. V _ JJ A IV n. u ± 1 V AID 
FOR THE 
TREATMENT AND PREVENTION 
OF 
UTERINE DISORDERS. 
By WILLIAM GOODELL, M. D., 
Physician in charge of the Preston Retreat, Clinical Lecturer on the Diseases of Women and Children, 
in .the University of Pennsylvania, etc. 
From letters of inquiry which I am re- 
ceiving from widely distributed portions of 
this country, I am led to infer that a few 
hints with regard to the treatment and the 
prevention of the more ordinary forms of 
uterine disorders will not come amiss to 
some of the many readers of this journal. 
In order, however, to make these hints as 
practical as possible, this paper will be made 
up mainly of categorical answers to the 
leading questions of my correspondents. 
But for this very reason it will necessarily 
be somewhat dogmatic as well as desultory 
in its character; and will also, I fear, com- 
. pel the frequent use of the first person, an 
egotism for which, in advance, I ask indul- 
gence. 
-The instruments which I 
recommend the students of the University 
to purchase at the outset of their practice 
are as follows :- 
One base-expanding bivalve speculum 
(a modification of Smith's}, whose blades 
are three inches and three-quarters long, 
and one inch and a quarter wide. Two glass 
speculums (Fergusson's), the one not longer 
than five inches and three-quarters, with 
the smaller aperture measuring one inch and 
a quarter in diameter; the other five inches 
long, and at the smaller aperture seven- 
eighths of an inch wide. Two probes or 
applicators, of aluminium wire-, with one ad- 
justable handle. One uterine tenaculum. 
One small volsella forceps. One speculum 
forceps. One uterine sound. One uterine 
repositor. One hard rubber uterine syringe 
with a long and flexible nozzle. One ute- 
rine dilator. 
This list by no means exhausts the num- 
ber of instruments required for special casesi, 
of uterine disease. But, in my opinion, no 
one can intelligently and successfully treat 
the ordinary diseases of the womb without, 
at least, the foregoing instruments. 
At first blush the blades of the bivalve 
speculum (Figs. 1 and 2), may seem too 
short. But practically, if their tips be di- 
rected to the previously ascertained site of 
the cervix, it will be found that, when wide- 
ly separated, they will so stretch the uterine; 
end of the vagina as to bring down the cer-( 
vix into the field of vision, not only very, 
close to the eye of the physician but within- 
reach of his index finger. For diagnostic! 
or for operative purposes these are advan- 
tages not to be overlooked. In very rare 
cases, such as of fat women, whose vaginas 
are large and flabby, of those in whom, by a 
fibroid or an ovarian tyrnor, or by pregnan- 
cy, the womb is lifted up above its accus- 
tomed site, the cervix may not be well ex- 
posed by this instrument. In these very ex-i 
ceptional cases the larger of the Fergusson : 
speculums may be substituted for the bi- 
valve. The smaller glass speculum is put! 
down in the list because it will occasionally! 
be found useful in the examination of un- JUAL HUNT'S IU11 THi. 
Fig. 1. 
long for easy carriage, and be- 
cause I have found that the wire 
is very liable to break off at the 
line of junction with the han- 
dle. The uterine sound should 
have merely the usual knob at 
the distance of two inches and 
a half from its tip. If other- 
wise graduated it will very soon 
snap off at one of the deep 
notches made to mark off the 
inches. It should, further, con- 
sist of one piece; else by the 
wearing away of the thread of 
the uniting screw the relation 
between the handle and the tip 
is lost. One more word with 
regard to the sound. It should 
never be introduced until the 
physician has first satisfied 
himself that the womb is not 
gravid ; and this golden rule 
holds good for all uterine ap- 
plications. I lay stress on this point, 
for I once carelessly brought on an abor- 
tion in an estimable married lady, who 
was quite as much surprised at the result, 
but not quite so much mortified as I was. 
Again, I have, on more than one occasion, 
been consulted fcr uterine disease by design- 
ing women, who, being pregnant, sought 
advice with the hope of having a cheap rid- 
dance, induced by the treatment. Once, 
after arranging to meet a physician who 
lived some twenty miles off, I received a 
countermanding telegram followed by a let- 
ter, explaining that the supposed uterine 
disease of his patient, a reputable married 
woman, was pregnancy, and that her sole 
object was the hope of having abortion 
provoked by the examination. His suspi- 
cions had been aroused by mine, and by 
working on the fears of his patient he ex- 
torted a confession. These facts should lead 
one to be on one's guard. 
Local Treatment-The following agents 
employed at the clinic of the University are 
enumerated in the order in which they are 
ordinarily used. The undiluted commercial 
liquid carbolic acid (Calvert's No. 4), or a 
saturated solution of the crystals; a solution 
of one drachm of nitrate of silver to the 
ounce of glycerin; a saturated tincture of 
iodine; fuming nitric acid and the solid 
stick of lunar caustic. 
With the exception of the last, each caus- 
tic is applied by means of a film of cotton 
Fig. 2. 
married women, or of those in whom the 
introitus vagince is either unnaturally small 
or hysterically contracted. Yet even in 
these cases, after the slow admission of one, 
and then of two fingers, the parts can usu- 
ally be sufficiently dilated for the admission 
)f the bivalve speculum. Under ether this 
can always be done. 
I feel quite sure that physicians who have 
once used this speculum, with the woman 
lying on her back, will never wish to return 
to their old-fashioned cylindrical or quadri- 
valve speculums. One hint, however, to 
those of my readers who do not feel dis- 
posed to give up their long-used glass specu- 
lums for a new and untried instrument. The 
Fergusson speculums as sold in the shops are 
entirely too long and too narrow. For ex- 
ceptional cases it is well to have on hand the 
two sizes above given; but the best working 
speculum of this kind is, in my experience, 
one not over five inches in length, and with 
the smaller aperture not under one inch and 
one-eighth in diameter. 
The uses of the other instruments will be 
indicated in the proper place; but a word 
here with regard to two articles on the list: 
The probes, or applicators, of aluminium 
wire, are chosen because this metal is flexi- 
ble and resists the action of most of the cor- 
rosive agents employed in uterine therapeu- 
tics. A sliding and removable handle is 
recommended for these applicators, both be- 
cause a fixed one makes the instrument too wool wrapped evenly around about two 
inches of the aluminium probe, beginning 
at its tip. Jeweler's cotton is the best for 
this purpose; it is chemically cleaned, and 
has a long and fine fibre. These probes are 
usually roughened for that distance, in or- 
der to give the cotton a hold which would 
prevent it from slipping off and remaining 
behind in the uterine cavity. This rough- 
ening, however, makes the subsequent re- 
moval of the cotton too tedious, and too lia- 
ble to stain the fingers. I therefore prefer 
to use a smooth probe, taking care, in that 
case, to wrap the terminal end of the cotton 
very tightly. But, as this needs a skill 
which practice alone can give, it would be 
well for a beginner to make use at first of 
the roughened wire. The ordinary uterine 
sound can of course be resorted to for the 
same purpose; but the stronger acids soon 
corrode it, while the bulb at its tip makes 
the removal of the cotton a dirty and diffi- 
cult process. 
The probe thus armed, after being dipped 
into one of the above liquids, I always carry, 
through a speculum, up to the fundus of the 
zvomb whenever the internal os per- 
mits it topass. In the great majority 
of cases this can be done, provided 
ihe anterior lip of the cervix is first 
hooked down by the uterine tenacu- 
lum (Fig. 3); a procedure which 
steadies the womb and straightens 
it out. My reasons for cauterizing 
the whole mucous tract of the 
womb are fourfold, (a) If the mu- 
cous coat is alone involved, the 
symptoms often fail to inform me 
how far up the disease has extended. 
(&) Owing to the absence of any 
sub-mucous connective tissue, the 
inflammation of the mucous mem- 
brane must sooner or later more or 
less involve the parenchymatous 
structure, and this must be avoided 
at all hazards, (c) Whenever the 
internal os is sufficiently patulous 
to admit the armed applicator, I 
accept this fact as an evidence that 
the disease is not limited to the cer- 
vix. (cZ) By this practice, in a meas- 
ure empirical, I err on the safe side, 
and obtain far better results than I 
did when limiting my applications 
to the cervical canal. Nor is this 
bolder plan of topical medication 
more hazardous than the ordinary one lim- 
■flwwv. araraxxi a aaai az a avjo T JJH A AW Al WA U A -Lu-IL A 1.1 JLU ±7 J. 0V±X D . 
ited to the cervical canal. Out of a yearly 
average of over one thousand five hundrec 
uterine applications of this kind, at the 
University clinic, to say nothing of my own 
private patients, we have not yet heard of a 
death from this cause. Nor have we seen 
any but light and manageable attacks of 
perimetritis, and these very seldom indeed. 
The cases in this clinic consist of out-pa- 
tients, who, after an application, however 
strong, have necessarily to go home, many 
to adjacent towns lying within a radius of 
twenty miles. In this clinic, also, we are 
reluctantly compelled even to insert sponge- 
tents, and yet the only case of mischief fol- 
lowing their use occurred in a woman with 
a fibroid tumor, in whom the tents were in- 
troduced at her own home. But even in 
this case J am disposed to think that the 
peritonitis lighted up can be more fairly at- 
tributed to the repeated examinations, made 
with finger and sound, by the five physi- 
cians present, than to the tents. At any 
rate, it taught me the lesson to forbid any 
but absolutely necessary examinations of the 
uterine cavity. I have about come to the 
conclusion that he is the most successful 
gynaecologist who is the most plucky, and 
that, no matter how severe or mild the treat- 
ment of uterine disorders, the percentage of 
accidents will be about the same, and that at 
very low one. The only severe attack of peri- 
metritis of which we have any knowledge 
followed the application of the solid stick of 
nitrate of silver merely to a patch of granular 
erosion on the cervix. In my private prac- 
tice I have yet to see, from this cauterization 
of the whole mucous lining of the womb, 
any worse results than an occasional attack 
of uterine colic, but rarely so urgent as to 
require morphia hypodermically. For all 
pelvic inflammations induced by a uterine 
treatment, or, indeed, for those following 
labor, I am in the habit of recommending 
from 16 to 24 grains of quinia during the 
twenty-four hours; morphia in quarter- 
grain doses repeated frequently enough to 
keep under the pain; and, while the pulse 
runs high, from 60 to 80 grains of the bro- 
mide of potassium. From the umbilicus 
downward the abdomen is to be painted 
twice a day with the compound tincture of 
iodine, and then to be covered by a large 
mush poultice, over which is spread a piece 
of oiled-silk or a well-greased sheet of brown 
wrapping-paper. The diet is to consist o' 
beef-tea and milk ad libitum, egg-nog, ar 
FIG. 3. SOME PRACTICAL HINTS FOR THE 
more or less of whiskey or of brandy. When 
che pelvic pains are very acute the morphia 
should be given hypodermically until they 
are controlled. 
With the exception of that of the fuming 
nitric acid, the liquid applications are to be 
made about once a week, and to be constant- 
ly changed about from one to another. In 
order to insure a thorough cauterization, it 
will often be advisable to make two or three 
applications, the one directly after the other, 
until the walls of the uterus are irritated 
into contracting down upon the probe, and 
griping it; and also when the cervical canal 
is not very patulous, first to stretch it open 
by the uterine dilator. In making these 
applications no other care need be taken 
than, before removing the speculum, to 
swab out or syringe out the redundant por- 
tion of the fluid, which has run down over 
the posterior lip of the cervix. But, in order 
to apply the nitric acid safely, greater pre- 
cautions must be taken. The cervical canal, 
unless very patulous indeed, must be pre- 
viously dilated, eitherby a tent or by the dila- 
tor, preferably by the latter. If the bivalve 
speculum be used, very great care should be 
observed to avoid touching the walls of the 
vagina with the acid. Whatever the specu- 
lum, water enough to reach to 
the lower margin of the os should 
be thrown into it, by that very 
handy little instrument, the uterine 
syringe (Fig. 4). Immediately after 
the application, several syringefuls 
of water should be projected upon 
the cervix. A tampon of cotton- 
wool, with a withdrawing thread 
attached, may then be dipped into 
water and left for twelve hours in 
contact with the cervix. After ten 
days or two wTeeks have elapsed, one 
of the milder caustics may be ap- 
plied. In obstinate cases I have 
sometimes found it necessary to 
make a second application of this 
powerful acid. This, however, 
should not be done before a month 
has passed by, lest closure of the 
cervical canal should result. When 
granular erosion is associated with 
a gaping or an everted os, there is 
no better treatment than by this 
acid. In such a case it must be ap- 
plied freely to the cervical canal 
and less so to the uterine cavity. 
Tn menorrhagia springing from a congestion 
or from a sub-involution of the womb; in 
cases of wombs too tender to bear the pres- 
sure of a hard pessary ; in obstinate leucor- 
rhoea, it does much good when boldly carried 
into the uterine cavity. I am very partial 
to this escharotic, nor have I yet found that 
its use is followed by symptoms more ur- 
gent than those produced by the milder 
caustics. In carrying this acid about, one 
caution must be carefully observed by the 
physician for his own protection. By the 
jolting of a carriage, or by other constant 
agitation, a gas is generated which, upon 
the quick removal of the stopper, violently 
forces a fine spray of the contents out of the 
bottle. He must therefore avert his face 
while he slowly removes the stopper, which, 
by the way, should be made of glass. 
The solid stick of nitrate of silver is no 
great favorite in our clinic. It gives more 
pain than the liquid preparation, is less 
manageable, and often causes a brisk hemor- 
rhage. Its prolonged use is so apt to be fol- 
lowed by a hard, gristly cervix, or by con- 
traction, or even by closure of the cervical 
canal, that it is restricted pretty much to those 
cases in which the os is gaping or everted. 
By first warming the tips of the aluminium 
probes and then dipping them into fused 
nitrate of silver, they receive a coating of 
the caustic which can be readily passed up 
into the uterine cavity; not, however, with- 
out considerable uterine colic. A common 
test tube held over the flame of a candle is 
all the apparatus necessary for this purpose. 
This is an admirable way of treating sub- 
involution and other affections of the body 
of the womb. In stubborn cases of amenor- 
rhoea advantage may thus be taken of its 
tendency to excite hemorrhage. Whenever 
this caustic is passed up into the uterine 
cavity the hypodermic syringe should be 
within reach. 
A saturated ethereal tincture of iodine be- 
ing much stronger than the corresponding 
alcoholic tincture, I have found very useful 
in marked cases of cervical endometritis. 
But the fear lest the subtle vapor of the ether 
should escape through the fallopian tubes 
into the peritoneal cavity, or should force 
in some of the liquid before it, has made me 
somewhat chary of introducing it into the 
uterine cavity. 
The above caustics being applied weekly, 
in the meantime the woman should herself 
daily irrigate the womb with tannin, lead 
or zinc solutions. A very excellent one is a 
FIG. 4. TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
5 
strong or even a saturated solution of the 
chlorate of potassa. For this purpose the 
Davidson syringe is the best. A still better 
treatment is the introduction, at bedtime, 
into the vagina, of a suppository containing 
a few grains of the acetate or the iodide of 
lead, of the sulphate of zinc, or, what is bet- 
ter, from five to ten grains of tannic acid. 
For obstinate congestions, apart from local 
depletion, one drachm of the fluid extract of 
ergot, or an equivalent dose of one of its pre- 
parations, should be nightly introduced into 
the rectum, either by a suppository or by a 
starch clyster. As vaginal suppositories are 
expensive and quite difficult to make, cer- 
tain very efficient substitutes can be used. 
For instance, the tannin or any other dry 
astringent powder may be projected by the 
woman herself upon the cervix, through the 
nozzle of one of those ingenious tin toys 
which are imported from France for the pur- 
pose of scattering "roach-powder" about. 
Or else-after the plan of my friend, Dr. E. 
L. Duer-a teaspoonful of glycerin, contain- 
ing five grains or more of tannin, of acetate 
of lead, or of sulphate of zinc, may be poured 
into a hollow pressed by the thumb into the 
centre of a thin sheet of cotton-wool, not 
quite so broad as one's palm. The edges be- 
ing now gathered up and securely tied, there 
will be formed a small and dry tampon, 
which the woman, after getting into bed, 
can herself push up against the cervix. For 
convenience of removal, the ends of the 
string should be left long enough to.hang 
outside of the vulva. Medication by vaginal 
suppositories is to be preferred to that by 
vaginal injections, because in the former the 
remedy lies longer in contact with the cer- 
vix, and because it is probable that more or 
less of it is carried up directly into the ute- 
rine cavity, either *by capillary attraction or 
by that reversed peristaltic or suction action 
of the uterine fibres so lately described. In 
future, when the vaginal suppository is men- 
tioned, the term will mean, indifferently, 
some one of the above methods. 
I am more than ever impressed with the 
ftrct that in general the caustic applications 
are made too continuously for nature to have 
fair play, and that irritation and inflamma- 
tion are actually kept up by too short inter- 
vals of rest. It is, therefore, my habit, after 
making from four to six applications, each 
one a week apart, to send my patient away 
just before a catamenial period, with direc- 
tions not to return until two such have 
passed. Not only will much be gained by 
this intermission in the treatment, but an 
opportunity for impregnation is thus given. 
With regard to the conjugal relations dur- 
ing local treatment, while, as a rule, absti- 
nence is recommended, I yet sanction the 
advice of the apostle, that "the husband 
render unto the wife due benevolence; and 
likewise also the wife unto the husband." 
While coition should always be completely 
performed, on the one hand the husband 
must not be too • exacting; on the other, the 
wife should not restrain her own inclina- 
tions ; for intercourse, then, appe'ases the 
congestive orgasm of the reproductive appa- 
ratus. 
Local Depletion.-Since congestion is the 
essential basis, thepunctum saliens of uterine 
disorders, it stands to reason that local 
blood-letting should be the remedy. When- 
ever, therefore, the cervix has lost its natural 
pink or gum-like color, and becomes crim- 
son, it needs depletion. For this purpose 
nothing answers better in the end than two 
or three leeches pushed up to the cervix 
through a glass speculum. In leeching, the 
os uteri must first be well plugged 
by a clean morsel of cotton, with a 
withdrawing thread attached; other- 
wise a leech may creep into the ute- 
rine cavity and fasten itself there, 
giving intolerable anguish. The 
week succeeding the catamenial 
flux is always the best time for their 
application. But leeches are often 
capricious, always expensive, some- 
times unattainable, and their appli- 
cation is a tedious and unpleasant 
job. A substitute is therefore neces- 
sary. In lieu thereof, once a week 
or a fortnight, the cervix may be 
punctured at three or more points 
by Buttle's spear-pointed scarifica- 
tor (Fig. 5.) by a straight-pointed 
bistoury, or by a tenotomy knife. 
Not more than from two to four 
tablespoonfuls need be taken at one 
time. The difficulty usually con- 
sists in drawing blood enough, 
but occasionally too much will 
flow. I have seen it spout out as 
if a large vein had been struck. 
It is well, therefore, to watch for a 
moment the first puncture before 
making others. In a large, flabby 
and angry-looking cervix, in cases 
of retroflexion accompanied by marked con- 
Fig. 5. gestion, blood enough will often escape from 
but one superficial puncture. In firmer and 
paler cervices the punctures must be made 
deeper and more numerous. The point of 
the instrument should penetrate to a depth 
of from one-eighth to one-quarter of an inch, 
and, in order to enlarge the opening, should 
be withdrawn by a slight turn of the wrist. 
To collect the blood as it flows out of the 
speculum, without soiling the clothes of the 
patient, I have found nothing so convenient 
as an ordinary kitchen gravy-ladle of tinned- 
iron, which has its well-earned place in my 
leather bag. 
After the bleeding has ceased, the uterine 
application is to be made. If it persists, a 
stream of cold water may be thrown upon 
the cervix, or each bleeding point can be 
touched with the solid stick of nitrate of 
silver. Often the mere introduction of the 
ordinary application into the uterine neck 
and cavity will so condense the tissues as to 
stop the bleeding. On very rare occasions I 
have been obliged to tampon the vagina 
loosely with cotton-wool dipped in a solu- 
tion of the subsulphate of iron. Local 
depletion is a very important adjunct to the 
treatment of uterine diseases. It is, indeed, 
often the pith of the treatment. Its neglect 
is a common cause of failure. The condition 
of the cervix is not, however, always an 
infallible criterion as to the necessity for 
drawing blood, for the congestion of the 
womb may be limited to its body. Deple- 
tion may, therefore, in general be resorted 
to whenever the womb is hypertrophied; 
whenever its body is tender to the touch, or 
too sensitive to bear the pressure of a pes- 
sary ; whenever pelvic pains resist the ordi- 
nary treatment, and, Anally, in most cases of 
flexion or of dysmenorrhcca. No inflexible 
rule can be laid down with regard to the 
number of times this operation should be 
performed. My own custom is to draw 
blood at intervals of a week or two until the 
general or local symptoms are decidedly 
improved. 
General Treatment.-One cardinal rule in 
the treatment of all uterine disorders is the 
internal administration of iron, and of other 
tonics, unless contra-indicated. To these 
may be added, -whenever the womb, as a 
whole, is congested or hypertrophied, ergot, 
quinia, arsenic, or bromide of potassium, 
either singly, or more or less in combination. 
Whenever one of my patients can or will 
take cod-liver oil in conjunction with the 
syrup of the iodide of iron, I feel that half 
the battle is won. The bowels should be 
kept soluble. An excellent pill for this pur- 
pose, to be taken at bedtime, is:- 
R.-Ext. colocynth. comp., gr. ij ; 
Ext. belladonnas, gr. |; 
Ext. gentianm, gr. j ; 
01. carui, gtt. ss. M. 
Et ft. pil., No. j. 
The following tonic pills are much pre- 
scribed at the clinic:- 
R.-Acid, arseniosi, 
Strychnias sulph., aa gr. gl 
Ext. belladonnas, gr. £ 
Cinchoniae sulph., g. jss ; 
Pil. ferri carb., gr. ijss. M. 
Et ft. pil., No. j. 
R.-Acid, arseniosi, gr. 
Cinchoniae sulph., gr. jss ; 
Ferri et potass, tart., gr. ij. M. 
Et ft. pil., No. j. 
The sulphate of cinchonia in these pills 
may be advantageously substituted by a pro- 
portionate dose of sulphate of quinia, the 
former being used simply on account of its 
cheapness. One pill may be given after each 
meal. Basham's iron mixture, with the 
addition of fractional doses of strychnia, will 
be found very admirable in its effects. 
There are so many indifferent recipes for 
making this celebrated mixture, that I shall 
here give the one which seems to me to be 
the best:- 
R.-Tinct. ferri chloridi, ; 
Acid, acetic, diluti, fl ; 
Liquor, ammonias acetat., ; 
Curafoa, 
Syrupi simplicis, aa fl.sj; 
Aqum q. s. ad M. 
Sig. One tablespoonful after each meal. 
The following formula makes another very 
elegant and generally useful preparation of 
iron:- 
R.-Tinct. ferri chloridi, ; 
Acid, phosphorici dilut., fl 3iij ; 
Spts. limonis, fl 3j ; 
Syrupi simplicis, ; 
Aquas q., s., ad M. 
Sig. One tablespoonful after each meal. 
The dilute phosphoric acid is added, both 
because it is a valuable nerve tonic, and be- 
cause it has the property of disguising the 
styptic taste of the iron ; so much so that 
children readily take this mixture. 
When patients complain of nervousness, 
or of sleeplessness, the bromide of potassium 
must be given, either alone or in combina- 
tion with other remedies. A cheap mixture, ■ix*jcrxxxiu.xjxi x xxxvxz i an f Liii iivii vr UTEKIKE JLHSUKIZEKS. 
7 
much thought of at the University clinic, is , 
as follows:- 
R.-Potassii bromidi, 
Rad. calumbse contus., 
Rad. zingiberis contus., aa ; 
Ferri sulphat., gr. xxx ; 
Aquae bullientis, Oj. 
Steep for twelve hours and then strain. 
Sig. One tablespoonful in a wineglassful of 
water just before or just after each meal. 
I cannot say much for the palatableness 
of this infusion, nor more for its pharma- 
ceutical elegance. But it does good, and we 
therefore give it largely to our poor patients. 
For a better class of patients the following 
nervine can be prescribed with very general 
satisfaction:- 
R Elixir humuli, 
Elixir valerian, ammoniat., 
Elixir lactucarii, aa §ss. M. 
Sig.-One dessertspoonful at bedtime, or 
during the day when necessary. 
When ergot is indicated it may be given 
continuously and in full doses, either by the 
mouth or by the rectum. The suppository 
is made by inspissating the fluid extract by 
a moderate heat and incorporating it with 
cocoa butter. Of these two modes of admin- 
istration I much prefer the latter, as it 
does not disturb the stomach. In country 
practice the ergot may be given in a starch 
clyster. 
In addition to these remedies an effort 
should be made to distract patients from 
self, to make them forget that they are 
invalids. Their tendency is to give too 
much heed to every little ailment. They 
should be urged to give up the recumbent 
posture, to take regular exercise, and to 
expose themselves, without veils and para- 
sols, to the direct rays of the morning sun. 
Woman, as well as plants, needs sunshine. 
Tea and coffee should be given up, and milk 
or claret substituted. A wholesome diet of 
easily digested meats and vegetables should 
be ordered, pastry interdicted, and the old 
adage inculcated of " early to bed and early 
to rise." A moderately cool bath may be 
taken daily, provided no great fatigue is 
induced by it, and a healthy glow follows 
its use. The brisk rubbing down after a 
cool bath, by putting many muscles into 
play, is one means of furtively giving exer- 
cise to those patients who are indisposed to 
take it as such. The corset should be dis- 
carded ; the clothes must fit loosely and be 
supported from the shoulders. However 
unreasonable this advice may have seemed 
to the woman while her health was good, 
she will now usually adopt it, but not with- 
out many a pang and many an inward 
struggle. No vanquished knight ever 
yielded up his armor with worse grace. 
For obvious reasons, when young girls or 
unmarried women exhibit symptoms of 
uterine trouble, an examination by the 
finger or by the speculum, or a treatment 
requiring the use of the latter, should never 
be insisted upon, until other measures have 
first been faithfully tried. These measures 
will be limited to the hygienic and constitu- 
tional treatment just detailed, and to such 
local remedies as the patient herself can use, 
viz., the hot douche, the hip bath, vaginal 
suppositories, vaginal injections, etc. 
Retroversions andRetroflexions.-For these 
forms of displacement, and for those forms of 
prolapse in which the womb is not unduly 
lengthened out, Hodge's closed lever pessary 
is one of the best. When fitting proper- 
ly, it acts physiologically by propping up 
the dislocated fundus, and by restoring the 
posterior wall of the vagina to its natural 
length. Again, since its anterior bar plants 
itself firmly against the posterior surface c 
the pubic symphysis, or against the angle 
formed by the converging rami of the pubic 
bones, it offers a very efficient and powerful 
support. It will not, however, always an- 
swer. Whenever the relaxation of the parts 
is great, or the vaginal portion of the cer- 
vix has disappeared, as it sometimes will 
through senile atrophy, or through the strip- 
ping off of the vagina by the upward trac- 
tion of the womb in repeated pregnancies, 
the physician may be driven to the globe-, 
or to the ring-pessary. But this alternative 
should be deemed a misfortune, for all pes- 
saries which distend the vagina at the ex- 
pense of its length are mere makeshifts. 
Such instruments cannot effect a cure, since 
by overstretching the vagina laterally, and 
by thus impairing its tonicity, they weaken 
this great supporting column of the uterus, 
and, in prolapse, tend to confirm the usual 
cause of the displacement. Further, the 
ring-pessary is not trustworthy, and needs 
watching, for it is liable, by its elastic pres- 
sure, to excite ulceration and to become 
buried up by over-arching granulations. In 
this manner it sometimes eats its way into 
the bladder or the rectum. There are few 
physicians with a large uterine practice 
who have not had to dissect out a ring vital- the unheated, portion of the pessary, with 
the concavity of its curve looking down- 
ward, is grasped by the thumb and fingers, 
and so compressed that the anterior portion 
of each lateral bar slightly converges to- 
wards its fellow. While still undergoing 
this pressure, the pessary is quickly carried 
to a deep wash-basin, one-fourth full of cold 
water. The tip is now bent almost at right 
angles by pressing it for a moment strongly 
against the dry surface of the basin, over 
which it is then made quickly and firmly to 
glide down into the water below. The con- 
tact with the water at once " sets " the pes- 
sary in the desired shape. The sand bath is 
certainly the handiest and cleanest way of 
moulding these pessaries, but, unless care- 
fully watched, it is liable to overheat and 
spoil some of them. 
This form of pessary I can confidently re- 
commend as one that will best fit the large 
majority of cases ordinarily met with of 
retroversion, retroflexion, or of prolapse. 
By comparing a Hodge pessary with Fig. 6 
the alterations in shape will be at once seen. 
A side view is given at A and a front view 
at C. 
Whenever the body of the womb is too 
tender to bear the pressure of this hard rub- 
ly imbedded in the vagina. Another very 
great objection lies in the fact that, when 
made of poor and brittle rubber, as these 
pessaries usually are, they crack at one 
place or more during the process of their in- 
troduction; and then, sooner or later, by 
the rusting of the steel wire at these points, 
they spring open. This accident I have so 
repeatedly seen as to make me timid about 
using them. When the base and neck of 
the bladder are very sensitive, or when, as 
in some old women, the vagina has lost its 
elasticity and is shortened, Cutter's pessary 
answers a very admirable purpose. It is 
practically a Hodge pessary, having an ex- 
ternal fulcrum attached by an elastic band 
to an abdominal belt. 
My friend, Dr. Albert H. Smith, has made 
a modification of Hodge's pessary to which 
I am very partial, the more so because it 
meets several very important indications. 
The healthy vagina is a cone-shaped tube, 
widening out above and narrowing down as 
it approaches the vulva. Its uterine por- 
tion is thin, membranous and almost de- 
void of muscular fibre; while its lower por- 
tion is rich in elastic and muscular tissues, 
md powerfully acted upon by the strong 
muscles of the perineum. Now, Hodge's 
pessary being of a uniform width through- 
out, in fact, a parallelogram in shape, will 
often unduly stretch laterally the vulval, 
viz., the narrowest, portion of the vagina, 
while it too loosely fits the uterine portion. 
The pressure being unequally distributed, 
is liable not only to irritate the points of 
firmer contact, but also to cause the pessary 
to tilt over on its side, or to become other- 
wise displaced. Again, its front bar, by 
pressing upon the pubic bones, may irritate 
the overlying soft parts, and may also so 
compress the urethra as to make micturi- 
tion painful. To avoid these defects, and 
also to distribute the pressure in front over 
the surface of the anterior vaginal wall, 
which responds to the movements of the 
diaphragm, Dr. Smith slightly narrows 
this pessary anteriorly, and then bends the 
tip thus rounded sharply downwards, at al- 
most a right angle. 
The Hodge pessary is readily moulded 
into this shape in the following manner :- 
The anterior part only is either dipped into 
boiling wax or lard (the temperature of boil- 
ing water is not high enough), or else is 
(buried in sand heated to about 350° Fahr. 
When sufficiently plastic, the uterine, viz., 
FI Cl. 6. 
ber pessary, the provisional use of inflated 
rubber rings will be called for. These air- 
cushions must be used in conjunction with 
local depletion, with intra-uterine applica- 
tions of carbolic acid as a local anaesthetic, 
and with the hot douche, the last, provided 
the woman can herself remove and re-intro- 
duce this pessary. Some stubborn cases I 
have overcome by a free application of fum- 
ing nitric acid to the uterine cavity. When- 
ever these inflated rings cannot be pro- 
cured, wads of oakum or sponges dipped 
into a weak solution of carbolic acid will 
answer as very good substitutes. The dis- TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
9 
tressing pelvic pains and aches which tor- 
ment these patients will be greatly alleviated 
by passing into the vagina, at bedtime, a sup- 
pository containing one grain of morphia 
and two of the extract of belladonna. 
In most cases of retroversion or of retro- 
flexion it will prove advantageous to stretch 
out the contracted utero-sacral ligaments by 
the repositor (Fig. 7). This instrument is 
used by introducing the stem into the ute- 
rus, and then giving varying angles to it by 
a screw in the handle. In this manner a re- 
troverted womb can be temporarily forced 
into a state of anteversion. The womb 
when flexed should also be straightened 
out, by giving varying curves to the sound; 
or by first seizing and drawing down the 
cervix with the volsella, and then pushing 
up the fundus by a finger passed up either 
into the vagina or the rectum. By this 
manoeuvre a retroverted womb can also be 
readily redressed ; but it is then best not to 
push the fundus directly upward over the 
jutting promontory of the sacrum, but some- 
what laterally, so as to 
make it skirt this bony 
shelf. As will be seen, un- 
der its appropriate head- 
ing, the uterine dilator 
bids fair to do much good 
in obstinate cases of retro- 
flexion. 
One word here on the 
subject of the volsella 
(Fig. 8). Since it main- 
tains its hold better than 
the tenaculum, it is to me 
one of the most precious 
instruments in my bag, 
amounting in value almost 
to a third hand. Apart 
from using it, as above de- 
scribed, in redressing or 
straightening out any 
kind of version or flexion 
of the womb, it subserves 
other useful purposes. By 
hooking down the cervix 
and holding it steady, it 
materially aids in the in- 
troduction of sponge-tents. 
For the same reason, upon the removal of 
the tent, it renders the exploration of the 
uterine cavity with the finger very much 
easier than by the usual plan of forcing 
the womb down upon the finger by supra- 
pubic pressure, a procedure always painful, 
and in a fat woman, very difficult of execution. 
By thus lowering and fix- 
ing the womb, it facilitates 
very materially the re- 
moval of intra-uterine 
polypi, or the scraping 
away of benign or of ma- 
lignant growths from the 
cervix or the fundus. In 
such cases, I usually ap- 
ply it without the aid of 
the speculum, and gene- 
rally seize hold of the an- 
terior lip. In redressing 
versions, a mechanical ad- 
vantage is gained by seiz- 
ing hold of that lip whose 
name does not correspond 
with that of the version. 
Thus, in retroversions the 
anterior lip is seized; in 
anteversions, the posterior 
lip. But inflexions, as one 
object of the traction is to 
stretch out the flexed side the most, that 
lip should be seized whose name corres- 
ponds with that of the flexion. This advice 
is theoretically correct; but it may not al- 
ways be found practicable. Let me here 
state that I teach all right-handed students 
to use the left hand for making uterine ex- 
aminations and for other internal work. 
This leaves a clean right hand for manipu- 
lating the various instruments and for any 
necessary outside work. 
Anteversions and Anteflexions of the 
Womb.-Since these conditions are more or 
less the natural ones of the nulliparous or of 
the healthy uterus, and especially so when 
the bladder is empty, it by no means follows 
that every case of hysteria or of pelvic irri- 
tation exhibiting these forms of displace- 
ment requires a uterine treatment. I am led 
to make this remark, because a congestive 
irritation, or, perhaps, an inflammation of 
one ovary, or of both, is often at the bottom 
of symptoms usually referred to the above 
displacements, and because many a hysteri- 
cal woman has, consequently, been unfortu- 
nately subjected to a purely uterine treat- 
ment, when it should have been a moral 
one, or a constitutional one, or, at the most, 
an ovarian one. The paramount influence 
of the unseen ovaries over body and mind 
is too much overlooked. With much truth 
J?IG. 8. 
FIG. 7. 10 
SOME PRACTICAL HINTS FOR THE 
it has been said, that anatomically we may 
speak of the " womb and its appendages," 
but that physiologically the womb is really 
an appendage of the ovaries. True, the 
contiguity of these structures, and their 
intimate nervous, vascular and functional re- 
lationship, make them so mutually depend- 
ent, that a disease in the one is very likely 
to beget a derangement in the other. But, 
without committing myself to the doctrine 
that hysteria in woman is, primarily or 
secondarily, always an ovarian expression, 
I am sure that it is often present when no 
lesions whatever can be discovered in the 
uterus proper. Hysteria is pre-eminently 
a disease of the unmarried, of the newly 
married, and of the sterile. But, since in 
them the womb is naturally anteflexed and 
anteverted, so this physiological condition 
is liable to be mistaken for a pathological 
one, and to be treated, that is to say, mal- 
treated accordingly. The diagnosis is, there- 
fore, not always clear, but, when dysmenor- 
rhcea is present, when the womb is mark- 
edly tender or congested, or it exhibits other 
unmistakable objective evidences of disease, 
when, in addition, the marriage is an unfruit- 
ful one, then may the hysterical and other 
subjectivesymptoms be intelligently referred 
to the uterus proper as the primal cause. 
Since typical examples of pure anteflexion 
alone, or of pure anteversion alone are rarely 
to be met with, the one lesion usually 
blending with the other, the same kind of 
treatment for each will often answer. By 
the same means as were described for cases 
of retroversions and of retroflexions, but of 
course in an opposite direction, the utero- 
vesical folds of the peritoneum must be 
forcibly stretched out, and the womb, when 
bent, straightened out. This should rarely 
be done oftener than once a week ; in the 
meantime anodyne vaginal suppositories at 
bedtime will usually be very grateful. At 
each visit local depletion and topical reme- 
dies will also be generally called for. Since, 
as has been remarked, these forms of dis- 
placement more commonly occur in unmar- 
ried or in sterile women, the cervical canal is 
often tortuous and contracted. Tents of 
sponge, or of laminaria, or of slippery-elm 
bark will, therefore, be needed as auxiliaries 
to the treatment. This method of cure, 
however, being tedious and unsatisfactory, I 
have lately, with great success, been treating 
these cases by forcible dilatation ; an opera- 
tion which will shortly be described. 
The treatment of this class of displace- 
ments by pessaries is by no means so satisfac- 
tory as in the former class. No two cases 
can in this respect be treated exactly alike. 
The difficulty lies in the construction of an 
instrument that shall lift up the body of the 
womb by pressure made in front of the cer- 
vix, without irritating the bladder through 
which the support must be communicated. 
By pushing the cervix forward the Hodge 
pessary will sometimes, in pure cases of 
anteversion, tilt the fundus backward off 
from the bladder. Sometimes in anteflex- 
ions, by sharing with the bladder the 
weight of a congested womb, it will alleviate 
the vesical distress. Again, this instrument, 
in conjunction with an abdominal brace, 
will at times give much comfort. In a few 
selected cases Thomas' anteversion pessary 
will act admirably; but in the majority it 
cannot be borne. It has, however, served me 
some very good turns, and I, therefore, give 
a cut of it. (Fig. 9.) It is practially a Smith- 
pessary armed posteriorly with a movable 
bow, which is added to make pressure upon 
FIG. 9. 
the fundus uteri. In its introduction and 
removal some degree of knack is needed. 
After closing it, it is introduced and lodged 
behind the cervix, just like a Hodge pessary. 
Then, by insinuating the index finger 
between the bow and the pessary proper, 
the former is prized up and swung forward. 
Since, in the removal, the bow flaps back on 
the posterior bar (B) and tightly pinches 
the cervix, the latter must be pushed up- 
ward out of the gripe by means of the index 
finger. This sleight of hand should be taught 
to the patient, so that she herself may be 
able to remove the pessary, or to explain the 
method of its removal to a physician igno- 
rant of its peculiar construction. Otherwise, 
he will tug away in vain at its anterior bar 
(A), and be at his wits' end to know how to 
get it out of the vagina. 
The ordinary globe- and ring-pessaries 
will occasionally answer when other mea- 
sures fail. Of all mechanical agents, I have, TKEAiinr.ni t ainji ekeveivtiujn nr uterine 
11 
in the long run, found the inflated ring 
pessary to be the best. This soft-rubber air- 
cushion can generally be well borne, while, 
by the admission of the cervix into the 
opening in its centre, the fundus is tilted off 
from the bladder. This pessary has, however, 
three grave faults: it over-distends the va- 
gina ; it soon becomes useless by collapsing ; 
it is very liable to generate offensive dis- 
charges. Yet, in spite of these objections, I 
am often driven to its provisional vise, while 
resorting to such measures as are calculated 
to relieve the congestion, for after all this is 
the marrow of a successful treatment. 
My experience with the intra-uterine 
stem pessary has not been very encouraging. 
It may be a very excellent pessary ; it cer- 
tainly is a very good one, to watch. In a 
very few cases of anteflexion it has answered 
admirably. In the majority the womb 
has resented its presence. In one case a 
smart inflammation set in, which kept my 
patient confined to bed for two weeks. In 
another, the agony was unbearable. Their 
use involves so much care and anxiety that 
I have pretty much discarded them from the 
treatment of the out-patients. In private 
cases I occasionally use the glass-stem pes- 
sary, which is the least irritating one, but 
which tends to slip out. Chambers' hard rub- 
ber stem pessary has recently been so lauded 
by the British medical press, that I intend to 
give it a fair trial. In the only case in which 
I have thus far employed it, so much irrita- 
tion was excited that its removal became 
imperative within six hours after its intro- 
duction. By being split into two portions, 
which spread apart, this stem has the great 
merit of not slipping out, and that, I fear, is 
its sole merit. But, with regard to intra- 
uterine stem-pessaries, my own conviction 
is that they have had their day, and that, 
since the discovery of the method of rapid 
dilatation, they will in the future be occa- 
sionally used for a few days, and then only 
after this operation. 
Before quitting this subject, I should add 
that Hewitt's modification of the Hodge 
pessary has, in my hands, occasionally given 
great comfort, after the failure of every 
other kind of pessary. It is, however, like 
its fellows, adapted only to single and iso- 
lated cases, cases which cannot be deter- 
mined beforehand. From the foregoing 
record of my experience with pessaries, it is 
plain that he who, in anterior displace- 
ments, trusts to mechanical means alone, is 
doomed to disappointment. He, on the 
other hand, who combines the therapeutic 
with the mechanical treatment, will meet 
with the greatest success. Under the next 
heading I purpose to give an additional 
method of treating this stubborn class of 
flexions, which will, I believe, in the great 
majority of cases, yield the very best results. 
Rapid Dilatation of the Cervical Canal.- 
This most valuable operation can, at a pinch, 
be imperfectly performed with the ordinary 
curved uterine dressing forceps. A far more 
efficient instrument, however, is a delicate 
uterine dilator, which, in shape, is like the 
former, but whose blades are stronger, and so 
constructed that they diverge as the handles 
approximate (Figs. 10 and 11). By the aid of 
the tenaculum, or of the volsella, applied 
FIGS. 10 AND 11. 
through a speculum, the anterior lip of the 
cervix is seized, and the dilator is introduced 
as far as it will go. Upon gently stretching 
open that portion of the canal it occupies, 
the stricture above so yields that, when the 
instrument is closed, it can be made to pass 
up higher. Thus, by repetitions of this ma- 
noeuvre, little by little, in fifteen minutes' time, a cervical canal is tunneled out which 
previously could not admit the finest probe. 
As soon as the cavity of the womb is gained, 
the blades are withdrawn far enough to 
lodge their tips just above the internal os, 
and their handles are then brought firmly 
together. When the cervix is cartilaginous 
in character, or so unyielding as to bend 
these delicate blades, then a much larger 
and stronger dilator, with a screw in the 
handles, must be used. For ordinary pur- 
poses I have found the more delicate instru- 
ment sufficiently strong, while it has the 
merit of requiring no previous dilatation of 
the canal by tents, and the further merit of 
preparing the way for the admission of the 
larger instrument when needed. It can very 
frequently be used without the aid either of 
a speculum or of a tenaculum; and in un- 
married women this method should always 
first be tried. This operation is a painful 
one, and may demand the use of ether, but 
I have very generally done it without. 
Some of the constrictor fibres are ruptured, 
sometimes audibly, and a few drops of blood 
may trickle out of the os. The woman will 
complain of soreness for one or two days; 
beyond that I have not seen any bad results. 
In operating with either instrument care 
should be taken to keep the blades from slip- 
ping up so far into the uterine cavity as to 
press upon the fundus ; otherwise great mis- 
chief might result. To prevent this danger, 
I am not sure but these instruments would 
be the better for shorter blades, say two 
inches long at the most, or for a broad 
shoulder placed at that distance from the tip. 
After such a forcible dilatation the cervical 
canal does not usually return to its previous- 
ly angular or contracted condition. Since 
lateral extension of elastic bodies antago- 
nizes their length, the cervix shortens and 
widens; and the plasma, provisionally 
thrown out by the submucous lesions sus- 
tained by the dilated part, serves still fur- 
ther to thicken and stiffen its tissues. In 
other words, the stem-like neck of the pear- 
shaped womb is shortened, widened, 
strengthened and straightened. Hence for 
straightening out anteflexed or retroflexed 
wombs, and for dilating and shortening the 
canal in cases of sterility or of dysmenor- 
rhoea, arising from stenosis or from a conical 
cervix, the dilator will be found to be a most 
efficient instrument. In its results it is not 
infallible; but, by it I have, at one sitting, 
cured cases of long-standing dysmenorrhoea, 
and relieved absolutely all the distressing 
symptoms of several very obstinate cases of 
anteflexion, and thus far of every stubborn 
case of retroflexion. Dr. John Ball {New 
York Medical Journal, October, 1873, p. 363) 
recommends the use, for a few days after dila- 
tation, of an intra-uterine stem. I have not 
yet found it necessary to splint the womb in 
this manner; but his suggestion is plainly a 
valuable one, and not to be forgotten. 
Chambers' intra-uterine stem, or a tent of 
slippery-elna bark would then be my pre- 
ference. A few 
notches cut in the 
latter will prevent 
it from slipping 
out. Dr. Ellinger 
also states {Archiv 
fur Gyndkologie, 
Vol. v., Part II, 
1873, p. 268) that 
he has found forced 
dilatation to be a 
very efficacious 
remedy for flex- 
ions. The blades 
of his instrument 
(of which a front 
and side view are 
given in Fig. 12) 
are made short, sc 
as not to reach, and 
thereby to injure, 
the fundus uteri. 
They also open 
parallel to one an- 
other, and there- 
fore, do not tend 
to slip in or out. 
In these respects it 
is an instrument 
superior to those 
previously de- 
scribed. But, on the other hand, the latter 
are more simple in construction, and, conse- 
quently, less expensive. I have been sur- 
prised at the improvement following a forced 
dilatation made, in cervical endometritis, for 
the easier introduction of remedies. Perhaps 
this may be explained partly by a 
change produced in the nutrition of the 
parts, and partly by the temporary paraly- 
sis of the constrictor fibres, just as fis- 
sures of the anus are cured by forcibly dilat- 
ing the sphincters. Since the cervical canal 
tends to remain open, good results may be 
expected from this operation in the hemor- 
PIG. 12. *. «**..*. v-.K.ux., A X T XIL1 LXV A1 VI -V» A num AU XJ AkJVJ Atl/lUAVO. 
13 
rhages caused by sub-involution, or by fib- 
roid tumors of the womb. In metror- 
rhagic attacks and in other cases requiring 
the injection of fluids into the uterine cavi- 
ty, I have obtained a free avenue for the 
escape of the liquid by first dilating the 
canal with this instrument, and then by in- 
troducing the nozzle of the syringe between 
the expanded blades. Hitherto, the great 
danger of the fluids being forced into ute- 
rine vessels or through dilated fallopian 
tubes into the abdominal cavity, by spasm 
of uterine fibres and coarctation of the in- 
ternal os, has deterred me from often resort- 
ing to the use of intra-uterine injections, 
even in stubborn cases of endometritis. 
But now, the conjoined use of the dilator, 
as described above, has, by robbing the ope- 
ration of its greatest risks, inspired me with 
more confidence, and I shall certainly try 
these injections in all cases which other 
means have failed to relieve. The uterine 
dilator will also be found very efficient in 
preparing the cervix for the admission of 
the armed applicator, and for the reception 
of a stem-pessary or of a large tent. What 
is better still, it will often obviate the neces- 
sity for using a tent. It is but just to add, 
that to Dr. Ellwood Wilson is the profes- 
sion of this city indebted for this method of 
rapid dilatation, a method which bids fair 
to revolutionize the treatment of many ute- 
rine disorders. 
Uterine Tents.-Tents maybe made indif- 
ferently of sponge, laminaria, or of slippery- 
elm bark. By glueing together two or three 
slips of the last, very good-sized tents can 
be constructed. Sponge and laminaria tents 
ought not, as a rule, to be left in longer than 
twenty-four hours. The cervix, while they 
are in, should be irrigated every two or 
three hours, during the waking hours, with 
a strong solution of table salt, or, what is 
better, with a saturated solution of the chlo- 
rate of potassa. I reject carbolic acid, be- 
cause it does not ordinarily mix well with 
water; and the permanganate of potassa, be- 
cause it weakens the elasticity of the sponge- 
fibres, and stains the clothing. Such deter- 
gent injections saturate the sponge and cor- 
rect the fetor. They also, by imbibition, and 
by capillary attraction, pass up into the ute- 
rine cavity, and thereby lessen the risk from 
septicaemia. When a tent is put in as a cer- 
vical plug to arrest a uterine hemorrhage, 
then these detergent injections are not neces- 
sary, for the blood that will ooze past or 
through the tent, by washing away the pu- 
trid secretions, keeps it sweet. It then can 
be kept in for over twenty-four hours. For 
this reason a tent may, with comparative 
safety, be put in the day before that one on 
which the catamenia are expected, and be 
kept in during the flow. This has been re- 
peatedly and successfully done for sterility 
arising from stenosis; but for this purpose, 
the dilator would now be my choice. The 
slippery-elm tent can be left in much longer, 
as it softens down, and becomes dissolved by 
the discharges. Although inferior in expan- 
sive power to the other two, yet it will be 
found of great value in cases requiring no 
very great dilatation, and a prolonged treat- 
ment, such as in flexions. The introduction 
of tents will be much facilitated by the pre- 
vious use of the uterine dilator, and by the 
fixation of the cervix with the tenaculum 
or the volsella. By this means they can 
often be slipped in without the use of the 
speculum. Much time and safety will be 
gained if, after the introduction of one large 
sponge-tent, it is surrounded by a fagot of 
smaller tents, made of laminaria. 
Let me here impress upon my readers the 
importance of dilating the cervical canal 
with but one introduction, or, at the most, 
with but two introductions of tents. It is 
not, save with rare exceptions, the tent, or 
the batch of tents, crowded in at the first 
visit, that is attended with risk, but those in- 
serted at the second or at the third visit. 
The history of the reported fatal cases shows 
that the danger increases with every fresh in- 
stallment of tents. It is greater at the second ; 
greatest at the third. This is probably owing 
to the fact that the removal of the first tent, 
or batch of tents, more or less abrades the 
now irritated mucous coat of the canal, and 
by this raw surface are absorbed the putrid 
discharges generated and retained by the 
subsequent tents. It is especially in cases 
of previous pelvic inflammation, and in 
those of interstitial or of submucoid fibroids, 
that I dread the effects of a series of tents, 
and avoid such a use of them as much as 
possible. Let me, however, add that, since 
adopting the plan of injecting the above- 
given detergent solutions, I have yet to see 
the slightest ill-effects from the introduction 
of tents. 
Abdominal Supporters.-Within a few 
months I have become convinced that 
much advantage can be gained from a judi- 
cious use of braces as adjuvants to the treat- 14 
SUiffK rKAVirijAL urrrro run ttitj 
ment of uterine disorders. Alone, they may 
not cure, but they certainly will often palli- 
ate those symptoms which are referable to 
pressure upon the pelvic organs. ' They 
seem to me to be especially indicated when- 
ever a pessary fails to relieve the woman of 
the feeling that the lower portion of her 
abdomen needs an external support, a sup- 
port which she instinctively seeks to give 
by pressure with her hands. There certain- 
ly is, in my experience, no surer way of get- 
ting a bed-ridden, hysterical woman on her 
feet again than by their use. The moral 
effect of their adjustment is, in such cases, 
good; and by interposing a shelf upon 
which the abdominal viscera partly rest, 
they relieve a congested womb or an irrit- 
able ovary from undue pressure. The pro- 
prietary character of these instruments has 
very naturally prejudiced the minds of the 
profession against them; but fas est ab 
hoste doceri. 
The rationale of their action is briefly as 
follows : From the oblique inclination of the 
pelvis to the spinal column, which is pro- 
duced by the natural hollow in the back and 
by the more or less sigmoid shape of the 
spine, the axis of the trunk does not coin- 
cide with that of the pelvis. The womb and 
the ovaries, therefore, lie in a measure under 
the shelter of the sacral promontory and of 
the lower lumbar vertebrae. For the same 
reason, the sum of the weight of the super- 
natant abdominal viscera is spent upon the 
smooth surface of the pubic bones, and 
upon the adjacent abdominal wall, but not 
upon the womb, although it is the lowest of 
the pelvic organs. The little pressure to 
which it is subjected is not in a vertical line 
but in an oblique one. 
A displaced or a flexed womb may in it- 
self give rise to no unpleasant symptoms 
whatever; but let it once take on a con- 
gested or an inflamed condition, and the 
weight of the abdominal viscera at once be- 
comes oppressive. If now, pessaries being 
found inadmissible, a suitable brace is put 
on, a portion of this load is taken off by its 
pad, which, by pressing the abdominal wall 
upward and inward toward the sacral prom- 
ontory, forms a shelf upon which the vis- 
cera rest. Further, by this virtual shorten- 
ing of the conjugate diameter of the superior 
strait, the space into which the viscera tend 
to settle is lessened, and consequently, the 
womb is to that extent the more protected 
from sudden succussions. 
Again, whenever the retentive power of 
the abdomen is lost, say by the absorption 
of the fat-packing in the omentum and in 
the abdominal walls; by the general de- 
crepitude of old age, or by the muscular 
debility of ill-health, the woman's figure 
often becomes greatly changed. Her spine 
now loses its double curve and becomes 
bow-shaped ; her shoulders droop, her chest 
bends forward, she stoops; the pelvis, de- 
parting from its obliquity, becomes more 
nearly at a right angle to the spine; and the 
axis of the superior strait, instead of strik- 
ing a point in the tinea alba below the um- 
bilicus, tends now to coincide with that of 
the trunk. As a consequence the intestines 
crowd down into the pelvic cavity, and the 
sum of their weight now converges, not 
upon the pubic bones and their adjacent 
muscles, but directly and vertically upon 
the nicely poised reproductive organs. But 
since the womb and the ovaries were never 
intended by nature to be the atlas of the ab- 
dominal organs, the one resents the burden, 
and the other bends and sags down under 
it. A pessary, by shoring up the womb, 
gives some relief ; but common sense points 
clearly to the necessity of bringing back the 
erect carriage, of restoring the sigmoid curve 
to the spine, and of swinging the pelvis 
back into its oblique position. To meet 
these indications a brace is needed, one 
which is both abdominal and spinal. 
Guided by these hints, I feel sure that 
some of my readers will be able to get once 
more upon her feet a patient who has been 
doomed by her friends to a bed-ridden life, 
on account of some supposed spinal affec- 
tion. For let me here remark that, since 
most women in delicate health exhibit one 
or two very tender spots in the spine, diffi- 
cult locomotion dependent upon uterine or 
ovarian trouble is very liable to be mistaken 
for "spinal irritation" or " spinal inflam- 
mation." 
Prolapse of the Womb.-For a clear un- 
derstanding of this lesion, and for its better 
treatment, it should be divided into three 
distinct varieties : (a) prolapse of the womb 
proper, viz., a descent of the womb as a 
whole; (&) prolapse of the cervix from 
growth (hypertrophic elongation) of its 
vaginal portion ; (c) prolapse of the cervix 
from elongation (by traction) of its supra- 
vaginal portion. In the first variety there 
is a descent of the whole womb, together 
with its furniture of ovaries and ligaments ; nvrarXENT ajnd dke V EN TIUN OF UTERINE DISORDERS. 
15 
and but little, if any, increase in the length 
of the uterine cavity. In the other two 
there commonly is, although unessential, a 
more or less sinking down of the fundus, 
either from the newly acquired weight of 
the cervix, or from traction upon the cervix, 
and there always is a marked increase in the 
length of the uterine cavity. 
The degree of displacement in the first 
variety, being proportionate both to the 
weight of the prolapsing body and to the 
relative relaxation of its supports, the womb 
will be found either more or less low down 
in the vagina, as in incomplete prolapse, or 
else wholly extruded from the vulva, as in 
complete prolapse. The terms complete pro- 
lapse and incomplete prolapse are, to my 
thinking, preferable to those of prolapsus 
uteri and procidentia uteri, because no two 
writers agree as to the meaning of the latter 
terms; for by some they are used inter- 
changeably, as if they were synonyms, and 
by others in a contradictory sense. An in- 
complete prolapse is a common accompani- 
ment of retroversions and retroflexions; in 
fact, the latter are but transitional stages of 
descent modified by the firmness of the 
vesico-uterine attachments which sling the 
womb from its middle. The complete pro- 
lapse can be readily discriminated from the 
other two varieties, by noting the inversion 
of the vagina, and the distinctness with 
which the whole of the projecting pyriform 
tumor can be outlined by the grasp of the 
fingers. The uterine cavity will not be found 
unduly lengthened out, and the tip of the 
sound can be felt in the mass outside of the 
vulva. To clinch the diagnosis a rectal ex- 
amination will show that the womb and 
vagina have vacated the pelvis. Although 
not so frequently met with as the third vari- 
ety, prolapse of the cervix from elongation 
of its supra-vaginalportion, yet it will occa- 
sionally be found in old women, whose 
vaginas have become lax and wrinkled 
through the absorption of the fat-packing of 
the pelvis, or whose spines have lost that 
important double curve. In younger wo- 
men, sub-involution, or such congestions as 
increase the thickness of the uterine walls 
in every direction, long-continued vomit- 
ing, tight-lacing, the wearing of skirts un- 
supported from the shoulders, lacerations of 
the perineum, and last, not least, the pro- 
longed use of the obstetric binder, are the 
usual factors in the production of this kind 
of displacement. 
In the treatment of this variety of pro- 
lapse, whether complete or incomplete, the 
same kinds of pessaries are to be used as are 
mentioned under the heading of retrover- 
sions and retroflexions. In some cases Cut- 
ter's or Spooner's pessary answers best. In 
very rebellious cases the proprietary cup- 
and-stem pessaries will sometimes, although 
very rarely, be found useful in propping up 
the womb. In addition to its replacement, 
the womb, when congested, must be treated 
by local depletion, by the hot douche, by va- 
ginal injections of solutions of common salt, 
of the chlorate of potassa or of the astringents, 
and by the topical remedies previously de- 
scribed. The patient must be enjoined to 
keep the contents of the bowels soluble, to 
avoid the lifting of heavy weights, and to 
wear loose clothing supported from the 
shoulders. To maintain the erect carriage, 
and to restore the sigmoid curve to the spine, a 
suitable brace will often be found an excellent 
adjuvant to the above treatment. Of course, 
the perineum, when torn, must be restored. 
This operation will of itself temporarily pre- 
vent the extrusion of the womb; but it can 
give permanent relief only when it fur- 
nishes to the pessary a firm base of support. 
For, by this time, the uterine supports have 
become very much relaxed or stretched; and 
the uterus itself, from friction and from ex- 
posure to the air, has acquired some degree 
of hypertrophy, in its totality, however- 
fundus, corpus, and cervix-and not in one 
portion to the exclusion of the other. 
In the second variety of prolapse, viz., 
prolapse of the cervix from growth of its vagi- 
nal portion, an entirely different condition 
obtains. As its name indicates, through 
nutritive activity the vaginal portion of the 
cervix becomes larger and longer than na- 
tural. Although its increased weight drags 
down the womb somewhat, yet this is so 
unessential a sequence that this affection has, 
by Virchow, been termed "prolapse of the 
womb without locomotion of its fundus." 
A very marked degree of growth is uncom- 
mon. Whenever the vaginal portion of the 
cervix is so long as to protrude from the 
vulva, it is, as a rule, either a congenital 
condition, or an exaggeration of a congeni- 
tal condition, and is therefore found in nul- 
liparae. One of its modifications, the coni- 
cal cervix', is interesting from its bearing 
upon dysmenorrhoea and sterility. In child- 
bearing women, through cervical metritis 
excited by the contusions of repeated labors, 16 
SOME PRACTICAL HINTS TDR THE' 
the vaginal portion takes on a hypertro- 
phy, but this is less an elongation than a 
general increase in every direction. There 
is yet another form of hypertrophic elonga- 
tion which involves one lip of the os, usu- 
ally the anterior. From its resemblance to 
the snout of the tapir it has gained the name 
of tapiroid. All these acquired forms of hy- 
pertrophy are usually traceable to the inju- 
ries sustained in labor or to defective invo- 
lution. 
By consulting the diagram (Fig. 13) it 
will be seen that the diagnosis of this affec- 
tion is not difficult. Its character is suf- 
ficiently marked by the unnatural length of 
the uterine cavity, by the absence of vagi- 
nal inversion and of vesical prolapse, and by 
the presence in the vagina of a cone-shaped 
the cervix from elongation {by traction) of its 
supra-vaginal portion, is entirely distinct 
from the other two, and is, perhaps, the 
most commonly met with. Essentially it is a 
hernia of the bladder and of the vagina act- 
ing mechanically upon a tensile womb. In 
other words, the initial event is a prolapse 
of the conjoined bladder and vagina, which, 
by traction on the cervix of a congested or 
of a subinvoluted womb, draws out the then 
ductile supra-vaginal portion, viz., that por- 
tion of the neck and body which lies be- 
tween the uterine ligaments above, and the 
vesico-vaginal attachments below. The 
lower portion of the corpus participates in 
this elongation, because its muscles are less 
strongly developed than those of the upper 
portion. But the elongation is greatest 
at and about the internal os, because, 
from the absence of muscular structure 
at this point, the resistance there is 
least. By impeding the circulation of 
the vaginal portion, this traction begets 
an eversion of the os and a circular hy- 
pertrophy of its lips. 
By examining figure 14, it will readily 
be seen that the term prolapse of the 
womb, as applied to this kind of elonga- 
tion, is a misnomer; because, although 
the cervix protrudes from the vulva, it 
does so more through elongation than 
from displacement. There is a descent 
of the cervix, a prolapse of the cervix, if 
you please, without necessarily any 
sinking down whatever of the fundus. 
Protruding from the vulva there will 
be found a large boggy tumor, looking 
very like the snout of a pig or the penis of 
a horse. In shape like a truncated cone, 
its apex will be occupied evidently by 
the vaginal portion of the cervix, which is 
clubbed, hypertrophied, but not much elong- 
ated. Theopening at the apex is usually fun- 
nel-shaped through the eversion of the lips of 
the os, and the cervical canal thus lies ex- 
posed to view for some distance up ; so that 
the internal os becomes almost ah external 
one. Upon grasping the tumor it will be 
found that only a portion of the womb is out- 
side of the vulva, and that the apex, which 
corresponds to the vaginal portion, is soft 
and spongy; while, run ning through the base 
of the tumor, as far up as it can be reached, 
may, on firm pressure, be felt the wire- 
drawn supra-vaginal portion of the cervix 
as a hard stem or cord, not thicker than the 
little finger. Very commonly, from expo- 
Fig. 13. 
tumor evidently prolonged out of the cer- 
vix, and bearing at or near its extremity the 
os externum. This form of prolapse needs 
no treatment unless the growth of the cer- 
vix is excessive, or unless it interferes with 
the comfort or the fecundity of the woman. 
Whenever the cervix is unduly voluminous 
it may be amputated, and that by the scis- 
sors, the 6craseur, or the galvano-cautery. 
The merely conical cervix, however, rarely 
needs shortening. Slow dilatation by 
sponge-tents just before the catamenial flux, 
or preferably, rapid expansion by the dila- 
tor just after, will usually be followed by 
conception, and parturition then completes 
the cure. 
The third variety of prolapse, prolapse of sure to the air, from friction, and from the 
contact of the urine, which can no longer be 
projected in a stream, the tumor is the seat 
of two or more true ulcers, always exca- 
vated, sometimes covered by a croupy exu- 
dation, and usually liable to bleed. The 
fundus may, or may not, descend very ma- 
terially; and upon this circumstance de- 
pends the kind of treatment. The sound, 
by a little coaxing and by raising its handle, 
will, in the great majority of cases, pass in 
to a distance of not less than five inches 
When the protruding mass is pushed back 
into the vagina, the sound always gives 
a much shorter measurement. This beha- 
vior is worthy of note, because it is one of 
the proofs that the supra-vaginal portion of 
the cervix is lengthened out by traction; 
and that, when relieved of the weight of 
the bladder and vagina, it shrinks back like 
an overstretched rubber band. 
On sounding the bladder it will be found 
so greatly prolapsed as to form a large por- 
tion of the hernial mass, for the tip of the 
sound will be felt outside of the vulva, very 
near to the apex of the tumor. The vagina 
is turned completely inside out, forming a 
hernial sac which contains (see fig. 14) the 
supra-vaginal portion of the cervix uteri, a 
very large pouch of the bladder, the vesico- 
uterine and the recto-uterine peritoneal 
folds, and occasionally a small pouch of the 
rectum. In exceptional cases the whole 
womb will, in a state of retroflexion, finally 
overcome the resistance of its ligaments, 
and get entirely outside of the vulva and 
wholly in the vaginal sac. The weight 
and size of the tumor will then make the 
woman straddle widely as she walks, and 
cause her to lead a very miserable life. The 
appearance of the tumor under such circum- 
stances is so peculiar as to be hardly mis- 
takable. It is very faithfully represented by 
figure 15, which I have copied from an 
admirable paper by Dr. Isaac E. Taylor.* 
The bulge of the retroflexed fundus makes 
the posterior wall of the vaginal sac hang 
down below the snout-shaped cervix, like a 
dewlap. 
In this third variety of prolapse pessaries 
are usually of no avail whatever. They can- 
not keep up the prolapsed cervix without 
bending almost double its elongated and 
stein-like portion, and the pain is, therefore, 
liable to be unbearable. Even a perineal pad 
Fig. 14. 
is generally insupportable. Rest in bed for a 
few weeks, by taking off the weight of the 
prolapsed bladder and vagina, will cause the 
overstretched cervix to shrink back very 
materially ; and a suitable pessary, such as 
Hodge's, Cutter's, Spooner's, or a cup-and-' 
stem pessary with an external base of sup- 
port, might then be adjusted, which would, 
perhaps, keep the prolapsing organs in their 
proper position. But at best, the womb is too 
ductile, the vagina and perineum too relaxed, 
even when contracted by appropriate opera- 
tions, to render this treatment other than te- 
dious and unsatisfactory. The desideratum 
here is something that can furnish a support 
to the unstable pelvic organs, and, at the same 
time, consolidate the ductile womb by giv- 
ing a fillip to the now dormant process of 
involution. Whenever, therefore, the fun- 
dus uteri has barely sagged down, that is ta 
say, the uterine ligaments have been strong 
enough to resist the traction, a radical cure 
is attainable by the ablation of the vaginal 
portion of the cervix, and this should be 
done either by the wire-6craseur, or by the 
galvano-caustic loop. The long continued 
suppuration from the open wound sets up 
such nutritive changes as permanently con- 
tract and consolidate the elongated portion 
of the cervix, and cause it, by virtue of the 
uterine stays, to sustain in situ the bladder 
and vagina. Before amputating the cervix\ 
for fear of injury to the bladder, its lower 
boundary line must be accurately defined. 
* On Amputation of <he Cervix Uteri; Bellevue 
and Charity Hospital Reports, 1869. This can be done by the sound, or better 
still by stretching open the urethra with the 
dilator, and then introducing the little fin- 
ger into the bladder. The chief danger 
attaching to this operation is the risk of 
invading the abdominal cavity by acci- 
dentally removing, along with the cervix, 
a piece of the recto-uterine pouch ; for un- 
fortunately there are no diagnostic marks 
for ascertaining the depth of this fold of the 
peritoneum. When the fundus is low down, 
or is wholly extruded, as shown in figure 15, 
allay uterine colic and pelvic pains ; 3. To 
lessen the inconveniences arising from the 
weight and bulk of these tumors; 4. To 
check their growth. 
To stay the hemorrhage is the most im- 
perative of all the indications in the'treat- 
ment of these growths, and as such I shall 
dwell on it at some length. For this pur- 
pose, a day or two before the one on which 
the menses are expected, relieve the pre- 
cursory engorgement of the pelvic viscera, 
by a saline cathartic, and put your patient 
to bed, where she is to stay during her sick- 
ness. Such rest, and I mean functional rest 
as well as physical rest, will alone often 
check the flow. If it fails, givea teaspoonful 
of the fluid extract of ergot every two, three, 
or four hours, according to the urgency of 
the symptoms. In the long run ergot is, 
here, our sheet anchor. Next to ergot ranks 
gallic acid, given in doses of from twenty 
to thirty grains, repeated every two, three, 
or four hours. I know nothing better to 
check the most alarming hemorrhages, 
either from the womb, as in menorrhagia, 
or from the bowels, as in typhoid fever. 
When serious emergencies of this kind arise, 
to give smaller doses is mere trifling. Any 
table syrup will disguise its taste and re- 
duce its bulk. Sometimes one will succeed 
best by combining ergot with gallic acid, to 
which must often be added morphia enough 
to allay the severe pelvic and uterine pains. 
Quite recently Spencer Wells and others 
have highly lauded a free exhibition of an 
infusion of Vinca major, the greater peri- 
winkle of our flower gardens, in the pro- 
portion of two ounces to twenty of boiling 
water. I have no experience with it; but 
such recommendations make it worthy of 
trial. I have seen an old woman's remedy 
of cinnamon boiled in milk act like a charm, 
when other medicine failed. Leeching or 
scarifying the cervix a day or two before the 
menstrual flux will relieve the local con- 
gestion and very materially lessen the 
bleeding. 
During the intervals between the hemor- 
rhages iron in some form is indicated; not 
given alone, but in combination with such 
medicines as lessen the congestion of the 
womb. For this object ergot and the Indian 
hemp sustain the greatest reputation. 
Digitalis and arsenic have many advocates, 
and so has ipecacuanha. All these remedies 
must be given in doses as large as can well 
be borne. A favorite mixture of my own , 
Fig. 15. 
then, in addition to the ablation of the 
vaginal portion of the cervix, must the 
vulvo-vaginal opening be contracted. This 
is done by paring from the labia and the 
vagina a horse-shoe strip of mucous mem- 
brane, about an inch wide and extending 
to points a little below the level of the mea- 
tus urethrae; and by bringing together the 
raw surfaces by wire sutures, just as in the 
secondary operation for lacerations of the 
perineum. By combining these two opera- 
tions I have succeeded in finally curing 
cases which every other method had failed 
even to relieve. 
Fibroid Tumors of the Womb.-The treat- 
ment of this class of growths may be divided 
into, the palliative and the radical The 
former aims to accomplish the following 
ends: 1. To stay the hemorrhage; 2. To TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
19 
which, by the way, I often give in every 
kind of uterine engorgement, is- 
B. Tinct. ferridi chloridi 
Acid, phosphorici dil. 
* Ext. ergota? fluid. aa.fl.5j. 
Aquae cinnamomi M. 
Sig.-One dessertspoonful after each meal, 
in a wineglassful of water. 
Tf, by these means, the hemorrhage is not 
checked, then inject subcutaneously a hypo- 
dermic syringeful of the fluid extract of 
ergot, or an equivalent dose of a concentrated 
infusion of the powdered ergot. Should 
there be no response, then the physician 
may proceed in the usual way to tampon 
the vagina. He will, however, find it a far 
better practice to plug up the canal of 
the cervix; for not only will he thus least 
inconvenience the woman, and also more 
effectually control the existing hemorrhage, 
but, further, he will lessen the tendency to 
future ones. For this purpose squeeze into 
the os the largest sponge-tent possible. Or 
else, expose the cervix by a speculum, hook 
down the anterior lip, and then,with a sound, 
pack, little by little, into the os and cervical 
canal all that is possible of a long and nar- 
row strip of lint. First dip the lint into a 
saturated solution of Monsel's salt, and also, 
for convenience of removal, leave a short 
tail outside of the os. Of these two methods, 
I much prefer the former; because, since 
some blood will always ooze out by the side 
of the sponge and through its substance, it 
can be kept in for two or three days without 
becoming fetid; and because it is a fact that 
whatever dilates the cervical canal of a 
womb containing a fibroid tends to lessen 
the frequency and duration of the hemor- 
rhagic attacks. Repeatedly, after using a 
sponge-tent, either for diagnostic purposes 
or as a tampon, have I seen the hemorrhages 
much diminished for weeks and even 
months. 
Let me advance a step further; for, to 
combat this most formidable of symptoms, 
to confront, what Homer calls, " the purple 
death," we must be armed at all points. A 
woman cannot be always kept tamponed, 
or for an indefinite length of time, and yet, 
when the tent is removed, she may bleed as 
badly as ever. Stretch open, now, the cervi- 
cal canal by the dilator, and after introduc- 
ing the slender nozzle of the uterine syringe 
between the open blades, inject into the ute- 
rine cavity one or two drachms of the tine- 
ture of iodine, or as much of a strong solu- 
tion of Monsel's salt. Or else push up into 
the uterine cavity, as far as it can be made 
to go, a piece of lunar caustic weighing from 
five to ten grains, and let it dissolve there. 
Another way is to swab out the uterine cavi- 
ty with fuming nitric acid, in the manner 
previously described. Any one of these 
plans is, for the time being, usually very 
efficacious. But supposing it fails; or the 
hemorrhage, after being arrested for a few 
days, returns with renewed violence. The 
canal of the cervix must now be so opened as 
to admit the index finger. This is done by 
incising the whole canal, either bilaterally 
with the hysterotome (Fig. 1G), or at several 
points with a probe-pointed 
and curved bistoury. In per- 
forming the latter operation, it 
is best to expose the cervix 
with a speculum, and to steady 
the anterior lip with the vol- 
sella. Whenever the cervix is 
thinned down to a mere rim, a 
strong pair of curved scissors 
will readily slit up the margin. 
In case the cervix is long and 
uneflaced, my own plan is to 
stretch the canal open by the 
dilator, and crowd into it a 
fagot of laminaria tents, before 
resorting to cutting instru- 
ments. My reason for this is, 
that, very commonly, after such 
a dilatation of the os, the fur- 
ther descent of the tumor pre- 
vents the opening from closing. 
The mode by which a perma- 
nent expansion of the canal 
controls the hemorrhagic ten- 
dency is not yet clearly under- 
stood. It is not the only em- 
pirical fact in medicine which 
has to be taken on trust. But 
experience teaches, that, after 
such an expansion, the hemor- 
rhages often remain for months 
in abeyance. 
Stripped of its power to bleed, a fibroid is 
shorn of much of its power to do harm; but 
there will remain for treatment pelvic pains, 
and vesical and rectal tenesmus. More 
commonly at the menstrual periods, but 
also at other times, the womb is excited to/ 
extrude the foreign body. These pelvic 
pains and these uterine colics will often tax 
one's skill and tact. Much can be gained 
FIG. 16. 20 
SOME PRACTICAL HINTS FOR THE 
from rest. Frequent warm baths may as- 
suage the vesical and rectal irritation. Ano- 
dyne suppositories, either rectal or vaginal, 
always give much comfort. Two grains of 
the watery extract of opium will be enough 
for a rectal suppository; and one grain of 
morphia with two of the extract of bella- 
donna, for a vaginal one. This method of 
giving anodynes is better than that by the 
mouth, which leads sooner or later to the 
habit of opium-eating. 
To lessen the inconvenience arising from 
the weight and bulk of these tumors, vari- 
ous forms of pessary may be tried. But 
they are only available when these fibroids 
are small enough to move about pretty freely 
in the pelvic cavity. Whenever they are too 
bulky to sink down very low into the 
pelvis, or, having been artificially pushed 
up, the indication is to maintain them above 
the brim, external support must be resorted 
to. An elastic broad belt, stiffened by slips 
of whalebone, and kept in position by a 
perineal strap, will then give much comfort 
by relieving the pelvic viscera from pres- 
sure. I have been able to send on a jaunt 
through Europe a patient with a very large 
fibroid thus supported. 
To check the growth of these tumors, it 
will be necessary to advise total abstinence 
from sexual intercourse, more or less of the 
recumbent posture, loose dresses, a some- 
what sedentary life, and a spare but whole- 
some diet. Such medicines must be given 
as are known to lessen the flow of blood to 
the reproductive organs. This class of reme- 
dies comprises ergot, digitalis, cannabis in- 
dica, borax, cinnamon, and the bromide or 
the iodide of potassium. Every means 
must be used to prevent portal and pelvic 
congestion. With this object in view, the 
contents of the bowels must be kept soluble, 
and rest strictly enjoined before, during, and 
after the menstrual flux. Broken down 
constitutions fearlessly build up by vege- 
table and mineral tonics; by stimulants 
very exceptionally. All growths thrive 
best in a cachectic soil. By these means, 
and by those previously noted, the physi- 
cian will very generally succeed in tiding 
his patient safely over the perils of the 
menstrual period of her life; and, the 
climacteric once reached, her future will 
thereafter be one of comparative comfort. 
So large a measure of success cannot be 
promised of the radical treatment of these 
tumors. Hitherto very many different 
remedies have been tried, but with such in- 
different success, that it would be a waste of 
time to enumerate them. The most feasible 
and rational plan is that proposed by Prof. 
Hildebrandt, of Konigsburg (Half- Yearly 
Abstract, January, 1873, p. 248), which bids 
fair to prove of great value. He reports 
that he has successfully treated nine cases 
of fibroid tumors of the womb by daily in- 
jections of the aqueous extract of ergot 
under the skin around the umbilicus. By 
this treatment one fibroid, reaching above 
the navel, entirely disappeared. Another, 
which so filled the entire abdominal cavity 
as to press upon the false ribs, was much re- 
duced in volume. In the other cases the 
tumors were greatly diminished in size ; and 
in each one all the alarming symptoms, 
such as menorrhagia, metrorrhagia, ieucor- 
rhcea, and uterine colics, disappeared. The 
duration of the treatment was from two to 
four months, the daily injections being in- 
termitted only during the catamenial period. 
In one case only did the toxic effects of the 
ergot compel a discontinuance of the treat- 
ment. For these injections, Prof. Hilde- 
brandt uses an ordinary hypodermic syringe- 
ful of a solution containing three parts of 
ergotin to 7.5 parts each of glycerine and 
water. The mode of action of the ergotin 
in these cases was, probably, its property of 
contracting the uterine walls, whereby the 
nutrition of the tumor was interfered with. 
It is, therefore, very questionable whether 
any but interstitial and submucoid tumors 
can be acted upon. For the subperitoneal 
fibroid would be outside of the grasp of the 
uterine fibres. From this treatment so 
many successful cases have been reported in 
the journals (See Report on Obstetrics in the 
Trans. State Med. Society of Pennsylvania, 
for 1873, p. 86), and I have seen such good 
results from it, that I can confidently re- 
commend its adoption. Headache, severe 
uterine pains, and a spurious hectic fever 
evinced the constitutional action of the ergot 
in the cases of which I have cognizance. 
The local effects of the injections were at 
first great pain and redness of the skin at 
the seat of puncture, and an occasional 
small abscess. The last, however, can be 
generally avoided by carrying the nozzle of 
the syringe deeply down to the level of the 
muscular parietes of the abdomen. As there 
is no standard preparation of ergotin at all 
trustworthy, I should recommend from ten 
to fifteen minims of the officinal fluid ex- TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
21 
tract of ergot, diluted with enough of water 
to fill the hypodermic syringe ; or the same 
amount of a concentrated infusion of pow- 
dered ergot, of equivalent strength. Or 
else, Squibb's solution of ergot, which is 
double the strength of the officinal fluid ex- 
tract, may be used. When the subcutaneous 
treatment cannot be borne, an enema of one, 
two, or three drachms of the officinal fluid 
extract, in an ounce of thin starch-water, 
may be given every night at bedtime. By 
inspissating the fluid extract by very mode- 
rate heat, large amounts can be incorporated 
with a rectal suppository. 
Prof. Hildebrandt's method promises so 
large a measure of success, that it seems 
hardly worth while to advert to the surgi- 
cal treatment of these tumors. Yet time 
may show that there are interstitial and sub- 
mucoid fibroids not amenable to the hypo- 
dermic treatment. Of course all peduncu- 
lated submucous growths are to be treated 
like polypi. Before the appearance of Prof. 
H's article, there were reported several suc- 
cessful cases of enucleation of these fibroids 
by forcible traction with volsellte and pow- 
erful supra-pubic expression, after the divi- 
sion of the capsule. But, more in accord- 
ance with nature and less rude, does a 
partly expectant plan seem to me, viz., after 
the incision into the capsule, to depend for 
the further extrusion of the fibroid upon 
the expulsive action of ergot, and upon re- 
peated attempts with the finger at enuclea- 
tion, resorting to avulsion only after the 
fibroid begins to project from the os, or to 
show other signs of commencing dislodge- 
ment. 
The treatment by ergot may also in some 
cases so increase the peristaltic action of the 
uterine fibres, as to force an interstitial 
fibroid towards the abdominal cavity, where 
it becomes subperitoneal, and then loses 
much of its power to do harm. In this 
manner, also, an originally interstitial or 
submucous fibroid may be more and more 
forced into the uterine cavity, until it is con- 
verted into a fibroid polypus, which is amen- 
able to surgical treatment. It is, however, 
doubtful whether an interstitial fibroid ever 
becomes polypoid, without first losing its 
muscular or mucous investment; that is to 
say, without the process of spontaneous enu- 
cleation. The simplest and safest method 
of effecting such an extrusion is to dilate 
the os by several incisions, and to keep up a 
persistent contraction of the uterine fibres 
by the continuous hypodermic use of ergot. 
If, however, there should be no disposition 
on the part of the fibroid to become poly- 
poid, then may its capsule be divided. But 
not unless the case is an urgent one, the 
hemorrhage uncontrollable, the bulk-pres- 
sure unendurable. 
Cancer of the Cervix Uteri.-Whenever 
the cervix is the seat of a malignant or of a 
quasi-malignant growth, the indications are 
to check excessive serous or bloody dis- 
charges, to correct the fetor, to allay pain, 
and to prolong life. Very fortunately, that 
physician who diligently carries these out 
will often give a new lease of life to his pa- 
tient, and sometimes bring about her cure. 
A plan which covers these indications is, 
to remove all of the cervix possible as soon 
as the disease has been discovered. The best 
instrument for this purpose is the galvanic 
battery, with its caustic loop and porcelain 
burners. Since, however, on account of the 
expense, the bulk, and the limited range of 
usefulness of this apparatus, few physicians 
will care to purchase it, I shall confine my 
remarks to the wire-bcraseur 
(Fig. 17), which is very gener- 
ally adopted as its substitute. In 
the adjustment of the loop of 
this bcraseur certain very neces- 
sary precautions must be taken. 
The cervix should be noosed 
only while the womb lies in its 
natural position ; for if the latter 
be first dragged down by the 
volsella, as is often recom- 
mended, the vagina becomes 
partly inverted, aud the cervix 
is made to appear longer than it 
really is. Hence the operator 
is very likely to slip up the wire- 
loop higher than it should go, 
and may, therefore, include in 
its bite a portion of the bladder 
and of Douglas' pouch. To still 
further insure their safety, it is 
advisable to pass up the shaft of 
the bcraseur in front of the cer- 
vix, where the insertion of the 
vagina is lowest, and then, by 
it to push up the womb before 
the loop is tightened. On ac- 
count of the excessive vascularity 
of a cancerous cervix, the screw 
of the instrument should be 
turned very slowly. 
If, upon the ablation of the cervix, any 
FIG. 17. 22 
SOME PRACTICAL HINTS FOR THE 
portion of the growth remains behind, it 
should be scraped away or dug out by the 
finger nails, or by sharply edged curettes or 
scoops. The instruments that I use have 
been made after Simon's pattern, but a very 
efficient curette can, it seems to me, be ex- 
temporized by heating red hot the tip of a 
long and narrow spatula, and then bending 
it to a slightly oblique angle. If the surface 
is a large one, the hemorrhage attending this 
scraping process is somewhat free until 
healthy structures are reached, but the risk 
to life is trifling if care be taken not to en- 
croach upon the peritoneum. Should the 
womb be movable, this operation will be 
much facilitated by holding the stump of the 
cervix steady by means of the volsella for- 
ceps. A cotton tampon, such a one as de- 
scribed at page 5, is then charged with the 
dry subsulphate of iron, or with a glycerole of 
the same, and pushed up against the raw 
surface, where it is to remain for twenty-four 
hours. Vaginal injections of warm and 
saturated solutions of the chlorate of potassa 
should be made twice or thrice daily. I pre- 
fer warm water to cold, because it dissolves 
a far greater amount of this salt. During 
the healing process, any tendency to cicatri- 
cial closure of the cervical canal is to be met 
by the occasional use of the dilator. After 
one or two weeks have elapsed the speculum 
should be introduced, and every vestige of 
the disease thoroughly cauterized with fum- 
ing nitric acid. If need be, this application 
must be repeated over and over again at 
intervals of about a week. For many con- 
secutive months the patient should be put 
on the use of iron, arsenic and ergot-the 
iron to build up the system ; the arsenic to 
repress the tendency to reproduction and 
to systemic poisoning; the ergot to starve 
out these growths by shortening their ra- 
tions of blood-pabulum. From this treat- 
ment much cannot be expected in the way 
of absolute cure. But the immediate ef- 
fects have been extremely satisfactory to 
all the parties concerned. Life has been 
prolonged and rendered endurable; the 
hemorrhage has been stayed ; the fetid dis- 
charge arrested ; the appetite restored, and 
abed-ridden patient once more put on her 
feet. Even when the womb is firmly fixed, 
from extension of the disease to points be- 
yond operative reach, yet much will be 
gained by the removal of all the growth 
possible. 
Whenever the wire-6craseur cannot be made 
to encircle the diseased structures-as for 
instance, when the ulcerations are too deeply 
excavating, or too extensive, or the cervix 
does not project sufficiently-then the friable 
portions of the mass should be broken off or 
scraped away by the finger nail or the 
curette, and the surface well swabbed with 
nitric acid. The previously given form of 
constitutional treatment should be adopted. 
Sexual intercourse must be absolutely for- 
bidden, for attempts at coitus are frequently 
followed by serious hemorrhages. From 
the very repulsive nature of this disease, 
this caution may seem unnecessary ; but the 
fact is, that the sexual appetite of the woman 
is often greatly increased by a pruritus vulvoe 
and by the excessive vascularity of the 
reproductive organs. With regard to other 
local treatment besides the nitric acid, Dr. 
Burow, of Kbnjgsberg, has given such un- 
qualified praise to the continuous applica- 
tion of the chlorate of potassa in substance 
(Lancet, April 12th, 1873, p. 525). that I 
shall certainly give this drug a fair trial, 
and meantime, recommend it on his author- 
ity. He sprinkles the sore with the chlorate, 
and then covers the whole with a wet com- 
press. As the crystals exert a more power- 
ful action than the powder, he first uses the 
latter, and replaces it by the crystals when 
sensibility has abated. With alleged suc- 
cess, pepsin in powder has lately been ap- 
plied to these cancers in pretty much the 
same way, but with it I have no experience. 
In addition to the means employed by the 
physician, the patient herself should be 
taught how to check the constantly recur- 
ring hemorrhages. This she will very gene- 
rally be able to do by injections of ice-water 
into the vagina, by cotton-wool tampons 
containing tannin, or the subsulphate of 
iron, either in the form of a dry powder or 
in that of a glycerole, or charged with a 
paste made by thickening a saturated solu- 
tion of alum with tannin. These tampons 
or suppositories should, by the way, be re- 
moved, as a rule, in from two to three hours ; 
for if left in longer, they may become so ad- 
herent to the warty surface of the cancer, 
as in their removal to tear off the more fri- 
able portions, with a renewal of the hemor- 
rhage. Vaginal injections of any of the as- 
tringents, as strong as they can be borne, 
will also prove of service. When pain is 
present, morphia may be incorporated with 
any of the above washes and suppositories. 
A very handy instrument for the woman & awauaa a aul.eili a aaa'vxz a iiaj t ajii a avxi wi V nmxiXXJ kJ A ►JV/lVX/XLi IK O. 
23 
to use, in making a prolonged contact of 
styptic or deodorant fluids to the cervix, is a 
glass tube like the vaginal portion of a Fer- 
gusson speculum, to one end of which is at- 
tached a rubber bulb. 
To correct the horrible odor, vaginal 
washes containing alum or carbolic acid, 
the hydrate of chloral, or the chlorate or 
the permanganate of potassa, will be found 
extremely useful. Of these the hydrate of 
chloral has my preference, because it is not 
only an admirable deodorant and antiseptic, 
but a very prompt local anaesthetic. The 
plan by which I have best succeeded in 
making my patient the least disagreeable to 
herself and to her friends, is the frequent 
use by day of some one of the above 
washes, and at night the introduction of a 
suppository containing a few grains of 
chloral, or of the chlorate of potassa. When- 
ever the disease is far advanced, and the 
patient's sufferings are very acute, her eu- 
thanasia is all that is left to the resources of 
art. Anodynes should, therefore, be given 
without stint, in any way, shape or form 
the sufferer may prefer. For the agonizing 
pains in the back, so common in advanced 
stages of the disease, the promptest relief 
will be gained by a hypodermic injection of 
morphia, but a more permanent one some- 
times follows the use of dry or wet cups 
over the sacrum, or the application of a 
few leeches. For the suppression of the se- 
cretion of urine, occasionally seen in women 
suffering from this cruel disease, Martin, 
of Berlin, states that there is nothing better 
than small doses of the iodide of potassium. 
Polyi-)us of the Womb.-For all practical 
purposes, a uterine polypus may be defined 
as a stalked or sessile tumor, hanging from 
the mucous surface of the womb, and par- 
taking of the same histological characteris- 
tics as the stroma from which it springs. 
It usually occurs singly, but I have removed 
two from the uterine cavity, which, like 
gall stones, were flattened on the surface of 
impact. It is most probably the result of a 
perverted nutrition, brought about by some 
congestive or inflammatory action of the 
womb, just as a nasal polypus owes its be- 
ing to a chronic catarrlj. 
The most common symptom evoked by a 
polypus is hemorrhage, but the amount 
bears no proportion to the size of the tumor. 
At times the menstrual flux appears at the 
usual 'period, but is excessive; more fre- 
quently the interval shortens; then, again, 
blood may dribble away more or less all the 
time. Other symptoms are leucorrhoea, 
vomiting, and expulsive pains, the last two 
as the result of uterine distention. 
The polypus ordinarily met with is the 
small glandular variety, which appears to 
consist of one ovule or more of Naboth. In 
size it rarely exceeds a marrow-fat pea, and 
is found just within the os externum, or 
hanging out of it. Since it retreats before 
the finger into the cervical canal, and thus 
escapes detection, a speculum should al- 
ways be used. A bivalve is here the best, 
because, by making the os gape widely open, 
it may reveal one so high up in the canal as 
to be beyond the reach of the finger. From 
its soft and slippery nature, it eludes the 
grasp of any ordinary forceps, and, there- 
fore, should be either snipped off with a pair 
of scissors, or twisted off with a fenestrated 
forceps (Fig. 18.) Any tendency to hemor- 
rhage can be controlled 
by an application to the 
stump of fuming nitric 
acid. 
Polypi that start from 
the uterine cavity grow 
to a much larger size, 
and, when first discov- 
ered by the physician, 
are rarely smaller than 
a hickory nut. Vary- 
ing much in size, they 
will be found either 
wholly in the vagina, 
or partly in the vagina 
and womb, or wholly 
within the uterine cav- 
ity. Whenever they 
hang loosely in the va- 
gina, or dangle partly 
out of the dilated o?, 
like the clapper of a 
bell, there is no diffi- 
culty or hazard in their 
removal. They can of- 
ten be twisted off, but 
no great force must be 
used for this purpose, 
lest the root of the stalk should wrench 
off a portion of the uterine wall. They can 
be snipped off with a pair of scissors curved 
on the fiat; or the stalk can be first put on 
the stretch, and then scratched through 
with the nicked nail of- the index finger 
just as a blunt knife severs the strands of 
rope when tightly stretched. The safest, 
Fig. 18. 24 
and therefore the best plan, is, however, to 
noose the pedicle with the loop of the 6cra- 
seur. Should the polypus prove so large as 
to fill up and greatly distend the vagina, it 
may be impossible to reach the pedicle. In 
such a case different plans may be pursued, 
but the tumor must be got away by hook or 
by crook. One method is to cut off as large 
a slice as possible by a very strong wire loop 
slipped up as high as it will go. On the re- 
moval of this slice the rest of the polypus 
will descend still lower, so that at a second 
or third trial the pedicle will be reached. 
The risk from hemorrhage is not very great, 
even when the tumor is of large bulk. Be- 
fore the 6craseur came into use, I once as- 
sisted at an operation in which a very large 
polypus was removed with a curved pair of 
scissors. Although the pedicle was not 
reached until two large slices had been cut 
off, each after an interval of a week, no 
hemorrhage requiring a tampon took place. 
Another plan consists in seizing the growth 
with the midwifery forceps, or by two very 
strong volsellre, and in dragging it outside of 
the vulva. The wire loop of an 6craseurcan 
then be thrown around the pedicle. If this 
instrument is not attainable, the pedicle can 
be sawed off by a fine but strong piece of 
hempen twine, in the same manner as a bar 
of soapi is often cut into uniform pieces. If 
knotted at two or three points, the twine 
will sometimes cut better. Either method 
reduces the risk of hemorrhage to a mini- 
mum. As these very large tumors often 
spring from the cervix, care must be taken 
to follow down the reflected fold of the va- 
gina upon the cervix, so as not to apply the 
twine or wire so high up as to include a por- 
tion of the womb or of Douglas' pouch. 
One hint with regard to the wire 6eraseur: 
Whenever no great power is needed to cut 
through the noosed pedicle, each end of the 
loop may be fastened to the traveling but- 
ton. But when the object to be cut off is 
large, the one end of the loip should be fast- 
ened (as represented in figure 17) to one of 
the immovable bars projecting from the 
shaft near the handle, and the other end 
twisted around the traveling button. Since 
only one end of the loop now travels, the 
movement is slower, but the half-sawing 
action thus gained greatly increases the 
power, and lessens the chance of having the 
wire snap. 
Inversion of the womb being a very rare 
accident, is for this reason very liable to be 
mistaken for a polypus. When a polypus, 
partly projecting from the uterine cavity 
into the vagina, has contracted adhesions 
with the margin of the os, the diagnosis be- 
tween it and an inversion of the womb may 
be very difficult. Sometimes the womb is 
partly inverted by a polypus, and the in- 
verted portion may be mistaken for the pedi- 
cle. To make out this diagnosis, remember, 
first, that, unless directly after labor, the tu- 
mor of an inversion is scarcely larger than 
the non-gravid womb. Hence, a volumin- 
ous tumor distending the vagina cannot be 
simply an inverted womb. Next, pass up 
the sound, and if it indicates a length of two 
inches and a half, or more, beyond the edge 
of the os, the tumor is notan inverted womb. 
If it cannot be made to enter more than an 
inch, the womb is probably partly inverted. 
If no cervix and no uterine cavity can be 
discovered, and the tumor is not larger than 
the non-gravid womb, it is very likely to 
prove an inversion of the womb. To con- 
firm the diagnosis, give ether, pass up the 
index finger, or even half of the hand, into 
the rectum, and try to reach above the tu- 
mor. If inversion be partial, a cup-like de- 
pression, like the bottom of a bottle, will be 
found where the fundal vault should be. If 
inversion be complete, the womb will be ab- 
sent from its accustomed site. Sometimes, 
however, in spite of these methods, the diag- 
nosis will still be doubtful. Stab now the 
tumor with an acupuncture needle, and if 
the woman flinches, it is the womb, and not 
a polypus, for the latter is not sensitive. 
Again, to make sure of no error in this mat- 
ter, withhold all anaesthetics, and tighten 
the loop of the 6craseur very slowly. If now 
the woman complains of great pain, some 
portion of the womb has been noosed. 
Hence, in doubtful cases, the inference is 
plain never to use anaesthetics while the 
pedicle is being cut through. 
When a polypus, starting from the fun- 
dus, contracts adhesions with the os, these 
must be broken up by the fingers or cut 
through with the scissors, before the true 
pedicle can be reached. The tapiroid cer- 
vix, adverted to under the subject of pro- 
lapse, may be mistaken for a polypus. But 
as the remedy in each is the same, no harm 
will accrue from a false diagnosis. The tale 
told by the existence of an os externum, 
and of a uterine cavity, should never per- 
mit a completely prolapsed womb to be 
mistaken for a polypus. iiuLa.iair.JXT ajnu ekeV ENTION OF UTERINE DISORDERS. 
25 
The intra-uterine polypi are by no means 
so easily disposed of as the other two varie- 
ties. The first difficulty in the way is to dis- 
cover the growth ; for it may be so small as 
not to enlarge the womb appreciably; the 
cervix may not be effaced or the os dilated ; 
or the sound may impinge upon the polypus 
and deceive the physician by a false meas- 
urement. Since the most prominent symp- 
tom is hemorrhage, the first thing to be 
done, when this persists, is to explore the 
uterine cavity with the finger. For this 
purpose the canal of the cervix must be dila- 
ted by tents, and in the manner previously 
described ; due heed being paid to the cau- 
tion of effecting this dilatation, if possible, 
with but one batch of tents. This method 
of gaining the cavity of the uterus -will not, 
however, always be necessary, and here is a 
hint worth remembering. During the cata- 
menial flux, the temporary increase in the 
bulk of the tumor, through congestion, to- 
gether with the resulting labor-like pains, 
so opens up the canal as often to permit the 
passage of the finger. This fact should be 
explained to tlie woman, else her innate 
feeling of delicacy would cause her to shrink 
from an examination at such a time. 
An intra-uterine polypus having been dis- 
covered, how is it to be removed ? By adopt- 
ing the following plan, somewhat modified 
from that of Dr. Kidd, of Dublin, I have not 
yet been foiled : The woman is first ether- 
ized, and afterwards brought in the dorsal de- 
cubitus to the edge of the bed, where each leg 
is supported by an assistant. The operator 
now seizes the anterior lip of the os with a 
volsella, drags the womb down as low as 
possible, and then entrusts the instrument 
to one assistant, with the injunction to hold 
it steady. Meantime the other assistant 
renders efficient aid by keeping up a firm 
supra-pubic pressure upon the fundus. The 
operator next introduces the index finger of 
his left hand into the uterine cavity, and 
by it as a guide seizes hold of the polypus 
with a second volsella. He now tries to 
twist the tumor off, but, for reasons pre- 
viously given, with no great force. Failing 
in this, he, in order to gain more room in the 
vagina, removes the first volsella, and then 
slips the wire loop of an bcraseur over the 
handles of the second. This volsella is now 
put in the hands of an assistant, who makes 
firm downward traction with it, while the 
operator proceeds to slide the loop up beyond 
its claws and over the polypus. When the 
pedicle is reached, he draws in the slack of 
the loop, but, before tightening it, causes 
the traction of the volsella on the polypus to 
be relaxed, and then pushes up the fundus 
of the womb with the shaft of the bcraseur. 
The object of this manoeuvre is, not only to 
restore the vault of the fundus if it has been 
partly inverted by the traction on the poly- 
pus, but also to get the loop close up to the 
root of the pedicle. A few turns of the wind- 
lass in the handle of the Gcraseur now cuts 
off the polypus, which, being still held by 
the volsella, is finally extracted. In like 
manner may the projecting portion of a sub- 
mucoid fibroid be shaved off flush with the 
uterine wall. The remaining portion is then 
usually expelled later by the process of 
spontaneous enucleation. Should the phy- 
sician not possess an Scraseur he may, per- 
haps, be able to scratch through the pedicle 
with the serrated nail of his index finger, 
or sever it either with a curved and probe- 
pointed bistoury, or with a long pair of scis- 
sors curved on the flat. Sometimes he may 
be able to saw through the pedicle by a 
piece of twine carried up and worked by 
means of Gooch's double canula. 
A polypus once removed never returns, 
but a second one dwarfed by the pressure of 
the first may now rapidly grow. There is, 
however, a sarcomatous growth of peculiar 
malignancy, hitherto referred to by writers 
under the name of "recurrent fibroid," 
which may deceive the physician into the 
impression that he is dealing with a simple 
polypus, and lead him to give, as I once 
did, a favorable prognosis. It bleeds very 
freely, emits a very bad odor, and feels much 
like placental tissue. The structure is so fri- 
able as to break down under very slight 
traction. The constriction of the portion 
protruding from the os gives the idea of a 
pedicle ; but on following it up with the fin- 
ger, it will be found to have no circum- 
scribed uterine attachment, but to lose itself 
in an analogous intra-uterine mass. It in- 
variably returns, and the woman always per- 
ishes eventually, but life may be prolonged 
by scraping and gouging away all of the 
growth possible, by cauterizing the surface 
from which it springs, and by using the re- 
medies recommended for cancer of the womb. 
In concluding this subject, let me urge 
the importance of removing a polypus found 
in the vagina during either gestation or 
labor, or in the uterine cavity after delivery. 
For, from the injuries it will sustain, or has 26 
already sustained from labor, it is very lia- 
ole to become gangrenous and to kill the wo- 
man by putrid or purulent absorption. 
SOME PRACTICAL HUNTS rvit the 
reason why a woman should not sit up in 
bed, or even slip into a chair, whenever she 
feels so disposed. These are not idle phrases, 
but the conclusions of a long and well-sifted 
experience. Such movements excite the 
womb to contraction and empty it and 
the vagina of putrid lochia which may be 
incarcerated by a clot or by the swollen con- 
dition of the soft parts. When, therefore, 
the lochia are offensive, these upright posi- 
tions should be insisted upon, as being, in 
fact, better deodorants than any detergent 
vaginal injections. By equalizing the circu- 
lation and by increasing its force, they also 
tend to lessen the passive congestion of the 
womb as a whole, the engorgement of the 
placental site, and especially that blood-sta- 
sis kept up by the dorsal decubitus in its now 
thickened posterior wall, which is, in my 
opinion, a very common cause of posterior 
displacements. 
The prolonged use of the obstetric binder 
is another factor in the production of female 
complaints. The binder may be useful for 
the first four-and-twenty or forty-eight hours 
after labor; for it fills up the void left by the 
emptying of the womb; it givesagrateful 
feeling of support; it hinders the occurrence 
of a concealed hemorrhage, and presents a 
bar to the ingress of air into the uterine 
cavity. But when kept on simply for the 
purpose of preserving the shape, by paralyz- 
ing those abdominal muscles which it is in- 
tended to strengthen, it not only defeats the 
object so dear to the heart of every woman, 
but it weakens the retentive power of the 
abdomen. It also does harm by crowding 
the intestines upon the womb, and the womb 
down into the pelvic cavity. Again, by 
forcing backward upon the vena cava and 
upon the pelvic veins so hard a body as the 
womb, making it, in fact, the pad of a 
tourniquet, it impedes the freedom of the 
circulation in that organ, and greatly im- 
pairs the process of involution. Pharaoh 
could have devised no surer way of over- 
coming the fruitful health of his Hebrew 
subjects, than by an edict enforcing the 
prolonged use of a tight obstetric binder. 
The lochia must be watched. If, in the 
third week after delivery, they still linger 
on, the inference may safely be made either 
that the cervix is the seat of unhealed 
lacerations, or that the process of involution 
is interrupted ; or that both conditions may 
co-exist, for the former usually determines 
the latter. Astringent vaginal injections or 
PART II. 
Hitherto the treatment of the more com- 
mon forms of uterine affections has been 
briefly considered. I now purpose to sug- 
gest some means for their prevention. To 
stamp them wholly out may be impossible, 
but the alert physician can do much towards 
balking their approach. On the one hand, 
by prudent forethought and by -watchful 
care, he can guard his puerperal patients 
from disease. On the other, by forewarning, 
he can forearm. 
For the furtherance of these ends, I shall 
group my remarks under two heads; the 
first exclusively medical in character; the 
second less professional than laical. To this 
division I shall with less scruple sacrifice 
strict continuity, both because there is no 
sharp dividing line between that which con- 
cerns the physician and that which concerns 
his patient; and because I humbly hope that 
my readers may deem the lay-portion of 
, sufficient importance to justify its perusal 
by their friends, neighbors, and patients. 
SPECIAL HINTS. 
Puerperal Convalescence.-Let the physi- 
cian see to it that his patient has a good 
getting up, as well from a miscarriage as 
from a natural labor. Lactation should be 
encouraged, and from the first day the diet 
should be generous. The canonical purge 
on the third day should be dispensed with ; 
it weakens the body needlessly, and tends to 
promote the absorption of septic matter. 
Premature exertion must not be allowed. 
On the other hand a recumbent posture 
ought not to be too rigorously enjoined. I 
feel persuaded that this tradition of the 
lying-in chamber does more harm than 
good, for nothing so relaxes muscular fibre 
as a confinement in bed. In my experience, 
women feel stronger on the fifth day after 
labor than they do on the ninth or four- 
teenth, if kept in bed. Among the ancient 
Greeks, those models of physical strength 
and beauty, the women took a bath on the 
fifth day. That this was also a custom of 
(he Romans is evident from a play of 
Plautus, entitled " Truculentus, or the 
Churl." Since labor is in general a strictly 
physiological process, there can be uo sound £ 
suppositories will now prove to be important 
therapeutic agents. To this local treatment 
m-'-y be added a constitutional one of iron 
and quinia, the former according to pre- 
viously given formulae, the latter in suitable 
doses, amountingin the twenty-four hours to 
from eight to twelve grains. Apart from its 
undisputed tonic properties, quinia firmly 
constiinges uterine fibre, and, therefore, 
greatly aids the process of involution. Ergot 
and strychnia are also useful remedies to 
fall back on ; wine or beer must not be for- 
gotten. If, after the puerperal month, pains 
in the back, leucorrboea and other well- 
known symptoms indicate the presence of 
some uterine disorder, it is evident that in- 
volution has been retarded. The speculum 
must then be used, and the usual uterine 
applications made, beginning with the 
milder ones, for now, if ever, is the time by 
such means to treat the condition of subin- 
volution, or to cure other puerperal lesions. 
If a patient has previously suffered from 
uterine disease, she should, after delivery, 
be at once put on a treatment of ergot and 
quinia. By shortening the excursipns of 
uterine fibres in their alternate contractions 
and relaxations, these medicines propor- 
tionately lessen the diastolic engorgement of 
the womb. I am not sure but Credo's 
method of placental delivery, by supra-pubic 
expression, acts in an analogous manner. It 
certainly empties the womb of all clots and 
squeezesit down to its mininum capacity. 
Such a patient also needs the timely aid of 
the forceps. For it prevents that laxness of 
uterine fibre following a long and weary 
labor, and hence provokes a more complete 
involution. But for that matter, no lying- 
in-woman should be allowed to linger on in 
the expulsive stage of labor, when her 
physician possesses the requisite skill to 
shorten it. 
Lacerations of the Perineum.-The imme- 
diate closure of the rent in lacerations of the 
perineum ought by this time to be fully' re- 
cognized by the profession as a very im- 
portant means for the prevention of future 
mischief to the reproductive organs. As I 
have elsewhere shown {Trans. of the State 
Med. Society of Pennsylvania, for 1873), and 
here take the liberty of repeating, the loss 
of every fibre of muscle in the perineum 
entails a corresponding loss of power in the 
floor of the pelvis, and a consequent impair- 
ment of support to the reproductive organs. 
The sustaining power of the vaginal column 
nnsanusnr ITIU rius V TIU3N UF UTEKliNE DlSOKDEKiS. 
27 
depends upon the integrity of its perinea] 
abutments. It is the tonicity of the vaginal 
walls, and the pelvic connections of the 
womb that mainly keep it in place. These, 
in a case of torn perineum, may not at once 
yield, but will sooner or later; for air gains 
access to the womb, irritating and congest- 
ing it to such a degree that it ultimately 
prolapses from an acquired hypertrophy. 
Unless, therefore, the rent is simply cutane- 
ous, or very slight indeed, it should not be 
left to nature. Further, it is far more ra- 
tional to take advantage of the necessary 
confinement in bed after delivery, and to 
close the wound at once, while its surface is 
raw and the maternal soft parts are compara- 
tively numb and insensible, than to post- 
pone the operation to a time when the wo- 
man shall be nursing, when the cicatrized 
flaps shall demand quite a formidable ope- 
ration for their denudation, and when a 
special confinement in bed for two weeks or 
more will be needed. 
My own method is, immediately after the 
delivery of the placenta, to pass deeply two 
or more wire sutures, securing each one by 
merely twisting its ends together. In bad 
rents, the first stitch is entered not quite, 
half an inch below the lower angle of the 
wound, and about an inch from its margin. 
When the sphincter ani is torn, the cutane- 
ous points of entrance and of exit of the 
first needle should then be nearly on a level 
with the lower margin of the anal onfice, 
and the suture should pass around the whole 
wound. This purses up the tissues from be- 
low upward, and secures complete coapta- 
tion. Enough opium must be daily given 
to keep the bowels quiet for a week. 
In severe lacerations the woman's knees 
must be kept bound together for a week, 
and her urine drawn off for three or four 
days. On the third or fourth day, but not 
earlier, lest the process of immediate union 
should be interrupted, vaginal injections 
of weak solutions of carbolic acid, or of the 
permanganate of potassa, are made twice in 
the twenty-four hours. These soothe the 
parts and correct the bad odor of the dis- 
charges. Without reference to any special 
time, the sutures are removed as fast as they- 
become loose, usually from the seventh to 
the ninth day. On the eighth or tenth day 
a seidlitz powder, or one dessert-spoonful of 
castor oil, is given every four hours until aa > 
inclination to go to stool is urgent; then an 
injection is given in order to liquify the con- 28 
tents of the lower bowel. This method of 
uniting the parts, both in the immediate 
and in the secondary operation, after the cic- 
atrized surfaces are denuded, I can warmly 
recommend, as I cannot recall but one case, 
and that a very unruly one of puerperal 
mania, in which there was failure in obtain- 
ing a very good union. It ought, however, 
to be stated, that in secondary operations 
superficial sutures should be placed between 
the deep ones, and that the latter should be 
clamped with perforated shot. In order 
also to pare each side of the rent with uner- 
ring uniformity, after freshening the surface 
of one side, its exact print in blood can be 
got on the other by pressing the nates to- 
gether for an instant. A very troublesome 
symptom in these oases is flatus. If it does 
not yield to valerian, a gum catheter should 
be very carefully passed up into the rectum. 
Many lacerations are, in my opinion, ow- 
ing to the common mistake .of making so 
firm a pressure upon the perineum as to 
prevent it from undergoing an equable dila- 
tation. The portion thus compressed can- 
inot take its share of the general tension, 
;and the strain is thr >wn on the fourchette. 
Further, the pressure of the hand, by ob- 
structing the free circulation of blood, im- 
pairs the vitality of the perineum. Bruised 
and benumbed, it is no longer a living tis- 
sue, capable of responding intelligently, so 
to to the requirements of the occa- 
sion-when to repel, when to solicit the ad- 
vance of the head-and this nice point na- 
ture can very generally determine far better 
than the physician. Again, the word "sup- 
port,11 as applied to the perineum, is a mis- 
nomer. No " support," in the ordinary ac- 
ceptation of the word, is afforded to the pe- 
rineum by direct pressure. If such a method 
ever accomplishes any good, it is by retard- 
ing the advance of the head, in other words, 
by supporting the head through the inter- 
posed perineum, and not by supporting the 
perineum itself. Why not then support the 
head by pressure directly applied to it, in- 
stead of through a medium which requires 
perfect freedom from all restraint in order to 
undergo the requisite and inevitable amount 
of dilatation? Finally, a majority of the 
advocates of "support" contend that it is 
most needed at the very moment of expul- 
sion. But the woman, in the agony of the 
\flnal throes, is very likely to jerk herself 
away from the hand of the accoucheur. Of 
Course, then; the perineum, being abruptly 
SOME" KKAUllVALi HLi ra IUK inE 
released from the counter-pressure, is more 
liable to yield to a strain suddenly sustained 
for which its iibres are unprepared. Ob- 
stetric teachers recognize this danger, and in 
vivid language caution the student against it. 
Although I believe that in the vast 
majority of labors the perineum does best 
when let alone, yet cases do undoubtedly 
arise which demand an intelligent assistance, 
nor can the line of demarcation be always 
drawn between natural and morbid con- 
ditions. Whenever the head in an occipito- 
anterior position is too much flexed and the 
vertex bears on the perineal centre, threaten- 
ing perforation ; whenever, in an occipito- 
posterior position, the head is too little 
flexed, the forceps is urgently needed. For 
cases of extreme rigidity, or of an under-sized 
vulval opening, ether will be found a potent 
remedy. Apart from a direct and retarding 
pressure upon the presenting part itself, the 
only manual aid that I permit myself to 
render is as follows:-Insert one or two 
fingers of the hand into the rectum, the 
woman lying indifferently on her side or on 
her back, and hook up and pull forward the 
sphincter ani towards the pubes. The 
thumb of the same hand is then to be placed 
upon the foetal head, scrupulously avoiding 
all contact with the fourchette. For this 
method I claim the following advantages :- 
(a) By pulling up the sphincter ani toward 
the pubes not only is nature imitated, which 
always dilates the anal orifice, but the 
perineum is brought forward without direct 
pressure, and its dilatation is diffused over 
its entire surface, causing a corresponding 
relaxation of the strain on the posterior com- 
missure in the line of its raphG. In addi- 
tion, its muscular fibres are crowded up to, 
and consequently strengthen, the line of 
greatest tension ; just as a prudent general 
hurries up reinforcements to the point of 
attack. <6) The same force which dilates 
the sphincter ani compels the occiput to hug 
the pubes and favors extension, especially if 
the fingers in the rectum are hooked over 
the prominences of the foetal face or over the 
chin, (c) This aid is not liable to sudden 
interruption from the movements of the 
woman. (cZ) The thumb of this hand, to- 
gether, if necessary, with the fingers of the 
free hand, can, by direct pressure upon the 
presenting part, restrain its too rapid ad- 
vance, without exciti ng that reflex uterine ac- 
tion which is so frequently evoked by the i rri- 
tation of contact with the perineum, (e) The TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
29 
Circulation of the blood remains free; the 
nerves are not benumbed by a double pres- 
sure, and the perineum, therefore, continues 
in its natural condition, that of a living, 
elastic and sentient tissue. This method I 
have more fully described in an essay pub- 
lished in the American Journal of the Medi- 
cal Sciences, January, 1871, p. 75. To it I 
beg leave to refer those of my readers who 
are interested in the subject of the manage- 
ment of the perineum during labor. 
Misdirected traction on the after coming 
head, viz., too much in a downward direc- 
tion as the head is about to emerge, is very 
commonly followed by a very bad rent of 
the perineum. Even in head-presentations, 
requiring apparently but slight traction, the 
use of the forceps will often occasion a slight 
tear in the vagina, which the passage of the 
shoulders prolongs into the perineum. From 
too hurried a delivery, or from faulty trac- 
tion, I have seen so many bad lacerations 
following* the use of this instrument, even 
in practiced hands, that I cannot withhold 
the opinion that, in the majority of cases, 
nature can accomplish the final delivery of 
the head through the soft parts much better 
than the physician. In the essay previously 
adverted to, I use the following language, 
which the riper experience of three years 
more has not induced me to change:-" De- 
livery by the forceps, even in skillful hands, 
will often produce laceration ; for the head is 
liable to be brought down too quickly upon 
the unprepared soft parts, and it becomes a 
very nice point indeed to determine the 
exact moment when delivery may be ended 
with impunity. The cautious physician is 
liable to be caught, as it were, 'on the 
centre.' He sees the perineum stretched 
outtoa perilous thinness, and the fourchette 
almost cracking under the strain. In doubt 
whether the moment has arrived to raise 
the forceps-handles and turn out the head, 
or to depress them and thus restrain its ad- 
vance, he wavers, and in a twinkling the 
fibres part. On the other hand; the im- 
patient physician is tempted to turn out the 
head before the parts are sufficiently dilated. 
Finally, what is still more frequent, at the 
last moment the physician's courage fails 
him, and he depresses the forceps-handles 
just as the head has begun to emerge ; a 
course equally fatal to the integrity of the 
perineum." My advice is, therefore, that, 
other things being equal, as soon as the 
perineum is well dilated, the forceps should, 
as a rille, be removed, unless the blades an 
so firmly imbedded in the child's tissues 
that their withdrawal requires a force w-hict 
might hasten the delivery of the head. This, 
practice, if not so brilliant, will, I believe, in 
the long run be found much the safer. 
At the risk of becoming prosy on this sub- 
ject, I wish to add my conviction that, 
through sentiments of delicacy, many 
lacerations of the perineum escape the notice 
of the physician. After the delivery of the 
placenta, he should, therefore, make it a 
rule to introduce the index-finger into the 
rectum ami the thumb into the vagina. By 
bringing them together he can estimate the 
thickness of the intervening tissue, and thus 
determine whether any extensive laceration 
has taken place. If a rent be discovered he 
should decently inspect the parts. By day- 
light this examination can iw lly be made 
without the knowledge of the patient. 
When candle-light is needed, he will be 
compelled either to make some excuse or 
boldly explain his object. 
GENERAL HUNTS. 
One potent cause of invalidism in our 
women is that keeping up of appearances 
which infects every class of society. In 
other countries, where the wall of exclusive- 
ness is insurmountable, each class accepts 
the situation, and lives and moves in accord- 
ance with the requirements of its position in 
life. Here, every one feels, or tries to feel, 
" as good as " one's neighbor ; but this feel- 
ing of equality, in one sense a virtue, is such 
no longer when the poor ape the extrava- 
gances of the rich. The man asserts his 
equality by his ballot; the woman, by her 
needle. In the one this self assertion is 
a periodic explosion, and he feels the bet- 
ter for it. In the woman it is a life-long, 
heart-wearying struggle. Hence that end- 
less cutting, and basting, and turning; 
that perpetual needle-plying, which is the 
canker of so many of our households. Our 
very servants catch the folly, and spend 
all their wages and all their leisure in vying 
with the toilets of their mistresses. By this 
foolish rivalry the mothers and daughters 
of this land destroy the little health that a 
false system of education has left to them. 
What physician is there who has not seen 
ambitious mothers break down under the 
burden ; or who does not expect some of hi 
patients to be at least laid up by their sprirg'' 
and autumn dressmaking? One word here 30 
iUAlt rKxilllCAL nil's 13 1 UK lilK 
about the sewing-machine. While I do not 
oelieve all that is laid to its charge, yet its 
treadle motion does undoubtedly lead to 
pelvic and portal congestions. In spite of 
myself I have become convinced that no 
woman who,operates on this machine as a 
trade can long escape from some uterine 
derangement. Even its family use is not 
unattended with risk, because, although in- 
termittent, it is liable to be too prolonged. 
Were not the subject already too hack- 
neyed, I might enlarge, as other causes of 
ill-health, upon late hours and social dis- 
sipations, upon that false and restless 
philanthropy which neglects home, and 
upon that unhappy discontent which forgets 
that to be loved one must be loveable. 
Woman shines best and thrives best, not in 
the adulation of society, not in obtrusive 
self-assertion, but in the quiet and faithful 
performance of her home duties. The heat 
and stir of life is food for man's more rugged 
nature. The wholesomest passages of her 
life are those which, like the thesis of a 
symphony, are unpercussed and unaccented. 
The banishment of the corset from the 
waists of those who have attained to years 
ot discretion would be a great boon to the 
sex; but the profession is powerless against 
the Moloch of fashion. Their disinterested 
warnings in that direction are like those of 
Cassandra, truthful, but unheeded. The 
family physician can, however, do the nex 
best thing, and that with some show of suc- 
cess. He can solemnly adjure the tightly 
harnessed mothers of the land not to allow 
their growing and romping daughters to 
put on the maternal armor. He can 
earnestly plead for the support of their 
underclothing by the use of shoulder straps 
or of " skirt-supporters." This advice is not 
untimely, for I am assured, on the good 
authority of a fashionable corset-maker, that 
even the school-girl of the period has an 
ideal waist. A waist to which she squeezes, 
and laces, and toitures herself down, for the 
simple reason that it is always more slender 
than her own. 
Too much brain-work, too little house- 
work, is another trying evil of our land. 
Precocious cleverness is at tai nable on ly at the 
cost of physical and sexual development. 
Manifold diseases, many of them of a uterine 
complexion, date from the recitation room. 
Under the high pressure system of our pub- 
ic schools, even a class which ought to live 
y manual labor is made unfit for it. Hence 
an inability to work attaches degradation to 
domestic labor, and town and city teem, 
therefore, with pale-faced and flat-chested 
women, who seem to have no other hold on 
life than a capacity for momentary en- 
thusiasm; no other aim in life than the 
absolute Nothing, the Nirvana of the Budd- 
hist. Our great-grandmothers got their 
schooling during the winter months, and let 
their brains lie fallow for the rest of the year. 
They knew less about Euclid and the 
classics, than they did about housekeeping 
and housework. But they made good wives 
and mothers, and bore and nursed sturdy 
sons and buxom daughters, and plenty of 
them at that. From the age of eight to that 
of sixteen our daughters spend most of their 
time either in the unwholesome air of the 
recitation-room, or in poring over their 
books when they should be at play. As a 
result the chief skill of the milliner seems to 
be directed towards concealing the lack of 
organs necessary alike to and to 
maternity, and the girl of to-day becomes 
the barren wife or the invalid mother of to- 
morrow. Surely a civilization that stunts, 
deforms, and enfeebles, must be unsound ! 
To reform these abuses, to reclaim woman 
to womanhood, to make wives helpmates 
in the true sense of the word, is then one 
great mission of the physician, a mission 
which he must cheerfully and dutifully ac- 
cept. 
Marcus Aurelius, St. Augustine and other 
great and noble men wrote with tender 
affection of what they owed to a mother's 
love, to a mother's care. If that imponder- 
able essence, the mind, can be moulded and 
shaped by a mother's heed, why not the 
body? Why should not the culture of the 
one be as much an object of maternal 
solicitude as the culture of the other? To 
preserve, then, the priceless gem of health, 
let the physician teach mothers how to pre- 
side over the physical education of their 
daughters, how to pilot their frail bodies 
safely through the shoals and quicksands of 
girlhood ; for at this time of life an ounce of 
mother is worth a pound of doctor. To this 
end, girls should be early made to throw 
back their shoulders, to maintain an erect 
carriage, and to walk with toes pointed out- 
ward. This attitude puts into action muscles 
which increase the obliquity of the pelvis to 
the trunk, and consequently lessens the 
downward pressure of the abdominal viscera 
upon the pelvic oigans. Their clothing TKBAi'MElN'r AND PRa_ ; OF UTERINE DISORDERS. 
31 
should be thick and warm; their shoes 
stout and roomy; their brains not over- 
taxed. Candies, doughnuts, and hot bis- 
cuits must be struck out from their fare; 
such trash has made our dentists world- 
renowned. Habits of regularity in sleep, as 
well as in the evacuations, should be scrupu- 
lously enforced. Over-work in a constrained 
position, especially that at the sewing- 
machine, must be forbidden. Let them daily 
take sunshine and exercise in the open 
air. But, on the other hand, let them, 
during their monthly sickness, avoid pic- 
nics, sleigh rides, dancing parties and other 
like imprudences. The risks from suppres- 
sion should be vividly pointed out, else they 
could haidly be persuaded to forego plea- 
sures which, at such times, are fruitful 
sources of mischief. Mothers should, there- 
fore, diligently supervise the catamenial 
week of their daughters, and at that time 
forbid all over-work of brain and body. 
Would that all women could betaught to 
look upon the law of periodicity in their 
nature not as an affront to womanhood, not 
as the mark of a curse, but as a dower of 
health and beauty if respected, as the 
leaven of life-long invalidism when abused I 
Let mothers select the books which their 
daughters read. None of the namby-pamby 
trash of our circulating libraries, none oi 
the prurient literature of the day, should 
cross the threshold of a well-ordered home. 
It heats the blood ; it inflames the passions; 
it goads on to precocious pubescence; it 
throws a halo of false and sickly sentiment 
around the day-dreams of youth. Let 
mothers themselves be implored neither to 
buy nor to borrow those vile pamphlets 
which flood the length and breadth of this 
land; a literature which, while professing 
in good faith to treat of the conjugal rela- 
tions, covertly panders to our worst instincts, 
and defiles with the slime of an impure 
fancy. While on the subject of books, let 
me here urge upon my readers the perusal, 
and the circulation among their patients, of 
two most excellent works ; the one, " Wear 
and Tear," by Dr. S. Weir Mitchell; the 
other, "Sex in Education," by Dr. E. H. 
Clarke. A timely essay by Dr. Nathan 
Allen on "Physical Degeneration" {Psycho- 
logical Journal, October, 1870), can also be 
read with much profit. To these authors I 
am indebted for some of the thoughts em- 
bodied in this paper. 
Certain causes of uterine diseases there 
are, which I would gladly leave unnoticed 
for it is hard, in acceptable language, even to 
allude to them. But so wide-spread are the 
evils resulting from them, that to pass them 
by would be a flagrant sin of omission. 
"Two things come not back," said the 
Caliph Omar, "the sped arrow and the 
spoken word." Deeply impressed by the 
wisdom of this saying, I shall try so to 
write on these delicate subjects, as never to 
regret what I have written. 
Arguing from a strictly practical and not 
from a sentimental point of view, but with 
all reverence, thelove interchanged between 
man and woman is no mere operation of the 
mind, no sheer intellectual process. How- 
ever pure this passion may be, it is necessa- 
rily twofold in its nature. It is an alloy, 
made up, like ourselves, of body and mind ; 
t he grosser mould so interfluxed with the more 
ethereal, that the one findsits most passion- 
ate expression in the fruition of the other. 
Abstract love between the sexes cannot, 
therefore, exist in any other sense than that 
engendered by blood ties. Forgetful of this 
absolute law of our being, sentimentalists 
have judged too harshly of Abelard, and 
lavished too one-sided a sympathy upon 
Heloise. Without further comment, the 
antenuptial relations, at least such as cus- 
tom commonly sanctions in this land-and, 
I believe, in no other-are therefore, when 
prol >nged, very disturbing elements to a 
young girl's health. Long engagements, by 
keeping up a wearing nervous erethism, are 
not only recognized, but even classified, by 
alienists, as one of the causes of insanity in 
women. Much more frequently the nervous 
exaltation is spent upon the reproductive 
organs; for there follows an awakening of 
sense which is not, as in man, appeased by 
the distractions of business pursuits. Ute- 
rine trouble from this source any open-eyed 
physician will over and over again see. 
Now, it is true that in love affairs the phy- 
sician must be no meddler; match-making 
is certainly not his business. But, as a 
tried and valued friend, as a brother be- 
loved, he can speak out when others may 
not even hint. Or, when consulted by the 
anxious mother about symptoms in her 
daughter plainly referable to the reproduc- 
tive organs, he can disclose the cause, and 
thus be the means of hastening on the cure. 
If the caresses of lovers are prejudicial tc 
good health, every like lelation between th 
sexes must be exposed to like dangers. I> 32 
oo many rural districts, and in the lower 
passes of citizens, such license is tolerated 
n the social intercourse between the youth 
U each sex as must be destructive both to 
good health and to good morals. But, since 
it is not to my present purpose to appear as 
a social reformer, I shall confine my re- 
marks to the hygienic aspect of the subject. 
The "old folks" are shelved too soon. 
Young people are left too much to them- 
selves, and thrown too much together. 
Their social gatherings are too rarely pre- 
sided over by their mothers or their seniors. 
As a very natural consequence, their games 
become coarse, their forfeits immodest, and 
little by little this freedom from restraint is 
liable, finally, to degenerate into such gross 
familiarities as would be improper between 
even affianced lovers. An unnatural sex- 
ual excitement is thus kept up, which must 
do physical harm. Of the moral harm I 
i say nothing; the fathers who read these 
; lines must draw their own conclusions. In 
i this matter I am plainly at a loss to see how 
i a physician can interfere in any other way 
than by setting a good example in the order 
and decorum of his own household. A 
nimbler wit than mine may work out some 
better way; if so, his be the credit; I do 
but throw out hints. 
The excesses of the honey-moon journey, 
conjoined with its fatigues and its discom- 
forts, are too often the starting-point of ute- 
rine disease. Here, again, will the family 
physician delicately proffer his counsel. In 
chosen words he can hint at moderation in 
all things, and suggest the avoidance of the 
usual exhausting round of travel and of 
sight-seeing. Such wordswill then, indeed, 
be words spoken in season. He must, still fur- 
ther, take cognizance of the sexual relations 
between husband and wife, relations which, 
when abused, are productive of much mis- 
chief. All excess in that direction he will 
discountenance. Unmastered importunity 
and too submissive an affection must be 
met by separate beds, by uncommunicating 
rooms, and if need be, by strong expostula- 
tion. Criminal abortion he must denounce, 
and that boldly, if he values the health and 
happiness of his fellow-creatures, and a 
clear conscience before God and man. The 
evils of incomplete coitions and of other de- 
testable arts practiced to frustrate concep- 
tion, he will paint in no neutral colors. 
Apace forbids more than a brief allusion fo 
Uhese secret sins, which, like the plague of 
SOME PRACTICAL mivrs iok tite 
the frogs, creep into our " houses, and bed- 
chambers, and beds." Suffice it to say that 
outraged Nature is resentful, and makes 
fierce reprisals whenever woman receives 
"the seed of another life" in any other 
way than that by which it tends to become 
fruitful. As West has pointed out {Diseases 
of Women, Leet, VI.), and as I have tried to 
show {Philadelphia Medical Times, Febru- 
ary 1st, 1872, p. 16), no woman who deliber- 
ately thwarts the plain intention of the in- 
stitution of marriage can long escape from 
the very worst forms of uterine disease. 
There is, moreover, a disastrous connection 
here between these sinful practices and im- 
morality. Dishonor the body, the temple of 
the soul, and you dishonor the soul. The 
artifices and accoutrements borrowed from 
the brothel inevitably do damage, not only 
to good health but to good morals. Blunted 
pleasures lead to estrangement, to unfaith- 
fulness, to divorce; the wife lapses, so to 
speak, into a mistress; and the marriage 
tie is degraded into a carnal contract 
which regards alone the necessities of the 
flesh. Much sad experience, alas! has 
proved irrefragably two axioms: that preg- 
nancy is a necessary condition to healthful 
and happy marriages; and that there is no 
innocuous expedient whereby maternity 
can be shunned ; no safe stratagem by 
which man can balk God's first blessing and 
first command tv man. 
The sympathy between the mammary 
glands and the uterus is so close as to have, 
in the treatment of post-partum hemor- 
rhages, a positive therapeutic value. By 
condensing the womb and diverting the 
blood from it, lactation up to a certain point 
acts beneficially. But by exhausting the 
woman's strength and producing morbid 
impressions upon the womb, over-lactation 
becomes in itself a cause of uterine disease. 
It also very seriously compromises the health 
of the sucking child. Whenever, therefore, 
a nursing woman finds that the act of suck- 
ling is followed by a pain in the back, or by 
other symptoms of uterine irritation ; when- 
ever she suffers from dizziness, dimness of 
vision, sore mouth, shortness of breath, pal- 
pitations of the heart or night-sweats, she 
should be urged by her physician to wean 
her child. I use tlie word urged designedly, 
because lactation is often prolonged beyond 
all reason, simply as an antidote against con- 
ception. 
Nothing so certainly undermines the ute- TREATMENT AND PREVENTION OF UTERINE DISORDERS. 
33 
rine health as the wear and tear of nursing 
the sick. The unwholesome air of a sick 
chamber, the close confinement, the selfish 
exactions of the patient, the broken rest, all 
tend to enfeeble the system. Then the un- 
due exertions made at arm's length, such as 
in lifting or in turning a helpless invalid, so 
violently strain the diaphragm and the ab- 
dominal muscles as to force down and per- 
manently displace the womb. Forewarned 
by the physician, the nurse, be she kin or 
stranger, will daily take a stroll in the open 
air, and in some way make up for loss of 
sleep. 
The proverbial constipation of the poorer 
class of women in our cities, and of those 
women who live in the country, is another 
cause, and an exceedingly common one, of 
uterine disease. Such defective sewerage of 
the tfody, by the resorbtion of foul gases and 
of effete matter, degrades the blood, starves 
nerve-centres, breeds dyspeptic ailments, 
and begets pelvic and portal congestions. 
In this chain of sequences there is no miss- 
ing link. Uterine congestions are also pro- 
duced mechanically by the irritation or the 
pressure from hardened faeces ; uterine flex- 
ions and displacements brought about by 
the straining efforts to empty the bowels. 
Over-d4stention of the bladder, by drawing 
up the cervix and thrusting the fundus 
over backward, is, undoubtedly, a very im- 
portant factor in the production of retroflex- 
ions and retroversions of the womb. Yet 
what poor woman is there who is not thus 
daily exposing her womb to these displace- 
ments ? 
These irregularities of habit in our sallow- 
hued women are in a great measure owing 
to the discomfort, inconvenience and inde- 
cent exposure of their closet accommoda- 
tions. Where is the privy that invites, 
rather than repels an operation of tire bow- 
els? When is it ever sheltered from the 
rude blasts of winter; or not poisoned by 
noisome stenches, acrid vapors, and unclean 
flies? Where is the privy that is not over- 
looked by the back buildings of all the 
neighboring houses, or not placed at such 
an embarrassing distance from the house as 
to be, in bad weather or in dark nights, ab- 
solutely inaccessible? Where, in the coun- 
try, and for that matter, in cities also, is not 
to be found the privy made up of rough 
boards rudely spiked together, with cracks 
wide enough to destroy all privacy, with a 
door without a bolt, and generally hanging 
by one hinge, with a crescent-shaped hoi 
for a window, and with its sole article c 
furniture a barrel of rasping corn-cobs 
After such an unsightly but truthful pic 
ture, can we wonder that the calls of nature 
are looked upon as grievous dispensations ot 
Providence, as hateful duties which are to 
be put off as long as possible, and obeyed as 
seldom as possible? To a delicate woman 
the exposure to the weather is a serious 
risk ; to one who is menstruating it is a con- 
stant menace ; while to the refined woman 
the exposure to view compels the postpone- 
ment of her physical duties to night-fall, or 
until driven to them by a sheer necessity 
which knows no law. 
Now, what is the remedy? Clearly such 
closets as civilized Christian beings, living 
in the nineteenth century, are not degraded 
by using; closets that are decent, comfort- 
able and accessible. To educate the com- 
munity up to the reception of this whole- 
some truth is the duty of the physician. He 
must tilt his lance against everything in the 
shape of a privy, and set a good example 
himself, by using, when water closets are 
not available, an earth closet in his own 
family. Such a closet, not larger than an 
old-fashioned arm-chair, can be moved 
about from room to room, or be put where it 
will be both private and accessible. Nor will 
its presence poison the surrounding air, for 
there is no better deodorizer of oiganic refuse 
than the dry earth contained in its hopper. 
As a fit ending to this series of papers, jus- 
tice to myself prompts me to remind the 
reader that, as the title indicates, I have 
thrown out mere hints, which he must de- 
velope; bare outlines, which he must fill 
up The fullness of a great and important! 
subject cannot be compressed within even' 
the generous space allotted to me in this 
Journal. The most that I have attempted 
has been to " vulgarize " what has hitherto 
been monopolized by specialists. Nor have 
these papers pointed out all the sources of 
mischief to the female reproductive organs. 
Other unsuspected correlations undoubt- 
edly exist, for life is complex, and woman | 
" fearfully and wonderfully made." These 
every physician will search out for himself, 
and when discovered, wage an unending 
war against. To heal sickness is noble, to 
prevent sickness is nobler, for thereby is su' 
fering most lessened, and thereby does o' / 
profession best show its disinterestedness.