organs 


2nd year. 




8 years and 10 


Full term, 




Iquee, 1779. 


developed. 






months. 


dead. 


Bodd . 






1 year irreg- 
ular, 7 
years reg- 
ular. 




8 rears and 

10J months. 




IfolitOT 




Hair on pubes 


4th year. 


s years and 


Premature, 


Foetus 






at birth. 




3 months. 


5th month. 


months'. 


Dodd . 


Lancet, 1881. 


Pubes and 
axilla cov- 
ered with 
hair. 


12 months. 


8 years and 
10 months. 




Weighed 7 
lbs. 


Rowlett 


Trans. Med. 

.lour. 


A few weeks 
after birth. 


12 months. 


9 years and 
3 months. 


10 years. 


7| lbs. 


Bayliss . 


Brit. Med. 




9 years and 




10 years and 


Alive. 




and Surg. 




10 months. 




8 months. 


weighed 8 lbs. 




Jour. 1846. 












Robertson . 


Midwifery. 






12th year. 


12 years and 
a tew 
months. 




Smith . 


Luinl. Mnl. 
Gazette, 
1848. 


No history. 


10 years. 


11 years. 


12] years. 


Fully devel- 
oped. 


May . 


Lancet, 18S0. 




Once before 
conception. 




13 years. 


Well devell 
oped. 


Beywood 


Brit. Med. 




12 years and 


12 years and 


L8 years and 




Smith 


Jour. 1881. 




6 months. 


8 months. 


4 months. 




Wilson . 


Kilhi. Mnl. 
Jour. 1861. 


No precocity. 




12 years and 

9 months. 


18 years and 
6 months. 


Full grown. 


Chapman 


Assoc. Mnl. 
Jour. 1856. 






L8 years and 
i month. 


18 years and 
10 months. 


Full grown. 



5. It has been asserted that among the causes tending