**3u*~. ■Yf)V. UIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY O* "t9J' 1.»^7^f" ? > • ,-& -9 NLI1 0Q10E2TL, 7 >-• iisr-mrjw 3X7 Asvaarr TVNOIIVN 5 -"'^P^f'" IN/ ^ I 3NIOI0.3W dO AHVaan IVNOIIVN 3NIDI03W dO AHVaaM IVNOIIVN : / 2 DICINE NATIONAL LIBRARY OF MEDICINE 3NiDia3w do Aavaan ivnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3 "-^as/ *- v/m? i JDICINE national library of MEDICINE NATIONAL LIBRARY OF MEDICINE NLM001022967 s / v~?- l^- t I W i xW! aan ivnoiivn 3nioi<33w do Aavaan ivnoiivn 3nidiq3w do Aavaan ivnoiivn I /% I 3ia3w do Aavaan ivNor 3 \ OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDIC aan ivnoiivn snidiosw do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn dNiDiadw do Aavaan ivnoi. OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE \3 '% NATIONAL LIBRARY OF MEDICI s ^4 \ I aan ivnoiivn snidiqsw do Aavaan ivnoiivn snioiqsw do Aavaan ivnoiivn X 4/1 OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE ^^ aan ivnoiivn snioiosw do Aavaan ivnoiivn 3nidiq3w do Aavaan ivnoiivn dNiDiasw do Aavaan tvnoii ' o NATIONAL LIBRARY OF MEDIC 3K/ M'x l ''Mi SNiDiasw do Aavaan "ivnoii OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE —a ■i 5 v>,_-^e- 6s. DIQ3W dc .an TVNOIIVN 3NiDia3w do Aavaan ivnoii X i w> I m OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE < ,—ox _.- ,/r»—. \^5 i $%/\ NATIONAL LIBRARY OF MEDICI CYCLOPAEDIA PRACTICE OF MEDICINE. Edited by Dr. H. von ZIEMSSEN, PROFESSOR OF CLINICAL MEDICINE IN MUNICH, BAVARIA. VOL. X. DISEASES OF THE FEMALE SEXUAL ORGANS. Bt PROF. CARL SCHROEDER, of Erlangen, Bavaria. ©ranslattfc ij EDWARD W. SOITAUFFLEU, M.D., of Kansas City, Mo.; LEONARD WHEELER, M.D., of Worcester, Mass.; WILLIAM L. RICHARDSON, M.I)., of Boston, Mass.; and EDWARD B. BRONSON, M.D., J. HAVKN E.MEI1SON, M.D., and PAUL F. MUNDE, M.D., of New York. ALBERT H. BUCK, M.D., New York, EDITOR OF AMERICAN EDITION. ^f- c- '■■ < v> O <*• ue:;.\ T>1" CD >&frr?4+ NEW YORK: WILLIAM WOOD AND COMPANY. 27 GREAT JONES STREET. 1S75. 1 WB V, 10 Entered according to Act of Congress, in the year 1875, by WILLIAM WOOD & CO., In the Office of the Librarian of Congress at Washington. ALL RIGHTS RESERVED. John V. Trow & Son, $ PRINTERS AND BOOKBINDERS, B05 to 213 East Twelfth Street, NEW YORK. ERRATA. VOL. I. Page 14, thirteenth line from the bottom, " vaccination" should read " inoculation." VOL. II. Page 7, ninth line from the bottom, " element " should read " elements." Page 172. second line from the bottom, " more" should read "less." Page 194, last line, "months" should read " weeks." Page 353. last line of foot-note, " 9 " should read " 328." Page 453, third line from the top, " spinal" should read " spina." VOL. III. Page 290, second text-line from the bottom, " ounces" should read " drachms." Page 558, fourteenth line from the top, and also seventh text-line from the bottom, the dash between "liver " and " echinococcus " should be a hyphen. A biographical sketch of the author will be given in Volume V.—Editor's Note. 3 n ■") CONTENTS. Gynecological Examination. page History................................................................. 3 The position of the patient................................................ 5 Manual examination..................................................... 7 External examination................................................ 7 Internal examination................................................. 9 Conjoined method of examination..................................... 10 Examination with the uterine sound....................................... 15 Dilatation of the cervix for diagnostic purposes.............................. 21 Examination by inspection................................................ 20 Disk asks of tiie Uterus. Malformations........................................................... 32 Entire absence and rudimentary development of the uterus.—Uterus bipar- tite ........................................................... 33 Uterus unicornis, with or without a rudimentary horn of the opposite side 36 Uterus duplex, uterus bicornis...................................... 38 Uterus septus....................................................... 39 Uterus foetalis, uterus infantilis....................................... 40 Congenital atrophy of the uterus...................................... 42 Atresia of the uterus, the vagina, or the vulva.—Hematometra.—Uydrometra 43 Unilateral hainatometra, with duplication of the genital canal................. 58 Stenosis of the uterus..................................................... 65 Hypertrophy of the uterus................................................. 72 General hypertrophy................................................. 72 Hypertrophy of the cervix................................................. 75 Hypertrophy of the infruvaginal portion.................................... 76 Hypertrophy of the supravaginal portion.................................... 80 J/yj'i rtrophy of the median portion......................................... 87 Atrophy of the utenis................................................... 93 Inflammation of the parenchyma of the uterus.—Metritis..................... 9G Acute metritis....................................................... 96 Chrouic metritis.—Infarction of the uterus............................. 101 (Translated by Paul F. Munde, M.D.) Inflammation of the m neons membrane, endometritis......................... 126 Acute endometritis................................................... 126 VI CONTENTS. PAOE 129 Chronic endometritis.—Catarrh of the uterus........................... Catarrh of the whole mucous membrane............................... Endometritis cervicis, catarrh of the cervix.—Ectrojnon of the os uteri. -Enlarged follicles. — Ovula Nabothi...................................... Mucous polypi................................................. Follicular hypertrophy of the lips of the os uteri............................. _' Erosions and ulcers of the vaginal portion of the uterus ...................... 1,J,J • 153 The simple erosion................................................... 154 The papillary erosion................................................ Follicular ulcer...................................................... ,KJ Phagedenic, or corroding ulcer of the uterus........................... I56 Chancre of the vaginal portion....................................... 15(i Flexions and versions..................................................... 10' Lateral deviations of the uterus............................................ 1°5 Excessive mobility of the uterus.......................................... 186 (Translated by Leonard Wheeler, M.D.) Descent and prolapse of the uterus......................................... !"" Elevation of the uterus................................................... *14 Inversion of the uterus................................................... *15 000 Hernia of the uterus...................................................... ^~i Pruritus................................................................ 557 Coccygodynia........................................................... 559 (Translated by Edward B. Bronson, M.D.) DISEASES FEMALE SEXUAL ORGANS. SCHROEDER. GYNECOLOGICAL EXAMINATION. HISTORY. Gynecological examination, as practised at the present day, is essentially a product of this century. If we were obliged to dispense with the speculum, sound, and conjoined or bimanual examination, and confine ourselves solely to the digital explora- tion of the vagina and cervix, we should find ourselves almost powerless against the diseases of the uterus and its appendages. The methods of examination of the ancients were exceedingly defective. Soranus, however, one of their best representatives, was acquainted with the method of digital exploration, the examination with the sound (at least its introduction into the vagina, where it "ad imum usque penetrat") and the vaginal speculum (dLOTrrpto-fio*;), which affords the best means of ascertain- ing whether a hemorrhage comes from the uterus or vagina. In the third chapter of his book, he also clearly and precisely distin- guishes the uterus from the vagina, beside describing the posi- tion, shape, and various parts of the womb. Regarding the dis- eases of this organ, he makes the important observation, " Morbo laborans in consensum rapit ventriculum et meninges," and speaks of the "pudendum muliebre seu sinus muliebris, velut intestinum, in quo etiam coitus fieri solet." He also mentions the differential diagnosis of abdominal tumors, and distinguishes pregnancy from ascites, and from solid tumors, which he classes under the name of f^vki] (mola). These latter, he says, are dis- tinguished from ascites by the fact that the hand cannot press into or displace them, and because there is no tympanitic reson- ance, and no fluctuation when percussed with the hand. However remarkable these statements may appear, consider- ing the early period at which they were made, the views they express probably never became general, and, at any rate, were 4 SCHROEDER. —DISEASES OF FEMALE SEXUAL ORGANS. entirely lost sight of until the middle ages, when, at the end of the seventeenth century, eminent French physicians began to practise midwifery as a specialty, and again developed the art of gynecological examination. It is surprising that the method of conjoined manipulation, which was already known to Puzos (f 1753), Levret, Baudelocque, Jorg, W. J. Schmitt, and others, should not have been properly appreciated until it was resusci- tated within the past few years, principally through the efforts of Kiwisch, Veit, Hoist, Schultze, and others; it is equally surprising that even at the present day many gynecologists do not seem to be perfectly familiar with this mode of examination, although it has done far more to improve the art of diagnosis of female diseases than the invention of the uterine sound. The vaginal speculum also has come into general use only since the beginning of this century. The ancients, it is true, were acquainted with the instrument; Soranus and Paul of iEgina mention it, and in the excavations at Pompeii a specu- lum was found, the three branches of which are expanded by a screw. In later authors also, Abulcasem and Rueff for example, we find representations of specula, which, however, were only used for the purpose of dilating the vagina in order to permit the application of craniotomy instruments to the head of the fcetus. But Ambroise Pare describes specula with three branches, which he states expressly are adapted to the purpose of bringing malignant tumors of the cervix better into view; illustrations of similar two- and three-bladed specula are like- wise given by Scultetus in his Armamentarium Chirurgicum. Nevertheless, it is only since the invention by Recamier of the cylindrical speculum with a handle, that the vaginal speculum has come into general use as an aid in making the diagnosis. Its shape has in recent times undergone so many modifications that in multiplicity of form it might almost vie with the obstetrical forceps. The uterine sound was first used by Levret, who in 1771 employed it in the case of polypi, and for the purpose of measur- ing the length of the uterine cavity in hypertrophy of the cervix. Chambon, Vigarous, Desormaux, Dance, and particularly Lair, also made use of the uterine sound as an aid to the diagnosis. GYNECOLOGICAL EXAMINATION. 5 Its utility was still further developed, and the instrument brought into general use by Simpson in England, by Huguier in France, and by Kiwisch in Germany, almost at the same time ; each observer apparently acting independently of the others. The sound was warmly received on almost every side, and, indeed, before the general introduction of bimanual palpa- tion, was the only means at our command by which we were able to ascertain the position and size of the body of the uterus. Latterly, however, the sound has been, in a measure, supplanted by the more perfectly developed bimanual palpation; but still in many cases it is a very useful, and in some an indispensable auxiliary. THE POSITION OF TIIE PATIENT. The position of the patient during examination is of the greatest importance, if we wish to obtain full and satisfactory results. It is only exceptionally that a woman is examined in the erect posture, as, for instance, when we desire quickly to inform ourselves by the touch of the condition of the external genital organs—the vagina and the cervix—or when we wish to see how a strong abdominal pressure affects the genital organs. Other advantages than these are not gained by the examination in the erect posture. The supposed advantage of bringing the internal genital organs nearer to the vaginal orifice is more imaginary than real; for in the erect posture the womb is tilted forwards, in consequence of which the cervix is deflected back- wards, and rendered more difficult to reach with the finger than in other positions of the body (as, for instance, when the patient lies upon the back and the bimanual method of palpation is employed). The examination in the erect posture should be rejected for several reasons : first, it affords only very superficial infor- mation by the touch regarding those parts mentioned above ; secondly, the external and conjoined methods of examination cannot be employed in this posture; and finally, the impor- tant aid afforded by the sense of sight must here be dispensed with. 6 SCIIKOEDER.—DISEASES OF FEMALE SEXUAL OUGANS. In England examinations are generally made in the lateral position. The patient lies on her left side, on a table covered by a mattress; her left arm is extended over on the back, the left thigh is slightly flexed, the right one more so. The phy- sician stands behind the patient and examines with his right hand, the thumb resting on the perineum. The lateral position, for the purpose of digital examination, should be abandoned ; partly because the sensitive palmar sur- face of the index finger is turned towards the posterior wall of the vagina, and the curvature of the finger and that of the vagina, therefore, do not correspond; but principally because conjoined manipulation is either impossible in this position or is very inconvenient. In using the original Sims's speculum the lateral position becomes necessary; but we shall refer to this point later. The dorsal position is the only one in which conjoined manipulation is admissible, and therefore, considering the im- portance of this method of examination, it must be regarded as the ordinary position for gynecological examinations,—all the more so because it is equally well adapted to the other methods of exploration (particularly the introduction of the speculum). Of course in the dorsal position the patient requires to be properly arranged. The ordinary position in bed usually suffices for digital ex- ploration, if the head of the patient is laid horizontally and her lower extremities are abducted. If the bed be a mattress, and not a feather bed, the internal and external examinations, as well as the two combined, can be performed with convenience and facility. An examination with the speculum, however, is ex- ceedingly inconvenient under these circumstances; partly on account of the low position of the patient, and partly because of the difficulty of obtaining a good light. Hence, if a thorough investigation is deemed necessary, and we desire to avail ourselves of all the diagnostic means at our disposal, a special couch must be prepared. A mattress is placed upon a table of moderate height, upon which the patient is made to lie down. The feet may be placed upon two chairs or upon the border of the mattress, but the abdominal parietes, GYNECOLOGICAL EXAMINATION. 7 are most thoroughly relaxed if the feet are held by assistants in the lithotomy position. Inasmuch as the preparation of such a couch for every exami- nation is very troublesome, the gynecologist should provide him- self with a table or chair especially devised for the purpose. We consider all the contrivances which have been invented to simulate the ordinary sofa, and which, when occupied by the unsuspecting patient, are suddenly, by the turning of a crank, converted into complicated office chairs, to be unnecessary and wrong in principle. We require of a good examining chair merely that it should be practical and convenient. In order that it may be of a light and not too imposing form, it should be made of iron and not of wood, and be provided with a proper movable support for the patient's feet. Its height should be such as to place the vulva of the patient on a level with the elbow of the examiner. A wooden step should be provided as a rest for the physician's foot, so that the forearm used in the examination may find a convenient support upon the knee. Chairs of this kind, which answer this purpose more or less completely, are described by Baumgartner,' Mauke,4 and Bres- gen.* We have used satisfactorily one devised by Veit, and con- structed by the instrument-maker Eschbaum, in Bonn. This chair is in every respect adapted to gynecological examinations, excepting that it is not convenient for abdominal auscultation, nor for the examination in the lateral position. MANUAL EXAMINATION. External Examination. External examination is practised alone only in large abdo- minal tumors, for the purpose of ascertaining their shape, bound- aries, and consistence. The examination consists essentially in a careful palpation of the surface of the abdomen. A fami- 1 Wien. med. Woch., 1863, Nos. 37 and 38. ! M. f. Geb., vol. 26, p. 208. 8 Berl. Klin. Woch., 1873, No. 37. 8 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. liarity with the manipulation is best acquired by frequently practising it upon women near the end of pregnancy. Palpation is best performed by placing both hands upon the abdomen, the fingers being extended and touching each other, and then by means of short, quick impulses, testing the resist- ance offered to the hand at different spots. The better defined and harder the tumor is, the more perceptible are its boundaries to the touch. Palpation is much facilitated if the abdominal walls are thin and lax, and especially after complete evacua- tion of the bowels and bladder. Intestines filled with fseces or gas offer the most frequent obstacle to palpation. The physi- cal condition of the abdominal parietes is also very important; even large, hard tumors can frequently be only very imperfectly defined on account of the very thick abdominal walls containing a deep layer of adipose tissue. Some women, again, with the best intentions, are quite unable to relax their abdominal mus- cles. These difficulties must be overcome by pressing in the hand more deeply during each expiration, by attracting the attention of the patient with inquiries concerning her history, and, as a last resort, by anaesthesia. Anaesthesia should certainly always be employed when an important therapeutic measure depends on the evidence acquired by palpation, and the latter has yielded no absolutely positive results. There are a number of conditions which may be mistaken for abdominal tumors, such as a large accumulation of adipose tissue in the abdominal walls, partial contractions of the abdominal muscles, fatty omentum, tympanites, and faecal concretions in the intestine, all of which give the sensation of a diffused resistance, in some cases even of an indistinct tumor, and may there- fore give rise to an erroneous diagnosis. I can call to mind two patients who were sent to me for ovariotomy, whose ovaries were not only not diseased, but who did not even have a circumscribed abdominal tumor. Among the records of cases of so-called "spurious pregnancy" such instances are by no means rare. Percussion is a very important diagnostic auxiliary in many abdominal tumors. The limits of solid and encysted fluid tumors may, it is true, be more accurately and clearly defined by means of palpation ; but where there is free fluid in the abdo- minal cavity, or in the case of very flaccid cysts, palpation is unsatisfactory, and we have to depend upon percussion. In some other cases also, in which palpation is attended with GYNECOLOGICAL EXAMINATION. 9 difficulties, percussion is preferable; but generally palpation is so much more certain and reliable, that when there is nothing to interfere with its employment, percussion may be dispensed with. Auscultation is likewise required only in large abdominal tumors; but in these cases it acquires a very great importance through its enabling us to diagnosticate pregnancy. The so- called uterine souffle, which originates in the larger arteries, is heard, not so very seldom, in large fibroids, and also, though very rarely, in ovarian tumors. In tern a I Examination. The internal examination per vaginam is performed by intro- ducing the index finger of one hand into the vagina. This is done by passing the well-oiled forefinger from the fourchette into and through the ostium vaginae ; the other fingers being extended upon the perineum. In case it is desired to touch the anterior wall of the vagina, and the anterior vaginal vault, it is advisable to flex the other fingers into the palm of the hand. The several organs, with which the exploring finger comes in contact in its progress inward, should be noted in the following order : fourchette, introitus vaginae, vaginal walls, together with any enlargement of the neighboring organs (bladder or rectum), which would cause protrusion of the vaginal walls, anterior and posterior vaginal cul-de-sac, cervix, and lower segment of the uterus, as well as the pelvic cellular tissue surrounding these organs. As accurate and comprehensive an idea of the condition of the above-mentioned organs may be obtained by the examina- tion per vaginam, as it is possible to obtain by the sense of touch in any part of the body. Very valuable information is thus often acquired; still the upper half of the uterus, the tubes and ovaries, together with their peritoneal envelope, and a large portion of the pelvic con- nective tissue—that is, just those parts of the genital apparatus which are pathologically the most important—remain unex- plored. 10 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The examination is, as a rule, easy and simple to perform, and it is but seldom necessary to introduce two fingers. Very rarely are any decided impediments encountered, although occa- sionally the examination may be exceedingly difficult. Large tumors which interfere mechanically with the vaginal exploration, as well as extreme constriction or atresia of the vaginal entrance, are rare. The most com- mon obstacle, although rarely an insuperable one, is an intact hymen. The opening in the hymen is generally sufficiently large to admit the finger, if introduced gradu- ally and with care; but the introduction is usually so painful as to make it advisable, unless the orifice of the hymen is unusually large, to examine virgins under anaes- thesia ; the same may become necessary also in women whose vaginal aperture is pathologically sensitive. TJie internal examination per rectum is employed either when the vagina is impassable, or as a valuable aid and supple- ment to the vaginal examination. It should be particularly borne in mind, that in all kinds of retro-uterine tumors, the exploration by the rectum is unequalled in value by any other method. Tumors of tolerably large size are frequently dis- covered only by means of this method of manipulation, and one is often surprised, upon a rectal examination, at the great size of a tumor which appeared insignificant when examined through the vagina. It is, therefore, my invariable rule to examine retro- uterine tumors, not only per vaginam, but also per rectum. In some cases, also, in which the vagina is short and unyielding, as in women who have not borne children, exploration through the capacious rectum is preferable to the vaginal examination. Conjoined Method of Examination. VM, Krankh. d. weibl. Geschlechtsorg., 2 Aufl. Erlangen, 1867, p. 2te.—Hoist, Beitr. z. Geb. u. Gyn., H. 1. Tubingen, 1865, p. l.—Schultze, Jenaische Z. f. Med. u. Nat. Leipzig, 1864, I., p. 279, und 1870, V., p. 113.—Sims, Clinical Notes on Uterine Surgery. New York, 1871, p. 8. The peculiarity of conjoined manipulation is, that the organs to be examined are pressed between both hands. For this pur- pose the index finger of one hand is used for the internal exam- ination—usually per vaginam—while the other hand presses upon the abdomen. GYNECOLOGICAL EXAMINATION. 11 The hand on the outside pushes the organs in the true pelvis toward the finger in the vagina, and vice versa. In this manner the two hands grasp the organs of the true pelvis, being separ- ated from them externally only by the abdominal walls, intern- Fio. 1. Conjoined method of examination. ally only by the vaginal mucous membrane. It is important that the two hands should accurately correspond to each other, in order that the organ under examination may lie exactly between the internal and external palpating fingers. For the purpose of bimanual palpation it is best that the patient be placed on an examination-chair (although the manipu- lation may also be accomplished with tolerable facility on an ordinary bed), and the index finger of one hand is then intro- duced into the vagina in the manner described above. While the finger is placed against the cervix or the anterior vaginal cul-de- sac, the other hand is slowly pressed deeply into the abdominal wall-above the symphysis pubis, the examiner taking advantage of each expiration, if the parietes are tense, to sink it still deeper. If the hand has not been pressed in too close to the symphysis (in which case the uterus is liable to be pushed backwards), the normally situated uterus is soon grasped between the fingers ; its position, size, shape, consistence, and mobility are ascertained, 12 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. and the physician then proceeds with his finger to examine the remaining pelvic organs. Having quitted the uterus, he then brings his fingers into close proximity to each other, with only the abdominal and vaginal walls between them. If, then, the true pelvis is explored while the fingers are constantly kept just opposite each other, hardly any tumor, however small, will escape detection. The left lateral half of the pelvis is best examined by the left index finger, and the right half by the right finger. In this manner the condition of the several organs in the true pelvis may be ascertained very definitely ; the uterus can be felt, unless the circumstances are very unfavorable, with great dis- tinctness, even when it is dislocated backwards. Its shape, con- sistence, and mobility can be made out with perfect ease. To esti- mate its size with any accuracy is more difficult; generally the liability is, where the abdominal walls are rather thick, to esti- mate it too large. Caution should also be exercised in judging of its position, because pressure upon it from without is some- times liable to dislocate the womb backwards, though much more commonly forwards. On either side of the uterus are felt more particularly, the uterine appendages, the free border of the broad ligaments, the tubes and round ligaments ; the latter feel like thin cords rolling underneath the fingers. The normal ovaries may also be detected as small spherical bodies, which easily slip away from the finger. Pathological growths are the more easily detected by conjoined manipulation, the harder they are and the nearer they lie to the anterior pelvic wall. If properly performed, the procedure of conjoined manipula- tion causes no pain whatever, only a slight discomfort when the pressure is very deep and strong ; the ovaries merely, according to our experience, are somewhat sensitive to firm pressure even in their normal condition. In every case, when proceeding to make an examination, I place one hand on the abdomen and allow it to rest there quietly, or with gentle pressure, while I explore the vagina with the other. The advantage of this is, that the patient becomes accus- tomed to the external hand, which, when required, is ready to perform its part in bimanual palpation. The procedure is rendered difficult or impossible by all the GYNECOLOGICAL EXAMINATION. 13 circumstances mentioned above, as being obstacles either to the vaginal or to the external examination. In the former case we are prevented by constriction, shortness, and hypersesthesia of the vagina ; in the latter, by thick, unyielding abdominal walls, contracted abdominal muscles, and distended intestines or bladder. The value of conjoined manipulation will be readily appre- ciated if we consider that, by means of the external examination alone, no part of the normal sexual organs is accessible, while by the internal examination only the vagina and the lower seg- ment of the uterus are felt, whereas by bimanual palpation the entire contents of the true pelvis are brought within reach of the examiner's fingers. It is not saying too much to assert, that from the introduction of conjoined manipulation dates a new era in gynecology. Only in the case of very large tumors is conjoined manipula- tion superfluous, owing to the fact that they generally lie close to the brim of the pelvis, thus rendering it more advantageous to make the external and the internal examinations separately. Instead of combining abdominal palpation with the vaginal touch, the internal part of the examination may also be made through the rectum. Of course, the latter mode is chosen when- ever the vaginal exploration is impossible or difficult. Besides, it is particularly valuable in the case of a short, tense vagina, with unyielding vaginal vault, and, above all, in connection with retro-uterine tumors. In some cases, especially where the genitals are very flaccid, the thumb can be introduced deep into the vagina, simulta- neously with the rectal examination, and in this way the recto- vaginal septum and Douglas's cul-de-sac may be very conve- niently explored. The examination per rectum has of late been greatly im- proved by Simon,1 who has demonstrated that, under chloro- form-narcosis, four fingers, and even the entire hand, may be passed into the intestine. For this purpose the patient is profoundly anaesthetized, and 1 Archiv fur klin. Chir., B. 15, p. 99, and Deutsche Klinik, 1872, No. 46. 14 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the lower portion of the bowel cleansed by injections of warm water. The well-oiled hand is gradually passed through the anus —first two, then four fingers are introduced, and finally, also, the thumb is passed in with a rotary dilating motion. If the cuta- neous margin of the anus threatens to tear, it is better to incise it at once in one or more places. The lower portion of the rectum is wide enough to easily accommodate the hand, and the bowel does not begin to narrow until it receives an investment from the peritoneum, which attaches it to the sacrum. This point is situ- ated at about the third sacral vertebra,—from twelve to fourteen centimetres (about six inches) above the anus. Above this only Pig. 2. Rectal palpation, after Simon. four fingers of the hand can pass. If care is taken to avoid forcible dilatation of the sigmoid fiexure, this exploration is not dangerous; the lacerations or incisions of the cutaneous border of the anus heal rapidly, and even injuries of the sphincter are completely obliterated in the course of twelve days. The dilata- tion itself, at the most, produces merely a temporary inconti- nence. The above method of examination is of especial value in GYNECOLOGICAL EXAMINATION. 15 those gynecological cases in which a connection is suspected between large tumors and the sexual organs. When the uterus is situated behind the tumor, its relation, or that of the ovaries, to the tumor, can be ascertained only in this way. In the great majority of cases, if conjoined manipulation is employed, the introduction of four fingers will suffice. EXAMINATION WITH THE UTERINE SOUND. Simpson, Sel. Obst. and Gyn. "Works. Edinb., 1871, p. mi.—Huguier, De Thystgro- mgtrie, etc. Paris, 1865.—Kiwisch, Klin. Vortr., etc., 4 Aufl., B. 1. Prag, 1854, p. 36.—Scanzoni, Beitr. z. Geb. u. Gyn., I. p. 173.—Joseph, Berl. Beitr. z. Geb. u. Gyn., B. III. p. 23. As the interior of the uterus is not ordinarily accessible to the finger of the examiner, specially constructed sounds are used for the exploration of the uterine cavity. The construction of the instrument is a matter of very great importance. The old-fashioned, thick, inflexible sounds of Ger- man silver are perfectly useless. A good uterine sound (see Fig. 3) should be neither too thick nor too thin (two or at the most three millimetres in diameter), and should be provided with a very small button-shaped tip. Above all, it should be made of flexible metal (tin, copper, or fine silver), so as not to be perfectly rigid within the genitals, and in order to permit of a different shape or curvature being given it by simply bending it, according to the requirements of the case. It will be found convenient to have a slight enlarge- ment, about seven centimetres (2f in.) from the point, to mark the normal length of the uterine cavity, and for this distance it is bent to correspond with the normal anteversion of the uterus. A centimetre scale marked on it facilitates measurements ; but the markings should be very superficial and not cause any roughness. The manner of using the sound is exceedingly simple. It should be held as lightly as possible, and it should never be forgotten that the fingers are holding an exploring instrument which is to seek an already existing canal, and not to bore a new one. Conjoined manipulation should always precede the intro- 16 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. duction of the sound, to determine the direction which the instrument is to take. In marked flexions at the internal os the sound should have a more decided curvature ; it will then be found more difficult to introduce it into the ex- ternal os, but it will pass the os internum more easily and without injuring the mucous mem- brane. In introducing the sound, its tip is to be passed into the external os, under guidance of the finger, and then, feeling our way forward, we should push the instrument on in the direction of the uterine canal, which has been previously ascertained by conjoined manipulation. At the internal os it is generally necessary to depress the handle of the sound towards the perineum, since the uterus is somewhat anteverted. The indications for the use of the sound are stated very differently by different authors. Some gynecologists employ it almost without exception in every case ; others, however, use it comparatively seldom, only when they expect to derive from it some especial, not otherwise obtainable information. I must confess that I belong to the latter class. The most important indication is the meas- urement of the length of the uterine cavity, which cannot be ascertained in any other way. The size of the uterus may, to be sure, be esti- rju. o, snver uterine sound, mated with tolerable accuracy by bimanual pal- reduced size. . •<• -\ • rr> • a, More decidedly curved, pation, it the examiner has had sufficient prac- tice ; it is, however, extremely difficult, if the abdominal walls are very thick, and especially if the uterus itself is particularly flaccid. Under these conditions, though the organ may be indistinctly felt, it is impossible to determine its exact length. We must consider, moreover, that the size of the uterus, as estimated by external palpation, and the length of its cavity, do not coincide. A comparison of the results of palpa- tion and measurement of the uterine cavity by the sound will 0TNEC0L0GICAL EXAMINATION. 17 frequently give us the thickness of the uterine wall. The sound may further be employed to determine the thickness of this wall, by feeling for the tip of the instrument in the uterus externally, and thence estimating the diameter of the intervening uterine tissue. A second indication relates to the ascertainment of the course talcen, by the uterine cavity. Generally this course can be deter- mined with sufficient accuracy by palpation alone, and only ex- ceptionally do we need the sound as a diagnostic aid in uterine displacements. There are cases, however, in which the uterus cannot be felt separately, or in which palpation affords us no information regarding the course of the uterine cavity. The for- mer is often the case in large inflammatory exudations, in which the uterus is, so to speak, walled in, and its position cannot be determined by palpation ; the latter happens particularly in the case of fibroids, which may change the external shape of the uterus, as well as the course of the uterine cavity, in various ways, concerning which only the sound can give us any precise knowledge. A further use of the sound is to decide whether the uterus is empty or not. This is by no means as easy as is generally sup- posed. An obstacle at the internal os (constriction, a fold of mucous membrane, flexion, spasm) may give rise to the suspi- cion that a foreign body occupies the uterus, and, on the other hand, in eases in which the uterus does contain a foreign body, the sound may either easily i^enetrate this body (as in the case of soft coagula), or pass between it and the uterine wall. The latter may happen in the case of polypi, but especially in preg- nancy, where the sound, when dexterously guided, hardly meets with any resistance at the internal os. Great experience and an extremely delicate touch are essential in deciding this question, and even with these advantages, mistakes are not always avoided in difficult cases. A suspicion of pregnancy, of course, precludes the use of the sound. A very important, although rare, indication is presented when it is desired to test the permeability of the uterine canal. The presence of atresia or constriction of this canal can be ascer- VOL. X.—2 18 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tained only by the sound, and often only by one of very small size. In some cases the sound may be exceedingly serviceable in facilitating, or even rendering possible, palpation of the uterus. In this connection we do not so much refer to the cases in which a retroflexed uterus, which is with difficulty accessible to the touch, is lifted forward by means of the sound, as to those in which the uterine walls are exceedingly flaccid and thin, and where palpation of the uterus is impossible, unless the womb is supported by the sound; the tip of which may then generally be felt so distinctly as to appear to lie directly under the abdo- minal peritoneum. In testing the mobility of the uterus the sound should be used with the greatest care; indeed the instrument is but seldom needed for this purpose, and should never be employed when inflammatory adhesions are present. When this is the case, the mobility of the womb may be tested equally well by conjoined manipulation; and, besides, under these circumstances the sound is dangerous. Occasionally, however, when the question arises as to how intimately the uterus is connected with a pelvic tumor, the sound may be used to great advantage. As a test of the sensitiveness of the internal surface of the uterus, the sound should be employed with great caution; still, valuable hints respecting treatment may be given by the differ- ent degrees of sensitiveness evinced at the internal os, the fun- dus, etc. Although the introduction of the sound, by a person who has some degree of dexterity, is, as a rule, a very simple operation, yet various difficulties may be encountered. Foremost among these are constrictions of the cervical canal, which may require the employment of sounds of very small size. When the con- striction is not congenital nor cicatricial in character, but is due to a swelling of the mucous membrane, a very fine sound should not be used, because it is liable to catch in the little folds of mucous membrane, whereas a sound of larger size will pass through readily. The deviation in the position of the cervix, in versions of the uterus, rarely gives rise to any trouble in introducing the sound, GYNECOLOGICAL EXAMINATION. 19 since, with a little practice, the point of the instrument can be passed into the displaced os, and the position of the cervix may be easily altered. More difficulty is often experienced in over- coming the angle at the junction of the body and cervix in flex- ions. We have already mentioned that in such cases the sound must be bent ; moreover, in anteflexion it must be depressed towards the perineum ; in retroflexion it is introduced with the concavity pointing backwards. Tumors, particularly fibroid, which obstruct the uterine canal, render the introduction of the sound more difficult. A good silver sound will, however, bend so easily as to adapt itself to the direction of the canal. In some cases a thin elastic catheter, into which a wire has been introduced, is preferable. A very rare occurrence is the detention for a few moments of the sound by a temporary spasmodic contraction of the inter- nal os. We have yet to speak of the^ dangers which may attend sounding of the uterus. As a rule, I consider the sound harmless, provided it is employed by an experienced hand, and the direction which it is to follow has been previously ascertained by conjoined manipulation; and, in the case of flexions, provided it is bent at the proper angle. But even under these conditions the use of the instrument may exceptionally be followed by inflamma- tion. In acute inflammations of the uterus and its immediate vicinity, it is best to avoid sounding, although if the physician is very expert, and the results to be derived are sufficiently impor- tant, the attempt may be cautiously made. In chronic inflam- mations, the danger is much less, but still exists, and therefore the sound should generally be avoided. Above all, the fact should be constantly borne in mind that the use of the sound involves the least danger when it produces no alterations in the position of the uterus. That the sound is not to be used in case of pregnancy has been already observed. We will here only urge the importance of always bearing in mind, when about to employ the sound, the possibility that pregnancy may be present, and, moreover, that 20 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. not unfrequently this possibility is realized in cases where the presumption was against it. The fact that, unless the ovum is ruptured, gestation is gene- rally not disturbed by a careful examination with the sound, is no excuse for a thoughtless or incautious employment of the instrument. If the sound is forcibly and carelessly introduced, hemor- rhage and violent inflammation may ensue, even in a normal state of the womb. Perforation of the normal uterine wall by the sound rarely occurs, and is most frequently met with in con- nection with artificially induced abortion.' We say the normal uterine wall, because in soft, flaccid, puerperal uteri, even a very careful introduction of the sound may cause a perforation of the doughy uterine walls. The cases in which the sound has been passed very deep into the non-enlarged uterus (from 15 to 20 centimetres above the external os) have not attracted the atten- tion of gynecologists until quite recently. Duncan2 and Veit3 first described such cases; Hildebrandt4 then reported two instances in which he claimed positively that he had sounded the Fallopian tubes. Honing,6 however, showed that the sound- ing of the tube, laterally situated as it is, and firmly attached to the broad ligaments, is out of the question, if the point of the sound can be felt near the umbilicus, and I have also been convinced in two cases" that the sound must have perforated the uterine tissue. Noeggerath' and Martin8 have lately demonstrated the occurrence of perforation at the autopsy. Simpson" also states that in " superinvolution " of the uterus, he has several times seen the sound pass through the uterus into the abdom- 1 Petrequin and Foltz (Bulletin de l'Acad. de Med., 34 p. 1253) report a case in which the sound, having been introduced for the purpose of inducing abortion, disap- peared through the os, and was finally extracted through an incision in the abdominal wall under the umbilicus. 2 Edinb. Med. Jour., June, 1856. 3 Krankh. der weibl. Geschlechtsorgans, 2 Aufl., p. 258. 4M. f. Geb., B. 31, p. 447. 6 Berl. klin. Wochenschr., 1870, No. 16. 6 See Alt, Berl. klin. W., 1870, No. 42. 7 Amer. Jour, of Obst., IV., p. 329, where cases by Budd, Tlwmas, and Reynolds are also reported. 8 Neig. u. Beug. d. Gebarmutter, 2 Aufl. Vorwort, p. VII. The case of Rabl- Ruclehardt and Lehmus (Berl. B. z. Geb. u. Gyn. Berlin, 1872, B. II., p. 12, and Berl. Llin. W., 1872, No. 1) is more fully reported. 9 Diseases of Women, p. 604. GYNECOLOGICAL EXAMINATION. 21 inal cavity without evil consequences. Besides these, cases have been reported by Zini' as instances of sounding the tubes, which belong under this same head, and Lawson Tait's2 examples of " uteroperitoneal fistula," which he attributes to unobserved ruptura uteri inter partum, are doubtless to be explained in the same manner. In the majority of these instances the patients were tuberculous, and had suffered from post-partum hemorrhage or severe puerperal disease of some kind. In such cases, according to Klob,3 the uterus may undergo fatty degeneration, so that its substance readily tears, "the laceration being bridged over by delicate mucous fibres like the web of a spider." Under these circumstances the uterus will natu- rally permit even a carefully manipulated sound to pass through its spongy wall and enter the abdominal cavity. In none of the above-mentioned cases, strange to say, did any evil result follow the perforation. It is perfectly obvious that the sound cannot enter the normal uterine orifice of the Fallopian tube; on the other hand, two cases reported recently have demonstrated the fact that the tube may exceptionally become so dilated that the sound may pass into it. In the first of these cases, which was described by Lehmann,4 there was an ovarian tumor of the right side ; the uterine orifice of the right tube was so patulous that the sound, which had been introduced to the depth of 28 centimetres, had, with- out doubt, passed into the tube. In the second case, related by Bischoff,5 there was also an ovarian tumor; the sound entered the uterus to the depth of 17 centimetres, and after death from ovariotomy the uterus was found dislocated so far to the right side as to place the uterine orifice of the left tube in a straight line with the uterine canal, and the tubal orifice was funnel-shaped, and sufficiently wide to easily admit the sound. The validity of the explanation given above, which applies to the majority of these cases, is, of course, in no way affected by these rare exceptions. DILATATION OF TIIE CERVIX FOR DIAGNOSTIC PURPOSES. Simpson, Sel. Obst. Works, 1871, p. 733.— C. Braun, "Wiener med. "Wochenschr., 1, August, 1863.—Sims, Clinical Notes on Uterine Surgery. New York, 1871, p. 39.—Spiegelberg, Volkmann's Samml. klin. Vortr., No. 24, p. 217. Inasmuch as the sound is but a poor substitute for the finger, it not unfrequently becomes desirable, for the purpose of diagno- 1 Sitz.-Ber. d. Vereins d. Aerzte in Steiermark, VII., p. 17, 1869-70. See also Schmidt's Jabrb., B. 151, p. 162. 2 Lancet, May 18 and October 2, 1S72, and Boston Gyn. J., Vol. VII., p. 147. 8 Pathol. Anat. d. weibl. Sexualorg. Wien, 18G4, p. 206. 4 Nederl. Tijdschr. v. Geneesk, 1870, I., p. 201. 6 Corresp.-Bl. Schweizer. Aerzte, 1872. No. 19. 22 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. sis, to introduce the finger itself into the cavity of the uterus. As a rule, this cannot be done without a preliminary artificial dila- tation of the cervical canal. It is impossible by incision to lay open the normal cervix sufficiently to admit the finger, and hence we are obliged to resort to a bloodless dilatation. This, however, cannot be adequately accomplished by means of forcibly dilating instruments, but a gradual stretching and relaxation of the cer- vix may be obtained by the introduction into the cervical canal of certain substances which expand slowly. At present only sponge-tents and laminaria are used for this purpose. Instruments of various kinds have been devised for the forcible dilatation of the cervix, both- for obstetrical and gynecological purposes. Osiander1 invented a two- bladed speculum, conveniently modified by Carus,2 and Basch 3 a three-bladed instru- ment. The one constructed by Mende4 is remarkably like the speculum matricis of Ambroise Pare. Priestley's dilator5 only imperfectly fulfils its object; that of Atlee 6 is similar to Osiander's, and Peaslee 7 of late recommends steel bougies of various sizes for gradual dilatation. Ellinger8 has recently devised an instrument for rapid dilatation, the branches of which are constructed with the design of pro- curing a perfect parallel expansion, but they are so thin that they easily bend. Although such instruments may occasionally be employed with success in the re- moval of stricture, they are nevertheless by no means adapted to supply the place of sponge-tents in cases where the cervix has not previously been prepared, and where the uterine cavity is to be rendered accessible to one or more fingers. Sponge-tents act principally by softening and relaxing the cervical tissue, and thus rendering it expansible, and in this respect they stand thus far unrivalled. Sponge-tents are generally prepared from ordinary bathing-sponges, which are cut into cone-shaped pieces from five to six centimetres in length, and varying in thick- ness. A hot wire is then pushed lengthwise through the cone, and the sponge is soaked in mucilage (Bantock,9 however, regards the mucilage as unnecessary). Tiie sponge is afterwards compressed by winding a fine thread tightly around it, commencing at the point of the cone. When the sponge is dry, the thread is 1 Annalen d. Entbind. zu Gottingen, 1804, B. II., 2, p. 385. 2 Gynakol., II., p. 286, T. III., Fig. 2. 3 Gemeins d. Zeitschr. f. Geb., B. VI., p. 370. 4 E. l.,p. 549. 5 Med. Times, March 5, 1864. 6 Amer. J. of Med. Se., April, 1871, p. 395. 7 New York Med. J., XL, 1870, p. 465. 8 Archiv f. Gyn., B. V., p. 268. 8 London Obst. Tr., XIV., p. 85. GYNECOLOGICAL EXAMINATION. 23 removed and the wire is drawn out; the irregularities are finally polished off with sand-paper, and the tent is ready for use. Sponge-tents may be made of any size (see Fig. 4); the English carbolized ones are the best prepared. The bougies of laminaria digitata, the perennial stalks of the sea-tangle, which were first recommended by Sloan, in Ayr,1 are superior to sponge-tents, in that they are much less likely to become offensive, and, by reason of their smooth surfaces, abrade the mucous membrane less; but they do not relax the cervix as well by far, neither do they expand as readily, and besides, they are not to be had of sufficient size; consequently they have never superseded the sponge-tent, notwithstanding the disagreeable qualities of the latter. According to Greenhalgh, hollow lamina- ria bougies are the best, because they swell quicker and better. The radix gentianae, which has recently been again recommended by Winkel,2 Fig. 4. Various kinds of sponge-tents, of natural size. has, we believe, no advantage over laminaria, excepting its greater cheapness. De- calcified ivory (which, after having been deprived of its inorganic constituents by 1 Glasgow Med. J., October, 1862. 2 Deutsche Klin., 1S67, No. 29. 24 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the action of acid, shrinks when dried, and when wet expands again) enlarges still less than laminaria. The sponge-tent may be introduced through a speculum or it can be simply guided by the finger. In the former case it will be most convenient to employ Sims' speculum, with the patient in the lateral position. After the cervix has been exposed to view, the anterior lip is seized with a hook and drawn forward, which causes the external os to gape, and the tent is grasped with the forceps and passed into the cervical canal, until its point extends beyond the internal os into the cavity of the uterus. With the cylindrical glass speculum the introduction of the sponge-tent is much more difficult, because the speculum pushes the cervix slightly upwards, and so is likely to produce a curva- ture at the internal os. With a little dexterity the sponge-tent may also be readily introduced with the hand, underneath the bed-clothes. For this purpose we place the left index finger against the cervix, and push the tent along the finger into the vagina; the finger guides it into the external os, and if the position of the body of the uterus has been previously ascertained, and the base of the tent is pushed correspondingly backwards or forwards, as the case may be, it can be passed without trouble through the inter- nal os. The other hand gives material aid by pressing the uterus down against the tent from without. The sponge-tent must not be greased all over, lest it expand too slowly ; the point only should be smeared with solid fat (not oil). It should be introduced rapidly, because the sponge quickly absorbs moisture, and when its point once becomes soft and swollen it is no longer possible to insert it. Care should be taken not to push the sponge in too far, because (especially in nulliparous women) the external os is very liable to close over the tent and render its extraction very diffi- cult. The sponge must be long enough, so that while it reaches beyond the internal os, it may project outside the os externum. If the tent is retained in place for a short time with the finger after its introduction, a tampon will not be necessary, because the rapid imbibition of the sponge suffices to retain it in posi- tion ; the laminaria, however, must be retained artificially. GYNECOLOGICAL EXAMINATION. 25 The length of time during which a sponge-tent should be left in situ, and the frequency with which it should be replaced by a larger one, depend entirely on individual circumstances. In women with wide, dilatable cervices, who have borne chil- dren, and especially if retained placental fragments or other intra-uterine tumors have already dilated the internal os, a single sponge-tent introduced for a few hours frequently produces all the dilatation that is needed. In a nullipara, however, with a firm, cartilage-like cervix and a narrow canal, the smallest sizes must be introduced first. In such cases it is advisable to begin with the slender laminaria bougies, which are easily introduced. It may become necessary to insert three or four sponge-tents in succession, each being a little larger than the previous one, until the cervix is sufficiently dilated, and more particularly until the resistance of the internal os is overcome. Every sponge-tent should be removed after from eight to twelve hours, when it will already have acquired a decidedly offensive odor. After carefully cleansing the vagina and cervix by warm-water injections, an examination is made, and then, if necessary, a larger tent is introduced, and so on until the cervix has been sufficiently dilated to permit the easy introduction of the finger into the cavity of the uterus. The sponge is removed by the hand, simply by loosening it in the cervix with the finger, and then extracting it, by the thread which is attached, as soon as it readily yields to the traction. Beneficial and useful as the sponge-tent is, it is nevertheless attended with various dangers.' Under all circumstances the introduction of a sponge-tent causes an irritation of the uterus and its immediate surround- ings ; sometimes the irritation is mechanical, and sometimes a source of danger is presented in the rapid decomposition of the secretions absorbed by the sponge, for which reason, very soon after its insertion, it acquires a fetid odor. (According to Law- 1 See Aitken, Edinb. Obst. Tr., vol. II., p. 185; von Gruenewald, etc., in the Tagebl. d. Rostocker Naturforschervers, 1871, p. 15G; Storer, Boston, Gyn. J., III., p. 12; Zschiesche, Dissert, in Greifswald, 1873. 26 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. son Tait, Med. Times, Jan. 10, 1874, sponge-tents impregnated with a five-per-cent. solution of oil of cloves do not become offensive.) Even a healthy uterus may become inflamed by the irritation of the tent; but of course a fresh inflammatory action is induced much more readily when metritis or perimetritis, although in a chronic form, exists beforehand. This measure, therefore, can never be regarded as perfectly harmless, and should always be undertaken with certain precau- tions. The sponge-tent ought never to be introduced at the office of the physician, but always at the patient's house, and while she is in bed, where she should also remain afterwards. The existence of inflammation contraindicates the use of the sponge- tent, although cases may occur in which the urgency of the symptoms necessitates dilatation of the cervix, irrespectively of this danger. The mucous membrane of the cervix is always considerably injured, but evil results do not generally ensue therefrom ; indeed, occasionally, the pressure of the sponge-tent upon the mucous membrane of the cervix, in its chronic hyperplastic con- dition, exerts a decidedly beneficial influence. Extreme danger may arise from the absorption of the pro- ducts of decomposition, which advances rapidly under the action of the sponge-tent, and may result in pysemic and septic infec- tion ; this absorption is most likely to occur when the sponge is introduced immediately after a bloody operation (incision of the external os).1 Thomas2 reports a case of tetanus which occurred twenty-four hours after the removal of the second sponge, and another case of fatal tetanus is related by Thompson.3 EXAMINATION BY INSPECTION. The examination of the abdomen by ocular inspection is not unimportant in the case of large abdominal tumors, although no particularly valuable diagnostic points are gained by it as a 1 See Olshausen, Samml. kl. Vortr., No. 67, p. 503. 2 Diseases of Women, 3d ed., Philadelphia, 1872, p. 91. 3 Columbia Hosp. Report, Washington, 1873, p. 102. GYNECOLOGICAL EXAMINATION. 2? rule. Under favorable conditions, however, the presence of free fluid in the abdominal cavity may be distinguished from en- cysted fluid by the flattening of the external surface ; the dis- tended bladder, also, when an abdominal tumor lies behind it, forms a spherical protuberance, which, from its shape, may be recognized simply by the naked eye. Ocular inspection of the vulva frequently furnishes impor- tant information, and is often indispensable. An accurate idea of the condition of the labia, frenulum, clitoris, meatus urina- rius, and hymen, can be obtained only by this method of exam- ination. Of still greater importance is the examination by sight of the vagina and vaginal portion of the cervix by means of certain specially adapted instruments. The instruments of this sort—uterine, or better, vaginal spe- cula—are of great variety. Carl Mayer, Verh. d. Berl. geb. Ges., VIL, 1853, p. 79.—Louis Mayer, M. f. Geb., B. 18, p. 11.—J. M. Sims, Amer. J. of Med. Sc, January, 1852, and Notes on Uterine Surgery. New York, 1871, y>. 10.—G. Simon, Ueber die Operation der Blascnscheidenfistel, etc. Rostock, 1862, p. 62. There are three kinds of specula : the valvular, or those com- posed of several blades, the cylindrical, and those which consist of several parts, which are disconnected, and must be held sepa- rately. Formerly the valvular specula were chiefly used, of which we will mention only the bivalvular speculum of Ricord, and the very convenient instrument of Cusco (Fig. 5). Specula with three and four valves were de- vised by Segalas, Charriere, and others. These valvular specula are introduced closed into the va- gina, and then opened by means Cusco's speculum. of various mechanical contriv- ances. The advantage which they possess of easily passing the 28 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. entrance of the vagina by reason of their small size, and thus causing no pain, is compensated by their liability to catch the folds of the vaginal mucous membrane on being withdrawn. Besides, if the cervix does not present itself at once, it is not easy to search for it with these instruments, and, moreover, they reflect the light imperfectly. For these reasons, and because they are difficult to clean, they are now but little used. Cylindrical specula are made of various materials—metal, wood, ivory, hard rubber, glass, porcelain. Outside of Germany, Fergusson's speculum (Fig. 6) is most used; in Germany, Mayer's milk-colored glass speculum (Figs. 7 and 8). Fergusson's speculum is a tube of glass, which is first sil- vered, and then covered with rubber varnish. Mayer's speculum consists simply of milk-colored glass or Fig. 6. Fig. 7. Fig. 8. Fergusson's speculum. Straight milk-glass speculum. Obliquely cut milk-glass speculum. porcelain. Both have a funnel-shaped expansion at one end, and are cut off straight or obliquely at the other. These specula have the advantage of being very easily cleaned, of not being acted upon by medicinal agents, and of giving a very good light. The cervix is very easily brought into the lumen of the speculum, even when dislocated backwards, and particularly so with the obliquely cut instrument, for which reason this variety has commended itself to general use. The GYNECOLOGICAL EXAMINATION. 29 straight-cut specula exert a uniform pressure upon all points of the fornix vaginae, and are therefore useful when it is desirable to produce an ectropion of the lips of the os, in order to gain a good view of the cervical canal. The alleged disadvantage of their introduction being very painful disappears almost entirely if they are skilfully manipulated. On introducing the speculum, we should remember that the sensitiveness of the frenulum and perineum is very slight, and that these parts are capable of considerable distention, whereas the anterior vaginal wall, at its attachment to the symphysis, and the eminentia urinaria are exceedingly tender. There are various ways of avoiding these sensitive parts dur- ing the passage of the instrument. While the index finger and thumb of one hand separate the labia, the speculum may be introduced by placing its upper edge, or tip, in the vagina under the meatus urinarius, and then slipping the lower edge rapidly over the fourchette; or, as I prefer, the bevelled tip is pressed against the fourchette and posterior vaginal wall, and the peri- neum sufficiently depressed to easily admit the whole calibre of the speculum without touching the sensitive urinary caruncle. In this manner even veiy large specula may be passed through the vaginal sphincter with much less pain than if we follow the clumsy, boring method of introduction by means of a wooden plug fitted into the speculum. As the speculum is pushed further up with a twisting motion, the anterior and posterior vaginal walls are seen to separate until their points of junction with the cervix are reached. Usu- ally the latter is easily found, especially with the bevelled-tip instrument ; difficulty is rarely experienced, excepting in ante- version, when it may become necessary to introduce the sound first, and then pass the speculum over it. Every physician should have an assortment of milk-glass specula, of different sizes, to correspond with the variations in size of the vaginal entrance. In multiparous women a speculum of the largest size can generally be introduced without causing much pain. Specula are generally made too long. The shorter the speculum, if it answer the purpose, the easier will it be to manipulate through it; beginners frequently experi- 30 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ence difficulty in finding the cervix, owing to the circumstance that they have already pushed the tip of the speculum beyond the vaginal portion of the cervix, into the vaginal cul-de-sac. Thomas l has devised a special " telescopic speculum," which can be lengthened or shortened as desired. We especially warn our readers against the funnel-shaped, milk-glass specula, which are now frequently exposed for sale; the upper end is so narrow as to give only a very small field of vision, and the supposed greater ease of introduction is so slight an advantage that only perfectly cylindrical instruments should be manu- factured. Recently other specula have been introduced into practice, which unquestionably facilitate the approach to the cervix and vault of the vagina vastly beyond any of those already men- tioned. Sims was the first to describe the " duck-bill" speculum, now known by his name (Fig. 9), by means of which merely the pos- terior wall of the vagina is depressed. The instrument cannot be used advantageously in the dorsal decubitus ; but in the lateral position, and still more in the knee-and-elbow posture (a la vache), the abdominal organs fall away from the pelvic inlet by gravita- tion, in consequence of which the anterior wall of the vagina is prevented from following the poste- rior when the latter is retracted by the speculum, and hence the vagina gapes open. Yet even in this position a small instrument is almost always needed to assist in holding the anterior wall back. Inasmuch as the employment of Sims's specu- lum absolutely requires a change from the dorsal to the lateral decubitus, and renders the presence of an assistant necessary to hold the speculum in place, its use is scarcely likely to become general in Germany, where it is customary for the phy- sician to be alone with his patient during a gyne- cological examination. Indeed, it can readily be dispensed with in ordinary cases, where it is only desired to obtain a view of the cervix. If the object is to expose the whole upper portion of the Fig. 9. Sims's speculum. 1 Diseases of Women, 3d ed., p. 75. GYNECOLOGICAL EXAMINATION. 31 vagina, for the purpose of a clear inspection or of an operation, we confess our preference for the specula of Simon (Fig. 10), which separate the vaginal walls in all directions, and are equally applicable in the dorsal position,—a point of particular impor- tance as regards the administration of an anaesthetic. These specula consist of a concave blade, c, for the posterior vaginal wall, similar to that of Sims ; of a plate, b, for the support of the anterior, and of two flat steel hooks, a, for the separation of the lateral vaginal walls. The two former may be constructed of different sizes, which may be made to fit the same handle. At least two assistants are required to hold them. In order to dispense with the assistants, similar specula Fig. 10. Simon's specula, a, lateral hooks; b, plate-shaped speculum for the anterior vaginal wall; c, concave gutter-shaped speculum for the posterior vaginal wall. have been constructed, which are designed to be self-retaining. Emmet, Foveaux, Pallen, Nott, Thomas, Hunter, Souchon, and 32 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Spencer Wells have devised such modifications, but they have never come into general use. The English, and especially the Americans, are indefatigable in the invention of new specula, of which the most important have been devised by the following persons : Meadows (Lancet, May, 1870); Blackbee (Lancet, December 9, 1871, p. 320); Albert Smith (Med. Press and Circular, December, 1869); Byrne (Amer. Jour, of Obst., IV., p. 287); Stockton-Hough (Boston Gyn. J., VI., p. 18) ; Brown (Boston Med. and Surg. Jour., July, 1869) ; Erich (Phila. Med. and Surg. Reporter, March 27, 1869). The apparatuses for artificial illumination recommended by Ploss,1 Tobold,2and Sedgwick3 are not likely, for obvious rea- sons, to find many supporters. The full daylight is necessary to a specular examination, but this is all that is required. DISEASES OF THE UTERUS. Malformations. Kussmaul, Von dem Mangel u. s. w. der Gebarmutter. Wiirzburg, 1859.—F'drst, M. f. Gel)., B. 30, p. 0 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. closed cavities ; thus, in the event of future hemorrhage, a haematocele is easily formed. The tubes may become so much dilated and attenuated by the increasing hemorrhagic exudation as to burst. Occasionally this happens spontaneously, but more frequently it occurs after the evacuation of the haematometra, when the uterus and tubes are carried downwards by the contrac- tion of the abdominal muscles, or by external pressure, in conse- quence of which the adhesions are lacerated. The blood accumulated behind the point of occlusion has a very characteristic appearance. It has the color of chocolate or tar, is thickish, not putrid, but merely condensed ; the blood-corpuscles are shrunken. The quantity of blood varies considerably, but is always less than would have been the case if the menses had con- tinued to flow in their normal amount during the time of reten- tion ; the largest amount—three, four, five kilogrammes—{between eight and fourteen pounds) is met with in atresia hymenalis. m After the menopause the accumulated secretion is no longer blood, but a clear or brownish serous or viscid fluid. Occa- sionally there is only a very small quantity of thick, tenacious, honey-like mucus ; in other cases the secretion is more abun- dant. If the atresia is situated at the internal os, as is the rule in these cases of hydrometra (Fig. 23), only the cavity of the cor- pus uteri is dilated ; the walls of the uterus rarely become hyper- trophic, but are generally much attenuated ; the mucous mem- brane resembles a serous membrane. If the external os is obliterated, the cervix first undergoes a spherical dilatation ; very rarely, and only when both orifices Fig. 23. Hydrometra, with atresia of the internal ob. MALFORMATIONS OF THE UTERUS. 51 are obliterated, does the uterus assume the hour-glass shape. The quantity of serous fluid is generally inconsiderable ; only very exceptionally does it amount to as much as two pounds. It is very rare for the contents to be of a different character; pyometra may arise if, as in the cases of A^oisin, Husson, Puech' and Eppinger,2 the uterine mucous membrane is in a condition of suppuration. If an atresia occur in a fresh puerpera, the lochia may collect in large quantity above the obstruction. Puech relates examples of this occurrence (Chambon and Guy). Symptoms. The atresia in itself gives rise to no symptoms, except the accumulation of the secretion above it. In congenital atresia, therefore, there are no symptoms until after puberty; in atresia acquired after this period, there are none until ovulation next occurs. Menstrual molimina appear without any discharge of blood, last a few days, and then dis- appear entirely. Gradually the intensity and duration of the molimina increase ; the free intervals become shorter, until finalty continual colicky pains, similar to those of labor, arise, which increase considerably in violence during the period of menstruation. Disturbances of the bladder and intestine super- vene, and the condition becomes exceedingly distressing. The continual pain by day and night is followed by complete loss of appetite, insomnia, and constantly increasing debility. In lij^drometra the symptoms are not equally severe, because the accumulation is more gradual and the atrophic, non-func- tionating uterus no longer responds with contractions to the dis- tention of its cavity. If the contractions (which appear precisely like dysmenorrhoeal symptoms—uterine colic) are wanting, the hydrometra gives rise to no trouble whatever. Results. If art does not interfere, the following results ensue : In haematometra the blood generally either bursts through the 1 Puech, 1. c, p. 28. • Prager Vierteljahrschrift, 1873, 4, p. 30. 52 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. occluding membrane, or escapes into the internal organs,—a dif- ference which renders it of great importance that the condition should be correctly diagnosticated. The former is the most favorable termination ; the occluding membrane is either rup- tured or is perforated by inflammation and gangrene. The former occurrence is most common in acquired, the latter in congenital atresia. The uterus itself may also burst—most frequently at the cer- vix, its muscular fibres having become separated—and its con- tents are then poured into the abdominal cavity (in one case, see Puech, 1. c, p. 58, they escaped into the adherent stomach); or the uterus may discharge its contents into the connective tissue behind the bladder. The blood then forces its way into the bladder, and the menses pass off with the urine. In the case of Graf' the blood worked its way downwards, and was discharged through the left nates. Very rarely, probably only when a hae- matocele has been produced by previous rupture of the uterus, does the blood burst into the rectum. The Fallopian tube, when distended by blood, is more apt to burst than the uterus, and the accident is usually followed by fatal peritonitis. Under certain conditions, to be further ex- plained in the chapter on haematocele, hemorrhage from the tube may lead to the formation of retro-uterine haematocele. The symptoms may all be relieved by the menopause super- vening, although this generally takes place only in acquired atresia, when it occurs at the normal climacteric period. Excep- tionally the menopause may occur so prematurely in congenital atresia, as to arrest the process ; under these circumstances, vica- rious hemorrhage may occur from the lungs, stomach, mouth, nose, or eyes. After the climacteric, the secretion from the uterine mucous membrane may dry up entirely, or the haematometra may gradu- ally change to a hydrometra. I once observed a gradual trans- formation of this sort in a woman, about forty years of age, with sarcoma of the cervix, who had acquired an atresia of the uterus after a severe application of the actual cautery ; afterwards, 1 Virchow's Archiv, B. 19, p. 548. MALFORMATIONS OF THE UTERUS. 53 when it became necessary from time to time to divide the atresia, the first few times blood was voided from the uterus, afterward serous fluid. Hydrometra is much less dangerous than haematometra. 'Hie dilatation of the uterus is generally less considerable, and the Fallopian tubes are not apt to be involved. A rupture of the uterus and tubes is therefore a very rare occurrence. Moreover, hydrometra rarely exceeds certain dimensions. The most favorable, and not a very uncommon termination, is the rupture of the adhesions (which are often merely superficial) at the internal os and upper portion of the cervix ; but the secretion may reaccumulate and break through repeatedly. It is a rare occurrence for the secretion to decompose, with the formation of gas, and give rise to physometra, which betrays itself by the escape of flatus from the vagina. Diagnosis. The diagnosis of atresia, as long as it produces no symptoms, is never made before puberty. As a rule, however, it is easy to recognize a haematometra, especially as the history of the case— at least in congenital haematometra—points to the menstrual retention, and directs attention to this pathological condition. In those cases, also, in which the disease has been acquired, this idea naturally suggests itself, because the subjects are generally women, in whom, after certain processes (severe confinement and childbed), a premature menopause has generally occurred, though menstrual molimina still continued. Conjoined manipulation will enable us to make the diagnosis with absolute certainty, even before the permeability of the genital canal has been tested. If the vagina is normal, the exam- ination is made per vaginam ; if it is wanting or impassable, the examination is made by the rectum. The condition of things will vary accordingly as the vagina, cervix, uterus, or tubes are distended. If the vagina is imperforate, the character of the large tumor in the true pelvis is evident at once, although occasionally small tumors attached to the larger body may obscure the diag- 54 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. nosis, especially as the danger of producing rupture of the dis- tended Fallopian tubes forbids making palpation with very firm pressure. In vaginal atresia it will hardly be assuming too much to regard the smaller tumor as the uterus, even if the oc- clusion be situated high up in the vagina. In the latter case a circumscribed tumor, if it at all resembles the uterus in shape, is invariably formed by the body of that organ at least, though the distended cervix may be included in the bulk of the large tumor. The tubes filled with blood are softer, and situated more posteriorly, and hence are less easily felt. The possibility of a uterus bicornis must always be kept in mind, because various malformations are frequently combined in the female generative organs. If the external os is the seat of the obstacle, the diagnosis may be attended with some difficulty. It is very important to be able to ascertain that the uterus distended with blood is spherical and very tense, almost like a full rubber ball. No other tumors possess such a characteristic consistence, with the exception of the rare malignant neoplasms of the body of the uterus. If the external os is closed, the cervix and vaginal portion are wanting, the cervix having been wholly included in the round tumor. The tumor then could only be mistaken for a sub- mucous fibroid, and this error can be avoided by a careful con- sideration of the history of the case and the symptoms, and by observing the different consistence. If there is still any doubt, the permeability of the canal must be tested with the sound, which would naturally encounter an obstacle at the spot where the tumor begins. In atresia of the hymen and lower portion of the vagina, in which the tumor projects as a reddish or bluish mass between the labia, the matter is much simplified. The diagnosis is most difficult in atresia of the internal os, because in this case the shortening of the cervix, which occurs besides only in submucous fibroids or polypi, is wanting. An error in the differential diagnosis between haematometra and pregnancy is not easily made, because the fonner affection is very rarely caused by an imperforate internal os. The difference in MALFORMATIONS OF THE UTERUS. sn consistence should guard us against such a mistake, for the nor- mally growing pregnant uterus is much softer and less tense than the organ when distended with retained menstrual fluid. Fibroid tumors also do not show this firm consistence. Malignant growths, however, may be equally tense, and moreover, since they sometimes present an impediment to the introduction of the sound, they may render the differential diagnosis peculiarly difficult. A hydrometra is much more rarely met with, and may seri- ously interfere with the diagnosis, because the history, in women beyond the climacteric, does not afford much information, and also because the tumor does not attain any considerable size. Conjoined manipulation, executed with care, will detect the enlarged uterus which differs from chronic metritis in its spheri- cal shape, and in the presence of an impediment to the passage of the sound. Interstitial and submucous fibroids, as well as carcinoma and sarcoma, may, however, occasionally give rise to mistakes. A somewhat unimportant diagnostic error may occur with reference to the character of the retained fluid. Direct signs, such as the reddish shade, caused by the blood shining through a thin hymen, are but seldom present. The question whether the tumor contains blood or serum, must generally be decided by the age of the patient, and in this way we may occasionally be in error. We have referred above to those cases in which there were several occluding membranes, and in which first only mucus escaped, the discharge of blood not taking place until after the second barrier had been divided. Bryck,1 however, found mucus instead of blood in the case of a girl eighteen years old, and Veit '2 in one twenty-three years of age. Instances in which the contents of the tumor are sanguineous after the climacteric period are rather more common. Puech3 reports a case of his own, and one each by Berard and Thompson. Eggel4 opened a haema- tometra in a woman sixty-six years of age. We may conclude from the interesting observation reported by Pistora—who found sanguineous contents in the tumor in a woman sixty-eight years of age, at whose autopsy uterine fibroids were discovered— 1 Wien. med. W., 1865, No. 11. 2 See Straeter, 1. c, p. 26. 3L. c, p. 26. 4 Berl. Beitrage zu G. u. G., 1, p. 108. 6 Berl. kl. W., 1870, No. 17, and 1872, No. 36. 56 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. that a haematometra in old women may occasionally be accounted for by the presence of neoplasms, which induce hemorrhages into the cavity of the uterus. Prognosis. It is evident from the way in which haematometra terminates, and from the preponderance of the unfavorable results, that the affection, if left to itself, is of an exceedingly serious nature. But the operation is not without danger. Experience teaches that especially in uterine atresia, with dilatation of the tubes, rupture of the latter is of so frequent occurrence immediately following the operation, that French operators (Boyer, Dupuy- tren, and Cazeaux, for instance) have declared themselves opposed to operative interference, and pronounce the patient lost under any circumstances. Rupture of the tubes after the operation is probably partly due to the uterine contractions which expel the retained blood from the uterus, in which contractions the tubes participate, but is owing mainly to the adhesions which are formed between the dilated tubes and the adjacent organs. The rationale of this accident is, that the tubes, which are firmly fixed above, are no longer pushed upwards by the tumor, after the evacuation of the vagina and uterus, but are pressed downwards by the abdom- inal muscles, in consequence of which they are torn. (In a case reported by Gosselin, G'az. des Hopitaux, 1867, No. 57, the autopsy revealed the fact that the adhesions of the distended tube with the omentum had caused the rupture.) The lacera- tion has doubtless been often caused also by the efforts of the operator to squeeze out the contents of the haematometra after it has been opened. As a rule, tubal haematocele is more common, and of larger dimensions when the atresia is situated high up ; consequently old uterine atresia is the most dangerous, while in obliteration of the hymen, or of the lower portion of the vagina, the danger is comparatively slight, although not entirely absent. A successful operation is followed by complete recovery, pro- vided the incision is prevented from closing ; indeed, a number of instances have been recorded where conception afterwards took place. MALFORMATIONS OF THE UTERUS. 57 Treatment. The only successful treatment consists in laying the tumor open by an operation, the time for which is chosen between two menstrual periods. In atresia hymenalis and inferior vaginal atresia the opera- tion is very simple. A crucial incision is made in the protrud- ing membrane, or, what is preferable, it is seized with a tena- culum, and a circular piece excised.1 If a simple, thin, transverse membrane obstructs the vagina higher up, it is merely incised sufficiently to permit the escape of the blood. Those cases in which the vagina is either partly or entirely wanting are much more serious. In order to avoid injuring the bladder or rectum during the operation of constructing a new vagina, it is advisable to operate at one sitting in the manner proposed by Amussat," that is, to slowly tear open a passage with the fingers, and by means of blunt instruments. This is done as follows : A catheter is passed into the bladder and given to an assistant to hold, and the operator introduces the index finger of the left hand into the rectum ; a transverse incision is then made between the anus and the urethra, which in these cases lie very near each other. After dividing the integument, the operator slowly ascends between bladder and rectum, using only the finger and handle of the knife until he reaches the tumor, which is most conveniently opened by means of a curved trocar. After this instrument has been passed into the retained blood, a director is introduced through the canula, the latter is withdrawn, and the opening is then enlarged with the knife or Simpson's metrotome. In order to keep the passage free, lami- naria bougies are introduced, and digital examination is fre- quently practised. Heppner3 makes an H-shaped incision, and by this means, together with the extension of the vertical inci- sion posteriorly, skin-flaps are formed, which he sews into the newly formed vagina. 1 Baker Brown. Surg. Diseases of Women, ".1 ed., p. 272. and Veit. 2 Observ. sur une oper. de vagin artificiel, 1835. 3 Petersb. med. Zeitschr., 1S72, GH., p. 552. 58 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. If the cervix is imperforate, it is best to use the trocar at once, as already described. If there is any indication as to the situation of the vaginal portion, the instrument should of course be introduced at this point, otherwise, quite far backwards ; for experience has shown that the trocar is most liable to be passed through the anterior wall of the uterus. The puncture of the tumor through the rectum, as recom- mended by Baker Brown,1 is to be avoided if possible. It may become necessary, however, in case of absence of the vagina, where it is impracticable to reach the tumor in the ordinary way. The tumor having been opened, it is of the utmost impor- tance that the blood be evacuated slowly, lest rupture of the tube occur in consequence of the above-mentioned cause. Above all, pressure on the abdominal walls is to be strictly avoided ; no injections are to be made, but, after the incision of the tumor, whatever fluid escapes of itself may be allowed to do so. The patient should then be lifted into bed with the utmost care, and the abdominal muscles kept perfectly quiet. Cautious injections should be made in the event of decomposition of the fluid which is still retained. The first menstrual period after the operation is still attended with some danger. Hydrometra should likewise be punctured with a trocar. In many cases, where adhesion has taken place from the growing together of opposite granulating surfaces, the sound suffices. UNILATERAL HAEMATOMETRA, WITH DUPLICATION OF THE GENI- TAL CANA- Rohitanshy, Zeitschr. d. Ges. d. Wiener Aerzte, 1859, No. 33, and 1860, No. 31.— Simon, M. f. Geb., B. 24, p. 292.—Hoist, Beitr. z. Gyn. u. Geb., H. 1, p. 63.— Schroeder, Krit. Unters. iiber die Diagn. d. Hsemat. retrout, etc. Bonn, 1866, and Berl. klin. Woch., 1866, No. Z8.—Neugebauer, Arch. f. Gyn., II., p. 246.— Freund, Berl. B. z. Geb. u. Gyn., II., p. 2Q.—Hegar, Berl. B. z. Geb. u. Gyn.. III., p. 141. Etiology. Unilateral haematometra is always congenital, and depends on 1 Surg. Diseases of Women, 3d ed., p. 284. MALFORMATIONS OF THE UTERUS. 59 the occlusion of one of the passages of a double genital canal. In the not uncommon complete, or in the partial duplication (see p. 38), both portions may be imperforate, and thus a double haematometra is formed (see Santesson. Preussische Vereinszei- tung, 1857, Xo. 50 ; Hoist, 1. c. p. 90, and Xelaton, Gaz. d. hop., 1S5G, Xo. 88, p. 350. in which last case perhaps only one-half menstruated). It is much more frequent, however, to find only one-half closed. These cases are particularly interesting, because, as a rule, while one side menstruates regularly, a haematometra develops on the other. The considerable number of cases reported during the past few years, prove that this affection is not an extremely rare one. We find altogether 38 cases on record belonging to this category, of which 29 came under clinical observation, namely, of Uterine atresia, 11, as follows: (1.) Leroy, Journal des connaiss.med.-chir., 1835, T. II., p. 181. (2.) Rokitansky, 1. c, 1860, No. 31. (3.) Thiingel, Klin. Mittheil., ls<;o, p. 55. (4.) Hoist. 1. c, p. 63. (5.) Jones, Brit. Med. J., July 22, 1865, p. 54; see M. f. Geb., B. 30, p. 180. (6.) OHiausen, Arch. f. Gyn., B. I., p. 41. (7.) Breslau. Schweiz. Z. f. Heilk., 2 Heft, 1863, p. 310, 4th case. (8.) Crede, M. f. Geb., B. 9, p. 457. 6th case. (9.) Jacquet, Berl. klin. W., 1874, No. 9. (10 and 11.) Hegar, I. c. (two cases in a rudimentary horn). Superior or middle vagined atresia, the following 12 : (12.) Veil. Frauenkrankh., 2 Aufl., p. 537. (13.) Deces, Bull, de la Soc. anat., Juillet, 1854. (14.) Passauer, Berl. klin. W., 1867, No. 26. (15 and 16.) Neugebauer, 1. c, p. 247 and p. 255. (17 and 18.) Breisky, Arch. f. Gyn., B. II., p. 84 and p. 451. (19.) Breslau, 1. c, p. 303, 2d case. (20 and 21.) Freund, 1. c, cases 1 and 2. (22.) Braus-Spiegelberg. Berl. klin. Woch., 1874, Nos. 10 and 11. (23.) Breisky, Arch. f. Gyn., B. VI., p. 89 (Hydrome- tra). Inferior vaginal atresia, the following 5 cases: (24.) Beronius. Preuss. medic. Zeit.. 18(32, No. 33, p. 259. (25.) Sehroeder, 1. c, p. 3. (26.) Hegar, M. f. Geb., B. 17, p. 41S. (27.) Hertzfelder, Oesterr. Zeitschr. f. prakt, Heilk., 26 Deo. 1856. (28.) Braun, Wiener med. Woch., 1861, p. 457. 6th case. Atresia hymenalis, 1 case : (29.) Simon, 1. c. p. 292. Besides these, the following five cases were observed in the dead subject; three being of uterine atresia, viz. : (30.) Rokitansky. 1. c, 1859. No. 33. first case. (31.) Clmrchill, Lancet. 1 lth Nov., 1805. p. 536. (32.) Hofmann, three cases of uterine malformation. Erlangen, 1869, Diss, inaug.. p. 16; and two of vaginal atresia, viz.: (33.) Rokitansky. e. 1., second case. (34.) Wrany, Prager Viertelj., 1868. 3. p. 39 To these are to be added five cases occurring in children, viz. : (35.) Otto, see Kussmaul. Von dem Mangel, etc., p. ISO (uterine atresia, with atresia of the vagina, which was single). (36.) Case in the Maternite. Gaz. d. hop.. 132. Nov. 13th, 1860. 60 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. (37.) Puech, Gaz. des hop., 1857, p. 586. (38.) Breisky-Klebs, Arch. f. Gyn., B. II., p. 92, note, the three last cases of vaginal atresia. Pathological Anatomy. There are several varieties of this malformation : (1.) Both canals of Miiller forming the double uterus may be completely developed, but the hymen of one side is imperforate. (2.) Both canals are fully developed, but one has not opened into the urogenital sinus, and the vagina of that side is, there- fore, closed irrrmediately behind the vulva, (3.) The development of one of Midler's canals has been ar- rested, its lower portion is wanting, and the vagina of that side, therefore, terminates in a blind pouch, either in the middle or higher up. (4.) The vagina is single, either because one of the canals of Miiller is imperforate to that extent, or because the two vaginal halves have become united. The uterus, however, is double, and one horn is closed. (5.) We may have a uterus unicornis with the opposite horn rudimentary ; the latter is hollow, but without any external opening (Hegar). Besides these varieties other complications may occur. Otto found in a new-born infant closure of one uterine horn, and of the vagina, which was single. In all these instances the uterus may be either septus or bicornis, but is generally the latter. The consequences of the unilateral atresia (see Fig. 24) are identical with those described above under haematometra, From the period of puberty, the menstrual fluid accumulates above the point of occlusion, and distends the genital canal; at first the vagina alone is involved in all cases where the occlu- sion is situated low down. Haematocele of the Fallopian tube may also occur, and entail the same dangers as were mentioned above. In amenorrhoea mucus and pus may collect, as was the case with a patient under the care of Breisky ; in the other case reported by Breisky, and in that observed by Brans, after the haematometra had been operated upon, pus collected in the half which had been obliterated. The last case reported by Breisky, MALFORMATIONS OF THE UTERUS. 6] in which a very large hydrometra had formed on the imper- forate side in a woman thirty-eight years of age, who had borne four children, is unique. Symptoms. The most prominent symptoms are periodical attacks of pain, quite similar to those met with in simple haematometra, but characterized by an accom- panying discharge of men- strual fluid. The distur- bances frequently, but not invariably, begin with men- struation ; occasionally they are deferred to a much later period. At the beginning, the symptoms of the dis- order are apparent only dur- ing the menstrual epoch ; later, however, the painful contractions are constant. It is important to be aware that the pain is not in all cases confined to the men- strual period, but that it may occasionally come on very suddenly. This may perhaps be accounted for by the supposition, that the two lialves menstruate at different periods. The occasional appear- ance of the symptoms later may be explained by supposing that for some time the obliterated horn did not menstruate at all, or but very slightly, and that the menstrual secretion only began or became increased in quantity after some particular event (sexual excitement, puerperal state). The tumor, consisting of the retained blood, makes its appearance most rapidly in deep occlusion of the vagina, in which case it soon protrudes between the labia. In the abdo- men it is not discovered till later. The influence on the bladder and rectum is the same as that of simple haematometra. Fig. 24. Unilateral haematometra, diagrammatic, after Freund. h, hymen ; vs. left open vagina ; us, left uterus; tn left tube; //■*, left round ligament: vd, ud, closed uterus and vagina on the right side, dilated by an accumulation of menstrual blood; til, right tube; led, right round liga- ment. 62 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The character of the menstruation varies. Usually it is nor- mal, but it may be absent for a greater or less time, or change to menorrhagia. The general health does not become affected in unilateral haematometra until a late period. The open horn may, of course, become pregnant, although at an advanced stage the diminution in space caused by the increas- ing tumor will materially interfere with conception. Terminations. These are substantially the same as in simple haematometra. External evacuation of the fluid is the most common termination, and is particularly apt to occur, because the tumor projects into the open genital canal, and often is separated from it only by a very thin septum. The rupture generally occurs in the septum, between the two uterine segments ; more rarely in the vaginal partition. Even after a termination so favorable as this, puru- lent inflammation and death may ensue. Another favorable termination, and the one which we should most naturally expect in this variety of haematometra, is the suppression of menstruation on the imperforate side, and the dis- charge of its functions by the other horn of the uterus. But it can scarcely be determined how common this fortunate issue is, since instances of it are very apt to escape medical observation. This was doubtless the case in the specimen in the Pathologico- Anatomical Museum of Erlangen, described by Hofmann, which belonged to a w^onian, sixty-four years of age, of whose history nothing was known, except that she had never borne children. The right imperforate cornu contained a cavity of only mode- rate size, which was partly filled by nodular protuberances of the mucous membrane of hemorrhagic origin. The unfavorable terminations do not differ from those of sim- ple haematometra. Diagnosis. The diagnosis is least difficult in cases of complete duplica- tion, and is usually made with ease if the possibility of this MALFORMATIONS OF THE UTERUS. 63 malformation is only borne in mind. Throughout the whole length of the vagina, from above downwards, a lateral tumor may be felt, which does not always lie exactly parallel to the permeable vaginal canal, but for embryological reasons usually winds somewhat spirally around the open vagina, the lower por- tion being situated somewhat anteriorly to, the upper somewhat behind, the vagina, or the reverse. The tumor is approximately cylindrical in shape, tense and fluctuating, and its continuation upwards is attached laterally to the permeable uterine horn. A tumor exhibiting these marks, and filled with fluid, cannot be anything else, and the puncture, which reveals the character- istic blood of haematometra, is hardly needed to confirm the diagnosis. A cystocele is distinguished from the conditions, for which it might possibly be mistaken, by means of the catheter; vaginal cysts do not grow to such a size, and are not attached to the vagina longitudinally ; an enterocele does not fluctuate nor form an abdominal tumor ; thrombi (hemorrhagic effusions in the cel- lular tissues about the vagina) are always connected with labor, and the puerperal state ; haematoceles are not found in this form, and x>erivaginal abscesses do not extend up so high. A cyst of the Bartholinian gland may possibly be mistaken for it in very exceptional cases where it extends equally high up, as proved by an observation by Honing.] The extension of the cyst into one of the labia majora, which is not possible in haematome- tra, must here also be relied upon as a sure mark of distinction. The diagnosis is much more difficult in those cases where the vagina is single and the blood is retained only in one uterine horn. A firmly elastic tumor, which presses the vaginal vault down- wards, is then felt closely adhering to the uterus. This fluctu- ating, sharply defined tumor, which is so closely attached to the uterus, or, where the uterus is distinctly double-horned, diverges above to the opposite side, is, after all, scarcely to be mistaken for any other neoplasm. The diagnosis is greatly strengthened by the fixed position of the intravaginal portion of the cervix, •M. f. G. B., 34, p. 130 64 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGAN'S. that is, by the fact, that on the side of the tumor the vaginal cul- de-sac is completely wanting ; in case of considerable distention of the closed horn the external os assumes a horse-shoe shape, with the open side turned toward the tumor. The diagnosis of a haematometra in a rudimentary horn is attended with the most difficulty. Hegar, however, succeeded in the two cases observed by him in making the diagnosis by exclusion. The connection of the tumor with the uterus by means of a cord, which is attached to the upper part of the dis- proportionably large cervix, and the presence of a uterus unicor- nis are the main points to be observed. The differential diagno- sis from a fibroid attached by a pedicle to the broad ligament is especially difficult. In case of need, the diagnosis may be settled by puncture of the tumor, which should be made through the vagina or the abdominal walls, according to the situation of the growth. Prognosis. As already stated above, the danger is not so great as in sim- ple haematometra, because, irrespective of the occasional sponta- neous cessation of the sanguineous exudation in the imperfo- rate horn, the rupture externally, namely, into the open genital canal, is much more common, and occurs much more readily. Treatment. The operation is performed in the same manner as in simple haematometra, by incising the lowest point of the protruding tumor. If the vagina is double, a crucial incision is made in the tu- mor, or a piece of its wall is excised, care being taken, how- ever—in order to prevent impregnation of that side—not to make the opening too large, lest by accident the penis should get into the previously imperforate half. In uterine atresia, the operation is best performed with a trocar, which is thrust into the protruding tumor, close to the external os. Very serious difficulties are present when the blood is con- STENOSIS OF THE UTERUS. 65 tained in the cavity of a pedunculate rudimentary horn. The operation is inevitable in these cases also, if the distress in- creases. An effort must be made to reach the tumor with the trocar from the vagina ; only in case of extreme necessity should it be done from the abdominal surface. Hegar attempted to induce adhesion of the tumor by previous cauterization of the vaginal vault. STENOSIS OF THE UTERUS. Mackintosh, Pract. of Physic, 4 ed., T. II. London, 1836, p. 481.—Simpson, Sel. Obst Works. London, 1871, p. 677.—Barnes, London Obst. Tr., Vol. VII., p. 120. —Sims, Clin. Notes on Uterine Surgery. New York, 1871, p. 177.—Greenhalghy London Obst. Tr., VIII, p.'142.—Tilt, e. 1., p. 262.—Beigel, Berl. klin. Woch., 1867, p. 493, and Graily Hewitt's Diseases of Women. Phila., 1868, p. 693.— Smith, Obst. Jour, of Great Britain, Feb., 1874, p. 705. Etiology and Pathological Anatomy. Stenosis of the cervix may be congenital or acquired ; if con- genital, generally the whole cervix is involved ; the external os is usually the seat of the chief constric- tion, rarely the internal os. In the nor- mal uterus (we do not refer here to the small cervix and external orifice of the undeveloped uterus), the intravaginal portion of the cervix is occasionally very long, hard, and cartilaginous, and projects as an uncommonly sharp conoidal mass into the vagina. On the tip of this mass is the external os, a very small, at times barely perceptible opening (Fig. 25), which is scarcely visible, even through the speculum (and then sometimes only when a small drop of mucus protrudes from it). Not unfrequently the anterior lip projects beyond, and slightly overlaps the posterior, closing the os as if with a valve. In rare instances the whole vaginal portion is swollen and oedematous. vol. x.—5 Fig. 25. Congenital stenosis of the cervix. 66 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Acquired stenosis is induced by various circumstances, par- ticularly by injuries during delivery and by puerperal inflamma- tory processes. It is, however, by no means rare in persons who have never borne children, even if we omit those varieties of constriction at the internal os resulting from flexion and fibroid tumors, which do not belong in this category. Stenosis may occur as the result of an inflammatory blocking up of the canal; or it may occur when there is inflammation of the mucous mem- brane, by the bursting of the distended cervical follicles (ovula Nabothi) and adhesion of their granulating surfaces ; or finally, by means of cicatricial contractions of all kinds, of which we will only mention those produced by cauterization. Symptoms. Two symptoms accompany obstruction of the cervical canal, of which the most important, pathologically speaking, is dys- menorrhcea. This symptom is characterized, as usual, by the occurrence of more or less severe uterine colic at the menstrual period, and this colic may occasionally increase to the most vio- lent paroxysms of pain. Although it is a general rule to find the pain corresponding in severity to the greater or less amount of cervical obstruction, this is by no means always the case. The rapidity of the hemorrhagic exudation from the uterine mu- cous membrane doubtless greatly influences the severity of the dysmenorrhoea. A gradual hemorrhage into the uterine cavity will naturally permit the blood to be discharged with sufficient rapidity, even through a very narrow cervical passage, without producing uterine colic. A sudden and profuse menstrual flow, on the other hand, will at times find some difficulty in passing through even a moderately narrow cervical canal, and as a consequence the cavity of the uterus will be forcibly distended, and possibly very severe dysmenorrhoea be produced. In this way we must seek to explain the circumstance, that in some cases of very narrow cervix, the act of menstruation is entirely painless, while in others, with but slight obstruction, the distress is very great. An additional consequence of the habitual irritation, to STENOSIS OF THE UTERUS. 67 which the uterus is subjected in aggravated dysmenorrhoea, may appear in the shape of metritis and perimetritis, and their symp- toms complicate those of simple stenosis. The second result of the stenosis is sterility. In this connec- tion we particularly desire to point out the fact that, clinically speaking, sterility does not, except in very rare cases, denote the absolute impossibility of conception, but generally only the pres- ence of a greater or less obstacle. It is exceedingly plausible to assume that the possibility of a meeting between the semen and the ovum is prevented in exact proportion to the degree of constriction existing in the cervical canal and at its external ori- fice, even though the mechanism, by means of which the sper- matozoa penetrate into the inner genital canal, be left out of consideration. The nature of this mechanism has not yet been elucidated. Formerly the opin- ion was generally held, that during coition the orifice of the male urethra touched the external os, and that at the ejaculation the semen was injected directly into the uterus. Aside from the fact, that the force of ejaculation certainly does not suffice to separate the contiguous walls of the uterus and propel the semen between them, we cannot for a moment entertain the idea that the two orifices lie in actual contact, and thus form a continuous canal between the male urethra and the cavity of the cervix. A piston-like movement of the penis, by which the latter, while being thrust into the vagina, pushes the ejaculated semen contained in the upper portion of that canal into the uterus, cannot be assumed, because the semen has sufficient room to escape at the side of the penis and into the vaginal cul-de-sac. The ciliary action of the epithelium has nothing to do with the propulsion of the semen, because the spermatozoa travel through the whole Fallopian tube to the ovary, and the cilia of the tubal epithelium vibrate in the opposite direction. The great length of this journey, made by the spermatozoa from the uterus to the peri- toneal termination of the tube,—a journey, therefore, of such length that we cannot reasonably suppose it to have been made under the influence of only a single force, —favors the assumption, that the inherent power of locomotion of the spermatozoa themselves is the most important and indeed the decisive factor in their progress. That their locomotor powers are by no means slight, has been proved by Lott,1 by direct observation; he saw them traverse the space of about one centimetre in one hour. We do not doubt that the existence of such a power of locomotion in the sper- matozoa is a sufficient explanation ; for in the pool of semen deposited in the vagi- nal cul-de-sac, into which the intra vaginal portion of the cervix dips, there is con- 1 Der Cervix Uteri, etc., p. 142. 68 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tained an enormous quantity of spermatozoa, of which it is necessary that only a very small number should find their way up the cervical canal. Another force still seems to be active in securing the entrance of the spermato- zoa en masse into the cervical canal, namely, a species of suction-power of the uterus. During cohabitation the plug of mucus which ordinarily occupies the cervical canal appears to be expelled into the vagina, and hangs down in the shape of a stringy mass, referred to by Kristeller.1 Of necessity, as soon as the expelling force ceases, an equal amount of mucus must be drawn up into the cervix, and as in the mean- time the semen and cervical mucus have become intimately commingled in the vagina, it stands to reason that with this alkaline mucus, which preserves the activ- ity of the spermatozoa—whereas the vaginal secretion is poisonous to them—a number of lively spermatozoa must be sucked into the cervix. The force expelling the cervical mucus is supposed by Sims2 to be the contraction of the upper portion of the vaginal wall, which presses the glans penis against the cervix; Kehrer,3 how- ever, endeavors to account for the expulsion by the active contraction of the cer- vix itself. Other observers, particularly Wernich4 and Fehling,6 believe that the mucous plug is expelled by an " erection " of the cervix, at the relaxation of which the mucus, commingled with semen, returns to the cervical cavity. A very narrow external os would impede conception, not so much by the mere presence of a constriction, as by greatly interfering with, if not entirely preventing, the process of expulsion and subsequent suction. Diagnosis. In the congenital form, our attention is at once attracted, in a digital examination, to the sharply conical shape of the intravaginal portion of the cervix, and to the exceeding small- ness of the external os. The condition of the cervix farther up must be ascertained by the use of the sound. The external os may be so small as to require the substitution of a slender sur- gical probe for the uterine sound; when the obstruction is due to tumefaction, however, a sound of not too slender proportions will be found more serviceable. Acquired stenosis is likewise detected by the sound. 1 Berl. klin. Wochenschr., 1871, Nos. 26-28. JLoc. cit.,p. 363. 3 Zusammenh. des weibl. Genitalkanals. ■ Giessen, 1863, p. 41. 4 Berl. Beitr. z. G. u. Gyn., B. 1, p. 296, and Berl. klin. W., 1873, No. 9. 5 Arch. f. G. B., V.,p. 342. STENOSIS OF TIIE UTERUS. 69 Prognosis. Life is rarely endangered by cervical obstruction, although the resulting dysmenorrhoea is a serious obstacle to the enjoy- ment of life's pleasures, and also may entail vitally dangerous diseases in the shape of metritis and perimetritis. By means of operative interference, not dangerous in itself, the prognosis at once becomes favorable, the dysmenorrhoea usually speedily dis- appears with the dilatation of the cervix, and frequently con- ception soon ensues. Treatment. The only rational therapeutical indication is the dilatation of the constricted cervical canal. This dilatation may be accom- plished in various ways, viz. : 1. By the introduction of bougies gradually increasing in size, by means of other mechanical dilators, or by means of sub- stances which swell by imbibition (laminaria and sponge-tents). The advantages and evils of these methods have already been discussed. As a rule simple dilatation is fully as dangerous as the cutting method, besides being less effective. The ease with which the cervical canal contracts again to its original size, after mechanical dilatation, is shown in a case reported by Barnes, in which, notwithstanding the constriction, conception took place; but the stenosis returned after miscarriage in the fifth month, that is, after an extreme degree of mechanical dilatation. This opinion regarding the transitory nature of the result will prob- ably also be found to apply to the new dilator recommended by Ellinger.1 2. Dilatation of the constricted cervical passage may also be achieved by operative means.2 For this purpose a variety of specially constructed instruments have been devised, some with one, others with two blades. To the former class belongs the 1 Arch. f. Gyn. B. V., p. 268. 2 Oppel, Wiener med. Presse, 1868, Nos. 34-36; G. Braun, Wiener med. W., 1869, Nos. 40-44 ; Henry Bennet, Brit. Med. J., Sept. 21, 1872; Ohhausen, Die blutige Erweiterung des Gebarmutterhalses, No. 67, der Samml. klin. Vortriige. 70 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. instrument described by Simpson (Fig. 26), which is simple in construction and thoroughly useful. The blade is kept con- cealed during the introduction of the instrument, and is made to protrude upon its withdrawal; in this way first one side of the cervix and then the other can be divided. In order to avoid this repeated introduction, similar instruments, provided with two blades, which are arranged to emerge on either side by pres- sure, have been constructed by Greenhalgh and Martin. In the hysterotome of Mathieu the two blades are made to protrude by merely withdrawing the instrument. A very simple two-bladed metrotome has been devised by Coghill' (Fig. 27). The instruments with only one blade have the disadvantage of making the first incision deeper than the second, because when the latter is made there is much less resistance at the back of the knife. With the two-bladed contrivances this is avoided; but even they are liable to cut unequally, because the tissues may be of different density on either side, and one knife may cut better than the other. The dilatation of the external os is apt to be rather slight with these instruments, and it is generally found necessary, in addition, to incise the cervix with the scissors. For this reason a more simple, and at least equally effective, plan is to discard all complicated instruments and operate only with the knife and scissors. After bringing the cervix into view in the speculum, and securing it with a tenaculum, the slender blade of a long pair of scissors, the handles of which are bent downwards (see Fig. 28) in order not to interfere with the view through the specu- lum, is passed into the cervix, and one side of the latter cut through to the vaginal insertion ; the scissors are then with- drawn and reintroduced, and the other side divided in the same manner. If the constriction extends to the internal os, the latter must then also be divided laterally, either with Simpson's metrotome, or with the small knives devised by Sims and others. Inflammation of the uterus and cellular tissue does not ensue 1 Edinb. Obstet. Tr., II., p. 340. STENOSIS OF THE UTERUS. 71 if the operation has been performed with clean instruments ; the hemorrhage, however, may be considerable, and occasionally serious. For this reason, and also to prevent the rapid union of the divided parts, it is advisable to cauterize the raw surface, either by touching it with a pointed actual cautery iron, or by inserting small pledgets of cotton, impregnated with chloride Fig. 26. Fig. 27. Fig. 28. Simpson's metrotome. Coghill's metrotome. Scissors for the division of the cervix through the speculum. of iron, between the edges. A large tampon should then be placed in the vagina to keep these pledgets in place. Other treatment than absolute rest for a few days is not required. On the following day the tampons should be re- moved, and precautions taken to prevent reunion, to which the cervix is very much disposed. The external os is best kept open by the finger, which is thrust into it daily, or every other day; the internal os, by the repeated introduction of thick bougies. 72 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. If the vaginal portion of the cervix is conically elongated and the external os very small, it is advisable to remove a portion of it with the knife and scissors, or, after Spiegelberg's plan, * with the galvano-cautery. HYPERTROPHY OF THE UTERUS. General Hypertrophy. Rlob, Pathol. Anat. der weibl. Sexualorg., pp. 124 and 203.—Sdxinger, Prager Vier- teljahrschrift, 1866, 1, p. 114.—Courty, Traite des mal. de ruterus, etc., 2 ed. Paris, 1872, p. 702. Etiology. True hypertrophy and hyperplasia of the uterus, i.e., an equable increase in size and number of all its constituent parts, particularly of its muscular fibres and connective tissue, is a very rare pathological condition. The physiological counterpart of this state is pregnancy; a general pathological hypertrophy of this kind is found most clearly developed in the case of abnormal contents in the cavity of the uterus, particularly in haemato- metra. Hyperplasia of the connective tissue alone is much more fre- quent. As a pure anomaly of nutrition, independent of inflam- mation, it is very rare ; but it is quite common as a consequence of subacute or chronic inflammatory processes, or, at least, as a secondary process, complicated with inflammation, as in defec- tive puerperal involution. A well-defined line can scarcely be drawn between simple hypertrophy and that form which is accompanied by inflammatory manifestations, at least such as are clinically demonstrable. Klob almost completely omits chronic metritis ; our own conviction, which we shall hereafter find occa- sion to explain more particularly, is that, for clinical reasons, we are, for the present at least, unable to spare the general path- ological condition known as chronic metritis, even though mor- bid changes, which are from an etiological stand-point totally different, be included under the term, and though all these 1 Archiv f. G., 5, p. 436. HYPERTROPHY OF THE UTERUS. 73 changes may not be due to inflammation. We shall, therefore, describe the great majority of cases of general increase in bulk of the uterus under the head of chronic metritis, and only consider here as instances of pure hypertrophy, without inflammatory origin, those cases in which an increased supply of blood has induced a corresponding increase in the nutrition of the uterus, without the occurrence of any primary or occasional subsequent inflammatory action. The most common example of this variety is the connective- tissue hyperplasia in tumors of the uterus, especially in intersti- tial fibroids. So much irritation is excited and maintained by these growths that, without the occurrence of the least inflam- matory action, the supply of nutritive material becomes more abundant than normal, and either a true hyperplasia, or, as a rule, a diffuse proliferation of connective tissue takes place throughout the whole uterus. That form of hypertrophy which, according to Seyfert,1 is occasionally met with in prostitutes, may be explained in the same manner ; the hypertrophic condition, however, which is not unfrequently seen in married women, whose generative organs are irritated by frequent but imperfect sexual intercourse, and which West2 classifies under the head of simple hypertrophy, should in all probability be generally designated as chronic metritis. Cases of hypertrophy from displacement, especially prolap- sus and flexions, only very exceptionally come under this cate- gory. The hypertrophy is caused by passive congestion; the displacement acting as an obstruction to the free return of blood from the uterus. The usual occurrence of inflammatory action in the course of the affection places this variety under the head of chronic metritis. The congestion is less likely to increase to inflammation in those cases of venous stasis dependent on dis- turbance of the general circulation, in consequence of cardiac or hepatic disease. The arrest of puerperal involution also, clinically speaking, 1 Siixinger, 1. a, p. 115. 2 Lehrb. der Frauenkrankh. III. Aufl., p. 111. 74 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. rarely belongs here. It is very rare to find such uteri merely enlarged without a trace of inflammation. As a rule, the uterus is found to be sensitive, or, at least, from time to time, an in- crease in bulk, accompanied by pain, takes place. We there- fore include this form also under the clinical condition of chronic metritis. Pathological Anatomy. The uterus in true hypertrophy does not differ microscopi- cally from that enlarged by connective-tissue proliferation. The microscope alone decides whether all the constituent parts are increased in nearly the same proportion, or whether the connec- tive tissue is particularly abundant. The uterus is especially enlarged, as a rule, in the anteropos- terior diameter, whereby it acquires a somewhat spherical shape. Its walls—particularly at the fundus and posterior surface—are considerably thickened. Its tissue is generally not very hard, but rather soft and succulent; not until the condition which causes the hyperplasia ceases, and the proliferation no longer continues, do the fresh connective-tissue elements undergo the change into fibres, which process is followed by cicatricial retrac- tion, and consequent induration. Symptoms. Since a simple increase in volume of the uterus, without any complications whatever, is exceedingly rare, the description of the symptoms is necessarily drawn rather from analogical deduc- tions than from personal observation. The uterus, increased in weight, changes its shape and position somewhat, the swelling of the antero-posterior diameter removes the concavity on the ante- rior surface, and the heavy fundus falls more forward, form- ing a stronger anteversion than is natural. Should the uterus, however, be disposed to a posterior displacement, retroversion of a high degree will occur. The consequences of these changes are sacral pain, a sensation of weight and downward pressure in the hypogastrium, and disturbed micturition; hysterical symptoms of various kinds may also make their appearance. In hyper- HYPERTROPHY OF THE CERVIX. 75 trophy accompanying other diseases (fibroids, prolapse), these hysterical symptoms predominate. Diagnosis. The general enlargement of the uterus is detected by means of conjoined manipulation. If its walls are of uniform thick- ness, if the organ is entirely devoid of sensitiveness, and no inflammatory action has ever been present, the diagnosis is that of simple hypertrophy. Treatment. During the first stage of uniform hypertrophy, even in the absence of all inflammation, slight but frequently repeated ab- stractions of blood are most effective, both in active and passive hyperaemia. If the hypertrophy is attributable to other disor- ders, these latter are to be treated. Very old cases are but little influenced by treatment; even that favorite remedy, the iodide of potassium, will scarcely be of service. HYPERTROPHY OF TIIE CERVIX. Levret, Jour, de med., T. 40, 1773, p. 352.—Homing, Lancet, Aug., 1844.—Ken- nedy, Dublin Monthly Journal, Nov., 1838, Vol. XIV., p. 319 (see Froriep's Notizen, 1839, B. IX., No. 193, p. 266).— Huguier, Memoires de l'acad. de mCdecine. Paris, 1859, T. 23, p. 279, and Sur les allongements hypertroph. du col de l'utgrus. Paris, 1860.—Stoltz, Journal hebdomadaire, Juin, 1859.— Scanzoni, Chronische Metritis, pp. 46 and 58. —Rumbach, Des allong. hypertr. du col de l'uterus. These. Strasburg, 1865, p. 5.—Saint-Vel, Gaz. de Paris, 1871, pp. 9 and 12.—Spiegelberg, Arch. f. Gyn., B. V., p. 411. Hypertrophic conditions of the cervix differ so much in accordance with the portion of the cervix affected, that we are compelled to consider them separately, even though we do not include the follicular hypertrophy of the lips, which, as proceed- ing merely from the mucous membrane, and genetically identi- cal with mucous polypi, we shall discuss in the chapter on cer- vical catarrh. The cervix, to describe it accurately, should not be divided into two sections—an infravaginal and a supravaginal—but, in 76 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. accordance with the different insertions of the anterior and pos- terior vaginal walls, into three portions. In Fig. 29, a, that part of the cervix situa- ted below the insertion of the anterior va- ginal wall designates the true infravaginal portion of the cervix ; c, that part situated above the insertion of the posterior vaginal wall, the true supravaginal portion ; while b represents the section between these two portions, being supravaginal in front, and infravaginal behind. Each of these three Fig. 29. Division of the cervix into three portions. P, peritoneum; Bl, bladder; a, infravaginal por- tion ; 6, middle portion (infra- vaginal behind, supravaginal in front); c, supravaginal portion. portions may become hypertrophic by it- self, and present a pathological condition totally different from the others. Let us first consider the hypertrophy of the portion a, the infravaginal portion proper. HYPERTROPHY OF THE INFRAVAGINAL PORTION. C. Mayer, Virchow's Archiv, 1856, B. X., S. A., p. 21.—C. Braun, Zeitschr. d. Ges. d. Wiener Aerzte, XX., 1864, p. 43.—Simon, M. f. Geb., B. 13, p. 424.—£az- inger, Prager Vierteljahrschrift, 1866,1., p. 120. Etiology. The causes of general '' peniform'' hypertrophy of the infra- vaginal portion are entirely unknown. Parturition cannot be specially blamed for it, because the most typical cases have occurred in nulliparae. Labor and the puerperal state are fol- lowed by other varieties of enlargement of the infravaginal portion, viz., an irregular, nodular hypertrophy, dependent on cervical inflammation, and coming under the head of chronic metritis and peculiar hypertrophic changes of configuration, which occur with particular frequency in large lateral lacera- tions of the cervix. Pathological Anatomy. The variety to be described here is characterized by the uniform hypertrophy of all the elements ; the infravaginal por- HYPERTROPHY OF THE CERVIX. 77 tion of the cervix is normally constituted, and its thickness is generally but little increased ; its length only is unusual. The mucous membrane remains unchanged, becoming hy- pertrophied only so far as is necessary to cover the elongated infravaginal por- tion. Occasionally, in women who have borne children, only one lip is hypertro- phic, and may assume the most peculiar shapes. The highest degree, however, of pathological develop- ment is found in nulliparae, in whom the infravaginal portion may attain such a size as to project from the vulva in the shape of a conical body, somewhat re- sembling the erected penis. The vaginal portion is firm and dense, and closely covered by the mucous membrane ; the external os is unusually small. In the case observed by me (represented in Fig. 30) an ordinary uterine sound could not be passed through the narrow os, from which hung a drop of mucus. (Figs. 30 and 31.) Fig. 30. True hypertrophy of the infravaginal portion. a, the hypertrophic infravaginal portion protruding some distance from the vulva ; 6, the narrow external os. Symptoms. The increase in volume does not in itself appear to cause great inconvenience, because the existing symptoms are exclu- sively due to the external protrusion of the growth. They thus resemble those commonly found in prolapsus, but the hyper- trophic elongation seems more sensitive, and therefore, lying, as it does, between the labia and thighs, usually causes great dis- tress. It will usually be found that a certain amount of discharge— 78 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. perhaps produced only by the mechanical irritation of the tumor—has been going on for some time, and is still present. Diagnosis. A careful examination will serve to distinguish this condition from all others. On conjoined manipulation we find the body of the uterus in its normal position, and on examination per vaginam, the cervix is felt to merge every- where uninterruptedly into the tumor, which projects free into the vagina, and can, therefore, be nothing else than the elongated infravaginal portion. Thus these physical signs fully suffice to dif- ferentiate this affection from poly- pus, inversion, and prolapsus, as well as from the supravaginal hy- pertrophy of the cervix. If the vaginal insertion is at its normal altitude in front and behind, only that portion of the uterus project- ing into the vagina is hypertro- phied. The hypertrophy of one lip is detected with still greater facility. An internal exploration shows us that the tumor is continuous with the lip, and in the same manner this form of hypertrophy may be distinguished, by the regularity in shape and uniform firmness of texture, from the affection known as follicular hypertrophy (to be described hereafter). Prognosis. If left to itself the tumor, when once it has passed the ostium vaginae, does not diminish, because from that time forth it is exposed to continual irritation, which excites it to still further enlargement. Fig. 31. The same case, seen in a pelvic section. HYPERTROPHY OF THE CERVIX. 79 Treatment. A cure is possible only by amputation, a not very dangerous operation, as an injury to the adjacent parts can easily be avoided, inasmuch as the infravaginal portion alone has grown downwards, and neither the bladder nor the peritoneum of Douglas's cul-de-sac extends into the tumor (Fig. 31). Since, furthermore, it is not necessary to amputate directly below the vaginal insertion, but only somewhat above the entrance of the vagina, owing to the fact that the involution always following the operation completes the process of reduction, injuries of the organs named do not occur during the operative cure of this variety of hj^pertrophy. The hemorrhage is, however, usually very considerable. The operation may be performed with the wire ecraseur, which divides the dense tissue smoothly and thoroughly, with the galvano-caustic loop, or with the knife or scissors. I prefer to operate with the knife, because neither the ecraseur nor Middeldorpff's galvano-caustic apparatus prevents hemor- rhage with absolute certainty, and their use excludes the suture, the most reliable haemostatic. If the tumor, as is usually the case, is not very voluminous, the following modus operandi is to be recommended : a thin linen band- age is passed around the tumor immediately below the vaginal in- sertion, and twisted so as to firmly compress the hypertrophic infra- SutureS) after ampu?t;o3n2'of the mfravaginal vaginal portion. We thus possess portion. a means of fixation of the tumor during the operation, and are enabled to operate without hemorrhage, because the loop com- pletely compresses the afferent vessels. Should an artery spirt, nevertheless, during the division, the bandage need only be twisted tighter, until the hemorrhage ceases. The tumor is now drawn down somewhat, and that portion be- low the vaginal entrance removed ; the sutures are then at once 80 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. applied, the cervical mucous membrane being united with the vaginal mucous membrane over the stump, and the gaping lateral edges being stitched together, as represented in Fig. 32, after the manner recommended by Hegar,1 Simon, and Spiegelberg.8 Sims applies the sutures in such a manner (Fig. 33) as to approximate the edges of the vaginal mucous membrane on the anterior surface of the stump to those of the membrane on the posterior surface, without regard to the mucous membrane of the cervical canal. Sutures thus applied have the great disad- vantage of not surely controlling the hemor- rhage, because blood may collect between the surface of the stump and the united mucous membrane loosely covering it, and so necessitate the opening of the wound. A cicatricial contraction of the external os may also result. If the infravaginal portion is unusually voluminous, it is better to incise it later- ally, excise a wedge-shaped piece from each lip, and unite the edges of the wound by deep parenchymatous sutures, after the manner to be described in the operation for median hypertrophy. Particular stress should be laid upon the fact that, by means of amputation, the cer- vix is not only shortened to the extent of the piece removed, but in consequence of the division of its large vessels the nutrition of the whole cervix is so materially impaired as to give rise to a fatty degeneration and involution similar to that which takes place after parturition. HYPERTROPHY OF THE SUPRAVAGINAL PORTION OF THE CERVIX. Fig. 33. Sutures according to Sims. Virehow, Verh. d. Berl. Ges. f. Geb., II, p. 205.—C. Mayer, M. f. Geb., B. 11, p. 163.—Scanzoni, Beitr. z. Geb. u. Gyn., IV., p. 329.—C. Braun, Zeitschr. d. Ges. 1 M. f. Geb., B. 34, p. 395, andTageblatt der Wiener Naturforschervers, p. 176. SL. c.,p. 440. HYPERTROPHY OF THE CERVIX. 81 d. Wiener Aerzte, 1864, p. 43.— Martin, M. f. Geb., B. 20, p. 203.—Barnes, Brit. Med. J., January 7, 1871—Spiegelberg, Berl. klin. W., 1872, Nos. 21 and 22.— Goodell, Prolapse of the Womb. Phila., 1873; and, Some Practical Hints, etc., Med. and Surg. Reporter, Jan. and Feb., 1874. We shall consider here only those cases in which that portion of the cervix becomes hypertrophic which is situated above the insertion of the posterior vaginal wall, viz., part c in Fig. 29, and exclude at the same time the secondary hypertrophy of the cervix, which is only the consequence of prolapse of the uterus. Etiology, Although in certain individual instances this supravaginal hypertrophy arises from unknown causes, similar to those occa- sionally underlying infravaginal enlargement, still in a large number of cases this condition must be regarded as the conse- quence of a primary prolapse of the vagina, — an etiological fact already pointed out by Cruveil- hier, and recently alluded to with special stress by Spiegelberg. It will be readily understood that the prolapsing vagina exerts general omnilateral traction on the cervix. If, as is usually the case, all the conditions favorable to pro- lapse of the uterus are also present (relaxation of its attachment to the adjacent parts), a secondary pro- lapse of that organ is the natural consequence. Should the uterus, however, be retained in its position by normal or pathological sup- ports, and thus be unable to fol- low the traction of the vagina, a drawing out of the cervix in a downward direction easily occurs vol. x.—6 Hypertrophy of the supravaginal portion of the cervix. a, body of the uterus; b. hypertrophy of the cervix; c, bladder; d, diverticulum of the blad- der. 82 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. —usually not merely a simple elongation with attenuation, but, through the irritation, an increase in bulk of the whole cervix. This causal connection was evidently the case in the specimen represented in Figs. 34 and 35, in which the vagina was so com- pletely prolapsed, that no trace of a vaginal cul-de-sac could be detected at the normal spot behind the urethra and in front of the frenulum, and the deeply prolapsed external os was almost covered and hidden from sight by the overlapping folds of the vagina (Fig. 35). The condition of the vagina shows that it was not secondarily dislocated by the downward growth of the cervix, but that the latter was drawn down by the prolapsed vagina. Pathological Anatomy. In this variety of hypertrophy, the body of the uterus con- tributes but very little to the marked elongation of the organ, which generally amounts to nearly six inches (fifteen centime- tres) ; the hypertrophy is confined chiefly to that portion of the Fig. 35. The same supravaginal hypertrophy; anterior view. cervix which is situated above the vaginal insertion. As a rule, this condition is due, as stated above, to the primary prolapse of the vaginal mucous membrane. But in the other class of cases, when the upper portion of the cervix grows downwards, the HYPERTROPHY OF THE CERVIX. 83 vaginal cul-de-sac must necessarily follow, and the vagina be- comes more inverted, the more considerable the hypertrophy, until finally, becoming turned entirely inside out, it protrudes from the body. The external os is thus found very low down, protruding from the vulva and covered by the inverted vagina (the condition is not distinguishable by the eye alone from prolapsus, as Fig. 35 shows), whereas the fundus is situated at its normal height, or but little lower, occasionally even somewhat higher than usual. The relations of the adjacent organs are here of supreme importance. Supravaginal hypertrophy differs essentially from infravaginal elongation, in that the latter affection merely de- notes the extension of the infravaginal portion {a, in Fig. 29), into the vagina, whereas, in the former (c, in Fig. 29) the neigh- boring organs, particularly the bladder and retro-uterine perito- neum, occasionally also the vesico-uterine duplicature of the peritoneum, which are closely attached to the upper part of the cervix, are dislocated downwards daring the growth of the latter. The extent of this dislocation is exceedingly variable ; a diver- ticulum of the bladder, and the retro-uterine peritoneum, how- ever, are generally displaced so far downwards in this variety as to reach to the tip of the tumor. The ante-uterine peritoneal duplicature usually remains unchanged. Symptoms. The appearance and symptoms of supravaginal hypertrophy resemble those of prolapsus uteri so much that these two con- ditions are very often mistaken for each other; in fact, the resemblance is so strong that Virehow termed the former affec- tion "prolapse of the uterus, without descent of the fundus." The symptoms also are identical with those of prolapse, and depend almost entirely on the presence of a tumor in front of the vulva. Even though the pain and actual discomfort may at times be slight, still the same troublesome and annoying conse- quences are present as in prolapse. 84 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Menstruation may be regular, but is often profuse and con- tinues long beyond the climacteric period. The distressing consequences of cystocele (stagnation and decomposition of the urine with consecutive vesical catarrh) may be wanting, if, as in the case represented in Fig. 34, the hyper- trophic cervix is so voluminous as to compress the entrance to the cystocele (the catheter could be introduced only with some difficulty, and even when the bladder was full, the pouch did not contain a drop of urine). Diagnosis. We shall consider here particularly the differential diagnosis from prolapse, because this disease at first sight is always taken for it, and it is easily distinguishable from other tumors found outside of the vulva (inversion, polypus). To mistake a simple prolapse of the vagina or uterus for a supravaginal hypertrophy is scarcely possible, because palpation and the sound determine the normal length of the uterus. It is therefore very easy to ascertain that, whilst the external os is situated outside of the vulva, the fundus remains at its normal height, and the cavity of the uterus is considerably elongated. This condition proves that the case is not one of simple pro- lapsus uteri, and the inverted and displaced vagina clearly distinguishes the affection from hypertrophy of the infravaginal portion. It may be very difficult to decide in these cases whether a primary or secondary hypertrophy of the cervix is present. By primary we mean the hypertrophy at present under discussion, in which the fundus has always remained at its normal height, the growth of the cervix downwards alone causing the disorder. There is no doubt, however, that secondary hypertrophy may occur ; that is, that there are instances in which there was first a simple prolapse of the uterus, in consequence of which the organ gradually became so much enlarged as to attain, with its fundus, quite or almost its original altitude. Anatomically, also, the two conditions resemble each other very much. In primary prolapsus, the bladder in front, and HYPERTROPHY OF THE CERVIX. 85 Douglas's cul-de-sac behind, sink down with the uterus, and remain down, even when the upper portion of the cervix grows upwards, and these same parts, being intimately connected with the cervix, are displaced downwards in the same manner as in primary hypertrophy of the cervix. It may, therefore, be exceedingly difficult to differentiate with absolute certainty between the two conditions. The chances will be in favor of primary hypertrophy, if the fundus remains at its normal height, and the prolapse of the vagina is primary ; that is, if the vagina (see Fig. 34) has pro- lapsed so completely as to throw itself into folds below, which are not filled out by the enlarged uterus. The hypertrophy is secondary, however, if the uterus pre- sents the appearance of having been pressed downwards with great force, so as to completely invert the vagina, or the traction outwards and upwards of the tense vagina has everted (ectro- pionized) the external os. Additional certainty is given to this diagnosis if the bladder and retro-uterine peritoneum are situ- ated rather high up,—a rare occurrence, to be sure, due to their secondary elevation by the growth of the cervix upwards. Such cases have been reported by Martin,1 Scanzoni,2 and R. Barnes.3 Prognosis. Without medical assistance the disease is very distressing and deleterious to health. The part situated outside of the vulva is exposed to constant irritation, and consequently does not decrease in size, but is continually inclined to enlarge still further. Ulceration, a discharge of sanious pus, or more rarely the dangers occasionally accompanying prolapsus, sooner or later make their appearance. Treatment. The amputation of the lowest portion of the cervix is very 1 M. f. Geb., B. 34, p. 328. 1 Beitr. z. Geb. u. Gyn., IV., p. 332. 3 Brit. Med. J., Sept. 30, 1871. 86 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. difficult of execution in this variety, because the bladder and Douglas's pouch extend down to the apex of the tumor. Hegar has, indeed, recommended for these cases his method of conical excision,' in which the incision is made obliquely upwards, ter- minating in the cervical canal at a point higher up than the ex- ternal wound, and thus excising a funnel-shaped piece from the cervix. But not even by this operation will it be possible to remove the whole portion exterior to the vulva, and subsequent involu- tion will in aggravated cases hardly bring about a sufficient dim- inution of the hypertrophy. Inasmuch as but little improvement is to be expected from an operation in true supravaginal hypertrophy, and the danger of wounding the peritoneum is very great (the bladder, too, should not be injured, and by aid of the catheter we may ascertain how far down it has descended), the question arises, whether there are no other means by which palliative assistance, at least, may be render- ed, the discomforts diminished, and the patients enabled to attend to their daily duties. The replacement, that is, the return of the external parts within the vulva, although at first sight impracticable, owing to the fact that the fundus is located at its normal height, is still possible by means of an acute flexion of the uterus. In the case represented in Figs. 34 and 35, I replaced the uterus without great difficulty, leaving it in the position shown in Fig. 36, in which it was retained by one of Mayer's hard-rubber ring pessaries. Upon the return of the patient, four days later, 1 See the passages quoted above, and Huffel, Gebarmutter und Scheidenvorfalle. Freiburg, 1873, p. 44. Replacement of the uterus in a case of suprava- ginal hypertrophy of the cervix. HYPERTROPHY OF THE CERVIX. 87 the uterus still retained the same position, and the patient expressed herself quite contented with her condition. Unfor- tunately she did not return a third time, probably only because her state had become endurable. It will therefore depend on further observations to show how far a hypertrophied uterus is capable of involution while sup- ported by a pessary in the manner just described. Huguier also saw good results from the use of pessaries in mild cases, and recommends a T-bandage, whenever the uterus can be returned within the vulva. If pessaries prove insufficient, the conical excision of the cer- vix may be tried. The cervix can be amputated quite high up, if, after the manner to be described in the next chapter, the anterior vaginal wall with the bladder, and the posterior wall with the peritoneum, be dissected off from the cervix for a short distance, and a conical piece be then removed from the latter. HYPERTROPHY OF THE MEDIAN PORTION OF THE CERVIX. When the middle portion (part b, in Fig. 29) of the cervix is the chief seat of the hypertrophy, the symptoms will differ from those already described, because this part is supravaginal at the anterior and infravaginal at the posterior lip. These cases are more common in my experience than the two other varieties, although, with the exception of a case by Graily Hewitt' (repre- sented in diagram but not described in the text) I do not find this form of cervical hypertrophy mentioned in the literature of the subject. Etiology. As a rule, this condition is doubtless induced by prolapse of the anterior vaginal wall, which elongates the anterior lip by downward traction and provokes its enlargement. That portion situated above the attachment of the anterior vaginal wall there- fore becomes hypertrophied (b, in Fig. 29). The middle section, b, of the posterior lip also increases in size. The traction of the Diseases of Women. Phila., 1868, p. 482. 88 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. vagina in these cases is followed, exceptionally, not by prolapse of the uterus, but by hypertrophy of the cervix, which result is very much facilitated, if the uterus is at the same time retain- ed by pathological adhesions in its normal position, and thus pre- vented from yielding to the trac- tion from below. In five cases of this kind observed by me, the uterus was thrice held fast at the brim of the pelvis by perimetritic adhesions, and once by large fi- broids. The correctness of this etio- logical explanation is proved by the condition of the anterior va- ginal wall, the primary prolapse of which is evident, although the firm attachment of the upper por- tion of the anterior wall to the cervix will still generally tend to preserve a trace of the anterior vaginal cul-de-sac. A case of hae- matocele observed by me also illustrates this point, and clearly shows how the cervical hypertrophy begins. Fig. 37 shows how the unusually deep prolapse of the anterior vaginal wall, a, has elongated the anterior lip. Fig. 37. Retro-uterine hasmatocele, IT, with elongation, particularly of the anterior lip, in consequence of the high degree of prolapse of the anterior vaginal wall, a. Moderate prolapse of the posterior vaginal wall, b. Pathological Anatomy. The uterus will be found to have undergone a considerable elongation, confined exclusively, or at least nearly so, to the middle portion of the cervix (b, in Fig. 29). This hypertrophy, as shown by the examination by Crevet1 of two amputated cervices, is entirely limited to the connective-tissue elements. There were so very few muscular fibres as to warrant the assump- 1 Inaug. dissert. Erlangen, 1874. HYPERTROPHY OF THE CERVIX. 89 tion that in connective-tissue hypertrophy the existing muscular elements become partly destroyed. (It can scarcely be doubted that these observations also apply to the other forms of cervical hypertrophy.) As the middle portion is closely attached to Fig. 38. Case of median cervical hypertrophy. the bladder, it draws down in the course of its growth a pouch of the latter, and as it is situated above the vaginal insertion, the anterior vaginal cul-de-sac also becomes dislocated downwards. At the posterior lip, the hypertrophy of the median portion assumes an entirely different aspect, because there the middle portion is situated below the posterior vaginal attachment, and the hypertrophy therefore is entirely infravaginal. For this reason, we find in the tumor, which lies in front of the vulva and is often mistaken for a prolapsus uteri, anteriorly, a pouch of the bladder extending either quite to the tip of the protruding mass, or nearly to it, and the anterior vaginal cul-de-sac effaced or very shallow. Posteriorly the condition is quite different; there the vault of the vagina still remains at its normal height, or is but slightly depressed, and the peritoneal duplicature of Douglas's cul-de-sac does not extend into the tumor. Symptoms. These entirely resemble those of the preceding variety, and consequently those of prolapsus uteri. 90 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Diagnosis. Hypertrophy of the median portion of the cervix cannot pos- sibly be mistaken for anything else, because the normal relation of the posterior vaginal cul-de-sac, compared with the low posi- tion of the anterior, is very characteristic. Treatment. In contradistinction to the preceding variety, this form is exceedingly amenable to operative treatment. I have operated on three cases after the following method, which, if I correctly understand the description given in the Am. Jour, of Med. Sc. for 1871 (p. 173), resembles that re- commended by Taylor. The patient having been anaes- thetized, the cervix is seized and steadied by Muzeux' double ten- aculum, and incised bilaterally up to the point where the posterior lip is to be amputated. The excis- ion of the posterior lip is then per- formed by cutting out a wedge- shaped piece in such a manner that the remaining cut surfaces will ex- actly fit each other; the sutures to hold them in contact should be introduced at once after making the incisions (see Fig. 43, aa). The sutures are introduced into the cervical mucous membrane, are then passed deep through the cer- vical tissue, and brought out at the very apex of the wedge. The needle is again introduced close by, passed deep into the parenchyma, and brought out near the posterior line of incision. The sutures are then at once firmly tied. The amputation of the anterior lip is then performed in Fig. 39. Pelvic section of the case represented in Fig. 38. a, body of the uterus; b, elongated cervix; c, short anterior vaginal cul-de-sac ; d, normal pos- terior vaginal cul-de-sac; e, pouch of the blad- der. The dotted line indicates where the incis- ion was made in the amputation. HYPERTROPHY OF THE CERVIX. 91 the following manner: The mucous membrane of the anterior lip is divided by a transverse incision about one centimetre below the apex of the vesical pouch, and the incision is then carried obliquely upwards through the substance of the lip towards the cervical canal, terminating at the point of amputation of the posterior lip. The sutures are applied in the same man- ner as described for the pos- terior lip; that is, the needle is first introduced into the mucous membrane of the cervical canal, then brought out at about the middle of the surface to be united, then reintroduced close by, and, always passing deep through the tissues, is brought out close above the divided mucous membrane of the anterior lip. In order to avoid injur- ing the bladder during the amputation of the anterior lip, it is advisable to intro- duce a male catheter (see Fig. 43) into the cystocele, and with its point to lift the lowest fold of the vesical mucous membrane as far as possible from the tumor. If the cystocele extends Fig. 40. Case of median hypertrophy of the cervix. a, external os; b, papillary excrescence at the urethral orifice. Fig 41. The same case as that represented in Fig. 40, in pelvic sec- tion. The uterus is held fast above by large fibroid tumors. 92 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. down to the apex of the tumor, the incision should be made close below it, and the vaginal mucous membrane dissected off from the cervix for a short distance before carrying the incision deep into the tissues. When both lips have been united by sutures, the gaping lateral incisions should also be closed by a few deep sutures. The hemorrhage from the incisions, which is occasionally pro- fuse, may best be prevented by passing a strip of linen around Fig. 42. Fig. 43. Median hypertrophy of the cervix. Amputation of the cervix in median hypertrophy, The dotted line indicates the point of amputation. shown above by a sagittal, below by a transverso section. the cervix, above the point of amputation, in the manner already described above, and compressing the tumor by means of tor- sion. This strip also serves as an excellent means of manipu- lating the tumor during the operation. The operation performed in this manner is not dangerous, because the peritoneum, being situated high up, can scarcely be injured, and the cystocele, the depth of which is easily ascer- tained, can be avoided. Secondary hemorrhage may be entirely ATROPHY OF THE UTERUS. 93 prevented by the deep parenchymatous sutures, also recom- mended by Hegar.1 The separate amputation of the two lips, after bilateral divi- sion of the cervix, is necessary in this form of hypertrophy, because only in this manner can the amputation be performed at a higher point behind than in front. This mode of operating is rendered advisable by the size of the tumor itself, which is often so great as to cause the stump, after the sutures have been applied, to resemble that of an amputated limb. The subsequent involution of the uterus is very complete. ATROPHY OF THE UTERUS. Kiwisch, Klin. Vortrage, etc., 4 Aufl. Prag, 1854, B. I., p. 142.—Chiari, Ch., Braun u. Spaeth, Klin. d. Geb. u. Gyn. Erl., 1852, p. 371.—Simpson, Diseases of Women. Edinburgh, 1872, p. 597.—Klob, Pathol. Anat. d. weibl. Sexualorg., p. 205.—Scanzoni, Lehrb. d. Krankh. d. weibl. Sex., 4 Aufl., B. I., p. 81.— Jaquet, Berl. B. z. Geb. u. Gyn., B. II., p. 3. Etiology and Pathological Anatomy. Omitting primary congenital atrophy, which we have already considered, the following forms of acquired atrophy of the ute- rus are to be distinguished : Senile atrophy occurs in conjunction with atrophy of the other genital organs. The vagina becomes unusually short and smooth, the infravaginal portion of the cervix disappears, the external os is a small opening bounded by thin folds, and the uterus is small and flabby, with attenuated walls. The internal os is not unfrequently constricted, giving rise to a usually slight degree of hydrometra. The vulva also becomes atrophic, the cli- toris is merely a small nodule devoid of prepuce and frenulum, and the nymphse may be so completely effaced as to leave the vulva bounded laterally only by the labia majora, which are also atrophic. Senile atrophy is usually confined to an advanced period of life, after the sixtieth year, and is frequently wanting even 1 Huff el, p. 46. 94 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. then ; for the uterus may remain normal in size, or even abnor- mally enlarged, till very late in life. If atrophy occurs sooner, close upon the menopause, or if exceptionally the climacteric period, and with it the atrophy, appear before the usual time, it frequently causes morbid symptoms, such as sacralgia, debil- ity, mental depression, hysteria. The occasional occurrence of an atrophic uterus in chlorosis has also been referred to. This atrophy, however, is scarcely acquired; I at least have never seen a case of this kind in which it was probable that the uterus had formerly been more fully developed. Puerperal atrophy takes place in various ways, viz. : (1.) In the beginning of the puerperal state, particularly in tuberculous women, but also in those ill with puerperal fever. The change in the uterus depends on defective involution, com- bined with incomplete regeneration; that is to say, the old uterus undergoes fatty degeneration, but the products of that degeneration are not completely absorbed, and the new muscu- lar fibres are but imperfectly formed. The walls of the uterus are thick, but soft and pulpy. Klob gives the following descrip- tion of this form: "The uterine tissue is grayish-yellow or yellowish-red in color; very friable and delicate mucous threads, like spiderwebs, stretch across the laceration." 1 This variety of atrophy has of late attained some importance from the fact that even a careful sounding of the uterus may produce a perforation of the pulpy wall. Such a perforation, however, may heal, as I once had the opportunity of observing at the post-mortem of a woman who died of tubercular disease a year and a quarter after the perforation of the uterus had taken place. The uterus was normal in density, and rather thick. The cicatrix of the perforation could not be recognized with certainty. (2.) Puerperal atrophy occasionally occurs in a gradual man- ner in ansemic, badly nourished women, who have nevertheless passed through a normal confinement and puerperal conva- lescence. With them, even though they do not nurse their children, menstruation does not reappear ; they look prema- 1 Klob, 1. a, p. 207. ATROPHY OF THE UTERUS. 95 turely aged, and always suffer from a variety of symptoms : peculiar subjective sensations in the abdomen, sacralgia, mental depression, hysteria. The uterus in such cases is either merely very thin and flabby, and hardly recognizable by palpation, so that the sound in it can be felt through the abdominal walls with unusual distinctness (the cavity of the uterus being of the normal length), or the cavity is shortened, and the walls attenu- ated, although at times not flabby. Chiari describes two cases, which were associated with an uninterrupted secretion of milk. In these cases we should endeavor by means of good nourish- ment and local irritation (cold douche, leeches to the cervix, introduction of the sound or intra-uterine stems, electricity) to restore the uterus to its normal condition. (3.) A very marked atrophy may follow puerperal diseases, either after primary destruction of the parenchyma of the ovary (in peritonitis), of which the amenorrhoea and uterine atrophy are the consequences, or after serious disease of the uterus itself (septic endometritis), during which the mucous membrane and the innermost muscular layer were destroyed. As a secondary condition, atrophy occurs, besides, in the fol- lowing exceptional cases: In fibroids, which may cause the almost complete absorption of the tissue of the uterus (hypertrophy, however, being the rule), especially if a number of tumors grow towards each other. At the autopsy a mass of fibroids is then found, without any appreciable uterine tissue. Through the pressure of other tumors (subperitoneal fibroids, ovarian tumors, plastic exuda- tions) the parenchyma of the uterus may become exceedingly atrophic. A parietal atrophy is frequently associated with an elonga- tion of the uterus, a condition which may be produced by large tumors, or by puerperal adhesions of the uterus above the pelvic brim. The mere disappearance of the infravaginal portion, how- ever, in these cases, is not to be considered as atrophy, for that part only of the cervix which projects into the vagina disap- pears ; but if the elongation is extreme in degree, the walls of the uterus may become very thin, and even lesions of continuity may occur. 96 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Scanzoni has, besides, observed several cases of atrophy of the uterus associated with paraplegia. INFLAMMATION OF THE PARENCHYMA OF THE UTERUS— METRITIS. Acute Metritis. Boivin et Duges, Traite prat, des malad. de l'uterus, etc., II. Paris, 1833, p. 198.— Becquerel, Traite clin. des mal. de l'uterus, etc., I. Paris, 1859, p. 385.—J- Henry Bennett A Prac. Treatise on Inflammation of the Uterus and its Appen- dages, etc. London, 1853, 3d ed.—Mikschih, Zeitschr. d. Ges. d. Wiener Aerzte, 1855, p. 500. Etiology. Menstrual congestion may increase to acute inflammation; this is especially likely to occur under the influence of cold, and also where there is an obstruction to the discharge of the men- strual fluid, as is the case in constriction or impermeability of the cervix due to flexion or tumors. The congestion accompanying the sexual act is less frequently followed by acute inflammation ; but a typical metritis may occasionally occur as a consequence of gonorrhceal infection. A traumatic origin, such as a blow or fall on the abdomen, etc., is rare, always excepting surgical measures. Of far more frequent occurrence is it after surgical applica- tions which violently irritate the womb. Injections of too hot or too cold water into the vagina, vaginal pessaries pressing against the retroflected uterus, cauterizations of the cervix, intra-uterine injections, the introduction of the sound or of a stem-pessary, deserve especial mention as causative agents. The inflammatory processes (purulent infiltrations) occurring in the neighborhood of cancer of the uterus, possess an entirely secondary importance.1 Pathological Anatomy. The uterus may swell to the size of a goose's egg; it is thick, hypersemic, succulent, almost doughy. The whole substance is 1 Sdxinger, Prag. Vierteljahrschrift, 1836, 1, p. 130. ACUTE METRITIS. tumefied, infiltrated with serum, and hypersemic, and ecchy- mose~3hre scattered throughout its tissues. Between the mus- cular fasciculi pus-corpuscles are found, usually only in small quantity, in some spots more abundantly The endometrium, as a rule, is also inflamed, and the serous envelope always participates in the change, being either hypera? mic or bathed in pus, or else covered with flocculent deposits, or even thickened. Symptoms. Acute metritis is a very rare disease, but some authors are manifestly in the wrong when they deny its occurrence; in my own practice I have seen four well-marked cases. It begins with violent fever, even with a sharp chill. Intense pain of a two-fold character is present: 1, a deep-seated pain in the cavity of the pelvis, similar to that met with in abortion dur- ing the early months, and 2, perimetritic pain, increasing on pressure, a sign characteristic of peritonitic trouble. If the metritis comes on dur- ing the menstrual period, as is quite frequently the case, sup- pression of the menses is the usual consequence, although violent menorrhagia may also occur. The uterus is found much swollen (see Fig. 44) and very sensitive, not only on pressure from without, but also when an attempt is made to raise it by pressing up the cervix with the finger in the vagina. The pain is most considerable on con- joined manipulation, when the uterus is grasped between the two hands. vol. x.—7. Fig. 44. Acute metritis on the third day of the disease. u u, the swollen walls of the uterus. 98 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Ischuria, diarrhoea, and tenesmus, with violent pain ; also nausea, more rarely vomiting, are other ordinary symptoms. Walking and standing, coughing, straining during defeca- tion, in short, anything that in- creases intra-abdominal pressure, will create intense pain. There- fore perfect rest in bed, with ele- vated pelvis, is very soothing to the patient. Acute metritis is always com- plicated with endometritis, and more or less perimetritis. The latter may, indeed, attain such a degree as to give rise to intraperi- toneal exudation (see Fig. 45). In uncomplicated metritis, after several days, the tenderness de- creases and a complete restoration to the normal state ensues if a suitable regime has been observed. Very frequently, however, the sequel is chronic metritis, that is to say, there is left a moderate degree of sensitiveness and swell- ing which undergo acute exacerbations from time to time. The termination in the formation of an abscess is unusual. The abscess may become caseous—although this occurrence, of course, is rare—or it may perforate either into the peritoneal cavity, with fatal results, or more favorably into the cavity of the uterus ; not unfrequently, however, after agglutination has taken place, it breaks into the rectum or through the abdom- inal walls. Judging from the scanty notices of this subject in literature, abscesses of the uterus appear to be extremely rare, particularly if we except puerperal cases.1 Scanzoni2 and Lados3 observed abscesses with perforation into the abdominal ! Saxinger, 1. c, p. 131, and Kiwisch, Klin. Vortrage, etc., II. Aufl., B. 2, p. 307. 2 Krankh. d. weibl. Sexualorg., IV. Aufl., B. 1, p. 203. 3 Gaz. Med. de Paris, 1839, p. 605. Fig. 45. The snme case on the sixth day of the disease, The uterus reduced in size and flexed. Peritoni tic exudation in Douglas's cul-de-sac. ACUTE METRITIS. 99 cavity and fatal peritonitis. Bird ' saw an instance of evacuation of the pus per rectum; Reinmann,-' one of perforation through the abdominal walls. Kiwisch3 opened an abscess which had perforated into the uterine cavity through the anterior vaginal cul-de-sac, and Hervcz de Chegoin4 rather indistinctly describes an abscess in the hypertrophic tissue of the uterus, which corresponded in size to the uterus at the fifth month of pregnancy; this abscess was opened by an incision through the abdominal walls. Ashford6 opened with a bistoury an abscess of the uterus which had been caused in a non-pregnant woman by efforts to induce abortion.6 I have myself seen two instances of large uterine abscesses, of which one, repre- sented in Fig. 46, had formed during puerperal convalescence, after artificial separation of the placenta. When the abscess was near perforation through the adherent abdominal walls, it was opened by the attend- ing physician, and discharged about a pint of pus. In the second case the abscess, which attained the size of a man's head, and finally broke into the rectum, followed close upon the careful introduction of the sound through the constricted cervix. Diagnosis. By conjoined manipula- tion we ascertain the mark- ed enlargement of the uterus, particularly in its antero- posterior diameter, and its sensitiveness, which is not confined to the peritoneal envelope alone. Both these symptoms, together with the fever and the course of the disease (gradual detumescence of the 1 Lancet, 1843, Vol. I., p. 645. 2 Voigtcl, Handb. d. Pathol. Anat., etc. Halle, 1805, p. 474. 3L. c, p. 305. 4 Soc. de Chirurgie, December 8, 1868 ; see Gaz. hebdom., Dec. 18, 1868, p. 811. B Columbia Hosp. Rep. Washington, 1873. 6 The frequently cited case of Bartholini (Hist, anatom. rarior. Cent. I. Hist. 97, p. 137i. which is expressly accompanied by the observation "sine pure " does not belong here. Fig. 46. Abscess of the uterus, u, uterine tissue: a, cavity of the abscess; p, portion adherent to the abdominal wall, at which point perforation took place. 100 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGAN'S. uterus), render the diagnosis sufficiently certain. The sound should not be introduced, because it greatly increases the pain and inflammation. It is not possible to diagnosticate abscesses of the uterus while they are still small. Larger collections of pus, however, are easily recognized, when it is possible to watch the slow but sure uniform increase in size of the uterus, and feel the fluctua- tion or, at least, firm elasticity produced by an accumulation of fluid. The adhesion of the enlarged uterus to the abdominal wall, when the abscess is on the point of perforating the latter, favors the supposition of the presence of pus. The sensitiveness of the uterus, moreover, when enlarged by an abscess, is but slight. Prognosis. The disease is never without danger, for death may ensue in consequence of suppuration or by the extension of the inflam- mation to the peritoneum. Chronic inflammatory conditions of the uterus are very prone to remain after the acute stage has subsided, and thus likewise render the prognosis unfavorable. Treatment. If an aggravated case is seen at an early stage, free local depletion, by means of scarifications of the cervix, in the manner to be described more in detail under the treatment of chronic metritis, will relieve the uterine congestion. If the pain is very intense and other symptoms of a participation of the peritoneum are present, the application of at least a dozen leeches to the abdominal integument above the symphysis pubis is advisable, and is to be followed, after the leech-bites have been allowed to bleed freely, by the application of ice to the abdomen. The scari- fication of the cervix should generally be repeated several times. In addition, mild but effective laxatives, such as castor-oil, are indicated. Rest in bed, with depressed head and shoulders, and slightly elevated pelvis, is absolutely necessary, and fre- quently relieves the pain so much as to enable the patient to do without chloral or the hypodermic administration of morphine. CHRONIC METRITIS. 101 When the first acute symptoms have subsided, and the fever has diminished,—the uterus, although much reduced in size, still remaining greatly enlarged,—the moist and warm Priess- nitz' compresses afford an excellent aid to absorption. In cases so inclined it will be found difficult to prevent the formation of an abscess ; a perforation into the abdominal cavity appears to be so rare that an artificial evacuation of the pus seems advisable only when the abscess can be reached with per- fect ease and safety. CHRONIC METRITIS—INFARCTION OF THE UTERUS. Wenzel, Krankh. d. Uterus. Mainz, 1816, p. 54, etc.—J. Henry Bennet, Pract. Treat, on Inflam. of the Uterus, etc. London, 1853, 3d ed.—Huguier, Gaz. des Hop., 1849, No. 127.—Recquerel, Traite clin. des mal. de l'uterus, 1859, I., pp. 157, 251, and 403.—Nonat, Traite prat, des mal. de l'uterus. Paris, 1860, p. 112.—Aran, Lecons clin. sur les mal. de l'uterus. Paris, 1858, p. 491.—Sey- fert, Spitals-Zeit., 1862, No. 38, and Sdxinger, Prager Vierteljahrsch., 1866, 2, p. 152. — Oppolzer, Wiener med. Jr., 1858, No. 19.—Scanzoni, Die Chronische Metritis. Wien, 1863.—Klob, Pathol. Anat, d. weibl. Sex., p. 124. The opinions of surgeons are as yet exceedingly divided on the subject of chronic inflammation of the uterus. Whilst for- merly the greatest variet}^ of affections, particularly scirrhus, were included under the terms infarction and engorgement, the later French authors, especially, now draAv the finest distinc- tions between almost identical, or at least closely connected, pathological conditions of the uterus. Thus, Becquerel distin- guishes, "La congestion sanguine," 2, "La congestion ou en- gorgement hypertrophique," and 3, the veritable '' inflammation chronique/" and Courty considers fluxion, congestion, engorge- ment, and metrite to be quite separate affections. In Germany there is so little uniformity of opinion on this subject, that some gynecologists pronounce chronic metritis to be the most common of all the diseases peculiar to women, and others almost deny the existence of such an affection. While Scanzoni includes under this term all the disturbances of nutri- tion which follow protiacted venous hyperemia, Seyfert believes infarction of the uterus to consist exclusively in defective puer- peral involution • and Klob, in his Pathological Anatomy of the 102 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Female Sexual Organs, does not class the changes met with in infarction with the inflammatory processes, but with the neoplas- tic growths, and describes them under the name of " diffuse connective-tissue proliferation." Thomas1 and Skene2 call the disease "areolar hyperplasia," "diffuse interstitial hypertro- phy," and " sclerosis uteri." My conviction is, that we cannot dispense with the clinical picture of chronic metritis, for we should otherwise be obliged to separate closely connected pathological conditions having the same symptoms, and requiring the same treatment. Neither do I consider the term "chronic metritis " to be so very improper, because it is probably nothing more than a war of words, whether that condition be called a hyperplasia of the connective tissue of a hyperaemic uterus, or the product of an exceedingly chronic inflammation. Indeed, I should be loth to dispense with the name "inflammation" for this very condition, partly because the treatment needs to be decidedly antiphlogistic, and partly because in the early stages we always have the clinical symptoms of inflammation—hypersemia, tumefaction, and pain. It should be noted in addition that all the cases in which the rather rare termination in induration—a change which occurs only at a late stage—has not taken place, undergo from time to time exacerbations, which present the features of a subacute, occasionally of even a quite acute inflammation. We therefore include under the term "chronic metritis" those cases also—placing them at the head of the list, because they are the most numerous—which originally arise indepen- dently of inflammation, such as defective puerperal involution, because inflammatory symptoms—hyperemia, swelling and pain —occur during their course, and also because the treatment of these etiologically separate cases is decidedly antiphlogistic. Simpson,3 indeed, expressly states that in a case of defective puerperal involution, the treatment should be antiphlogistic, even though all positive signs of inflammation be wanting. The collection of symptoms known as chronic metritis is thus 1 Diseases of Women, 3d ed., p. 274. 2 Amer. J. of Obstet., V., pp. 387 and 481, and VI., p. 353. 3 Diseases of Women. Edinburgh, 1872, p. 594. CHRONIC METRITIS. 108 made to comprise a large number of cases of etiologically differ- ent nature, but presenting clinically the same appearances and requiring the same treatment. Etiology. The hyperplasia of the connective tissue of the uterus accompanied by a variable degree of sensitiveness—this is, per- haps, the least reprehensible way of defining the condition in question—occurs under widely different circumstances. Very frequently a defective involution of the puerperal uterus is the cause of the trouble. This is most prone to occur in cases in which, during the early part of puerperal convalescence, inju- rious influences of various kinds acted on the generative system, such as: leaving the bed at too early a date, and too violent action of the abdominal muscles, brought about either by heavy work or by physical exertions, such as severe cough, repeated vomiting, etc. ; further, retained blood-coagula and fragments of the secundines, grave puerperal diseases with para- and perime- tritis, too early sexual intercourse, and other similar causes. Retarded in its metamorphosis by such influences, the uterus does not undergo perfect involution, the fatty degeneration and absorption of its muscular fibres are incompletely performed, or the newly formed tissues—muscular elements, and particularly connective tissue—are developed to such a degree as to leave the uterus considerably larger than normal. Miscarriages are espe- cially injurious, partly because women are proverbially less care- ful after them than after regular confinements at term, although the uterus is obliged to undergo the same metamorphoses, and partly because in quite a number of cases conception again takes place before the involution of the uterus has been properly accomplished, in which case the proliferation of tissue is re- newed and another miscarriage is then very likely to take place. Since nursing the child excites muscular contractions in the puerperal uterus, and these stimulate the process of degenera- tion of the cellular constituents to greater rapidity and complete- ness, the non-performance of this function on the part of the mother likewise aids in retarding involution. 104 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. We are not justified in designating this condition of defective involution in itself as chronic metritis, especially if it is merely a question of imperfect absorption of the muscular fibres, which had become immensely enlarged during pregnancy. A uterus retarded in its involution does not, however, remain stationary at this point; hence, in such a case, we are not dealing with a uterus which is simply enlarged, and which provokes symptoms merely by its size (by pressure on the neighboring organs and by its changed position), but rather with one which from being at first simply too large (after the puerperal state) gradually increased still further in size, became sensitive, and then was subject from time to time to acute exacerbations ; presenting, in other words, the characteristic picture of chronic metritis. In the next place, infarction of the uterus arises in conse- quence of continued or frequently recurring hyperemia, no mat- ter whether it results from active determination of blood to or permanent venous stasis in the organ. Active hyperemia may further be produced by all the various causes which induce a continued or often-repeated irritation of the uterus. In this category belongs the unfavorable influence exerted by frequent cohabitation under violent sexual excite- ment. Still more injurious are masturbation and the repeated imperfect performance of the sexual act, by reason of the impo- tence of the male. Dysmenorrhoea, also, in consequence either of a constricted cervix, or of a flexion at the internal os, may lead to a chronic inflammatory condition of the uterus ; this it may do by causing from time to time a retention of blood within the cavity of the uterus, and so exciting this organ to frequent contractions. Continual or frequently repeated irritation of the mucous membrane may also give rise to protracted hypersemia, and ultimately to chronic inflammation of the tissue of the uterus. Cases of neglected endometritis belong here, and also those not very rare cases in which there has been a repeated resort to non- indicated therapeutical measures, of which we will only mention the favorite practice of cauterizing the os with the stick of nitrate of silver. The chronic hyperemia of the uterus is far more frequently CHRONIC METRITIS. 105 caused by venous stasis in the organ, which is often due to dis- placement, particularly to retroflexion and -prolapsus, and be- sides to adjacent tumors which mechanically impede the return of blood. We refer here less to real pathological neoplasms, such as ovarian tumors, than to the protracted retention of urine in the bladder, to which the female sex seems to be systemati- cally educated, and particularly to the accumulation of fecal matter in the intestinal canal, which is habitual with most women, and especially with those in ill health. The stasis in the uterus is but rarely a part of the general obstruction in the sys- tem of the vena cava inferior, induced by disease of the liver, heart, and lungs. The most uncommon mode of development of chronic metritis is that from acute metritis, which has undergone but partial restitution in integrum. The origin first described, from defective puerperal involution, is by far the most frequent of all. For this reason, and also because some of the other causes usually, if not exclusively, operate in women who have borne children, it is only in excep- tional cases that we see well-marked forms of chronic metritis in nulliparous women. Of one hundred and two patients, of whose cases I have kept special notes, there were only seven who had never been pregnant. Of these, two had an intact hymen; on? masturbated ; one had been married only a fortnight, and three, although mar- ried, were sterile. Of the other patients, three had only miscarried, while the others had passed through regular confinements: eighteen through one; eight through two;' ten through three; eight through four; twelve through five; five through six; five through seven ; five through eight; one through ten ; and one through eleven, not counting the numerous miscarriages. Of the remaining nineteen patients, I find noted only that they had borne children. The large number of those who had been confined only once is explained by the fact that in nearly all of them the chronic metritis following puerperal convalescence entailed sterility. Pathological Anatomy. The characteristic feature of the process is the hyperplasia of the connective tissue ; proliferation of the muscular fibres is either entirely wanting or occupies a secondary position.1 The uterus is always enlarged, although usually not to a con- 1 According to Finn, Centralblatt f iir die med. Wissenschaften, September, 1868, the enlargement is principally due to the proliferation of the muscular tissue. 106 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. siderable degree ; in rare instances, however, it may increase to such a size as to reach to the umbilicus. Yeit,' indeed, saw a case in which the fundus projected two inches above the um- bilicus, and the cervix extended so far down as to require the support of a pessary. The enlargement is pretty equally distri- buted over all the parts of the uterus, but the increase in thick- ness of the walls lengthens more especially the antero-posterior diameter of the organ. The substance of the hypertrophied womb is soft, succulent, and reddish ; all its tissues are swollen and hyperaemic. The endometrium is usually also swollen and thickened ; at the os are found erosions and ulcerations, which we shall consider separately. The peritoneal envelope often shows ligamentous patches. In some cases the enlargement of the cervix preponderates. The os is generally broad, and both lips are swollen and elon- gated ; occasionally they are soft and succulent, frequently, however, firm and irregularly hard, rendering the differential diagnosis from carcinoma exceedingly difficult. The cervical mucous membrane is not unfrequently ectropionized. When the proliferating process has ceased, the newly formed connective tissue undergoes cicatricial retraction, the vessels become imperforate, and the young mucoid connective tissue becomes firm and fibrillated. The uterus then again diminishes in size, and on section exhibits an exceedingly firm, almost car- tilaginous tissue, which creaks under the knife, and has a white, anaemic, cicatricial appearance. Symptoms. Since infarction cannot readily develop from that rare form of disease known as acute metritis, it must necessarily occur in the majority of cases as a consequence of the above-mentioned etiological factors. Women wrho have been confined and were taken ill during puerperal convalescence, or who exposed themselves to severe 1 Frauenkrankheiten, 2 Aufl., p. 367. CHRONIC METRITIS. 107 exertions and hard work soon after an early getting-up, find that, although alwaj-s in good health before, they are not so well since their confinement. Sacralgia, abdominal pains, leucor- rhoea, a sensation of weight and pressure in the pelvic region, monorrhagia, constipation, a frequent desire to micturate, all these distressing symptoms prevent the woman from enjoying perfect health. To be sure, these symptoms are not generally sufficiently severe to cause the positive sensation of actual ill- ness. From time to time, however—every few weeks or months, sometimes with cv^ry menstrual epoch, although by no means constantly confined to that period—without apparent exciting cause, violent exacerbations occur. All the symptoms, especi- ally the sacral and abdominal pains, become so intense as to confine the patient entirely to her bed. Not unfrequently a flow of blood will appear independently of menstruation. After a week or more the symptoms diminish, and the general condi- tion of the patient becomes more tolerable, although still any- thing but agreeable. Sacralgia and the sensation of abdominal weight still remain. Obstinate constipation aggravates the diffi- culty very materially, for which reason most patients are accus- tomed to the regular use of laxatives. Occasionally the period between these exacerbations may be passed in tolerable comfort ; but their constant return entirely precludes the sensation of perfect health. The appearance of the symptoms in those cases in which the chronic metritis is induced by other causes is quite similar. Thus we are not unfrequently informed by girls who are suffer- ing from anteflexion, or constriction of the cervix with consecu- tive dysmenorrhoea, that they enjoyed perfect health until the period of puberty. As soon as menstruation appeared, however, it was attended with pain, occasionally to such a degree as to cause convulsions and syncope shortly before the actual flow. For months and years the condition between the menstrual periods is entirely normal. Gradually a change takes place ; the intervals, which formerly were undisturbed, no longer remain so, and little by little tliere is developed the complex of symptoms described above. In primary endometritis, as well as in retro- flexion and prolapsus, the body of the uterus often gradually 108 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. increases in size and becomes more tender, and the symptoms of these affections mingle with those of metritis,—the sacralgia and downward pressure excepted, as they are common to both. Thus finally, although the cause of the chronic inflammation differs in the cases mentioned, the same clinical features and the same symptoms present themselves to us, and we find ourselves justi- fied in considering these several conditions as one and the same type of disease; of course, as in every affection, the etiological differences should be properly estimated. An examination shows the following condition : The uterus is enlarged, particularly in the antero-posterior diameter, and positively, although not always highly, sensitive; it is only in exceptional cases that there is no pain on pressure during the specially favorable intervals ; at the time of the acute exacerbations, its volume enlarges, and its sensitiveness increases. The uterine cavity, as shown by the sound, is almost always elongated, but its walls are also thickened. In the more recent cases the consistence of the organ is not firm, but rather soft, at times even almost doughy, like the pregnant uterus at the third month. The condition of the cervix varies. In persons who have not borne children it is but moderately enlarged, tapering conically towards the small external orifice. In other cases, in persons who have had children, and particularly if the usual complica- tion of endometritis be present, the cervix is swollen and soft, or (in older cases) sometimes irregularly hard (as in carcinoma); the os is broad, its lips are thick, and the eroded, highly reddened mucous membrane of the cervix is everted and dotted with gray, translucent, rarely yellow, swollen follicles, containing pus. Other complications, particularly of an inflammatory charac- ter, are not uncommon. Perimetritic adhesions to the other organs of the true pelvis and to the intestine, chronic ovarian disease, stenosis and atresia of the Fallopian tubes, with the for- mation of small tumors (partial hydrosalpinx), are not unfre- quently met with. An overloaded intestinal canal often inter- feres exceedingly with conjoined manipulation. Menstruation is at times quite normal; in some cases the swelling of the cervix causes secondary dysmenorrhoea ; metrorrhagia is very frequent. CHRONIC METRITIS. 109 This last symptom is most obstinate, if not most profuse, when the cervix is the chief seat of the disease. Again we will call attention to the fact that, so far as our experience goes, the occurrence of acute and subacute exacerba- tions is the rule. At times, for weeks and even months the uterus is but little sensitive and only moderately enlarged, until the swelling again increases, and the acute sensitiveness and all the symptoms reappear. In the course of time other features gradually show them- selves. The digestion and appetite begin to fail, and the patients become debilitated. Pain of various kinds in the lum- bar region and lower extremities, vaginodynia, coccygodynia, paralysis of different organs, and the whole train of hysterical symptoms follow. Sterility is not the necessary, although the usual conse- quence of chronic metritis. It is caused not so much by the organic changes in the tissue of the uterus itself, as by the com- plications—endometritis, salpingitis, ovaritis, perimetritis, and displacements. If conception occurs, the pregnancy is often interrupted as late as the fourth or fifth month, a fresh, perfectly preserved foetus being expelled. Terminations. The disease known as chronic metritis may remain stationary a very long time—many years, indeed—in the manner already mentioned, viz., periods of comparative ease alternating with exacerbations of increased pain and discomfort. Even the men- opause does not always bring about a cure. Occasionally the condition becomes almost unendurable exactly at the climacteric period, and then gradually the symptoms disappear. In other cases, however, the uterus remains in the state of chronic inflam- mation far beyond the age of fifty years; the menses continue during this time, or irregular hemorrhages take place. Still the inclination to relapses undoubtedly decreases after the menopause, and cases met with after that period are most amen- able to treatment. Even at an earlier age, however, a suitable course of treatment 110 SCHROEDER -DISEASES OF FEMALE SEXUAL ORGANS. will not unfrequently succeed in restoring the uterus to its normal state, as regards size and sensitiveness, and the removal of all distressing symptoms. There always remains, it is true, a greater or less tendency to a return of the disease. In still other cases the affection proceeds to induration (described by Scanzoni as the second stage of chronic metritis). The newly formed connective tissue undergoes cicatricial retrac- tion, the uterus becomes harder and smaller, and premature amenorrhoea occasionally supervenes. The worst symptoms, especially the acute exacerbations, however, cease, and this pro- cess must therefore be considered at all events as a relative cure. Diagnosis. The diagnostic difficulties are dependent less on the sifting and positive classification of the results obtained by examina- tion, than on the exact limitation of the definition of the term chronic metritis. After what we have stated above it is not necessary to say more than that we diagnosticate this affection when we find the uterus uniformly enlarged, its walls thickened and generally sensitive, and when the case is chronic in char- acter. As a rule, it is easy to detect these conditions, and diffi- culties in diagnosis will be met with only exceptionally. For instance, the differential diagnosis from pregnancy is by no means always easy. The objective appearances may be nearly the same, for the size, shape, position, and consistence of the uterus are almost identical in both conditions. As a rule, however, in pregnancy the whole uterus is softer, a circum- stance particularly noticeable in the succulent, thoroughly soft- ened cervix. The sensitiveness, scarcely ever completely absent in chronic inflammation of the uterus, is wanting in pregnancy. The history gi^es us very valuable, although not always deci- sive points of difference. The most difficulty is met with when pregnancy occurs in a chronically inflamed uterus, a compli- cation always to be kept in mind in making the differential diag- nosis. Submucous and interstitial fibroids may also offer diagnos- tic difficulties. In the former, it is true, the cervix becomes CHRONIC METRITIS. Ill shortened, whereas it is always enlarged in chronic metritis ; and the abnormal contents of the uterus may be detected by the sound, or, in case of need, by dilating the cervix with sponge-tents. In interstitial fibroids, however, the uterus may be uniformly enlarged, and the marked hardness generally peculiar to fibroid tumors may be wanting in the individual case, —or, if the chronic inflammation has been of very long duration, the uterus may have become unusually hard. A distinct sensi- tiveness of the uterine tissue will, it is true, warrant the diag- nosis of an inflammatory process, but not the exclusion of a fibroid. If the history also does not aid us, and the sound affords no information, then the cervix must be dilated with sponge-tents, and we shall then be able to detect by an examin- ation with the finger whether one wall only is enlarged by a fibroid, or not. Prognosis. The disease is very tedious, and taxes the patience of the physician and patient to the utmost. Even though it does not directly threaten the existence of the patient, still the dura- tion of her life is positively shortened by the disturbances of general nutrition, etc., which it produces, and occasionally a severe hemorrhage or the spreading of the inflammation to the peritoneum may prove exceedingly dangerous, and even fatal. The transition into carcinoma, which has recently again been asserted by Noeggerath,1 is by no means a settled fact ; on the contrary, it is a matter of surprise, considering the frequency of the two diseases, that patients afflicted with chronic metritis do not oftener eventually suffer from cancer. Although not dangerous to life, as already stated, chronic metritis very materially embitters the existence. The patients never lose the sensation of being ill; their lives are nothing but alternations of periods in which they feel ill, but still not so much so as to incapacitate them from the ordinary duties of life, with those in which their sufferings are violent. The misery of the poor invalids is heightened by the usual accompanying 1 Amer. Jour, of Obst., I., pp. 505 and 610. 112 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. secondary affections of the intestine—of which the principal one, constipation, aids in increasing the uterine inflammation—and by various hysterical sequelae. A spontaneous care of the disease is probably never met with, certainly not before a very advanced age. It also obstinately resists treatment, and Scanzoni says, he never saw a case of complete recovery. This assertion is doubtless correct, if by recovery a complete restitutio in integrum is meant; but there is no question that by proper treatment the condition may be so much improved as to cause the entire disappearance of the symptoms; even in these cases of "cure," however, a certain tendency to relapse always remains. A priori, one might sup- pose that an intercurrent pregnancy and puerperal conva- lescence would entirely remove the disease, because the old enlarged uterus normally undergoes almost complete involu- tion ; unfortunately, however, experience teaches us that this lucky event hardly ever happens ; that, on the contrary, a new puerperal convalescence frequently aggravates the disease. Although it will appear from the above remarks that the prognosis is not a very favorable one, still we may usually expect by rational treatment to diminish the sufferings of the patient to a very great degree. Treatment. In accordance, therefore, with the importance which we have attached to the etiology of this trouble, it is of paramount im- portance to properly manage the diet during puerperal convales- cence. It would carry us beyond our prescribed limits, however, to give here a detailed description of these dietetic measures. In the next place we should see that, so far as may be pos- sible, the patient be not exposed to repeated and protracted determinations of blood to the uterus, or to chronic hyperaemic conditions. Finally, we should call attention to the importance of a suitable treatment of acute metritis, endometritis, and uterine displacements ; and in doing this we have mentioned the chief points of interest regarding prophylaxis,—at least so far as the avoidance of inflammatory uterine processes is concerned. CHRONIC METRITIS. 113 In order to prevent cases which at first are trivial in character from assuming the type of an inveterate chronic metritis, it is absolutely necessary that all cases of acute enlargement of the uterus, attended with sensitiveness, should at once be submitted to energetic treatment. Rest in the horizontal posture, avoidance of all injurious influences, particularly sexual intercourse, and repeated moderate local depletion in the manner presently to be described, are indispensable measures to be adopted until the uterus has regained its normal condition. A case of well-developed chronic metritis calls for positive antiphlogistic treatment, which is to be the more energetic, the larger, softer, and more sensitive the uterus is. If possible, the patient should enjoy complete rest, but at all events she should avoid all exertions which are likely to bring the abdominal muscles into active contraction (hard labor, jump- ing, also coughing and vomiting). It is positively injurious, however, for the patient to remain for a long time in bed or on a lounge, because the processes of nutrition and tissue-metamor- phosis, which in this disease should be especially stimulated, are thereby interfered with. The patient should therefore be directed to continue her daily avocations, but at the same time to avoid any particularly active exertions ; gentle exercise on foot, as well as the sojourn in the open air, are advisable, but should never be carried to the point of actual fatigue. The diet should be regulated—the meals being frequent, though moderate in quantity, and consisting of nourishing, easily digested food. The coarser vegetables, and all the articles of food which tend to increase the quantity of fecal matter, are to be avoided, the preference being given to animal food. Regularity in the evacuation of the bowels and bladder should be strictly observed. Sexual intercourse, as a rule, is to be forbidden, although in some women absolute abstinence ex- cites the generative organs more than does the moderate indul- gence of the sexual appetite. Among regular therapeutic measures, repeated local deple- tion occupies the foremost place in the treatment of chronic metritis. To be sure there are few measures, the success of which de- vol. x — s 114 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. pends so much on the manner of their employment as is the case with this operation. In the flrst place, I would call particular attention to the fact that where the object is simply to deplete, scarifications or punc- tures of the vaginal portion of the mucous membrane of the cer- vix should always be preferred to leeches, as a means of abstract- ing blood. I consider it very important to repeat the depletion frequently, but to remove only a very small quantity of blood at a time, which may readily be done by scarification, but not so easily and surely by leeches. The latter, besides, possess the fol- lowing disadvantages : On the one hand, it has always appeared to me that the suction of the animal exerts an irritation, by means of which an increased amount of blood is drawn to the organ which it is our desire to deplete. Further, it is never possi- ble to estimate accurately the quantity of blood to be abstracted by a certain number of leeches, because even a single bite may be followed by severe secondary hemorrhage. The pain of the leech-bite is frequently considerable, and violent uterine colic (not to mention the disagreeable urticaria observed by Scanzoni) may occur, even though the leeches do not crawl into the uterus. According to my experience, the scarifications possess none of these disadvantages. If the first incisions be superficial, and deeper ones be made only when the former do not yield suffi- cient blood, the amount of blood to be abstracted may be pretty accurately estimated. Secondary hemorrhage of any importance does not occur. The incision or puncture is frequently not felt at all; in some cases only does the patient experience a slight momentary pain. Scarification never gives rise to irritation, with subsequent hyperaemia; indeed, if the swollen follicles be punctured at the same time—a point to which we shall allude farther on—an exciting cause of inflammation will also be removed. As has already been mentioned, a great deal depends on the manner in which the scarifications are made. If the unfortunate patient is alarmed and horrified days before by repeated reference to the necessity of an " operation/' viz., the incision of the diseased mucous membrane, if a great display of instruments is made while preparing to perforin the CHRONIC METRITIS. 115 scarification, the fear will do her more harm than the slight local depletion will benefit her. I always make the scarifications, with- out preparing the patient for them in any way whatever, almost without her knowledge, and thus avoid all the fear and excite- ment which anaemic persons are liable to experience at the mere idea of the abstraction of blood. I also remove but very little blood at one sitting, frequently only half a tablespoonful, and increase the quantity to about one ounce only in plethoric patients with large hyperaemic uteri; but I repeat the depletion frequently, sometimes every third or fourth day, and believe— since after every depletion the quantity of blood previously pres- ent is to a certain extent restored—that these same local abstractions of small quantities of blood frequently repeated are far more successful than a single more abundant depletion. If there are acute exacerbations, or if the symptoms are aggravated at the men- strual epoch, I prefer to make the deple- tion at those times. Shortly before the expected appearance of the menses, the scarification is particularly beneficial. The dysmenorrhoea usually present is allevi- ated or disappears entirely, and the hem- orrhage is much diminished, especially in cases of menorrhagia ; the total amount of blood discharged during the catamenia and abstracted by scarification often being much smaller than was ordinarily lost at each menstrual period. The presence of chlorosis or anaemia is hardly to be considered a contra-indica- tion, for even such patients can readily spare half a tablespoon- ful of blood. The scarifications are best made with long-handled knives, specially constructed for the purpose, one of which should be convex, for incising the mucous membrane, and one pointed, for making punctures and tapping the follicles. In Fig. 47 are represented the useful scarificators devised by C. Mayer, with- Fig. 47. Scarificators of C. Mayer. 116 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. out the long handles. The operation itself is exceedingly simple. The best plan is to bring the cervix into view in a milk-colored glass speculum, and to incise the mucous membrane to an extent proportionate to the degree of hyperaemia of the uterus and to the quantity of blood to be abstracted. If swollen folli- cles are visible, they are to be punctured, and the inflammatory irritation thus reduced in two ways : by evacuating the contents of the follicle, and by the accompanying hemorrhage. Even though no follicles be visible, the clear secretion flowing from the puncture will frequently show us that an enlarged follicle lying under the mucous membrane has been opened. The incisions or punctures should be allowed to bleed into the speculum for a short time; the blood is then poured out, and the speculum removed without making any further appli- cation to the cervix. I particularly desire to warn against the practice of injecting cold water against the cervix, because the irritation of the cold fluid, although producing a momentary contraction of the vessels, is rapidly followed by their relaxation and increased plethora, and the result of the depletion is thus completely defeated. I have never felt the need of scarificators for the mucous membrane of the body of the uterus, such as have been recom- mended by various American gynecologists (Miller,1 Storer and Pinkham,2 Codman and Shurtleff).3 The beneficial influence of these small, frequently repeated, local depletions is self-evident. The uterus diminishes in size, its sensitiveness decreases, and the alleviation of the symptoms, particularly of the sensation of burning in the abdomen, is per- ceptible after each scarification. I have already mentioned the beneficial effects on monorrhagia. The excessive mucous secre- tion also frequently diminishes to a great extent in cases where it has not yet become chronic. The antiphlogistic remedy second in importance, cold, is far less frequently applicable, because it is very difficult to keep it permanently in contact with the morbid uterus, and its tempo- 1 Boston Med. and Surg. Jour., March, 1867, p. 138. a Boston Gyn. J., Vol. I., p. 85. 3E. 1., Vol. III., p. 6. CHRONIC METRITIS. 117 rary application does not produce an antiphlogistic effect, but, owing to the subsequent reaction, rather the reverse. An uncomplicated chronic metritis will scarcely ever call for the application of ice to the abdomen. If the swollen uterus be exceedingly painful, however, and the peritoneum on the point of participating in the inflammation, an ice-bag will be found very serviceable. The use of the cold douche to the cervix should be very carefully watched. In the cases of more recent date, as well as during the exacerbations, it should be discarded altogether, because there is no doubt in my mind that its action is that of a decided irritant. If it be used, however, the patient should gradually be accustomed to the low temperature of the fluid to be injected, and a weak stream of water only should be thrown against the cervix from the irrigator. Of very great importance in chronic metritis is the regular evacuation of the bladder and rectum. The former object is easily attained, the latter only with more or less difficult}', especially as we are obliged to deprive our patients of the in- jurious drastic cathartics to which they have become accus- tomed. If we can succeed in regulating the bowels by simple dietetic measures, we will obtain the most satisfactory results. A draught of cold water before breakfast, and the use of raw fruit or preserves (cranberries, prunes), will prove serviceable only in the milder cases. It is important that a regular, determined effort be made at a certain hour of each day, say after breakfast, to evacuate the bowels. Obstinate cases, however, will yield only to more effective means, and we may consider ourselves fortunate if the milder purgatives, castor-oil, salts, and the pre- parations of rhubarb and senna, produce regular defecation. Should all these measures prove ineffectual, on account of the torpid condition of the intestinal canal and the sluggish per- formance of the processes of nutrition, mere local therapeutical agents are no longer available, and a methodical system of treat- ment should be inaugurated and carried out, the object of which should be to increase the activity of the intestine, invigorate the whole nervous system by means of irritants to the skin, and improve nutrition and general tissue-metamorphosis. A course of treatment of this kind may be carried out at 118 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. home, the patient using cold ablutions and general frictions with cold water in the morning, and taking regular doses of mineral waters—above all, that of Friedrichshall and of the Hunyadi- Janos Spring in Ofen, Hungary—and, finally, a walk before breakfast. If the circumstances of the patients will permit, it is advis- able, during the summer season, to send them to some watering- place, or to one of the water-cure establishments, where a ra- tional and systematic course of treatment will materially improve the nutrition of the entire body. It is particularly in chronic metritis, with its tedious course, often extending over a series of years, that a change like this will be found beneficial. These summer trips to watering-places are assuming greater importance every year, and the correct and judicious choice of a spring is without doubt very material to the welfare of the patient, and may save the physician many subsequent re- proaches. For these reasons I consider it of sufficient practical importance to refer at least briefly to the indications which should guide the physician in sending patients to the principal medical springs. As regards the waters which are used as a beverage, patients with quite recent and not very marked chronic metritis, who are not anaemic and whose intestinal func- tions are in good order, but who suffer from severe leucorrhoea, should be sent, above all, to the Fiirstenbrunnen, Kranchen, Kesselbrunnen, Augusta-quelle, and Victoria-quelle of Ems (the new Bade-quelle, the Buben-quelle, and the Wilhelms-quelle are used principally for baths and injections); next, to Neuenahr, Tonnisstein, and, outside of Germany, to Vichy. If the patients are well nourished but flabby, and their metritis is of the most chronic form, associated with circulatory disturbance and venous plethora of the abdominal organs and torpid digestion, they should be advised to drink the waters of the Kreuzbrunnen and Ferdinandsbrunnen in Marienbad, or of the Rakoczy and Pandur springs in Kissingen. Soden in the Taunus Mountains, the saline springs of Elster, Franzensbad and Pyrmont, Karlsbad, Tarasp, Homburg, and Wiesbaden are other resorts of the same character. CHRONIC METRITIS. 119 If the patients are chlorotic, or have become anaemic from metrorrhagia, or if their nutrition has suffered in any way, except in consequence of grave gastric or intestinal catarrh, it is best to send them to the chalybeate springs, where, besides tak- ing the stimulating carbonic-acid chalybeate baths, they will be able to drink the ferruginous water. As transitional forms be- tween the alkaline-saline waters and those containing chloride of sodium with traces of iron, to which latter category belong Marienbad, Homburg, and Kissingen, may be mentioned Fran- zensbad, Elster, Rippoldsau, and the Ambrosius and Caroline springs at Marienbad. Pure chalybeate waters are found at Schwalbach, Pyrmont, Steben, Driburg, Booklet, Briickenau, Liebenau, Alexisbad, Cudova and Reinerz, St. Moritz, and Spa. Of equal importance with the internal use of these waters is the employment of medicated and mineral baths. The brine- baths and the carbonic-acid baths concern us chiefly in this con- nection. Like the chalybeate baths, they are probably bene- ficial only by means of their stimulating influence on the cutane- ous nerves ; and this effect is followed by a general stimulation of the nervous system, with a consequent increased activity of tissue-metamorphosis, not only progressive, but particularly and chiefly retrogressive. The cold brine-baths, which may also be artificially heated, are especially to be recommended for flabby, scrofulous women, whose uteri are large and thick, but only slightly sensitive, and in whom the disease has become so chronic as not to be marked by acute exacerbations. Of the pure brine-baths the choice lies between Reichenhall, Ischl, Kosen, Pyrmont, Wittekind, Cann- stadt, Kolberg, Elmen, Kreuth, and Bex; but those containing iodine and bromine should usually be preferred, and here we should mention first of all Kreuznach, with its old and well- established reputation, also the neighboring Miinster on the Stein, the Adelheid spring and Krankenheil near Tolz, Soden- thal near Aschaffenburg, Durkheim, Suiza, Hall in Upper Aus- tria, and Saxon-les-bains. The mud-baths, which are now found nearly everywhere, are probably to be used under these same indications; they have not yet, however, been sufficiently tested. 120 SCHROEDER.—DISEASES OF FEMALE SEXUAL OROANS. The carbonic-acid baths are also particularly effective, such as the thermal brine-baths, especially Rheme and Nauheim, also Kissingen, where the baths contain a very large amount of car- bonic acid, and are taken at quite a low temperature ; the Sool- sprudel, at Soden in the Taunus, should also be mentioned here. Then come the chalybeate baths, which act solely by the car- bonic acid which they contain, and of which we have already enumerated the most important. Although they lose a consider- able portion of their carbonic acid on being heated, they still possess more of that agent than the thermal brine-baths of Rheme and Nauheim. There are now also strong carbonic-acid baths at Homburg, which are fed by the Ludwigsquelle. Sea-bathing produces quite similar effects to those of brine- and carbonic-acid baths, and is therefore likely to be beneficial to women with not too feeble constitutions. Between the brine-baths and the indifferent (non-saline) ther- mal springs come the chloride of sodium thermal waters, distin- guished by the small amount of salt which they contain, and by their high temperature; such, for example, are those found at Wiesbaden, Baden-Baden, and Bourbonne-les-bains. The indifferent thermal waters, especially the tepid ones (28- 32° C, = 83-90° Fahr.), like those of Schlangenbad and Landeck, possess an extraordinary quieting power, and are therefore most likely to benefit debilitated women wuth increased nervous irritability. They are also well borne in cases of marked local hyperaesthesia. It will often be found exceedingly beneficial not to limit our- selves to either the internal or the external administration of mineral waters alone, but to combine both in a manner suited to each individual case. Thus the patient may drink the salt spring water in Franzensbad and Elster, the Kreuz or Ferdinand Spring in Marienbad, and at the same time take chalybeate or mud-baths ; in Pyrmont, the salt spring may be used internally, and brine or chalybeate baths externally ; in Kissingen, we may order Rakoczy or Pandur, together with brine-baths. While bathing in the springs at one place, the waters of other places may be used as an internal remedy ; thus the patient may, CHRONIC METRITIS. 121 for instance, while in Schlangenbad or Kissingen, drink the chalybeate waters of Schwalbach or Pyrmont, etc. In conclusion, we would again call special attention to the fact, that however valuable the use of mineral waters may be, they will never supply the place of local treatment, especially in the more recent cases and during the acute exacerbations, which, indeed, may be easily aggravated by their use. In general, then, it may be said that a sojourn at a mineral or thermal spring is beneficial only in old cases and during the period following local treatment; under these circumstances, however, it often works wonders, partly through the drinking of the waters, and partly by bathing in them ; not a little of the benefit, too, is to be attributed to a rational diet and to the change of surroundings. The baths noted for their stimulating action on the skin (brine and chalybeate baths) are particularly efficacious in chronic metritis, because they give new vigor to the whole pro- cess of tissue-metamorphosis, and, by modifying the circulation, tend to bring about the resolution and absorption of old inflam- matory hypertrophies of the uterus. This result is unquestionable, and acquires so much the more value because it cannot be accomplished in the same degree by other, particularly not by local, methods of treatment. The internal administration of iodine, however useful it may be in perimetritic exudations, is scarcely of more value in caus- ing the absorption of the neoplastic tissue in a uterus that has been inflamed for a long time, than the still much used mustard plasters and blisters, with which the skin is tortured. A not ineffective, but at the same time not innocuous agent, is the douche. The greater the difference of temperature in either direction, and the stronger the stream of water, the greater will be the irritation caused by the douche ; a strong stream of hot or cold wTater will, therefore, frequently be very effective in diminishing the size of the uterus, but will also carry with it the danger of inducing a fresh exacerbation of the old inflammatory condition. At all events, it will be well—as experience teaches us that hot or cold injections are borne very differently by different wromen—to begin nearly at blood-heat, and lower or raise the 122 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. temperature gradually, stopping the injections altogether when the}' are not well borne. If only a weak stream of water is to be injected, the plain irrigator is superior to any other contrivance ; a more powerful stream is thrown by Mayer's " clysopompe." Injections of tepid water (at a temperature of 88-95° Fahiv), when they are applied without force, so as merely to bathe the cervix, do not irritate, but actually soothe and relax the tissues, and are therefore, with proper care, useful even in recent cases. The same may be said of sitz-baths, which, when hot, cause an increased flow of blood to the pelvic organs, and may thus stimu- late absorption, but may also start a fresh inflammatory action. The so-called Priessnitz' compresses deserve particular men- tion for their stimulating influence on the absorbent vessels, and are also highly beneficial by reason of their quieting and pain- allaying qualities. The manner in which they should be applied is as follows: A thick-folded towel, clipped in cold water and wrung out so as not to drip, is placed on the skin of the abdo- men and completely covered, to the utter exclusion of air, by a piece of flannel or oil-silk. The heat of the body soon warms the wet cloth, which, evaporation being prevented, retains its mois- ture for a long time, and constitutes a permanent moist and warm compress. Many gynecologists highly recommend the local application of iodine. Scanzoni' introduces small sponges dipped in a solution of one drachm of iodide of potassium in one ounce of glycerine, and leaves them in contact with the cervix over night. Thomas2 employs the iodized cotton described by Greenhalgh, which is prepared by soaking eight ounces of cotton-batting in the follow- ing mixture and carefully drying it: Iodide of potassium, two ounces ; iodine, one ounce ; glycerine, eight ounces. A tampon of cotton so prepared is introduced into the vagina. It can scarcely be disputed that the general health is bene- fited by the iodine contained in the baths of Kreuznach—those to which mother-lye or brine of different strengths has been added 'L.c, p. 308 2 Diseases of Women, 3d ed., p. 299. CHRONIC METRITIS. 123 —and other springs (containing also bromine), but it is a ques- tion whether it exerts any influence upon the chronic infarction. An operation of great benefit, particularly in cases in which the thick hypertrophic cervix projects far down into the vagina, is the amputation of the infravaginal portion,1 by means of which the enlarged uterus is not only shortened to the extent of the piece removed, but its entire hypertrophic parenchyma, as has been demonstrated microscopically by C. Braun,2 is sub- jected to a process of involution similar to that occurring after deliver}', the result of which is a decided reduction in size of the organ. This operation possesses the additional advan- tage of acting as an efficient haemostatic in those cases in which profuse, often almost uncontrollable, hemorrhages occur from the inflamed and hypertrophic mucous membrane. If the uterus is situated low down in the pelvis, or if it is easily displaced by traction, so as to bring the portion to be removed in front of the vulva, the operation may be performed with the knife or scissors, and the edges of the wound united by sutures in the manner described by us when speaking of the amputation of the hypertrophic intravagmal portion. It is not advisable, however, to use too strong traction, because the inflammation may be increased thereby, or may spread to the peritoneum, and also because the anterior vaginal insertion may be- divided in such a manner as to form an actual cavity on one side of the uterus, between it and the bladder. If proper care is used, it is not likely that the incision will involve the bladder itself, or Douglas's cul-de-sac. To avoid this accident, however, it is well, before making traction, to mark the point of insertion of the vagina by the introduction of needles or by superficial incisions. A case in which the vaginal cul-de-sac was opened, and a positive cavity formed, was observed by Simon,3 and I have myself met with a similar experience. In a 1 C. Mayer, M. f. Geb., B. 11, p. 163. Simon, M. f. Geb., B. 13, p. 419. Spiegel- berg, M. f. Geb., B. 34, p. 393. and Arch. f. Gyn. V., p. 411. Hegar, E. 1., p. 394. Tagebl. der Wiesbadener Naturf.-Vers., p. 176; and Huffel, Anat. und op. Beh. d. Gebarcn. und Scheidenvorfalle. Freiburg, 1873, p. 44. • Zeitschr. d. Ges. d. Wiener Aerzte, 1864, p. 43. 3 L. c, p. 423. 124 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. woman who had borne eight children, and miscarried twice, I amputated the thick, long, unusually hard and nodular cervix, on account of profuse hemorrhages. I did so by seizing the cervix with a loop of cord and Muzeux' double tenaculum, and drawing it down until the intravaginal portion could be reached and removed in the vaginal entrance. On examination immediately after the amputation, the fin- ger passed into a cavity of such size in front of and to the right of the uterus, that I was first inclined to think that I had opened the bladder. The introduction of the catheter into the bladder showed me, however, that the instrument was separated everywhere from the finger in the cavity, although only by the thin vesical mucous membrane. In consequence of the increased inversion of the vagina, produced by the traction downwards, the intravaginal portion had evidently been divided too high up on the right anterior aspect, and the subperitoneal vesico-uterine space had been opened. After the incision the peritoneum and bladder had retreated upwards, and the uterus being still held down, an actual cavity had developed between the perito- neum, bladder, and uterus. With the exception of an attack of secondary hemor- rhage, which was arrested only by the energetic application of the actual cautery, the patient recovered without an untoward symptom. The wound healed perfectly, the hemorrhage and other discomforts ceased, and a year and a quarter later the patient again became pregnant. Since the production of an artificial prolapsus is not quite devoid of danger, it is usually advisable to operate without changing the position of the uterus. The amputation of the non-prolapsed cervix with the scissors or knife, and the subse- quent use of sutures, will be found so laborious—not to mention the considerable loss of blood which always attends the opera- tion—that other methods will usually be preferred. The chain ecraseur should never be employed, because it cuts through the mucous membrane of the cervical canal only after it has passed through the firm tissue of the cervix itself. Owing to this circumstance, the mucous membrane is not divided smoothly, and is often drawn into the canula of the ecraseur ; large pieces of the adjoining mucous membrane may thus be removed, and dangerous injuries of adjacent parts produced.1 The introduc- tion of protective needles, besides being difficult of execution, does not entirely guard against an accident. Much less dangerous is the wire ecraseur of Maisonneuve 1 Langenbeck, M. f. Geb., B. 11, p. 169; and B. 18, p. 17. Breslau, Bair. arztl. Int.-Bl., 1858, No. 3. Sims, Loc. cit., p. 201. Weinberg {Martin), Ueber Prolapsus uteri. Diss, inaug. Berlin, 1869, p. 14. CHRONIC METRITIS. 125 (see Fig. 48). The case of perforation of the bladder and Doug- las's cul-de-sac, reported by Meadows,1 which was probably due to the faulty application of the wire at the very outset, can scarcely be attributed to this instrument. Neither should I like to condemn it on account of a perforation of Douglas's pouch, which I was so unfortunate as to make, because the case was one of cancer, which had spread to the posterior vaginal wall. (The perforation closed spon- taneously, but death took place on the tenth day, from secondary hemorrhage from the stump.) Still, care is essential even with this instrument. The galvanic cautery, urgently recommend- ed by Spiegelberg, is less dangerous. The ease with which the wire can be applied will be greater in proportion to the depth (distance from orifice) of the place where the cervix is to be amputated. The division of the tissues should be accomplished with red heat only, that is to say, as slowly as possible, in order to avoid the risk of hemorrhage. Late secondary hem- orrhage during the separation of the eschar appears to be no very rare occurrence; constric- tion and atresia of the cervix may also ensue. The difficulty of guarding against hemor- rhage is a matter not to be overlooked. It is best prevented after the cutting operation by applying deep sutures. As a rule, the hem- orrhage is also easily arrested by the actual cautery, although in some cases even this may prove ineffectual for a time ; but in my ex- perience, if care is taken to have the bleeding pig. 4& surface fully exposed, and the cautery iron Wire 6craseur- applied again and again (in certain cases as often as twenty or thirty times), as long as a drop of blood exudes, its haemostatic effect is perfectly certain. The same can scarcely be said of the 1 London Obst. Trans., XL, p. 102. c 126 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tampon. A simple linen tampon is by no means a preventive, and even the tamponnement with cotton soaked in perchloride of iron is not absolutely safe, and is, besides, followed by the unpleasant result that the astringent constricts the vagina and renders the canal difficult of access, thus rendering it difficult, in case of necessity, to apply the actual cautery. For the treatment of the complications, especially endometri- tis and peritonitis, we refer to the respective chapters on these subjects. INFLAMMATION OF THE MUCOUS MEMBRANE. Acute Endometritis. Klob, Path. Anat. d. weibl. Sexualorg., p. 212.—Hennig, Katarrh d. inneren weibl. Geschlechtsorg., 2 Aufl. Etiology. Acute endometritis, if we exclude from consideration under this head the certainly closely allied changes immediately fol- lowing childbirth, is not a disease of frequent occurrence, and is never met with before puberty. It is most apt to occur during the menstrual period, and is generally brought on by some exposure. The suppression of the flow, so often observed, is to be regarded rather as the first symptom than as the cause of the disease. It may further be caused by any severe general irri- tation of the genital organs (excessive coitus), but especially by irritation of the mucous membrane of the uterus (injections, strong cauterizations, and mechanical injuries). Acute endome- tritis may occur, too, in the course of infectious diseases, such as typhus and typhoid fevers, cholera, measles, scarlet fever, variola, and also in cases of phosphorus poisoning.J Pathological Anatomy. The mucous membrane shows the well-known changes of acute catarrh. It is hyperaemic and swelled, with a velvety surface, and is so soft that on the cadaver it can oftentimes be 1 Hausmann, Berl. Beitr. z. Geb. u. Gyn., B. I., p. 265. ACUTE ENDOMETRITIS. 127 easily scraped off with the handle of the scalpel. Sometimes small hemorrhagic infarctions are found in the mucous mem- brane. The pathological change is generally greater in the mu- cous membrane of the body of the uterus than in that of the cervix. The condition of the vaginal portion is very like that of the beginning of pregnancy ; it is swelled and soft, there are often erosions on its surface, and the os is rounded. The ciliary epithelium soon disappears, the secretion of the diseased mucous membrane increases, that of the body of the uterus supplies at first a thin watery serum, which soon becomes thickened with cast-off epithelial cells (now and then we find a cast of one of the glands, the contents having come away unbroken), and later by an abundance of pus cells, so that it finally becomes whitish and opaque, or purulent in character. The secretion of the cer- vix, which is normally quite gelatinous, thick, and ropy, becomes thinner and turbid. The vitreous contents of the swollen folli- cles, too, become whitish, turbid, and at times purulent. In more severe cases the parenchyma of the uterus readily becomes involved in the inflammatory process, so that metritis, and even perimetritis, may be added to the original disease. The inflammation may also extend from the uterine to the vaginal mucous membrane, though the reverse is more common, espe- cially in gonorrhoea. Symptoms. The disease is accompanied by fever, and may begin with a chill. The fever, however, is usually not high, and lasts but a few days. In uncomplicated cases, abdominal pain may be entirely absent ; still, as a rule, there is a feeling of pressure and weight in the pelvis, and, under some circumstances, a deep- seated pain. The uterus is either not at all, or very little enlarged, and but slightly tender on pressure. The introduction of the sound is, however, painful, and in passing the internal os, or when it touches the fundus, the instrument may cause severe pain. The vaginal portion is reddened, often bluish, with erosions, or, not infrequently, ulcerations here and there on its surface, 128 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. while the follicles are swollen and filled with whitish or purulent contents. The characteristic symptom is the at first clear, but later, whitish or yellowish discharge, which the speculum shows to come from the uterus. Neighboring organs are not affected in uncomplicated cases further than that there is a frequent desire to pass water. Prognosis. The fever and abdominal tenderness last but a few days, the discharge continues a short time longer, and recovery follows. But very often, especially when the treatment is not judicious, a chronic inflammation and discharge will remain. In cases of gonorrhoeal origin the colpitis is often so severe that the uterine disease becomes of secondary importance. If the inflammatory process is communicated to the peri- toneum, by way of uterine substance or Fallopian mucous mem- brane, the disease may become dangerous to life. Diagnosis. If the above-named symptoms are present; if, with some fever and a copious watery discharge, the uterus is but little swollen and slightly sensitive ; if the visible mucous membrane of the cervix shows the above described changes, the diagnosis is suffi- ciently assured without trying the sensitiveness of the uterine mucous membrane with the sound, which it is better to avoid if possible. Treatment. Usually there is no need of any special treatment. Indeed, we must emphatically advise against the use of different local applications in acute endometritis. Our advice may be limited to rest in the horizontal position, interdiction of coitus, and care for gentle action of the bowels. If the amount of urine is small, and the desire to micturate frequent, soda-water may be given. Severe pelvic pain may be relieved by the Priessnitz CHRONIC ENDOMETRITIS. 129 compress. Local blood-letting is advisable only when the uterus is much swollen and very sensitive. The local application of astringents, which is to be avoided in recent catarrh, is advisable if the acute inflammation threatens to become chronic. Chronic Endometritis.—Catarrh of the Uterus. Blatin, Du catarrhe ut. ou des fleurs blanches. Paris, 1801; and Blatin et Nivet, Traite" des mal. des ferumes, etc. Paris, 1842.—Bureaud, Essai sur la leucor- rhee. Paris, 1834.—Jewell, Pract. Observ. on Fluor Albus. London, 1832.— Metre, d'Espine, Arch. gen. de med., 1836, T. X.—Durand-Fardcll, Journ. des connaiss. med. chir., Juli-Sept., 1840.—Robert, Des affections gran, ulc, etc. Paris, 1848.—Kauffnmnn, Verh. d. Ges. f. Geb. in Berl. 1852, B. V., p. 26.— Tyler Smith, The Path, and Treatment of Leucorrhoea. London, 1855.—Hennig, Der Katarrh d. inneren weibl. Geschlechtsth. 2 Aufl.—0. von Gruncwaldt, Petersb. med. Z., B. IX., p. 185.—Hildebrandt, Volkmann's Samml. klin. Vortr. Leipzig, 1872, No. 32. The name leucorrhoea (fluor albus, weisser Fluss, fleurs blanches, whites) used formerly to be employed symptomatically, merely to designate any discharge from the genital organs which was unmixed with blood ; no attempt being made to distinguish more nearly the place of its origin. For the most part it was tacitly or expressly taken for granted that it came from the vagina. The French alone, especially Gardien and Capuron, used the word in the sense of blennorrhcea of the uterus. Now that it has been decided, with a considerable degree of unanimity, that vaginal catarrh, existing by itself, is of com- paratively rare occurrence, the question is much discussed as to which of the two is the more frequent, catarrh of the mucous membrane of the corpus, or that of the cervix uteri. Aran, West, and others maintain that catarrh is much oftener met with in the body of the organ, while others still consider it very rare. In my opinion the affection is more frequently confined to the cervix, and the combination of the two forms is quite frequent, while catarrh of the body alone is very rare. AYhen the two forms are combined, the disease of the body is the more impor- tant, and we shall therefore speak first of the cases in which its lining membra in1 seems to be affected, leaving for the next chap- ter the consideration of the disease as confined to the neck. vol. x.—9 130 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Catarrh of the whole Mucous Membrane. Etiology. Catarrh of the uterus is now and then a sequel of acute endo- metritis, but occurs much oftener independently of it. Not unfrequently an excessive amount of secretion comes on gradu- ally in weak, scrofulous, or chlorotic women, especially in moist and cold tracts of country, like Holland, Belgium, and some parts of England, and, on the other hand, in hot climates. A chronic discharge from the uterus, after confinement, more com- monly occurs in women who do not nurse, though it is by no means confined to them. Such a discharge is usually more pro- fuse when portions of the secundines have remained adherent to the placental site. Under the head of causes, too, must rank all those conditions which are calculated to produce any fluxion towards, or a stasis of blood in, the uterus, conditions to which we have referred in detail, under the head of chronic metritis. The increased serous exudation normally preceding and following menstruation is also of importance, since, in scrofulous and chlorotic women, this watery discharge is apt to last longer and longer, till finally it continues through the whole intermenstrual period. Finally, as with oatarrh of other mucous membranes, we must recognize cold as a probably frequent cause. Pathological Anatomy. In cases of short duration the mucous membrane if* hypertro- phied, more or less exuberant, and in quite fresh cases, hyperae-. mic, soft, and succulent. Pigment spots of a dark red, brownish or blackish color, resulting from extravasations of blood, are found in the tissue. It is only quite at the beginning of the dis- ease that the mucous membrane is found reddened ; later it becomes of a more slate-gray color. The inner surface, that is, the surface facing the cavity of the uterus, is, for the most part, smooth, in places bossed, and the gland openings are plainly visible. In other cases we find regular granulations, the outer layers CHRONIC ENDOMETRITIS. 131 of the mucous membrane are thrown off, and the deeper layers ■sprout up irregularly. These granulations may form villous or polypous masses. The French in particular attach great impor- tance to the fungous growths of the uterine mucous membrane ;' but they certainly include under this head conditions which can- not be classed together, such as villous growths of the mucous membrane,2 placental polypus, and sarcoma. The secretion of the diseased mucous membrane is generally quite clear, its consistency thin, and reaction alkaline. Some- times it is brownish, rarely bloody, exceptionally, too, is thickly mixed with mucus or pus corpuscles. In catarrh of long duration the mucous membrane undergoes important changes. The ciliary epithelium is very soon de- stroyed ; later the cylinder epithelium is exfoliated, and replaced by low, polymorphous cells, more like pavement epithelium. At the same time the whole membrane becomes thin and atrophied, till finally the uterine cavity is lined merely by a layer of con- nective tissue. The glands either fall out, so that with the sim- ultaneous dilatation of the cavity little holes are found, which give the membrane a reticulated appearance, or they are closed in and form, later, little cysts, which, bursting, may leave shal- low excavations scattered over the surface. Chronic metritis often complicates the disease. In other cases the parenchyma is notably loose in texture. Symptoms. Since in endometritis of the body the cervix is also involved, we shall find with it the most important symptoms of cervical catarrh. Merely indicating this complication we will confine ourselves here to a consideration of the symptoms peculiar to the catarrh of the cavity of the body. First among the symptoms is the watery discharge which gives the disease its popular name, and which, though in some cases moderately great, is not rarely so profuse as to amount 1 Rouyer, Des fongos. uter. These. Paris, 1858. and Goldschmidt, Des fongos. de la cavite de l'uterus. These. Strasbourg, 1859. 2 Called by Slavjansky (Archiv. de Physiol., II. Serie, 1874, p. 53) "Internal Vil- lous Metritis." 132 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. to a copious blennorrhcea. As sequels of the profuse secretion, and sometimes when the discharge is in small amount, follow derangements of digestion and loss of appetite, with consequent decline in flesh and strength. In elderly women, with narrowed os internum, the blennorrha- gic secretion may collect in the uterus till forced out from time to time by its contractions, as previously noticed ; if the closure is complete, hydrometra results. When the disease, as so frequently happens, is complicated with metritis, the bimanual examination is often painful. When endometritis exists alone, the organ is usually tender only upon use of the sound, which, when it passes the internal os or touches the fundus, may cause considerable pain. Manifold disorders of menstruation may result from uterine catarrh. Hemorrhages are very common, occurring either inde- pendently of the catamenia (metrorrhagia), or as profuse men- struation (menorrhagia). They are more likely to be profuse, and may even endanger life, when the mucous membrane is in a granulating condition. Dysmenorrhoeal disturbances, too, are not rare, being most apt to occur when the swelling of the cervical mucous membrane has narrowed the channel of exit for the discharge. Amenorrhoea, which may be one of the first symptoms in the acute disease, always appears at a later stage in the chronic form, resulting, as it does, from the atrophy or destruction of the mu- cous membrane. Later in the disease we may have all the derangements previ- ously mentioned under the head of chronic metritis, such as dyspepsia, headache, and symptoms referable to the nervous system, especially the protean forms of hysteria. For details of this part of the subject, consult von Griinewaldt.1 Experience shows sterility to be a frequent sequel of chronic catarrh, which is readily explained in the early part of the dis- ease by the swollen condition of the mucous membrane, extend- ing perhaps from the os externum to the abdominal opening of the Fallopian tubes, and hindering the passage of either sperma- 1 Peters, med. Zeitschr., B. 9, p. 190, etc. CHRONIC ENDOMETRITIS. 133 tozoa or ova. Later, we find an exp_anation of the sterillity in the size of the uterine cavity and the smoothness of its walls, which afford no halting-place for the ovum. AA"e will here merely call attention to the importance of these conditions in the causation of placenta praevia. Instead of escaping alto- gether, the ovum is now and then, if not comparatively often, stopped at the inner os, and leads to placenta praevia. Routh 1 emphasizes the importance of circumscribed catarrh of the fundus. He distinguishes, in a most scientific way, four different forms, the first of which is accompanied by cramps, catalepsy, and mental derangement. According to him, the tenderness may be so great as to afford an explanation of Gooch's " irritable uterus." The course of the disease is as chronic as infarction of the uterus. If the patient remains without treatment, a well-estab- lished blennorrhcea will not improve until the uterus has become atrophied, its walls thin and flabby, and the mucous membrane destroyed, when it will die away of itself. Diagnosis. If, upon examination with the speculum, we find the cervix but slightly diseased, and at the same time a copious watery dis- charge from the os, then the whole lining membrane of the uterus is diseased. AYhether the parts principally affected can be distinguished by their sensitiveness to the touch of the sound seems to us doubtful. Prognosis. Though uterine catarrh does not immediately endanger life, the loss incurred through hemorrhage and serous discharge may have a most pernicious influence upon the general health. Cases do occur, however, in which a moderately large discharge con- tinues a long time without injury. Treatment. Kammerer, Amer. Jour. Obstet., II., p. 185.—Riegel, Deutsches Archiv f. Klin. Med., V., p. 404.—Spiegelberg, Volkmann's Samml. klin. Vortr., 1871, No. 24. 1 London Obstet. Trans., Vol. XII., p. 136. 134 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The great importance of prophylaxis must be mentioned in this place, though it is unnecessary to discuss it in detail, since it follows as a matter of course from the etiology. The value of constitutional treatment cannot be over-estimated, since it is often possible to cause the disease to disappear without local treatment, especially in cases where the catarrh is the result of chlorosis, scrofulosis, anaemia, or insufficient nourish- ment. A proper mode of life, in accordance with hygienic rules, nourishing, easily digested food, wine and iron, will often pro- duce extraordinary results. Baths, whether cold, sponge, sea, chalybeate, or salt spring, act favorably by their influence upon the general health. Internal medication is in general without influence upon the local process. Cathartics have no power to lessen the discharge, though they may be of use indirectly by relieving the costiveness which is so uniformly present, and which causes engorgement of the uterus. The drastic purges should not be used, but castor- oil or some of the salines will often induce a decided improve- ment. Most of the baths recommended in the treatment of chronic metritis act probably in the same way. Among them, Ems and Neuenahr are specially popular, perhaps on account of their excellent action in catarrh of other mucous membranes. It is a question how far the uterine mucous membrane is influenced by the local use of the douches (Bubenquelle in Ems) and suppo- sitories (Badespecula) of the watering-places. We come now to an unsettled but practically very important point. It is not easy to treat locally the main seat of the dis- ease, the mucous membrane of the body of the uterus, and the attempt will be attended by a not inconsiderable degree of dan- ger to the patient, so that the question becomes a very justifiable one, as to how far a local treatment of the easily accessible vagi- nal and cervical mucous membranes may be successful in influ- encing the disease proper. It certainly seems imperative, in con- sideration of the danger attending all intra-uterine medication, to try flrst the effect of general treatment and of local applications to the adjacent cervical mucous membrane. AVe have already CHRONIC ENDOMETRITIS. 135 called attention to the importance of the former, and will now consider the value of the latter. In the first stage of the disease, that of hyperaemia and swell- ing of the mucous membrane, mere scarification of the vaginal portion may avail to end the whole process, and, even in more chronic cases, the local treatment of the cervical mucous mem- brane, hereafter to be described, will often be successful in en- tirely removing, or at least favorably modifying, the disease existing higher up. In obstinate cases, however, in which there is pressing need of interference, we have only the directly local treat- ment left. Such urgent indication may be afforded by the blen- norrhoea or metrorrhagia from a granular mucous membrane. In the first case, injections into the cavity of the uterus afford by far the most efficacious mode of treatment. In the second, how- ever, the less dangerous sponge-tent is enough. The point of the sponge extends into the cavity, and, as it swells, it destroys the granulations by pressure, so that the effect of a single tent is often quite remarkable. At all events, it is certainly advisable to make trial of the tent before having recourse to a scraping of the mucous surface with the Recamier curette or Simon's sharp scoops, whereby the danger of the treatment would be much increased.] The forms of local treatment, when the blennorrhcea is pro- fuse, are most varied. The crayons recommended by Bec- querel and Rodier wTere at one time very popular. They were made up with tragacanth, and served to bring the remedy—usu- ally tannin in equal parts with the gum—in direct contact with the diseased surface. Nitrate of silver has enjoyed even greater popularity. The silver is combined with nitrate of potash, to make it less friable, and if the uterus is not flexed, or the cervix too narrow, a stick of the caustic is easily passed into the cavity of the uterus. It is recommended by many2 to break off the stick, and leave a piece in the cavity. It is immediately covered with albuminates, to be sure, and made innocuous, though at the same time inert. Furthermore, if the unprotected stick is used, its introduction so excites the cervix and os internum to contrac- 1 Chamberlain, Noeggerath, et al., Amer. Jour, of Obst., Vol. TV., pp. 719, 726, 728. J Courty, Malad. de l'uterus, 2d ed., pp. 291 and 699. 136 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tion, that not only is the operation made difficult or impossible, but the crayon becomes so covered by albuminates that the idea of its exerting any caustic action after the cavity is reached is illusory. For this reason various instruments have been con- trived for keeping the stick covered till it reaches its destina- tion. Spiegelberg1 uses an instrument like a uterine sound, hollowed to receive a crayon and a wire to thrust it out. Mar- tin2 invented a similar instrument, familiarly called the uterine pistol, which he uses for the introduction of any desired remedy into the cavity of the uterus. He has a mass made from glyce- rine and various powders, of consistency firm enough to allow of its being shaped into little crayons, the active constituents being chloride of iron, sulphate of copper, oxide of zinc, or tannin.3 Storer, of Boston,4 uses a like instrument. But the same objec- tion applies to this method as to the use of nitrate of silver; namely, the crayons are rendered inactive by becoming covered with albuminates, they work unequally upon the uterine sur- face, and, moreover, as foreign bodies they cause irritation. It is a better way to introduce the remedies in the form of easily soluble ointments, which may be made up with lard or glyce- rine, and introduced by means of an instrument similar to the one described above, carrying a perforated receptacle, the con- tents of which may be forced out with a piston.B There is still another method, introduced apparently by Mil- ler, and afterwards strongly recommended by Playfair.6 A bit of cotton is wrapped about the end of a common sound, dipped in the remedy, and introduced into the uterine cavity. By wrap- ping it loosely or tightly, it is possible to leave the cotton or with- draw it as desired. But this, too, is unsatisfactory, for either the application is wiped off in passing the cervix, or gets so coated with mucus as to prevent any action on the diseased parts. 1 L. c.,p. 228. 2 Berl. Beitr. z. Geb. u. Gyn., B. I., H. 1, p. 28. 3 The following is the formula: Take a grain and a half each of chloride of iron or oxide of zinc, and of powdered marshmallow root, and add enough glycerine to make into a crayon. 4 Boston Gyn. Jour., Vol. VII., p. 94. b Barnes' Ointment Positor. See Diseases of Women. London, 1873, p. 138. 6 Brit. Med. Jour., Dec. 11, 1869, and Lancet, 1870, II.. July 1. CHRONIC ENDOMETRITIS. 137 The surest means we have of producing a uniform effect upon the uterine mucous membrane is the intra-uterine injection of fluids. Such injections were used long ago by Lisfranc and A7idal de Cassis, and their employment is now becoming more and more general. The method, though efficient, is not without danger, and must therefore be employed with great caution. The instrument for making the injection is a small syringe, with a nozzle shaped like the uterine sound. C. Braun's1 pattern is an excellent one. The syringe is carefully filled, so as to contain no air. the nozzle introduced, and as much fluid injected as is thought proper. A series of published, and probably a much larger one of unpublished cases, show that the operation may produce dangerous symptoms, and even cause death. The bad results may follow: first, from the passage of the injected fluid into the peritoneal cavity, but, although careful experiments have shown the possibility of this, it is surely of very rare occurrence, and is indeed possible only under certain conditions. For instance, the fluid must be injected with consider- able force, while at the same time its return to the vagina is prevented either by a narrow cervix, a flex- ion, or, what oftener happens, by the active contrac- tion of the cervix about the nozzle of the syringe ; and even under these circumstances it is not probable that a sufficient quantity will enter the tube except when it is abnormally dilated at its uterine extremity. A great number of experiments have been made for the purpose of determining the possibility or impossibility of the passage of fluid through the Fallopian tubes. Vidal2 was the first to institute exj)eriments upon the cadaver. He found that with moderate pres- Fig 49 sure the fluid entered neither tubes nor veins. Hennig3 reached the „ ° Braun s syringe same conclusion. Klemm 4 also found that it was only with great for intra-uter- ine injections. difficulty that the fluid could be made to pass the Fallopian tubes, but that it entered the veins of the uterus and broad ligaments somewhat more 1 Filrst, Monatschr. f. Geburtsh., B. 26, p. 1. s Essais sur un traitement, etc. Paris, 1840. 3 Katarrh der inneren weibl. Geschlechtstheile. Leipzig. 1862, p. 12. 4 Ueber die Gefahren der Uteriu-Injectiou. Diss. Inaug. Leipzig, 1863. 138 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. easily. If the cervix was ligatured it required no very high pressure to drive the fluid through the tubes. These experiments on the cadaver admit, of course, of qualified conclusions only in regard to the living body. A number of cases, however, confirmed by autopsy, prove conclusively that such passage of fluid is possible. Von Haselberg,1 for in- stance, reports a case with autopsy, in which a solution of chloride of iron had pene- trated to the external end of the right tube. In this case the uterus was anteflexed, and the tube so dilated as to allow the passage of a large sound through its whole length. Barnes2 saw a case in which the same fluid had passed the distended left tube. Another case is reported by Kern.3 Cohnstein4 has written a historical account of intra-uterine injections. This author, making the mistake of supposing the word uterus to have had the same signification with the ancients as with us, ascribes to them the use of intra-uterine injections; whereas, as is commonly known, they included under this term both vagina and uterus.* Secondly, evil results may be caused without the entrance of fluid into the tubes, by a too forcible dilatation of the uterus, causing a metritis which may extend to the peritoneum. On account of these dangers, resulting chiefly from the lack of a free exit for the fluid, it is necessary to observe the following cautions: 1. Favorable cases must be selected, and those especially avoided which are complicated with any inflammation of the uterus itself or its appendages. There must be no tenderness in or about the uterus. Old adhesions remaining after inflam- matory processes are very undesirable, though not an absolute contra-indication. 2. There must be a free exit for the injected fluid. This may be obtained by using a nozzle with double canal, but a coagulum may easily stop the current, and hence it is better in every case first to dilate the cervix with a sponge-tent. 3. Only a small quantity of fluid must be injected. 4. The fluid should be slightly warmed, and slowly injected. If these precautions are strictly observed, we shall avoid with certainty all alarming accidents, as well as the uterine colic, so 1 Monatschr. f. Geburtsh., B. 34, p. 162. 2 Obstet. Operations, 2d ed., p. 468. 3 Wiirtemb. med. Correspondenzbl., 1870, No. 7. • Beitr. z. Therap. d. chron. Metritis. Berl., 1868. 6 See the criticism by Freund, Deutsche Klinik, 1869, pp. 229, 239, 325. CATARRH OF THE CERVIX. 139 often caused by contraction of the organ upon its abnormal contents. Where there is a flexion of the uterus, which will reappear upon withdrawal of the syringe, it is advisable to follow the advice of Haselberg,' and draw the fluid back into the syringe at the end of a minute or two. Hildebrandt2 thinks this procedure dispenses with the necessity of artificial dilatation of the cervix. A large number of different fluids are used for these injec- tions, but usually it is either tincture of iodine, or a solution of chloride of iron, acetate of lead, nitrate of silver, carbolic acid, alum, or tannin. Experiments have been made by Nott' to determine the action of these agents upon albumen. Accord- ing to him, alum and iodine have the advantage of forming no precipitate of albuminates, while all the others must form coag- ula in the uterus, which cannot come away through a small canula, The stronger agents, as concentrated solutions of nitrate of silver or chloride of iron, have, however, the advantage of destroying any exuberant growth of the mucous membrane. The most energetic local application is the galvano-cautery, as recommended by Spiegelberg.4 A porcelain tip is introduced cold, and then brought to a red heat. Spiegelberg considers it to be entirely free from danger. ENDOMETRITIS CERVICIS, CATARRH OF THE CERVIX.—ECTROPION OF THE OS UTERI.—ENLARGED FOLLICLES.—OVULA NABOTHI. Wagner, Archiv f. phys. Heilk., 1856, p. 493—C. Mayer, Ueber Erosionen, etc., p. 22.—Hildebrandt, Volkmann's Samml. klin. Vortr. Leipzig, 1872, No. 32. Etiology. The causes of cervical cartarrh are much the same as those of chronic inflammation of the mucous membrane of the body of the uterus, though this tract, or rather the neighboring mucous membrane of the vaginal portion, pathological processes of which ' L. c. 2 L. c. 3 Am. Jour, of Obst., Vol. III., p. 36. 4 Monatschr. f. Geburtsh., B. 34, p. 393, and 1. c, p. 231. 140 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. readily extend into the cervix, is much oftener exposed to mechanical violence. As the uterus from time to time changes position, the vaginal portion is rubbed against the walls of the vagina, and besides this it is exposed to injury from various external sources, such as coitus, onanism, and various thera- peutic measures. Pathological Anatomy. The mucous membrane of the cervix, especially its longitu- dinal folds (plicae palmatae) is looser in texture than normal, somewhat cedematous, and in the early stages hyperaemic. The mucous membrane of the vaginal portion is also swollen, and usually infiltrated and hard, but seldom cedematous. The secre- tion from the cervix is, as usual, thick, stringy, and tenacious, but its quantity may be much increased. With a longer dura- tion of the disease, the connective tissue of the hyperaemic, copi- ously secreting mucous membrane becomes much hypertrophied. It may increase to such an extent as to overfill the canal, and protrude from the external os, forming the condition called by Tyler Smith1 "inversion of the canal of the cervix uteri," and by Roser2 "ectropion of the os," in analogy with ectropion of the conjunctiva. This hyperaemic, easily bleeding mucous mem- brane, even in its natural state more red than the vagina, readily gives the impression of an erosion. The hypertrophied mucous membrane, besides protruding from the os, forms longi- tudinal folds within the canal. If the disease is confined to one lip, the swelled membrane, instead of protruding from the os, forms a tumor presenting at the orifice and differing in appear- ance from a polypus only in having a broad base instead of a pedicle. A further peculiar complication is the condition of the glands, which, in catarrh of the cervix, are regularly met with on the external surface of the vaginal portion—the assertion of Friedlander and Lott, that they are abnormal in this position, to the contrary, notwithstanding. These glands become of impor- tance through the retention of their secretion, which takes place 1 Pathology and Treatment of Leucorrhoea, p. 84. 2 Archiv d. Heilkunde, 1861. p. 97. CATARRH OF THE CERVIX. 141 in catarrh. Their openings become closed by the swelling of the mucous membrane, and finally the edges of the orifice unite com- pletely ; the inflammatory changes still go on within the closed follicle, as well as outside ; it fills with secretion and exfoliated epithelium, and a small cyst is formed. If the disease advances to suppuration, pus also is found in the cyst, the contents of which may remain purulent long after disappearance of the sup- purative catarrh. Usually, however, the secretion is clear, thick, and glassy, though the abundance of exfoliated epithelium often gives it a cloudy or milky white appearance. Under the microscope the secretion showTs ciliary epithelium, disinte- grated cells, free nuclei, colloid and mucus corpuscles. These cysts tend to perpetuate the catarrh, through the irritation which they cause. Their appearance varies much with their location, whether within or without the canal. AAxithin the canal, where the mucous membrane is but loosely connected with the muscular layer, the swelling follicle easily forces it up, form- ing an elevation on the surface which rises higher and higher, while the rapidly proliferating cells of the connective tissue close in below it, till finally the grayish-white cyst hangs like a little polypus on the surface of the mucous membrane. They form thus in large numbers within the cervix, presenting an appearance so characteristic that they have been known from ancient times as ovula Nabothi. Their appearance is quite different when they occur on the external surface of the vaginal portion ; there the mucous mem- bran*1 is so closely adherent to the tissues beneath that the swell- ing follicle is unable to raise it much, and cannot therefore be- come pedunculate, but appears merely as a translucent grayish cyst, lying under the mucous membrane, and perhaps elevating it slightly. The}- are recognized more easily when the contents become purulent, by their yellowish color. These follicular swell- ings run a very different course in different cases. If they are not too abundant, and the catarrh begins to improve, the secre- tion becomes thickened and they diminish in size. We find, then, numerous little yellow protuberances, which when pricked dis- charge a thick, comedo-like mass. The thickening of the con- tents may advance still further, till at last we find, scattered over 142 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the mucous membrane, only small points the size of a millet seed, the contents of which have become so firmly adherent that they can no longer be removed. If, on the other hand, the inflammation is more severe, and the follicles very abundant, these minute cysts furnish an addi- tional source of irritation to the mucous membrane, which becomes very hyperaemic, filled with large, distended blood-ves- sels, and increases to such an extent as to cause a considerable hyperplasia of the whole vaginal portion ; the thickly scattered, hard, swollen follicles are then seen resting upon an inflamed, reddened surface. The lips of the os become very much everted, giving the opening a thick, trumpet shape. The hyperplasia of the mucous membrane may be so great, and the part rendered so hard by the swollen follicles and inflammatory exudation, that the disease may be mistaken for carcinoma. Virehow calls the disease acne hyperplastica, and compares it to a toper's nose. The swollen follicles may burst, and so give rise to a follicu- lar ulceration. If several follicles, lying close together, distend a flaccid mucous membrane to a considerable degree, the result is seldom, as we shall see later, a follicular hypertrophy of one lip (see p. 149), but far oftener a mucous polypus of the cervix (see p. 145). Symptoms. Here also the most constant symptom is leucorrhoea, which may be followed by the same results as in catarrh of the corpus. If the hyperaemia is considerable, and the pressure of the follicles upon the surrounding tissues great, there results in many cases an almost unbearable sense of burning in the pelvis. The inevita- ble pain in the back, too, will not be absent. Menstruation may be normal; the discharge, however, is often increased in amount. The extensive swelling of the mucous membrane in ectropion of the os may cause not only a copious watery discharge, but hemorrhage so serious as to produce a high degree of anaemia. Sterility is not uncommon, caused in part by the swelling, in part by the profuse discharge, which washes away the sper- matozoa. Upon examination, the body of the uterus may be found CATARRH OF THE CERVIX. 143 quite normal, the cervix, however, thickened and often tender. The speculum shows the different appearances, as above de- scribed, of simple catarrh, ectropion, and swollen follicles. Moreover, the vaginal portion is often the seat of erosions and ulcers,—conditions which we shall consider in another place. The course of cervical catarrh is very chronic. The discharge may continue many years, and the swollen follicles may long remain unchanged. Diagnosis. Catarrh of the cervix may be recognized, upon digital exami- nation, by the swelling and infiltration of the vaginal portion, and, upon inspection through the speculum, by its characteristic appearances. Prognosis. Once firmly established, the disease, if left to itself, remains for a long time unchanged, or grows gradually worse, for the swollen follicles are a continual source of irritation; while, on the other hand, the irritated membrane continually causes new follicles to undergo cystic degeneration. Proper treatment, howT- ever, will generally produce, if not a complete cure, at least a nearly complete disappearance of the symptoms. Treatment. The same therapeutic means that are used in treating catarrh of the corpus, may be employed in treating that of the cervix uteri. At the head of the list stand nitrate of silver and carbo- lic acid. Here, however, the application of remedies is a much simpler affair. If it is desired to make the application only to the mucous membrane of the vaginal portion and the opening of the cervical canal, the solution may simply be poured into a porcelain speculum, or it may be applied with a brush. Med- icated crayons, or those of silver nitrate, can be brought in contact with the disease without difficulty. The sound, wrapped in cotton and dipped in the remedy, is also a ready means of making an application. Should the mucous membrane of the cervical canal be much 144 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. swollen and covered with cysts or granulations, it is best to use the sponge-tent; it crushes the exuberant growths and acts favor- ably upon any hemorrhage, as well as upon the blennorrhcea. The sponge may be used as a means of making a local applica- tion, as well as mechanically. Thomas' suggests two methods of preparing the sponge : either to fill the hole left by the wire with a preparation of cacao butter and the drug to be employed, or to dip the sponge, before being pressed, into a solution contain- ing the remedy, dry it, and then prepare it in the usual manner. Since the swollen follicles continually irritate the diseased mucous membrane, it becomes an urgent indication to empty them. This may be done through a speculum with a long- handled, sharp-pointed scalpel. The pressure of the swollen tis- sue and adjacent follicles is so great that the thick contents will usually be discharged spontaneously; if not, they may be emptied with the handle of the scalpel. If the woman lies upon the back, the follicles farthest back should be pricked first, so that the blood, which always escapes from the inflamed mucous membrane, may not conceal the field of operation. All the follicles to be found may be operated on at once, but the process will have to be repeated with a new crop, which will develop from the deeper part of the membrane. If ovula Nabo- thi exist in the cervical canal, where it is hard to get at them with a scalpel, they may be destroyed with solid nitrate of silver or by a sponge-tent. The emptying of the distended follicles has an extraordi- narily beneficial effect upon the irritated state of the uterus, an effect which may be explained on the one hand by the diminu- tion of pressure upon the neighboring parts, and on the other by the local abstraction of blood. After a few faithful repetitions of the operation, the swelling and inflammation, and gradually the discharge itself, will be found to have diminished so considerably that the application of astringents and caustics becomes unneces- sary. The treatment becomes more difficult in those cases where there is marked hyperplastic swelling of the mucous membrane ' Diseases of Women, 3d ed. Phila., 1872, p. 251. MUCOUS POLYPI. 145 with extensive ectropion. In milder cases of this sort, crude acetic acid works well, merely poured into the speculum and allowed to remain five minutes or so in contact with the diseased part. In severe cases larger or smaller pieces of the membrane may be excised, or it may be treated with a strong caustic, as chromic acid or chloride of iron. The latter is specially to be recommended where hemorrhage is a troublesome symptom. In very old cases it is better to make a thorough application of the actual cautery to the whole everted portion of mucous membrane. These are very satisfactory cases to treat, for the most obsti- nate hemorrhage, supposed perhaps to be due to cancer, may often be completely cured by a short course of treatment. If the hypertrophied cervix extends far down into the vagina, it is frequently better to amputate in the same way as in chronic metritis. Mucous polypi and follicular hypertrophy of one lip of the os tincae are pathologically closely allied to the catarrhal and hyperplastic conditions of the cervical mucous membrane. In both, the transformation of the follicles into cysts is the pri- mary change, and both show to a certain extent merely more advanced stages of the follicular changes occurring in catarrh. AVe shall consider these two conditions separately, since they differ so much in the way in which the tumor is formed. MUCOUS POLYPI. Nivct et Blatin, Archives gen., Octobre, 1838.— Oldham, Guy's Hosp. Rep., April, 1844.—Huguier, Soc. de Chirurgie. Paris, Mai, 1847.—Billroth, Ueber den Bau der Schleimpolypen. Berlin, 1855.—Hirsch, Histologic und Form der Uteruspolypen. Diss. Inaug. Giessen, 1855.— Wagner, Archiv f. phys. Heilk., 1855, p. 289.—C. Mayer, Vortr. iiber Erosionen, Excor., etc. Berlin, 1861.— Klob, Pathol. Anat. d. weibl. Sex. Wien, 1864, p. 133.—J. M. Duncan, Edin. Med. Jour., July, 1871, p. 1. Etiology. AA^e have already seen how, in catarrh of the cervix, the swell- ing follicles easily raise the mucous membrane, lying loosely vol. x.—10 146 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. over them, and form small elevations upon the surface, the bases of which become gradually smaller, till finally the little cyst remains connected with the mucous membrane by only a slen- der pedicle. Such a swollen follicle—an ovulum Nabothi—is in reality a miniature mucous polypus, though not generally bearing the name. But mucous polypi, properly so called, are formed by an exaggeration of the same process, so that an important part in the etiology of mucous polypi is played by chronic catarrh and its sequels of cystic degeneration of the follicles and alteration in the tissue of the mucous membrane, making it flaccid and more easily movable upon the parts beneath. Pathological Anatomy. Mucous polypi are made up of single follicles, or of several lying close together, which elevate the loose-textured mucous membrane covering them; and the process goes on till the final result is a polypus-like projec- tion of the mucous membrane, whose club - shaped extremity, made up of one or several folli- cles, hangs towards the external os, while a slender pedicle of mucous membrane connects it above. The polypus descends gradually by force of its own weight and the pressure of the uterine walls, till it protrudes from the external os. The folli- cles may pass through the changes already described under chronic inflammation. The contents may become thickened and the follicle scarcely perceptible ; oftentimes the follicle splits open, the walls collapse, and a shallow depres- sion is formed, which gradually disappears. The parenchyma of the polypus is made up of a finely fibrous Pig. 50. Mucous polypus of the cervix, the size of a walnut MUCOUS POLYPI. 147 connective tissue with numerous nuclei. The membrane cover- ing it is very vascular, its large supply of blood giving it often- times a cherry-red color, and it bleeds most readily. These polypi have their origin for the most part in the canal of the cervix ; still they are by no means rarely derived from the mu- cous membrane of the corpus, beginning probably in the uterine glands. Such, however, as have their origin here usually remain small, never reaching the cervical canal, so that they are not often discovered. It is very common to find them in autopsies, especially of elderly women who have borne many children. If such a polypus has its seat in one of the lateral furrows of the cavity, it will be found flattened antero-posteriorly. The cervical polypi, as above mentioned, quickly appear at the external os. Their size is usually between that of a pea and that of a hazel-nut, very rarely reaching the dimensions of a pigeon's egg. They are very variable, too, in aspect and consis- tency, according to the different conditions of the follicles, and according as the connective tissue is succulent and soft, or more fibrous and hard. If the polypus is made up of a number of follicles, individual ones may separate to form secondary polypi upon the main mass. Furthermore, the mucous membrane cov- ering the tumorJ may take on an exuberant villous growth, and we have then a papilloma with dendritic outgrowths. (This pap- illary growth may possibly originate, as in follicular hypertro- phy of a single lip, from the inner wall of the ruptured follicle.) Symptoms. The small polypi of the uterine cavity usually produce no symptoms at all. Cervical polypi, however, always cause more or less hemor- rhage, the blood coming from the hyperaemic and varicose ves- sels of the surface of the growth, and the bleeding being some- times very profuse. It often takes first the form of copious men- struation, to result later in irregular metrorrhagia. Leucorrhoea is present between the hemorrhages, and is, as the etiology of the disease would indicate, frequently of earlier date than the poly- 1 Klob, Pathol. Anat. d. weibl. Sexualorg. Wien, 1864, p. 139. 148 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. pus. Cervical polypi, as well as those of the cavity, when of large size, are always accompanied by sacral pain. They often cause sterility, partly by the mechanical obstacle which they present, partly by the constant serous or bloody dis- charge which attends them. Diagnosis. As soon as the polypus appears at the external os, the diagno- sis is easy. On digital examination a small, soft tumor is felt in the os, which, seen through the speculum, appears as a blood- red or more bluish mass, with the smooth exterior of the nor- mal, though perhaps very hyperaemic mucous membrane, be- neath which the yellowish or grayish follicles are often plainly to be seen. There is usually no difficulty in excluding fibrous polypi, for they are as good as never seen of such size in the external os, and, when the mucous polypus is unusually large, its consistence will always serve easily to distinguish it from the hard, fibrous polypus. Circumscribed swelling and granulation of the cervical mu- cous membrane, as it appears in chronic catarrh and diphthe- ritic inflammation, may much resemble a tumor lying in the external os, but the finger will easily decide between the broad swelling and the polypoid tumor. The question between polypus and an early abortion may be a difficult one to decide. The ovum presenting itself at the mouth of the uterus may closely resemble the ulcerated end of a polypus, and the history of the case may offer no solution of the difficulty. The hesita- tion, however, regarding the diagnosis, can be but temporary. Small polypi of the cervix, without symptoms, are of course not apt to be discovered. If urgent symptoms of concealed dis- ease be present, the os must be dilated with a sponge-tent, and a digital examination of the cavity made. Prognosis. Mucous polypi may become troublesome on account of long- continued leucorrhoeal and bloody discharge. Apart from hem- FOLLICULAR HYPERTROPHY OF THE CERVIX. 149 orrhages, however, they are seldom the cause of serious danger, the disease naturally tending to amelioration; for, as soon as the tumor has been fairly extruded from the os, the symptoms become less severe, and the polypus may even drop off spon- taneously. Treatment. The only indication is, of course, removal by operation, which may be done in different ways. If the polypus is very small and soft, the best way is to seize it with long forceps, close to its insertion, and twist it off. If we prefer to cut the pedicle, which, as it causes less injury to the mucous membrane, it is better to do where the polypus is large and its pedicle slender, the whole may be drawn down into a speculum by a small hook, and cut off with long scissors. Any after-treatment of the pedicle, such as cauterization, is entirely unnecessary, for there is no danger of severe hemor- rhage or of a return of the affection in the same place. A second polypus may appear after the removal of a first, but it was probably present before, and merely hindered in its descent by the presence of the one operated upon. Polypi lying higher in the canal, and therefore difficult of access, may easily be gotten rid of by means of the sponge-tent. It is harder to come at those in the cavity of the uterus itself, but after dilatation of the os they can often be broken up by the finger, or twisted off with forceps. Smaller-sized polypi may be destroyed by means of caustic injections. The removal of these polypi is a most satisfactory operation, removing, as it does, so easily and entirely, symptoms so annoy- ing, and perhaps even dangerous. FOLLICULAR HYPERTROPHY OF THE LIPS OF THE OS UTERI. Virehow, V.*s Archiv, 1854, B. 7, p. 164, und Die krankhaften Geschwulste, B. III., 1, p. 142.—Lebert, Traite* d'anat. pathol., T. I., pi. XL., p. 15.— Cruveilhier, Atlas d'anat. pathol., Livr. 39, pi. 3, figs. 2 et. 21.— Wagner, Archiv f. phys. Heilk., 1856, p. 509.—Simon, Mon. f. Geb., B. 23, p. 241.— Honing, Berl. kl. W., 1869, No. 6.—Ackermann, Virchow's Archiv, B. 43, p. 88.—Martin, Berl. Beitr. z. Geb. u. Gyn., B. II., p. 51. 150 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Etiology. Follicular hypertrophy, which consists in an exuberant growth of the mucous membrane, with cystic degeneration and, later, rupture of the follicles, is undoubtedly closely connected etiologically with mucous polypi. Just as in the latter disease a closed and swollen follicle of the cervical mucous membrane irritates, by its increasing weight, the surrounding tissue to rapid growth, and eventually protrudes in the form of a polypus, so also in follicular hypertrophy is transformation of the follicles into cysts the first step, and the different form of the tumor results from the fact merely that in this disease the end of the lip grows broad. The mucous membrane covering the outer surface of the vaginal portion is much more firmly attached to the underlying structures than that of the canal, and opposes much stronger resistance to the pressure of the swelling follicles, and this is probably the reason that a comparison is so seldom drawn between follicular hypertrophy and mucous polypus. Two con- ditions seem to me specially to favor the production of follicular hypertrophy: first, when the cervical mucous membrane, in women who have borne many children, is so everted by ectro- pion of the os that the end of the lip is no longer a part covered with closely adherent mucous membrane, but with that which originally lined the cervical canal, and which, as we know, is more inclined to hypertrophic growth; secondly, when the cervi- cal canal, in women who have never borne children, is so narrow that it cannot accommodate a polypoid growth within it; the proliferating mucous membrane is thus forced to grow downward and to protrude from the cervical canal as an extension of one of the lips. Pathological Anatomy. These tumors are specially interesting from the numerous forms under which they appear. From already published cases, and from one of my own not yet published (see Fig. 51), I have drawn the following description of the disease. FOLLICULAR HYPERTROPHY OF THE CERVIX. 151 The polypoid extension of one of the lips (one is diseased equally often with the other) presents the appearance of a pedunculate tumor, which Virehow has very aptly compared to an enlarged tonsil. Its parenchyma is made up of a very vas- cular connective tissue. Throughout the tumor, and even ex- tending into the pedicle, are large, closed, or sometimes ruptured cavities, clothed with cylinder epi- thelium and filled with mucus. These are the follicles, degener- ated into large cysts. The surface of the tumor is composed of well- developed papillae, covered with a pavement epithelium, which is often quite firm ; it is quite irregu- lar, owing to the bursting of the follicles beneath, which causes depressions, shallow or deep, ac- cording to the size of the cavities, and when two neighboring cysts burst, a sharp edge or even band of tissue may be left between the hollows made. Occasionally, as in the case ob- served by me, and mentioned further on, the walls of the degen- erated follicles may become the seat of rich fungous growths, which, as in the case reported by Ackermann, may become so large as to burst through the cyst, appearing here and there upon the outside of the tumor as cauliflower excrescences. (These primarily pure glandular growths with secondary fungous additions—as in ovarian cystomata—must not be confounded with papillomata of the vaginal portion of the os in which cystic degeneration has afterwards taken place.) The appearance of the tumor becomes much changed if it advances so far as to project from the vulva. At first this expos ure is only temporary and occasional, but finally becomes per- manent. Then all the follicles break, and the cavities (Krypton) become shallower, giving the surface a broken, scarred appear- Fig. 51. Follicular hypertrophy of the anterior lip. 152 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ance. The epithelium grows thicker and thicker, so that a firm tumor covered with epidermis is formed, which may be com- posed (as indeed it may be in earlier stages) of several lobes. These changes were most prominent in the case reported by Simon, in which there was a complication with true hypertrophy of the vaginal portion, though this was secondary, and caused probably by the dragging of the tumor. Symptoms. First among the symptoms of hypertrophy of one lip are leucorrhoea and hemorrhage. When the mass reaches the vulva, we may expect most troublesome dragging and bearing-down pains, resembling even those of labor, and finally, added to all this, the patient will have the annoyance and pain which the presence of a foreign body between the labia necessarily causes. Diagnosis. This form of tumor is unlikely to be confounded with any other, as the soft polypoid prolongation of one lip, composed of mucous membrane alone, is quite characteristic. Treatment. The removal of the tumor by operation is of course the only resource. This is to be effected at the level of the normal lip, and may be done with scissors or scalpel, but better, on account of the vascularity of the pedicle, by the galvano-caustic wire loop. Reference has been made to a case of my own (see Fig. 51), which I will report more fully here. The patient was a woman twenty-eight years of age, six weeks married. Two years before, after severe exertion, she felt something come down between the labia of the vulva. Of late it had come down oftener, but had returned spontaneously, mere sitting down being sufficient to effect reduction. She complained of menorrhagia and leucorrhoea. At the entrance to the vagina there was a soft red tumor, hanging by a gradually tapering pedicle to the anterior lip of the os uteri. It was removed by the galvano-cautery. A few days later a small mucous polypus was removed from the cervical canal, and uninterrupted con- EROSIONS AND ULCERS OF THE CERVIX. 153 valescence followed. Two years after, she was confined with a stout boy. The tumor measures an inch and three-quarters in breadth, and three-quarters of an inch in thickness, while the pedicle is one-third of an inch thick and three-quarters of an inch broad. Over the surface are numerous fissures and canals, into some of which the sound can be passed quite a distance. At the apex and at one other place little bridges of mucous membrane may be raised from the surface. On section, the apex is found to be filled with a cyst the size of a hazel-nut, with thick walls, and con- taining a tough, transparent mucus. The walls are thickly studded with a fine papillary growth. There are besides, in both tumor and pedicle, numerous small cavities (Krypten) which also contain papillary growths. EROSIONS AND ULCERS OF THE VAGINAL PORTION OF THE UTERUS. Otterburg, Lettres sur les ulcerations de la matrice, etc. Paris, 1839.—J. H. Bennet, Pract. Treat, on Inflam., Ulcerat., and Indur. of the Neck of the Uterus. Lond., 1845.—Robert, Des Affect, granul., ulc6r., et carcin. du col de Tuterus. These. Paris, 1848.—E. Wagner, Arch. f. phys. Heilk, 1856, p. 515.— C. Meiyer, Vortr. fiber Eros., Excor.. etc. Berlin, 1861.—Scanzoni, Chronische Metritis. Wien, 1863, p. 78. The Simple Erosion. An erosion is merely a circumscribed loss of the epithelial covering, which may be caused in one of two ways. First, and in the majority of cases, the epithelium is gradually removed by maceration. We then find bright red spots upon the visible part of the vaginal portion (the lower part is often everted), and also upon the opposite vaginal mucous membrane. Their edges may be well defined, or they may pass gradually over into the healthy membrane. They are smooth of surface and bleed readily if rudely touched, as, for instance, with the end of the speculum. The loss of epithelium may be caused, secondly, by an exudation from the papillae, which raises it first in vesicles from the size of a pin-head to that of a millet-seed, though now and then larger ; these vesicles then burst, leaving a spot eroded of epithelium, which increases in size by a repetition of the pro- cess in its neighborhood. This form of erosion is called by Scanzoni aphthous; by Lisfranc, Robert, and others, herpetic. Joulin' observed vesicles with clear mucous contents, which he called pemphigus. 1 Gaz. des hop., 1861, No. 40. 154 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The first sort is usually traumatic in origin, in that the epi- thelium, loosened by long maceration in the catarrhal secretion, is finally chafed and rubbed off, either by coitus, onanism, pes- saries, or even by unusual motions of the uterus itself, as when its weight is abnormally great, or the abdominal pressure in- creased by excessive exertion. If the discharge is very profuse or irritating in character, it alone may be sufficient to cause erosion. The aphthous form is the result of endometritis, the papillae of the mucous membrane secreting so copiously that the epithelium is raised in vesicles. The diagnosis is easily made by the specu- lum, the erosion being seen simply as a reddened spot, from which the moist, shining, epithelial covering has disappeared. The vesicles are distinguished from swollen follicles by their diminutive size, white color, and distinct elevation above the sur- face of the mucous membrane. This insignificant amount of disease produces no symptoms, and needs therefore no treatment. If the stagnating, irritating discharge be carefully removed by mild injections, the erosions will heal without further inter- ference. If the spots refuse to heal, if there is much serous oozing, or inclination to hemorrhage, they may be carefully touched with a solution of nitrate of silver of medium strength. The Papillary Erosion. By the continued action of the traumatic causes already enu- merated, the simple erosion may be developed into the papil- lary ulcer. The papillae left bare by the removal of the epi- thelium are continually irritated, and develop into granular, dark-red elevations, which the touch of even a soft brush will cause to bleed. The erosion extends both inwardly and out- wardly from the external os. If the amount of irritation be very great, the papillae take on a further growth, and the fine villi rise above the general surface. Rarely does the process go farther still, and take on the form of a true fungous granula- tion of the vaginal portion. AVhen it does, the mass now and then becomes so flattened by the vaginal walls as to look some- thing like a cock's comb, and is by English writers called cock's- EROSIONS AND ULCERS OF THE CERVIX. 155 comb granulations ; by the French, ulcerations fongueuses vege- tantes. In these villous growths there is great hyperaemia, the vessels lie quite superficially and exposed to injury, so that hemorrhage and all its evil consequences are specially apt to complicate this form. On this account, and because of a certain danger of can- cerous degeneration (see carcinoma of the cervix), the prognosis should be guarded. The diagnosis is easy, the gross appearances of the disease being so characteristic. It must not be confounded with ectro- pion of the hypertrophied mucous membrane, which, with its numerous folds and dark-red color, resembles it somewhat; still, the two conditions are not infrequently combined. The best mode of treatment is to pour crude acetic acid into the speculum, in sufficient quantity to cover the diseased vagi- nal portion of the cervix ; the acid should be allowed to remain there about five minutes, and the application repeated perhaps every other day. The papillae become white and withered, while the epithelium is excited to active growth, and even to suppuration. I would particularly caution against the use of the stick of nitrate of silver; it causes profuse hemorrhage and excites the papillae to more active growth. The larger fungous growths may be cauterized with per- chloride of iron, or chromic acid applied on a pledget of cotton, or with the hot iron. Growths larger still may be first excised with scissors, and then cauterized in the same way. Follicular Ulcer. The distended follicles described on page 141 may burst, especially if their contents are purulent, and, discharging the contained fluid, leave a small cup-shaped ulcer. The follicles themselves have been described under the head of cervical ca- tarrh. The ulcers remaining after their rupture are of no impor- tance whatever, and heal spontaneously, so that the rupture of the follicle must be regarded as a favorable circumstance. Should the base of the ulcer look badly and begin to granulate, it is well to touch it with solid nitrate of silver. 156 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The varicose ulcer described by Scanzoni and other gynecologists is probably either a simple or papillary erosion occurring in connection with varicose superficial veins of the vaginal portion. We have described these forms of ulcer as occurring inde- pendently, but it should be understood that they are very likely to be combined; the simple erosion, particularly, is very apt to take on a papillary character. The appearance of the ulcers may be much altered by too active treatment; for instance, the frequent touching of a papillary ulcer with solid nitrate of silver will cause an abun- dant development of flaccid granulations upon an unhealthy base, and the frequent application causes further a chronic irri- tation of the mucous membrane, characterized by oedema of the submucous tissue, which gives to the finger a peculiar sensation, as if the mucous membrane lay upon a cushion of fluid. If, in such a case, all active treatment be omitted, the oedema will soon disappear, and the ulcer heal spontaneously. Phagedenic or Corroding Ulcer of the Uterus. This form of ulcer, first described by Clarke, consists in a gradually progressive disintegration of the normal tissues, and is often, no doubt, confounded with rapidly disintegrating cancer, so that its existence has been denied by many ; but that it does occur has been established by the decisive observations of Rokitansky1 and especially Forster.2 It is a deep ulcer with hard edges and villous gangrenous base, uncontrollable in its course, and, so far as past experience shows, necessarily fatal. The diagnosis can be made only on the dead body, or at best by removal of the disease and examination with the microscope. For treatment, the actual cautery certainly deserves trial. Chancre of the Vaginal Portion. Chancre of the vaginal portion has the usual characteristics of the sore in other parts. It is very rare, and more rarely still does it acquire a phagedenic character. 1 Handb. d. path. Anat., III., p. 538. * Handb. d. path. Anat., II., p. 318. DISPLACEMENTS OF THE UTERUS. 157 DISPLACEMENTS OF THE UTERUS. ANTEFLEXION, ANTEVERSION, RETROFLEXION, RETROVERSION. Schweighduser, Ueber einige phys. u. prakt. Gegenst. d. Geburtsh. Niirnberg, 1817, p. 251.— W. J. Schmitt, Ueber d. Zurtickbeugung d. Gebarmutter, etc. Wien, 1820.— Tiedemann, Von den Duverney'schen, etc. Heidelb. u. Leipzig, 1840. —Simpson, Selected Obstet. Works, I., p. 681.—Pajot (Velpeau), Gaz. des hop., Juill., 1845, No. 82 et seq.—Rigby, Med. Times, Nov., 1845, p. 124 et seq.— Kiwisch, Beitr. zur Geburtsk. Wiirzburg, 1848, II. Abth., p. 134.—Verhandl. der Pariser Akad. d. Med., Gaz. Med. de Paris, 1849, Nos. 41-47.—Sommer, Beitr, z. Lehre v. d. Infarct, u. Flex. d. Gebarm. D. i. Giessen, 1850.—Mayer, Verb. d. Berliner Ges. f. Geburtsh., 1851, IV., p. 198.—Rockwitz, e. 1., V., p. 82, und De Anteflex. et retroflex. Uteri. Marburg. D. i. 1851.—Scanzoni, Sc.'s Beitrage, I., p. 40, und II., p. 161.— Valleix, Gaz. des hop., 1851, No. 129; 1852, Nos. 5-123; and l'Union, 1853, No. 106.—Duncan, On the Displacements of the Uterus. Edin., 1854.— Virehow, Verhl. d. Berl. Ges. f. Geb., IV., p. 80; Wiener allg. med. Z., 1859, Nos. 4, 5, 6, 20; und Mon. f. Geb., B. 13, p. 168.— Rokitansky, Wiener allg. med. Z., 1859, Nos. 17, 18.—Arneth, Petersb. med. Z. 1861, I., 5.— L. Mayer, M. f. Geb., B. 21, p. 426.— Klob, Path. Anat. d. weibl. Sex. Wien, 1864, p. 56.—Max Bernh. Freund, Die Lageentwickelung d. Beckenorgane, etc., in Breslauer Klin. Beitr., 1864, 2 H., p. 85.—Martin, Die Neig. u. Beug. d. Gebarm., etc., 2 Aufl. Berl., 1870.—Sdxinger {Seyfert), Prager Vierteljahrschr., 1866, IV., p. 44.—Meadows, Lancet, 18th and 25th of July, 1868.—Hueter, Die Flexionen des Uterus. Leipzig, 1870.—Crede, Archiv f. Gyn., 1870, I., p. 84.— Winkel, Die Behandl. d. Flex. d. Uterus, etc. Berlin, 1872.—Hildebrandt, Volkmann's Samml. klin. Vortr. Leipzig, 1870, No. 5.— Schroeder, e. 1., 1872, No. 37.-5. Schultze, e. 1., No. 50; Tagebl. d. Leipziger Naturf.-Vers., 1872, p. 81; und, Archiv f. Gyn., B. IV., p. 373.— Joseph, Berl. Beitr. z. Geb. u. Gyn., B. II., p. 107. History. It is very remarkable that such common affections as the backward and forward displacements of the uterus should have waited so long for recognition, and it can be accounted for only by the neglect of gynecological examinations. Attention was first called to it by the difficulties attending retroflexion in pregnancy. Before the present century, only very isolated in- stances of displacements in nulliparae had been published, and these had either been accidentally discovered on the dead body, 158 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. as in the cases reported by Saxtorph * and P. Frank,5 or had come to the knowledge of the observers through symptoms evi- dently occasioned by some complication, as in the cases pub- lished by Willich,3 Schneider,4 and Kirschner.5 Schweighauser was the first who gained any extended experience of the sub- ject ; he called attention to the fact that the backward displace- ments are more common in non-pregnant (thirty-nine cases) than in pregnant (five cases) women. He was supported by AY. J. Schmitt, who, at the same time, gave the history of a few cases of anterior displacement, representing it as very rare. The flexions were generally regarded as much more remark- able and rare, notwithstanding the fact that the cases of Sax- torph and Frank were retroflexions, as ascertained by a post- mortem examination. A more general knowledge of the frequency of anterior and posterior deviations of the uterus was first attained through the studies of Simpson and Kiwisch, whose investigations wTere facilitated by the use of the sound; and it is only in the most recent times that we have entered upon a study of the causes of these deviations founded upon the anatomy of the pelvic organs and their physiological variations. Definition and Etiology. The anterior and posterior displacements of the uterus are of two sorts. If, with the changed position of the body, the cervix turns in the opposite direction, so that the position of the whole organ is altered, while its form remains normal, the displace- ment is called version ; if, however, the cervix retains its normal position in the vagina, at the same time that the body of the uterus falls backward or forward, i.e., if the axes of the two portions form an angle, the displacement is called a flexion. The uterus is normally slightly curved forwards, so that a 1 111. soc. med. Havniensis, 1775, T. II., p. 127. 2 1786, Opusc. posth. Vienna?, 1824, p. 78. 3 Richter's chirurg. Bibl. G6ttingen, 1779, B. V., p. 132. « E. 1., 1791, B. XL, p. 310. 6 Stark's Archiv. Jena, 1793, B. IV., p. 637. DISPLACEMENTS OF THE UTERUS. 159 forward displacement is called anteversion, so long as this curve is not abnormally great, and likewise in pure retroversion there may be a slight (physiological) anteflexion. A displacement for- wards, then, is to be called a pure version, even when there is an appreciable angle in the anterior surface line ; wdiile, on the other hand, a posterior displacement is designated retroflexion, the moment the body and the neck form any angle at all. But these malpositions seldom exist uncombined: When the body is displaced, the cervix is generally turned more or less in the opposite direction, and a moderate amount of version exists with the flexion. As we attach greater importance to the flexions, we shall con- sider all those displacements as flexions in which the direction of the axes of the two portions of the uterus is not quite normal; and we shall class under versions only those in which the axis of the whole organ remains straight or is but slightly bent forwards. In order to understand well the way in which these malpositions occur, we must first obtain a clear idea of the normal relations of the uterus. The uterus lies in the true pel- vis, between the bladder and the rectum, as represented in Fig. 52, but is by no means immovably fixed in this position. The fun- dus has almost entire freedom of motion antero - posteriorly. The round ligaments, taking, as they do, a curved course, and having their insertion in soft parts, allow, even when normally tense, very considerable excursions backward. The cervix is more firmly connected, though it, too, is nowhere immediately joined to immovable parts, being bound to the unstable bladder in front and to the rectum behind. The vagina, furthermore, affords no Fig. 52. Normal position of the uterus when the bladder is only partially tilled. 160 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. firm support, but itself follows the movements of the cervix. Any considerable lateral motion is prevented by the lateral liga- ments, but beyond this the uterus has no intimate connections except with the adjoining organs—bladder and rectum,—which vary much in their own position, according to the quantity of their contents. The condition of the bladder, especially, has a decided influence upon the position of the uterus. If it is entirely empty, the uterus tips far forward, as in Fig. 53, and if at the same time the rectum is empty, there will be a large space Fig. 53. Fig. 54. Position of the uterus when the bladder is entirely Position of the uterus when the bladder is full to empty. distention. between the two organs to be filled with folds of intestine. As the bladder fills, its posterior wall presses the uterus back toward the rectum, and more or less of the intestine is crowded out of Douglas's space. If the bladder is overfilled, the uterus will be pressed quite back into the hollow of the sacrum and Douglas's space will be quite empty (see Fig. 54). The condition of the rectum has far less influence upon the position of the uterus, not having an immediate connective-tissue union with it. Douglas's space lies between them, and they are DISPLACEMENTS OF THE UTERUS. 161 connected on either side by the recto-uterine ligaments, which are inserted posteriorly not only upon the front of the rectum, but also into the posterior pelvic wall, and which prevent only a very considerable anterior deviation. AArhen the rectum is empty, Douglas's space is filled with folds of intestine, which, as the bowel fills, are gradually pressed upward, without the uterus being much affected, so that it is only when the rectum is exces- sively distended that the uterus is somewhat anteverted. The position of the uterus changes, then, decidedly with the varying contents of the bladder; the more nearly empty it is, the more marked are the anteflexion and anteversion of the uterus; and when the bladder is distended, the uterus may be forced into slight retroversion. If, then, anteflexion is regarded as normal under certain con- ditions, the question naturally arises whether under any cir- cumstances it should be considered a pathological condition. Schultze answers with an unconditional negative, but, as it seems to us, wrongly; for, as a rule, a high degree of anteflexion causes a series of decidedly pathological symptoms, such as dysmenorrhoea and sterility, and furthermore, there is a great difference between the normal anteflexion, when the bladder is empty, and the pathological displacement. To obtain a clear idea of this, compare Figs. 53 and 55. Such anteflexions as that shown in Fig. 55 are often con- genital, as proved by autopsies of the new-born, but we are not justified in calling them physiological on this account. We regard them as a pathological excess of a physiological forma- tion, because, as a rule, they cause symptoms, and often quite- serious ones, at the age of puberty. But anteversion is also met with in women who have borne children. In such cases the uterus is found flaccid, and sharply bent forward ; and the bladder, as it fills, merely displaces the whole backward without elevating the fundus. The deformity may be caused, in a flaccid state of the pelvic organs, by an unusual abdominal pressure. The union between uterus and bladder is not so firm as is usually supposed ; the connective tissue may be stretched to such an extent that the fundus finds room to flex itself anteriorly without resting upon vol. x.—11 162 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the bladder at all; and thus, as the bladder distends, the uterus is pushed back bodily, retaining its abnormal shape. The angle of flexion may be so acute that the fundus causes the anterior wall of the vagina to protrude into the vaginal canal. A high degree of pure anteversion is not often met with. It is produced under the conditions mentioned above, when the uterus is abnormally thick and firm, as in recent inflammatory states. In the normal condition of the uterus, however, an in- crease of abdominal pressure will regularly increase the angle of flexion, so that a pure version is not produced. An increase of weight within the fundus will produce the same effect as an increase of pressure upon it. A small fibroid in the body of the organ, or a general increase in its size and weight, as in chronic metritis or the puerperal state, will cause the uterus to bend forwards to an abnormal extent, either as a whole (version), when it is abnormally stiff, or in part (flexion), when of normal consistency or flaccid. A fibroid tumor will drag the uterus forward or backward, according to the changing position of the patient, so that there may be in the same person, at one time, an anterior, at another, a posterior displacement. As the uterus lies normally somewhat anteverted, a greater pathological importance should be attached to the posterior displacements. In health the uterus becomes somewhat retro- verted only during extreme distention of the bladder, a fact of great importance in the etiology of the posterior displacements, for it is easy to understand how the deformity may take place, if once the abdominal pressure becomes applied to the anterior sur- face of the uterus. Under such circumstances any considerable increase of pressure must tend to depress the fundus still more, and whether this produce version or flexion depends merely upon the condition in which the tissues of the uterus happen to be; if they are as firm or firmer than ordinary, a version will result, as the normally dense tissue admits of no backward flexion ; if they are relaxed and flaccid, especially at the inner os, there will be a flexion. And, furthermore, according as the conditions vary, so may a version become a flexion, and vice versa. The change from flexion to version is, to be sure, more DISPLACEMENTS ON THE UTERUS. 163 rare ; intercurrent inflammation may, however, cause it, and I have even seen it, as a temporary state of things, during the stiffening of the uterus in menstruation. The position of the uterus in the pelvis, whether high or low, is also important, since, as it sinks lower, the fundus falls more backward (see Fig. 75). As a rule, retroversion is the first stage, and then, as the tissues become relaxed, the organ bends. On the other hand, retroflexion may take place suddenly, under a powerful increase of the abdominal pressure (as in coughing, vomiting, falling, etc.), provided the uterus happen to be reclining at the time a little backward. Hildebrandt and Schultze attach great importance to the relaxation of the recto-uterine ligaments ; we would consider it, however, not so much an active cause as a favoring circumstance. The very considerable relaxation of these ligaments, so regularly found in cases of retroflexion, is often merely secondary. It is only in very exceptional cases that a malposition is caused by adhesions of the fundus, either anteriorly or pos- teriorly ; adhesions, it is true, are very commonly found with displacements, but, as a general thing, they are the result of the change in position, the parts having been long in contact and having finally become adherent. The purely secondary displacements, such as occur, for in- stance, with large abdominal tumors, which crowd the uterus backwards or forwards, need not be considered in this place. AVe shall close the etiology of these deformities with a brief recapitulation of the circumstances under which each displace- ment occurs. Anteflexion occurs in nulliparae as a congenital excess of a physiological state; it also occurs in women who have borne children, when, in a normal or relaxed state of its tissue, the uterus is exposed to any great and repeated increase of the abdominal pressure. Anteversion takes piace, with an abnormally dense and swollen uterus, under the same circumstances which, with a normal or flaccid uterus, would lead to anteflexion. Retroflexion is rare in nulliparae, occurring only when, by 164 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. reason of long-continued catarrh, the tissues of the uterus have become unnaturally loose. In women who have borne children it is especially apt to occur when the body of the uterus is large and heavy, and the region of the internal os loose in texture ; these causes being usually aided in a measure by powerful abdo- minal pressure acting in conjunction with a distended bladder. Retroversion would be produced, in nulliparae and pluriparae alike, by these same influences acting upon a normal or abnor- mally firm uterus. Pathological Anatomy. The displacements present themselves under the following forms: In anteflexion (see Fig. 55), body and cervix form an angle which opens forward and is more acute than it normally should be. The cervix retains its position in the vagina, unless, as is Fig. 55. Fig. 56. Anteflexion of the uterus. Anteversion of the uterus. frequently the case, a slight coexisting anteversion causes it to point backward. The body lies upon the anterior wall of DISPLACEMENTS OF THE UTERUS. 165 the vagina. The angle formed by body and cervix may be very acute. In anteversion (see Fig. 56), the axes of cervix and body may form a very obtuse angle or none at all, so that the greater the displacement the more is the os directed backward. In retroflexion (see Fig. 57), body and cervix form a varying angle which opens backward. If the case be one of pure retro- flexion, the cervix maintains its position; usually, however, there is some accompanying retroversion, which gives the os a direction toward the symphysis. In retroversion (see Fig. 58), the os is directed more and more toward the symphysis as the deformity increases, and in its most Fig. 57. Fig. 58. Retroflexion of the uterus. Retroversion of the uterus. exaggerated form the uterus may be completely turned over, the os looking directly upward. In both varieties of version the form of the uterus remains unchanged. In flexions, the uterus is now and then (in retroflexion) bent into the form of a retort; as a rule, however, the flexion is angu- 166 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. lar, and the point of flexion is almost without exception at the internal os. In very rare cases, where the cervix happens to be quite flaccid, the upper portion of it follows the body, the point of flexion then being in the cervix; on the other hand, Klob has reported one case where the angle was in the corpus uteri. In anteversion and anteflexion the fundus usually finds sup- port upon the bladder, and the amount of displacement is not great; under certain circumstances, already mentioned, however, it may force down the anterior vaginal wall, so that body and neck lie nearly parallel, and the fundus is just inside the vulva. In backward displacements the body sinks, without opposition, deep into Douglas's space, so that these dislocations are usually much more considerable. If the fundus falls very far back, a flexion is almost always the ultimate result. In none of the displacements does the region of the internal os preserve exactly its normal position. The cervix usually moves somewhat in a direction opposite to that taken by the fundus, and the upper part of the vagina moves with it. At the same time the internal os is often shifted to a somewhat higher position. The versions, whether pure or complicated with flex- ions, cause thus a flattening of the vaginal cul-de-sac,—either the anterior or the posterior one, as the case may be. Where there is a high degree of retroflexion, the os uteri becomes slightly patulous, the anterior lip yielding somewhat forward. Among the sequelae of these displacements, the most com- mon is inflammation of the parenchyma of the uterus and of the mucous membrane, brought on, especially in retroflexion, by the obstruction to the circulation and resulting hypostasis. Chronic metritis may also be caused, in backward displacements, by the mechanical violence to which the uterus is subjected during the passage of hard masses of faeces through the rec- tum, while in anteflexion dysmenorrhoea may have a causative relation. At a later period we may have irritation or inflammation of the uterine peritoneum, which may lead to adhesions (more rarely are the adhesions the cause of the displacement). After long duration of a flexion, the tissues about the internal DISPLACEMENTS OF THE UTERUS. 167 os gradually atrophy, and in old women the mucous membrane may unite across the canal, and stenosis result. In very rare cases the fundus of the retroflexed uterus may, by pressure, cause gangrene and perforation of the vagina or rectum.1 Symptoms. The different displacements have many symptoms in common; still certain ones are so much more prominent in one form than in another, that it will be more satisfactory to consider their respective clinical histories separately. Anteflexion. Under the head of etiology we have referred to the difficulty of deciding between a normal and an abnormal amount of ante- flexion, and remarked that the decision must depend in great measure upon the symptoms of the case. Two symptoms are commonly met with in cases of this kind, and will in general lead to the discovery of the disease, namely, dysmenorrhoea and sterility. The dysmenorrhea is caused by the obstruction existing at the point of flexion ; the menstrual flow is unable to escape, the cavity becomes filled with blood, which the uterus seeks to dis- charge by contraction, the effort causing peculiar colicky pains, like those of labor. The trouble begins with puberty, and, if not interrupted by treatment or pregnancy, may continue through menstrual life. The pain begins before the appearance of any discharge, and usually ends with a copious flow of blood; it may be so severe as to cause convulsions and loss of consciousness. The repeated irritation at each catamenial period may set up a chronic inflammation, which will cause pain between, as well as during, the periods. Sterility is observed especially often in cases of anteflexion, and yet we have observed a high degree of the deformity in women with whom conception promptly followed marriage. 1 Klob, Pathol. Anat. d. weibl. Sex., p. 69. 168 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Where there is anteflexion, the question is not of the impossi- bility, but of the difficulty of conception. With the same degree of flexion, conception may in one case readily take place, while in another continued sterility results. Urinary disorders almost always accompany anteflexion. There is seldom incontinence, but usually a frequent desire to pass water. Pains in the back, loins, and lower extremities,— the usual concomitants of uterine disease—are also complained of. The clinical history will be more complex if the malposition becomes complicated with metritis, perimetritis, and endome- tritis, with such symptoms as abdominal pain, fluor albus, and menorrhagia. Retroflexion. In retroflexion dysmenorrhoea and sterility are far less fre- quent, while hemorrhage becomes a more important symptom. The cause of this is probably owing solely to the fact that this malposition occurs, as a general thing, in women who have borne children. In such the cervix and internal os are usually freely passable for the menstrual discharge, and conception also can readily take place. But, on the other hand, the sequelae of pre- ceding pregnancies often remain in the form of metritis and en- dometritis. The circulation, already impaired by these morbid conditions, is still further disturbed by the deformity, and the hemorrhages made more and more frequent and profuse. That this is the real cause of the difference in the symptoms between anteflexion and retroflexion, is proved by the fact that ante- flexion is far less apt to cause dysmenorrhoea and sterility in women who have borne children, while in the nulliparae, who sometimes are afflicted with retroflexion, the symptoms are the same as in anteflexion. There is, however, another symptom of greater diagnostic importance than this, so prominent, indeed, that it may be called the most important symptom of retroflexion, that is, pain in the lower part of the spine. It is this symptom and, later, the hem- orrhages, which most often induce patients to seek medical advice. DISPLACEMENTS OF THE UTERUS. 169 Symptoms of paralysis are very frequent in retroflexion, occurring usually in the lower extremities, but sometimes elsewhere. This symptom may be hysterical; but, apart from this, it may be explained in various ways. In some cases it comes from local pressure upon the motor nerves of the lower extremity. Again, a local neuritis may lead to myelitis, or the x>aralysis may be simply reflex.' Chrobaka reports a case of retroversion where there was decided nervous disturbance of the respiration, which immediately disappeared when the uterus was replaced. Symptoms connected with the urinary organs may appear as in anteflexion, though as a rule not so frequently. Hilde- brandt calls attention to the fact that the retroflexed body of the uterus may compress the ureters so as to cause their disten- tion or even hydronephrosis. Anteversion. The clinical history of this disease cannot be given indepen- dently, since it is always complicated with metritis. AArhen it exists in any considerable degree, we have pain in the abdomen, hemorrhage, leucorrhoea, disturbances of the urinary apparatus and rectum neuroses and hysteria. Retroversion. Retroversion in slight degree and uncomplicated may exist without symptoms. If the uterus tips far back, we have symp- toms similar to those of retroflexion ; while if inveterate retro- version be complicated with chronic inflammation, the symptoms will be the same as in anteversion. Diagnosis. The simple versions are immediately recognized, upon digital examination, by the direction of the vaginal portion,—forward 1 Leyden, Samml. klin. Vortr., 1870, No. 2. Louis Mayer, Berl. Beitr. z. Geb. u. Gyn., II., p. 83. Peter, Gaz. des hopit., 1872, Nos. 10-12. 3 Wiener med Presse, 1869, No. 2. 170 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. in retroversion, backward in anteversion. The position of the body of the uterus is determined by the bimanual method of examination. In flexions the vaginal portion retains approximately its nor- mal position, so that the displacement has to be made out by bimanual examination alone. The diagnosis of anteflexion is made when cervix and corpus form a more acute angle than nor- mal ; that of retroflexion, when they form any angle at all (posteriorly). In anteflexion the fundus is easily felt, and as other tumors are rare in this location, it is not apt to be confounded with any- thing else. The diagnosis of retroflexion presents greater difficulties, the fundus in these cases being often not easily accessible to the bimanual method of examination. The discovery of a tumor, resembling the uterus in size and consistency, in the posterior vaginal cul-de-sac, may lead to serious error, even when we are confident that we can feel the angle of flexion, for extra-uterine tumors are not rare in this locality, and may lie so close to the cervix, at the level of the internal os, as to simulate the retro- flexed uterus ; it therefore becomes necessary to assure ourselves that the corpus uteri is absent from its normal position. If the bimanual method of examination is attended with unusual difficulty, or if, as in case of exudations surrounding it, the position of the uterus cannot be made out by palpation, recourse must be had to the sound. As a rule, however, it is possible to get along without it, and its use in flexions, where the location of the body of the uterus is unknown, is by no means free from danger. Prognosis. Versions and flexions are not in themselves dangerous to life; they may, however, by the complaints which they engen- der, by the length of time they continue, and by the complica- tions with which they become associated, interfere most seriously with the enjoyment of life, and lead to lasting derangements of health. Intercurrent pregnancy often effects a cure of the ante- flexion, or at least of the symptoms which it occasions. Of all DISPLACEMENTS OF THE UTERUS. 171 these troubles, retroflexions are the most disagreeable, for, once actually present, they almost never disappear spontaneously, and obstinately defy treatment. Treatment. Under this head we must first discuss the preliminary ques- tion, whether displacements of the uterus, as such, should re- ceive any treatment at all. Starting from the undoubted facts that cases are met with in which high degrees of forward displacement exist, without being accompanied by any symptoms of disease, and, furthermore, that other cases of very considerable retroflexion are observed in women who enjoy perfectly good health, many gynecologists have maintained that the displacements forward and backward occasion no symptoms at all, and that the manifestations of disease in such cases are always owing to complications, espe- cially to inflammation of either the mucous membrane or the parenchyma of the uterus. Even if this view be correct, yet it does not follow that it is irrational to treat the abnormal posi- tions as such; for it may most properly be maintained that the displacements easily lead to inflammation of the uterus, and that the natural way to avoid this result is to correct the deviations. It is then desirable, even from this standpoint, to treat the displacements when existing without symptoms ; but, on the other hand, most gynecologists of the present day are convinced that the cases of decided displacement existing without symp- toms are very rare exceptions, and that an abnormal position, as a rule, interferes decidedly with health. The treatment of displacements, as such, is therefore clearly indicated, and may be omitted for exclusive attention to the complications only when success becomes hopeless or can be attained only by means in themselves notably dangerous. Upon this point, too, opinions are much divided. We will now consider the means at our command for the reduction of the dislocation. First, it is not to be denied that in many cases general treat- ment is sufficient to produce very excellent results. The flexion 172 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. may be caused by a flaccid state of the uterine tissue, which is merely a part of the general condition, the patients being deli- cate, atonic, and, for the most part, decidedly chlorotic women. In such persons it is quite often possible so to strengthen the whole organism, together with the uterus, by the use of prepara- tions of iron, by cold sea, salt-spring, or iron baths, and by atten- tion to hygienic rules, that the flexion either entirely disappears, or is at least so far improyed as to relieve the most annoying symptoms. Moreover, this general treatment may be supported by local applications, such as the cold douche upon the vaginal portion of the cervix, cauterization of the flabby mucous membrane, and astringent injections. Finally, some strengthening influence upon the muscular tissue of the uterus may be expected from the internal use of ergot. Without other means, however, all these remedies can insure success only in certain selected cases, as mentioned above; at the same time, we do not hesitate to state explicitly that they are of extreme importance in many cases as aids to the mode of treatment we are about to describe. Better success has attended the use of mechanical contri- vances applied within the vagina or the uterine canal. The first step of the treatment is to replace the uterus; then an attempt should be made to retain the uterus in place by means of certain instruments. The first step, then, is the replacement of the womb, which is best accomplished by the use of the hands alone. In anteflexions, the operator should introduce the finger into the vagina and rest the end of it against the cervix, so as to hold it in a fixed position, while with the other hand he presses down between uterus and symphysis till he can elevate and force back the fundus. If the uterus is flexible, this can easily be done, and the fundus may even drop over backward, so as to produce a retroflexion ; but if, as is usually the case in congenital ante- flexion, the tissues of the organ are firm, it will be found possible to straighten it only to a limited extent, the uterus returning im- mediately to its old position the moment the hand is withdrawn. The reduction of retroflexions is therefore of more import- DISPLACEMENTS OF TIIE UTERUS. 173 ance. and this also, in cases which are not too unfavorable, is to be done with the hands. Introducing one, or better, two fingers into the vagina, the operator should slightly raise the fundus, and then seek to push it forward by pressing with the other hand from behind through the abdominal wall. In more difficult cases, the object may still be accomplished by first passing the fingers from the body of the uterus—after they have lifted it to a certain height—round to the anterior aspect of the cervix, and then pushing the latter back into the hollow of the sacrum. The replacement may be effected still more easily per rectum, and in the knee-elbow position. In some cases, the following peculiar method will be found to possess certain advantages: the forefinger, introduced into the rectum, is used to elevate the body of the uterus, while at the same time the thumb in the vagina presses back the cervix. If it is found impossible to replace the uterus with the hands, the intra-uterine staff may be used to advantage ; it should not be used, however, unless the uterus is quite movable, for if the uterus is fixed by adhesions, all attempts at replacement are, of course, to be given up. The use of the sound, so generally recommended for this operation, is attended with some danger, for, as the instrument, introduced with concavity downward, is turned over so that it may occupy the position which it usually has in the normal uterus, the uterine end is obliged to describe a long curve, a pro- cedure which may subject the uterus to serious injury. This lateral excursion may, it is true, be avoided by using the sound in the manner recommended by Rasch,1 i.e., to keep the uterine end still while the lateral movements are made by the handle, which is finally depressed. A still simpler and safer course is to replace the uterus by means of the intra-uterine pessary. In using the sound the operator holds the long arm of a lever, and thus is liable, with- out intending to do so, to exert undue power; while with the intra-uterine staff there is no chance to exert power, and the uterus can be but slightly irritated. 1 London Obstet. Trans., Vol. X11L, p. 247. 174 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. With the intra-uterine pessary (see Fig. 59) replacement is effected as follows: the staff, introduced into the uterus in the manner described below, converts the retroflexion into a retrover- sion. The bulb, lying then just behind the symphysis, is pressed back by the finger into the hollow of the sacrum, and the cervix is carried with it, while the stem, performing a half revolution about its transverse axis, carries the fundus forward. By this method the manipulation is still guided as much by the sense of touch as in the manual method, and may be desisted from in good time, if any obstacle is met with. It rarely happens that the dislocation is finally relieved by simply replacing the uterus, owing to the fact that the inclination to return to the old position usually remains. The cases in which this favorable result happens are generally those in which the displacement is of recent date and the uterus enlarged. In two cases, which occurred in my own practice, I was able to verify the fact that a fully retroflexed uterus retained its normal posi- tion after being placed there but once. In the first case the displacement occurred several weeks after normal labor; in the second, nine days after an abortion at the third month. In neither was the uterus much enlarged, and in both it had always previously been in normal position. In those cases, however, which usually present themselves for gynecological examination, and in which there is a displacement of long standing, it is not at all to be expected that the uterus will retain the normal position without the use of some mechani- cal means adapted to this end. Both the vagina and the canal of the uterus have been used as bases from which to accomplish this result. It is, of course, clear, that if the result can be satisfactorily accomplished from the vagina, it is to be preferred. Any instru- ment introduced into the genital canal is a source of irritation, some more, others less. The mucous membrane of the vagina is not so delicate as that of the uterus, and, even when irritated, Fig. 59. Intra-uterine pessa- ry, for straighten- ing the uterus. DISPLACEMENTS OF THE UTERUS. 175 Fig. 60. Eccentric vaginal pes- the symptoms are much less troublesome and dangerous than those caused by the more susceptible lining of the uterus. If, then, success is possible with instruments which lie in the vagina merely, it is by all means better to use them. Since the cervix preserves very nearly its nor- mal position in flexions, yielding but slightly in a direction opposite to that taken by the body of the uterus, it is plain that nothing is to be gained by the use of the common pessaries in- tended to maintain the normal position of this part. Since in retroflexion, however, the dislocation of the body backward is made more difficult by keeping the cervix far back in the pelvis, we may, under circumstances not too unfavorable, prevent the return of the deformity by retain- ing the cervix in this position by means of a vaginal pessary. An anteflexion is not much influenced by bringing the cervix forward, and cannot, therefore, be managed in this way. This method (in retroflexion) is certainly both more rational and more effective than any attempt to secure the same object by filling the posterior cul-de-sac with a large tampon, which does not answer the purpose at all, in fact rather favors a return of the displacement by crowding the cervix forward. The artificial dislocation of the cervix backward, by which the retroflexion of the body is to be prevented, may be accomplished in several ways. The first idea is, naturally, to keep the cervix back by means of eccentric rings, pessaires a contr aversion (see Fig. 60),' the thick side of Fig. 61. Lever pessary in position. 1 See Martin, 1. c, p. 66, who used them in the reversed position. 176 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. which is placed anteriorly. These rings, however, cannot be used, because they soon turn around, thus driving the cervix forward and favoring a return of the displacement. Better than this is Hodge's lever-pessary, which, to be sure, does not act by lever power exerted upon the body of the uterus, but by so stretching the posterior cul-de-sac that the cervix is drawn backward (see Fig. 61). In cases in which the tendency to a return of the displacement is not very considerable, it will sometimes keep the uterus in its normal position. The lever-pessary, which does not act, however, upon the principle of a lever, was invented by Hodge' and recommended in Germany more especially by G. Braun,2 Martin,3 and Spiegelberg.4 It is found in a variety of forms, of which the one without anterior cross-bar (see Fig. 62) is decidedly to be condemned, because the ends of the branches wound the vagina.8 In many cases the complete rings, with single (see Fig. 63) or double curve (see Fig. 64), which tightly stretch the vaginal cul- Fig. 62. Fig 63. Fig. 64. Hodge's pessary, open anteriorly. Hodge's lever pessary, with Hodge's lever pessary, with double single curve. curve. de-sac, are very useful. The flexible ones, which are made of copper wire, covered with rubber, and can be bent into the shape required for each particular case, are better than the ones made of hard rubber. Since the idea of elevating the body of the flexed uterus by lever power working from the vagina is an entirely mistaken one, we must condemn the form of pessary proposed by Graily 1 Wiener med. Wochenschr., 1864, Nos. 27-31. 2 Diseases Peculiar to Women. Phil., 1860. 8M. f. Geb., B. 25, p. 403. 4 Wiirzb. med. Z., 1865, B. VI., p. 117. B Not to mention the possibility of introducing them through the urethra into the bladder, three cases of which have now been reported in America (see Edwards, Bost. Gyn. J., Vol. III., 1870, p. 36). DISPLACEMENTS OF THE UTERUS. 177 Hewitt,' the peculiarity of which consists in its being provided with a curve intended to pry up the anterior vaginal cul-de-sac. It is not only incorrect in principle, but experience shows that it is not well borne. Somewhat similar is the anteversion pessary proposed by Thomas,' which consists of Hodge's pessary, upon the anterior aspect of which a horse-shoe lever is attached, intended to sup- port the uterus. Schultze has lately proposed an entirely unique form of pes- sary, intended to keep the cervix well back in cases of retro- flexion. The different shapes are shown in Figs. 65 and 66. Fis. C5. Tig. 66. Bchultze's pessary for retroflexion. Schultze's pessary for retroflexion. The lesser curve of the first receives the cervix, while the branches of the long curve are supported by the floor of the pelvis or the rami of the pubic arch. By this, as well as by the retrograde curve of the second form, the cervix is kept up and back, so that the recurrence of the dislocation is even more perfectly guarded against than by Hodge's pessary. I have used the instrument as yet only in a few cases, and have found it on the whole efficient, but at the same time I am convinced, as in fact Schultze himself admits, that it will not always answer the purpose. In one case, in which the cervix was held back perfectly well, the body, nevertheless, soon returned to its flexed position again, and the symptoms were not relieved. AA^e must, however, admit that Schultze's pessary answers its purpose as well as any vaginal instrument can, and, since the method of treatment from the vagina is more sparing of the parts and less dangerous than the intra-uterine method, we 1 Brit. Med. J., Feb. 2d, 1867. Lancet, Nov. 16, 1867, and Lond. Obst. Trans., IX., p. 63. 8 Diseases of Women, 3d ed., p. 362. VOL. X.—12 178 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. consider that Schultze has made a valuable contribution to our stock of mechanical contrivances for the support of the uterus. It has been sought to attain the same object by means of pes- saries which take their support from outside the body. Lazare- witsch1 recommends a pessary resembling the Roser-Scanzoni hysterophor, made of copper wire covered with rubber; and Cut- ter a has invented one which derives its support from an elastic staff or rod, which rests upon the sacrum and is held in position by an abdominal belt. The instrument has been modified by Thomas.3 But the surest method of bringing the uterus into its normal position, whether in case of retroflexion or anteflexion, is by means of a straight stem introduced into the cavity of the uterus itself. Winkel4 has given a detailed history of the var- ious attempts made to retain the uterus in position after it has once been replaced, and in the same work he gives illustrations and descriptions of the different instruments used.6 First of all, those apparatuses are to be condemned which support an intra-uterine stem by means of a belt fastened round the pelvis, since every shock received by the latter is communi- cated to the uterus. On the other hand, the simple intra-uterine stems, with a knob at the vaginal end, fail to fulfil the therapeutic indica- tions, their action being merely to convert the flexion into the corresponding version, without restoring the uterus to its normal position. The problem is, then, to contrive some apparatus for the vagina which will so far fix the intra-uterine stem that the uterus will be obliged to preserve approximately its normal position, not being immovably fixed, but allowed a certain amount of play. 1 Coup d'oeil sur les chang., etc. Paris, 1862. a Boston Gyn. J., Vol. V., p. 174. 3 Diseases of Women, 3d ed., pp. 363 and 379. 4L. c. 6 Besides the authorities cited, consult also Lumpe, Woch. d. Zeitschr. d. GeseL d. Wiener Aerzte, 1857, No. 15; G. Braun, Wiener med. Wochenschr., 1864, Nos. 16- 19; Haartman, Petersb. med. Z., 1862, II., p. 171 ; Hildebrandt, M. f. Geb., B. 29, p. 300; Olshausen, M. f. Geb., B. 30, p. 353, and Archiv f. Gyn., B. IV., p. 471; and Savage, Obstetr. J. of Great Britain, Nov., 1873, p. 503. DISPLACEMENTS OF TIIE UTERUS. 179 The solution of the problem has been attempted in a variety of ways. Generally the stem has been connected with a vaginal pessary, as has been done by Detschy,1 in his hysteromochlion, by Martin, in his elastic regulator, and by Winkel, Schultze, L6wenhardt,a Beigel,3 von During,4 and others. Most of these instruments labor under two disadvantages, viz. : the stem is fixed in the middle of the pessary, and the two are immovably connected. AVith such an apparatus it is impos- sible, in the first place, to force the uterus over to the opposite side from that which it has occupied, as it is desirable to do; and, in the next place, the pessary sinks, thus withdrawing the stem so far that it lies merely in the cervix. If the stem is placed eccentrically, the pessary is apt to turn round and assume the position which favors a return of the uterus to its old posi- tion. Besides all this, the stem attached to the vaginal pessary does not allow sufficient play to the uterus. I have found the purpose best answered by a tampon of cotton, so placed in the vagina as to hold the head of the pessary in any desired position, in retroflexion, for instance, far back, so that the uterus is strongly anteverted. It is, to be sure, a some- what complicated process, but I am confident that no other will entirely supply its place. I am in the habit of using, for the purpose of keeping the flexed uterus straight, a small stem of bone with a wooden knob, as shown in Fig. .59. The chief desideratum in an intra-uterine pessary is lightness, which is secured by the use of a variety of materials, such as ivory, bone, horn, wood, or hard rubber. The stem must be rather slim, but firm, with end well rounded, and not so long as to touch the fundus. The knob lying in the vagina must not be too small, and it is better to have it of spherical shape, this form not being so apt to wound the vagina as a disk. Those intra-uterine pessaries which retain their place by means of a spring (the stem separating into two elastic branches when it is placed in position), as recommended by Kiwisch and C. Mayer, and later by Greenhalgh,6 Wright,6 1 Wiener med. Wochenschr., 1857, Nos. 29-31. "Berl. klin. W., 1873, No. 35. 3 Wiener med. W., 1873, No. 12. 4 Deutsche Klinik, 1874, No. 1. 6 Lancet, 1866,1., p. 468. •Ibid., p. 200. 180 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. and Chambers,1 irritate the uterus so much that their use is entirely out of the question. The stem is simply introduced with the hand alone. The left forefinger touching the os serves as a guide for the point of the instrument, which is held in the right hand. It goes easily enough as far as the internal os, and then a little manipulation becomes necessary. If, for instance, there is a strong anteflex- ion, the ball of the pessary must be pressed as far as possible backward and upward, the moment the point of the instrument is actually within the internal os. In this way the flexion can be overcome entirely, i.e., while the body of the uterus remains undisturbed, the cervix is carried so far back that its canal runs in nearly the same direction as that of the corpus. This done, the stem slips readily into the cavity of the uterus. In retroflexion the procedure is the same, except that the ball is pressed forward and upward, instead of in the contrary direc- tion. This method of introduction is the least dangerous, because, by allowing the corpus uteri to retain its position, and by causing the stem to enter in the direction of the axis of its cav- ity, the least amount of irritation is produced. If the operator tries to straighten the organ by forcing the stem on in the direc- tion of the cervical canal, the wall of the uterus (the posterior in anteflexion, the anterior in retroflexion) will necessarily be much bruised. Once in the uterus, the stem, of course, overcomes the flexion; but if left to itself the uterus will remain in the corresponding version, so that by the mere introduction of the pessary we only convert a flexion into a version (see. Fig. 67). Now, in order to correct this version, and give the uterus tem- porarily the opposite displacement, we introduce, in retroflexion, for instance, wads of cotton between the ball of the pessary and the anterior vaginal wall, until the former is crowded as far back as possible (see. Fig. 68), which compels the uterus to assume an anteverted position. If, now, an additional wad is introduced to keep the stem in the uterus, the condition of anteversion 1 Obstet. J. of Great Britain, April, 1873, p. 21 ; May, 1873, p. 115, etc. DISPLACEMENTS OF THE UTERUS. 181 may be kept up at will, and still the instrument is not so firmly fixed but that sufficient play is allowed the uterus. The procedure is, to be sure, somewhat complicated, as the tampons must be changed every day, or at least every second day. They very soon become impregnated with the vaginal secretion, and are thus rendered offensive ; and even if this be somewhat delayed by the use of glycerine, still they get out of place so soon that frequent removal becomes necessary. In efficiency, however, this method, in my opinion, surpasses all others, since it enables us to give the uterus any desired posi- Fig. 67. Fig. 68. The intra-uterine pessary, after Introduction in The intra-uterine pessary in the same case, but a case of retroflexion; it causes the uterus to after the uterus has been brought into the assume the position of retroversion. position of anteversion and held there by suit- able means. tion, and to maintain it in that position for weeks together. In treating a retroflexion, for instance, the uterus is placed in ante- version, so that the intra-abdominal pressure is exerted upon its posterior surface, our hope being that after a time it will retain its place after removal of the pessary. To be sure, this hope will not always be fulfilled, for the inclination of the uterus to resume an abnormal position, in which it has lain 182 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. perhaps for years, is extraordinarily strong. Still, in certain cases, the displacement is cured for good, and in others there is at least decided improvement. The principal objection made to the intra-uterine method is not so much its inefficiency, as that, for the results obtained, it is too dangerous. In order to avoid the dangers referred to—principally inflam- mation of the uterus and its connections—it is quite necessary to select proper cases for the treatment. We have already called attention to the necessity of leaving the uterus alone, if fixed in its abnormal position by adhesions, for in such a case it is impossible to replace it without serious stretching or tearing of the adhesions. In all these cases the intra-uterine method of treatment is out of the question. It is further contra-indicated by an existing inflammatory condition of the uterus or neighbor- ing organs, metritis as well as endometritis, parametritis, or peri- metritis. If an inflammatory exudation takes place in the vicinity, or if the uterus itself becomes sensitive, the treatment must be given up. (Where great prudence is exercised, an exception may be made in cases of chronic inflammation of the uterus of very long standing.) The cases, then, which are adapted to the intra-uterine method of treatment, are the pure flexions uncomplicated by inflammatory processes. Very good results sometimes attend its use in congenital anteflexion, where the intolerable pain attending menstruation immediately disappears with the intro- duction of the stem, and conception not unfrequently follows years of sterility. Retroflexions, too, as they occur in nulli- parae,—though, to be sure, they are rarely seen,—may produce much the same symptoms, and are eminently well suited to this method of treatment. It is comparatively seldom that suit- able cases of acquired flexion are met with in women who have borne children, owing to the fact that this condition is much oftener complicated with inflammatory processes, and that it is usually accompanied by less troublesome symptoms, so that patients are less willing to carry out a long course of treatment. Even after a suitable case has been selected, it is by all means advisable to exercise the greatest caution in the beginning DISPLACEMENTS OF THE UTERUS. 183 of the treatment. It is my practice always to introduce the pes- sary at the house of the patient, and to require her to remain in bed for three days. At first, I do not attempt to accomplish more than the conversion of the flexion into the corresponding version, allowing the body of the uterus to retain its position at least for a time (see Fig. 67); if, in the mean time, the instrument has caused no trouble, I undertake the correction of the displace- ment on the second or third day. After a few days more have gone by, and the patient has not manifested any symptoms of inflammation, I allow her to resume her usual mode of life. After this, so far as my experience goes, inflammation is not apt to occur. At the catamenial periods I remove the pessary, either with the fingers, or, where this is difficult, with forceps. This is done not only for the sake of cleanliness, but also because, at this time, there is greater likelihood of inflammation, though this by no means regularly follows when the precaution is neglected. I am therefore disposed to regard the method of treatment by intra-uterine pessaries as very efficient, in appropriate cases, and not particularly dangerous. To be sure, if proper pru- dence is exercised, it is only a relatively small part of the flexions that can be so treated. But we must keep the fact in mind that in the majority of these cases the displacement as such does not admit of a permanent cure. The attempt has been repeatedly made to relieve the displacement by operation, and, as a general thing, the operation has been devised upon correct principles. In backward displacements, for instance, the attempt is made to unite the posterior walls-of the vagina and vaginal portion of the cervix by means of cauterization,1 or by freshening * the surfaces. Lovventhal' has proposed another method, but it is incorrect in principle, and has never been practically tested. The most radical operation is that of Koberle*,4 which consists in performing laparotomy and fixing the uterus in the lower angle of the incision. Neither can we recommend the operation for anteflexion devised by Sims,8 by 1 Courty, Mal. de l'uterus, 2d ed., p. 876. 9 Richelot, L'union medicale, 1868, Nos. 58 and 59. 3 Die Lageveranderungen d. Uterus. Heidelb., 1872. 4 Schetelig, Med. Centralb., 1869, No. 27. 6 Loc. cit. p. 155. 184 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. which the posterior wall of the cervix is split as high as the internal os; it is attended with danger, and at most relieves only a symptom of the flexion, the stenosis of the internal os, an object which may be safely attained in some other way. If the conditions of the displacement are such as to preclude any attempt at replacement, we are restricted to merely pallia- tive treatment, which in most cases avails to render the patient tolerably comfortable. The painful symptoms which depend upon the flexion as such, that is, more particularly dysmenorrhoea, and at times vesical derangements, are the ones specially amenable to the intra-uterine treatment, and will occupy our attention less in this place. The question here is chiefly in regard to the symptoms arising from the complications (especially simultaneous chronic inflammation of the uterus). Of course the displacement is usually the cause of the complication; nevertheless, the accom- panying disease can always be much alleviated, and by a proper regimen its reappearance, or at least a return of the worst symp- toms, may be prevented. It is not necessary to repeat here the treatment for the differ- ent complications. We will only mention, as of particular importance, that the very troublesome symptoms (pain and hemorrhage), caused by increased size and chronic inflammation of the uterus, may be best controlled by slight, frequently repeated scarifications. By this palliative treatment we may, in favorable cases, succeed in putting an end to the symptoms complained of, although the displacement still continues. In discussing the treatment, we have thus far considered the flexions only, and for the reason, as before given, that we con- sider them far more important than the versions, and because anteversion never, and retroversion only now and then, occurs without complications, i.e., without inflammatory swelling of the uterus. The principal indication in anteversion will be to get rid of the inflammatory thickening of the uterus, which, as above mentioned, is best done by scarification. After the tissues have returned to a comparatively healthy condition, the uterus may either lie in a normal position, or continue to be anteverted. DISPLACEMENTS OF THE UTERUS. 185 If the attempt to diminish the swelling proves ineffectual, and the worst symptoms are caused by the malposition, or if, as very often happens, they are induced by the extreme mobil- ity of the swollen uterus, the patient may often be entirely re- lieved by the introduction of a simple vaginal pessary, best, one of Mayer's rubber rings.1 The instrument acts by hold- ing the vaginal portion in the centre of the pelvis, and thus preventing it from making too great excursions, and also by giving the body (since in versions the two portions retain their proper relation to each other), a position more nearly normal. The frequently recommended abdominal support, the ceinture hypogastrique, acts in much the same way, by restraining the movements of the swollen uterus. That it should have any favorable action upon the displacement seems out of the question. Pure, uncomplicated retroversion occurs not very rarely as a temporary condition, and needs then no particular treatment. The patient should be enjoined to empty the bladder often, and to avoid any great or sudden exertion, since the latter, happen- ing when the bladder is distended, is likely to cause permanent retroversion, and, at a later date, retroflexion. If the uterus is permanently retroverted, the intra-uterine stem will render excellent service. The treatment is easier and prognosis better than in retroflexion. If retroversion is complicated with chronic inflammation, the same course should be followed as in antever- sion, though retroflexion is quite apt to follow the disappear- ance of the inflammation. LATERAL DEVIATIONS OF TIIE UTERUS. Tiedemann, Von den Duverney'schen Driisen, etc. Heidelberg, 1840.—M. B. Freund, Breslauer klin. Beitr., II. Breslau, 1864, p. 85. Lateral displacements of the uterus are of congenital origin, being usually caused by some peculiar development of the pelvic viscera, and they are certainly only in very rare instances pro- > C. Mayer. Monatschr. f. Geburtsh., B. 21, p. 416. 186 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. duced by foetal inflammation of one of the broad ligaments. Moreover, a slight tendency of the fundus to lean toward one side, usually the right, is physiological. Owing to the plastic state of the uterus during foetal life, congenital dislocations always occur in the form of flexions and not of versions. In extra-uterine life we may have either form. Lateral dis- placements are often caused by tumors. Parametritic exuda- tions force the uterus first toward the opposite side, and finally, as they cicatrize, draw it to the side in which they are situated. Other tumors of slow growth (fibroid, ovarian), so long as they are small, sometimes draw it in their own direction, but later crowd it the other way. Excepting the slight degrees of displacement, which are to be regarded as physiological, it is rare to find uncomplicated cases of lateral dislocation, i.e., cases not caused by other im- portant disease. Now and then, however, we do meet with cases of strong version combined with slight flexion (the uterus being freely movable) where it is impossible to discover a cause for the displacement. I have observed a high degree of version (toward the left) with torsion, in a woman confined only a week pre- viously ; it was so marked that the anterior surface of the womb faced toward the left. The uterus could be straightened, but it immediately went back again to its former position. Uncomplicated cases can hardly be said to cause symptoms, and when there are complications, the displacement becomes of entirely secondary importance. Any particular treatment is, therefore, very rarely necessary. EXCESSIVE MOBILITY OF THE UTERUS. Where there is abnormal mobility of the uterus, a state to which we have before only casually referred, we must carefully distinguish whether the uterus is bent or stiff, that is, whether the mobility consists in its assuming readily a position of flexion or one of version. In the latter case we shall find the uterus swelled, and the neighboring organs flaccid. The subjects are usually women who have borne children, in whom vagina, blad- der, rectum, and uterine appendages are very much relaxed, DISPLACEMENTS OF THE UTERUS. 187 while the uterus itself is chronically inflamed, hard, and some- what enlarged. So circumstanced, the uterus falls freely hither and thither in the pelvis, with the changing positions of the body, so that at different times we find ante-version, retro-ver- sion, or latero-version. In some cases the change of position is slight, in others, very great. This excessive mobility causes severe symptoms, such as pain in the abdomen and back, trouble in passing water, often a feel- ing of uncertainty, sometimes inability to walk, and, further- more, severe disturbances of the nervous system. The diagnosis has to be made by means of the bimanual examination, repeated at different times and in various positions of the patient, and by attempting to alter the situation of the uterus. If this can easily be done, and in a high degree, the mobility is greater than normal. The treatment of these cases is very satisfactory. As a rule, the symptoms yield as if by magic, the moment the uterus is fixed, and this can be done sufficiently well by means of a Mayer's rubber-ring pessary, which keeps the cervix in place, and so prevents any extended excursion of the corpus which is so inflexibly connected with it. On the other hand, extreme mobility of the flexed uterus is usually found when the organ itself is very loose in texture, and especially when a small fibroid in the flaccid corpus uteri causes it to sag hither and thither with the various movements of the patient. It is only in these latter cases that a slight mobility of the flaccid uterus gives rise to symptoms at all, and then by no means in such degree as in the condition just de- scribed. The treatment, however, is much more difficult. In many cases little or no complaint is made, so that there is no call for interference. In others we must try, in the ways elsewhere detailed, what can be done by constitutional treatment to im- prove the general health, and, with the aid of local irritation, to make the uterus firmer. If the mobility is caused by a small tumor, the abdominal supporter will oftentimes prove of use. As the tumor increases in size the mobility disappears spontaneously. 188 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. DESCENT AND PROLAPSE OF THE UTERUS. Eendrik&z, Descriptio hist, atque crit., etc. Berlin, 1838.—Froriep, Chirurgische Kupfertafcln.—C. Mayer, Verh. d. Ges. d. Geb. in Berlin, 1848, III., p. 123.—> Chiari, Braun u. Spaeth, Klinik d. Geb. Erlangen, 1855, p. 384.—A Mayer, Mon. f. Geb., B. 12, p. 1.—0. von Franque, Der. Vorfall der Gebarmutter, etc. Wurzburg, 1860.—Le Gendre, De la chute de l'uterus. Paris, 1860.—Huguier, Mem. de l'acad. de mSd. Paris, 1859, T. XXIIL, p. 279, and Sur les allong. hypertr., etc. Paris, I860.—Klob, Pathol. Anat. d. weibl. Sex. Wien, 1864, p. 8d.—Martin, Mon. f. Geb., B. 28, p. 166, and B. 34, p. 321.—Sdxinger, Prager Vierteljahrschr., 1867, 1, p. 89.—IF. A. Freund, Zur Pathol, u. Ther. d. veralteten In v. ut., etc. Breslau, 1870, p. 27.—Spiegelberg, Berl. klin. Woch., 1872, Nos. 21 and 22.— Huffel {Hegar), Anatomie u. oper. Beh. d. Gebarrn. u. Scheidenvorfalle. Freiburg, 1873. Historical Notice, Prolapse of the womb is a condition which, as might be supposed, has been known from the earliest ages. Hippocrates refers to it, and Soranus devotes an entire chapter to the subject, wherein, to a certain degree, he combats the erroneous views of his predecessors. Thus he censures Euryphon, who undertook to cure prolapsus by suspending his patients for twenty-four hours by the feet; as well as others, who, like many later authors, fumigated 'the exposed uterus with offensive substances, acting on the supposition that, like a living animal, it would seek to escape the foul odor. (Mice and lizards were also allowed to crawl over the exposed organ, in the hope of frightening it back to its place.) Soranus himself, having placed the patient in an appropriate position, used to return the womb to its proper situation, and introduce a woollen pessary into the vagina for its retention. Portions of the uterus that had become gangrenous were excised, and sometimes even the entire organ was extirpated. The writers who followed Soranus, however, fell far below his standard. Indeed, it is only very recently that the pathological anatomy of descent of the womb has been more minutely investigated. In practice, many similar affections, such, particularly, as hypertrophy of the cervix, are still confounded with prolapse of the organ. We are principally indebted to Huguier for drawing a distinction between these conditions. This author, while on the one hand he was right in holding that the majority of the cases of hypertrophied cervix were mistaken for prolapse, went too far to the other extreme, inasmuch as he almost entirely denied the occurrence of true prolapse. By descent and prolapse we mean changes of position of the uterus downwards towards the mouth of the vagina, so that the uterus leaves its normal position and the os uteri approaches, or even protrudes from, the mouth of the vagina. DISPLACEMENTS OF TIIE UTERUS. 189 Etiology. In cases of considerable descent, or of prolapse, the predis- posing cause will almost invariably be found to consist in a relaxation of all the pelvic viscera. It is true that a transitory and physiological descent of the uterus takes place with every powerful act of abdominal com- pression ; but the pressure being removed, the elasticity of the surrounding organs raises the womb to its place again. Where the pelvic viscera are not abnormally relaxed, it is only in very exceptional cases that acute prolapse is caused by the sudden excessive action of abdominal pressure (as by jumping, by a fall, by heavy lifting, or by vomiting, etc). When such a displace- ment is thus caused in a woman who has never borne children,' and in whom, therefore, the organs contiguous to the womb have never undergone the changes incident to pregnancy and the puerperal state, it must be due to a special extensibility of the parts concerned, dependent on an individual idiosyncrasy. The predisposition being present, increased weight of the uterus and added force of abdominal pressure will be found among the first determining causes of prolapse. As a rule, these causes co-exist. They are found to the great- est degree during the puerperal period, when relaxed pelvic viscera and an enlarged uterus are always present. If the intra- abdominal pressure is now increased, as in case of chronic over- filling of the intestinal canal, of large abdominal tumors, ascites, and especially of prolonged and severe bodily exertion, a dis- placement of the uterus downwards is very easily produced. In advanced age, relaxation of the organs of the true pelvis is liable to occur, aside from the puerperal condition, through the disap- pearance of adipose tissue to such a degree as to render pro- lapse possible. This is, indeed, no very rare occurrence, inas- much as, when the pelvic viscera have become especially relaxed, a gradual descent, and eventually prolapse, may take place, even 1 According to Weinberg's report of Martin's clinics (Ueber Prolapsus uteri, Diss. inaug. Berlin, 1869), only six nulliparous women were found among 174 cases of pro- lapse. Scanzoni found fifteen nulliparae among 114 cases. 190 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. when the uterus is of normal weight and the degree of abdom- inal pressure is not excessive. Fig. Absence of perineum. Fig. 70. Normal perineum. When the womb shows a tendency to dislocation down- wards, the question of whether complete prolapse can be accom- Fig. 71. Primary prolapse of the vagina. c, cystocele; r, rectocele. Fig. 72. Primary descent of the uterus, with in version of the vagina. DISPLACEMENTS OF TIIE UTERUS. 191 plished with ease or with difficulty depends, in the first place, on the degree of resistance offered by the floor of the pelvis and on the size of the vaginal entrance. In this respect, the more serious lacerations of the perineum, Duncan,1 to the contrary, notwithstanding, must be regarded as of the highest importance in the etiology of uterine prolapse. If the perineum has disap- peared, it is evident, as is shown in Figs. 69 and 70, that the route taken by the descending uterus is shorter, and the direc- tion more favorable for a descent; furthermore, the obstacles which it would otherwise encounter (pelvic floor, narrowness of vaginal orifice) are removed. Primary prolapse of the vagina is also a circumstance of the greatest etiological importance. This much is certain, that, in the great majority of cases, prolapse of the walls of the vagina (see Fig. 71) precedes that of the uterus. It is much more rare for this organ to descend, as represented in Fig. 72, merely inverting the vaginal walls by its descent. Notwithstanding all this, we cannot admit that primary pro- lapse of the vagina alone induces falling of the womb. The tension of the prolapsed vaginal walls draws the uterus down, only when its attachments to neighboring organs are re- laxed ; and usually, no doubt, the relation of things is such that the conditions which induce prolapsus vaginae likewise effect a relaxation in the neighborhood of the uterus and vagina, the same causes thus resulting in prolapse of the latter and descent of the former. Pathological Anatomy. As a rule, prolapse is practically divided into three grades or degrees: 1st. Simple descent, in which the uterus lies distinctly lower than is normal, but the os uteri is not visible between the labia. 2d. Incomplete prolapse, in which a part of the uterus lies outside of the vulva. 3d. Complete prolapse, in which the entire uterus, covered with the inverted vagina, lies outside of the external genitals, between the thighs. 1 Edinburgh Obstet. Transactions, Vol. II., p. 269. 192 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The vagina, if it is not independently displaced downwards, is more and more encroached upon with every descent of the uterus (see Fig. 72), so that the normal inversion of the vagina, whereby its mucous membrane covers only the vaginal portion of the uterus, becomes greater, and the vaginal mucous mem- brane thus encloses the larger part of the lower segment of the uterus. The further the uterus descends, the more is the vagina turned inside out, so that in ex- treme cases of complete prolapse (see Fig. 73) the cavity of the vagina entirely disappears, and the vaginal walls descend directly from the vulva, covering the uterus, which lies between the thighs. The vaginal mucous membrane, which is thus made to take the place of integument, undergoes very marked changes. It becomes hypertrophied in all its component parts—epithelium, submucous cel- lular tissue, and muscular coat. The greatest change takes place in the most superficial structures, the transverse folds, or rugse, disap- pearing even in simple descent of complete prolapse of the uterus. the uterus, while in complete pro- c, cystocele. , . , ■. . lapse the mucous membrane is ex- posed to the drying influence of the air, and to friction between the thighs, until thickening of the epithelium results in a tissue strongly resembling epidermis. Exposure to external injury often results in ulceration, or even in deeper losses of substance, which are usually covered with a yellowish tenacious discharge, and have elevated, puffy borders. The color of the vaginal mucous membrane is red, bluish-red, or even white, when there is no inflammation and the epithelium has become very much like epidermis. Indeed, this epidermoid alteration of the mucous membrane may be so complete that in negro women the inverted vaginal surface may become black. DISPLACEMENTS OF THE UTERUS. 193 In consequence of the blood-stasis that occurs within its walls, and the injuries to which it is exposed by its position, the uterus uniformly swells, so that the entire organ, and particu- larly its lower segment, becomes hypertrophied. The cavity is generally somewhat lengthened, though in the majority of cases not very much so, not over four or four and one-third inches (11 ctm.). Exceptionally, however, the supravaginal portion of the cervix may be so greatly hypertrophied that the fundus still occupies its normal plane, or it may even lie higher than is natural. Those cases in which the fundus uteri has never descended, but in which only the lower portion of the organ has grown until it protrudes from the vulva, and which, therefore, represent primary hypertrophy of the cervix alone, are usually classified with cases of true prolapse. To this I cannot agree, but am of the opinion that the term prolapse should be applied only to those cases in which the entire uterus has primarily descended. Although the organ does not usually increase much in size, merely enlarging by venous engorgement, still it may, exceptionally, grow to such a degree that the fundus may rise to its former height, or even higher. The enlarge- ment of the supravaginal portion of the cervix may then carry the bladder and the retro-uterine peritoneal fold up again, so that both may be about at their normal site. These cases, which, however, are tolerably rare, are hard to distinguish from primary hypertrophy of the supravaginal portion of the cervix. The differential diagnosis between the two was treated of under the head of hypertrophy of the cervix. We would here only remark that a considerable degree of ectropion of the os argues in favor of primary prolapse with secondary hypertrophy. Through the infiltration of the vaginal mucous membrane, which is displaced outwards, and the simultaneous swelling of the cervix, the conical form which normally belongs to the va- ginal portion of the cervix is lost, so that, leaving the mouth of the womb, the mucous membrane extends abruptly outwards, in order, then, to cover the lower uterine segment, no part of which can any longer be considered as vaginal. The os uteri is there- fore to be found at the lower end of the globular tumor, directed somewhat posteriorly. It may exhibit a condition of marked ectropion (called eversio by Martin), due to the fact that the vaginal walls, being put greatly on the stretch by the prolapse, draw the margin of the external mouth apart in every direction. The cervix is so turned inside out, by this means, that the exter- nal mouth may be formed by the middle portion of the cervical VOL. X.—13 194 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. canal. Indeed, the canal may be completely everted, so that the lower portion of the prolapse is covered with cervical mucous membrane, and the internal mouth takes the place of the exter- nal. On the other hand, in very old women, in whom the lips lie close together, the external mouth may be closed by adhesion. The relations of the remaining viscera of the true pelvis are of the greatest practical interest. The descending uterus (see Fig. 74) carries with it the bladder and the retro-uterine peritoneal fold; the posterior wall of the vagina also sometimes drags down a diverti- culum of the rectum, so that, in a complete prolapse, the bladder lies more or less extended over the an- terior wall of the uterus; behind the uterus there may be a rectocele, and then the fold of peritoneum dips deep down between uterus and rectocele. The bladder is usually displac- ed in such manner that the orifice of the urethra is apparent on the anterior surface of the parts prolapsed, and the canal of the urethra is usually directed from here downwards, opening into the bladder at a lower plane, though it may be irregular in its course, leading first upwards and then down. A part of the cavity of the bladder lies above the inner opening of the urethra, and a part, constituting the cystocele, lies below. If the prolapsed parts are not returned during micturition, the urine will stagnate in this dependent portion of the viscus, which may lead to vesical catarrh and to the formation of calculus.1 Distortion of the fundus of the blad- der may also lead to compression of the ureters, with the condi- Fig. 74. Incomplete prolapsus uteri. c, cystocele. 1 The formation of calculus has been observed, in cystocele, by Ruysch (42 stones), Gosselin, Goupil, and Huguier. DISPLACEMENTS OF THE UTERUS. 193 tions liable to arise in consequence, viz., dilatation of the ure- ters, hydronephrosis,1 etc. In some few instances of complete prolapse there is no cysto- cele, the wall of the bladder having detached itself from the cer- vix and having remained at its normal site. The rectal diverticulum may be enormous, as was particularly shown in the case observed by Freund.8 The peritoneum generally descends, behind, to the utmost point of the prolapse, but in front it remains at its normal height, about on a level with the internal os, or it may even lie Fig. 75. Diagrammatic representation of the retro- version of a descending uterus. Fig. 76. Complete prolapse of the anteflexed uterus u, uterus; F, a fibroid situated at the point flexion ; B, the bladder; D, intestine ; L, at- tachments of the uterus, of one'side. higher. Douglas' space is sometimes occupied by coils of small intestine ; in rare instances these are so abundant and so adhe- rent as to render the replacing of the prolapsed parts impossible. The uterus also drags the remainder of its appendages with 1 Phillips (London Obstet. Tr., XII., p. 276), Froriep (1. c, Taf. 338, 5 and 6, and 416, 3 and 4), Virehow (Verh. d. Ges. f. Geb. in Berlin, Bd. II., p. 209), C. Braun (Zeitschr. d. Ges. d. Wiener Aerzte, 1864, p. 44). The last two cases were instances of cervical hypertrophy. 3 Locus cit., p. 27. 196 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. it. The broad ligaments are greatly stretched, and only admit of the prolapse of the organ gradually, as they become more and more relaxed. Then they leave the sides of the pelvis, and occupy a hollow between the bladder and rectum, the floor of which is formed by the fundus uteri. At the edge of this hollow lie the tubes and ovaries, rendered hypersemic by stasis of the blood-stream. As the uterus in its descent must maintain the direction of the vaginal canal, and as this direction is from above downward, and from behind forward, that organ always takes the position of retroversion (see Fig. 75), and its normal curve forward is lost. Both these changes are easily effected, inasmuch as the womb prolapses only when the pelvic organs are relaxed. Its descent, as well as its retroversion, are the result of this relaxation ; but it is incorrect to look upon the latter as the cause of the descent. It is very easy for the influences already set forth, by their con- tinued action, to transform a retroversion into a retroflexion,1 so that we can readily understand why the prolapsed womb should frequently be retroflexed. Anteflexion is rare,2 inasmuch as the position of the uterus in its descent is such that this change can only be produced when the faultily developed organ is very un- yielding, or is held fast by adhesions. In the case delineated in Fig. 76 the anteflexion could not be corrected, during descent, on account of a small fibroid tumor located at the point of flexion, and which, no doubt, had already contracted adhesions. When prolapse occurs suddenly, perimetritis may follow, or it may arise later as an intercurrent affection, fixing the uterus in its new position by the formation of adhesions, and thereby rendering the prolapse irreducible. Symptoms. In those very rare instances in which prolapse occurs acutely, the sudden emptying of the abdominal cavity and the dragging 1 Schott (Wochenblatt der Zeitschr. d. Ges. d. Wiener Aerzte, 1861, No. 31) publishes a case in which the fundus of a retroflexed and prolapsed womb had caused gangrene and perforation of the vaginal wall against which it lay. 2 Franque, 1. c, p. 8, No. 7, Tafel 2, and Freund, 1. c , p. 36. DISPLACEMENTS OF THE UTERUS. 197 on the peritoneal bands lead to symptoms similar to those observed in inversion of the uterus, viz., severe abdominal pain, fainting, and profound nervous shock. The gradual descent of the organ produces a sensation of weight and dragging in the pelvis and pain in the back. Even in cases of complete prolapse, the disturbances are often no more serious than this—aside from the accompanying mechanical in- convenience ; indeed, exceptional cases may occur in which, the uterus being of normal size, all the usual symptoms fail. (I saw one such instance, in which the prolapsed parts protruded to the distance of nearly a foot.) As a rule, it is true, this condition is accompanied by a tormenting feeling of weight or pressure down- wards, and a pain in the back which sometimes becomes almost unbearable. Urinary disturbances are soon added, caused by the dislocation of the bladder and the decomposition of urine in the diverticulum ; patients are sometimes unable to pass water unless they at least partially replace the prolapse. Trouble with the rectum may also arise, and nervous manifestations, even to the point of well-marked hysteria. All physical exer- tion causes pain, because the womb is thereby pressed down- ward, and its attachments, already put to excessive tension, are still further dragged upon. These pains may be made ex- tremely severe by the effort of coughing, vomiting, the lifting of heavy weights, as well as by any great bodily labor. Another series of symptoms depends upon the mechanical injuries to which the tumor lying between the thighs is exposed. Whereas, at first, the womb spontaneously recedes at night, upon lying down, or indeed only protrudes after several hours of severe exertion, it gradually remains down longer at a time, even if it can still be put back at night, until finally, by reason of its constantly increasing size, or on account of adhesions that have been formed, it becomes almost or altogether irreducible. The tumor lying between the thighs, even though it may be returned at night, interferes, in the highest degree, with every sort of occupation, so that, if the prolapse is great, an active life becomes impossible. The more the tumor lies outside, the more readily are erosions produced, by means of friction and the macerating influence of secretions, both on the integument of the 198 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. thighs and on the vaginal mucous membrane covering the part prolapsed. On the latter it may result in large ulcers, with diphtheritic or ichorous surfaces. The bladder may be opened by the process of ulceration ; large portions of the uterus, which have become gangrenous, may be cast off, or the whole organ may be detached by the same process.' Menstruation is usually not interfered with. Sometimes it is scant}^ at others profuse. Sterility is by no means a constant result, inasmuch as coition may be accomplished after the re- placement of the tumor. In some cases it would appear that, in this act, the enlarged cervix has taken the place of the vagina.2 When the prolapsed uterus becomes impregnated it usually recedes as it enlarges. The course of this malady is usually quite chronic. The pro- lapse, if nothing is done for it, gradually increases, and finally becomes irreducible, owing to the increased size of the womb and to peritoneal adhesions. The weight of the tumor hanging be- tween the thighs, and the ulcers developed upon its surface, combine to render the condition of the patient one of extreme distress. Diagnosis. The very circumstance, that the diagnosis of uterine prolapse seems such a simple matter, doubtless accounts for the fact that it is often not distinguished from other similar affections, such, particularly, as hypertrophy of the cervix. One difficulty in the wTay of diagnosis arises from the fact that women ordinarily present themselves for examination at a time when the prolapse has been reduced. Sometimes it can be made to protrude again by causing the woman to strain or cough ; at other times, when this condition is produced only as the result of prolonged bodily labor, one must depend, for con- 1 The numerous cases recorded in former times of the casting off of the prolapsed uterus by means of gangrene are unreliable, and doubtless, in most instances, refer to the expulsion of new growths. More recent and reliable cases are reported by Elmer (see von Franque, 1. c, p. 11) and Edwards (Brit. Med. Journ., Feb. 6th, 1864). 2 See the cases of Chopart and Harvey, in von Franque, p. 14, and Aubinais (Gaz. des hop., 1866, No. 96). DISPLACEMENTS OF TIIE UTERUS. 199 firmation of the patient's statements, on the alterations that have been produced in the vaginal mucous membrane. If the prolapse is down, the tumor protruding from the vulva, lying between the thighs and covered with the everted vagina, is so characteristic that there are few other conditions for which it can be mistaken. Especial difficulty attends the differential diagnosis between this and hypertrophy of the mid- dle and upper portions of the cervix. I have already expressed myself on this subject in the chapter devoted to the study of the latter affection. The mistake of confounding a large polypus for prolapse, which may be made when an ulcerated spot on the former simulates the os uteri, will be corrected on a more careful exam- ination of the parts. It is not enough for the conscientious physician merely to determine the existence of prolapse ; he must ascertain the posi- tion of the uterus, by combined manipulation and the use of the sound, the relations of the bladder by means of the catheter, and the existence or extent of a rectocele by the introduction of a finger, or, in bad cases, of sounds into the rectum. Prognosis. Prolapse of the womb is an exceedingly chronic affection, which, it is true, but rarely endangers life by means of gan- grene, peritonitis, or even uraemia, but which, left to itself, con- stitutes a very burdensome and disgusting evil. Excepting in very recent cases, a radical cure is but seldom accomplished, although the annoyances incident to the condition may be removed, or at least materially relieved, by the employment of appropriate therapeutic measures. A spontaneous cure is very rare. It occurs most frequently by means of the uterus being bound down in its normal position through peritoneal inflammation, the peritonitis happening to supervene while the organ occupies its proper place, as, for instance, after its replacement subsequent to parturition. In quite exceptional instances inflammation, with cicatricial con- traction of the vagina, holds the uterus back ; or it may be 200 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. drawn up into the pelvis again, as is done temporarily during pregnancy, by the development of large tumors growing on or connected with the uterus, such as fibroid or ovarian tumors. Treatment. We will not enter upon the question of prophylactic meas- ures, which concern, to a great degree, the proper management of the puerperal woman. When prolapse exists, one may endeavor to effect a radical cure in harmony with the etiological conditions present: 1st, by diminishing the weight of the uterus ; 2d, by correcting the relaxed condition of its attachments ; 3d, by removing all exces- sive abdominal pressure; and 4th, by narrowing the distended vaginal entrance, or, better yet, by replacing the lost floor of the pelvis. Leaving out of consideration for the present the fourth indication, which is essentially operative in its character, there is no denying that, with due patience on the part of physician and patient, a good deal may be accomplished by careful atten- tion to the first three requirements. In the majority of cases, the abnormal volume of the uterus may be pretty thoroughly, though perhaps very slowly reduced, in the manner spoken of under the head of chronic metritis; abdominal pressure may be reduced to its minimum by pro- longed maintenance of the horizontal position, with a somewhat elevated pelvis. The most difficult matter is to do away with the relaxation of the uterine supports, though even here some- thing may be accomplished by the cold douche and invigorating diet.1 Still it is only in exceptional cases that the prolonged main- • 1 Andreef (Virchow's Archiv, 1872, Bd. 55, pp. 525), recommends, after the replacing of the uterus and the healing of any ulcers that may have existed, that the vaginal walls be painted with tincture of iodine (about 3 ss. diluted with an equal quantity of alcohol). This application, which may gradually be made stronger, should be applied every three or four days, and injections of cold water (68° Fahr.) should be used during the intervals. The action of this treatment is not to contract the vaginal canal, but to strengthen the uterine ligaments. DISPLACEMENTS OF THE UTERUS. 201 tenance of a recumbent position, the cold douche, and antiphlo- gistic treatment directed to the uterine swelling accomplish a cure. The wearing of an appropriate pessary, by supporting the heavy uterus, and preventing it from dragging on its attach- ments to neighboring organs, may cause those attachments to regain a certain degree of tensity, so that sometimes the pessary may only have to be used temporarily. In all attempts to combat the condition of prolapse, care must be taken to insure regular evacuations of the bowels and bladder. The radical treatment indicated above ordinarily requires so long a time for its accomplishment, and promises, besides, such uncertain results, that it is usually abandoned for the scheme of reduction of the prolapse and its retention by means of pessaries. The reduction is generally easy, if one does not attempt to return the vagina first, but presses directly against the lowest portion of the tumor. The position of the uterus must be care- fully regarded, otherwise, in crowding the organ backward against the sacrum, an artificial retroflexion may be produced. If the womb is returned to the pelvic cavity while still in a state of retroflexion, and a pessary is introduced, this will either not be tolerated or will cause perimetritis by its pressure against the fundus. The perimetritis may, it is true, result in a cure of the prolapse by binding the uterus fast in its place ; but it is accom- panied by other evils, and may, indeed, be the immediate cause of death. Such cases have been seen by Freund1 and by myself.2 The unpractical character of the proposition to cure prolapse by inducing an artificial retroflexion is self-evident.3 If the reduction is found difficult, the first thing to be done is to insure the emptying of the bladder and bowels. If it is still found impracticable, we may, by maintaining the patient in the recumbent position, by the use of cathartics, and finally by scarification, effect such a diminution in size of the prolapsed 1 Loc. cit., p. 32. 5 Volkmann's Klinische Vortrcige, Xo. 37, p. 334, and another case recently. 3 Seyfert, Prager Vierteljahrschrift, 1853, B. I., p. 156, and Aveling, London Obst. Trans., XL, p. 215. 202 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. parts that the reduction can usually be accomplished by an energetic effort, unless prevented by the existence of adhesions, or, more rarely, by large abdominal tumors. Pessaries can only be used immediately after the replacement of the prolapse, if no ulceration exists. Ulcers, however, usually heal quickly, if the parts can be kept in their place and the secretions washed away by means of injections, so that we seldom have to cauterize them. The increased size of the womb often disappears soon after its permanent replacement. Amongst the means for retention, the vaginal pessaries, two kinds are to be distinguished, viz., those with and those without a stem passing outside of the vagina. The latter class, or those without such a stem, find their support in the vagina itself, and prevent prolapse by so filling it, and keeping the vaginal walls on such a stretch that they cannot descend and escape at the vaginal orifice. The uterus then lies on the pessary. Those having an external stem obtain their support from metallic bands or bandages attached to the trunk ; they are therefore applicable to those cases in which the other variety of pessary cannot be retained, on account of relaxed vaginal walls or an enlarged ostium vaginae. In the course of time an extraordinarily large number of the most varied forms of pessary have been introduced. I shall confine myself to noticing a few of the most important of those which are still in use at the present day. Without making more than a passing allusion to the custom of introducing a common bathing-sponge into the vagina, satu- rated with glycerine or with starch, or with some astringent lotion, we may mention, first among the stemless pessaries, Mayer*1 s India-rubber rings (Fig. 77). A ring appropriate to the case must be selected, one not so large as unduly to distend the vagina, thereby causing pain or producing inflammation, and yet large enough not to escape too readily from the vaginal ori- fice. In some cases, with a very large vaginal opening, this acci- dent cannot be avoided. If Mayer's ring pessaries answer the purpose, no other means of support will be required, inasmuch as, owing to their flexibility, they adapt themselves accurately DISPLACEMENTS OF TIIE UTERUS. 203 to the individual form of the vagina. If, therefore, the size has been well selected, the pessary lies as comfortably in the vagina as if it were made for that individual case, a matter of no little consequence to an inexperienced hand. Furthermore, this variety of pessary is less irritating than others, provided it is removed and cleaned from time to time, say every four weeks, and the vagina syringed out. (By way of exception, I have sometimes seen an ichorous discharge follow their use within a short time, probably because the material of which they were constructed was of bad qual- ity.) If they are left in position for a long time, uninterruptedly, these, as well as every „ , Tr'G'""' ' x d 7 ' •> Mayer's India-rubber ring. other kind of pessary, may produce the worst possible results. I have myself seen incisions into the soft parts, made by the ring, into which one could lay the entire first joint of the finger. If, however, Mayer's ring pessary is kept clean, it usually irritates the parts but very little, and does admirable service, especially if the uterus is of normal size. I have even known a uterus measuring four and three-fourth inches to be reduced to three inches merely by the wearing of such a ring. The lever pessaries, previously described, made of hard rub- ber, as well as the rings of flexible copper wire covered with rubber, may sometimes be used to advantage, as they are often of service when Mayer's rings will not hold. The advantage of their being capable of being bent to the desired shape is abun- dantly compensated for, in practice, by the fact that, owing to their thinner and harder edges, they are more liable to cut through, and thus prove a greater irritant to the vagina. Inasmuch as, under ordinary circumstances, if the vagina is not uncommonly wide, the uterus can only descend in the axis of the vagina, thus assuming the position of retroversion in its descent, prolapse may be rendered impossible by forcing the organ to remain anteverted. This may be pretty well accom- plished by the pessary of Vulliet,1 as well as by the second form of Schultze's pessary (see Fig. 6&). i Nouveau moyen, etc. Geneve, 1871. 204 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. In France, Gariel's pessaire a Fair ' (a rubber bag filled with air) is in general use. The Zwarik and Schilling hysterophor2 (see Figs. 78 and 79) consists of two plates of the form of butterfly's wings, which can be laid together or spread apart by means of a screw running through a stem or handle to which they are attached. The instru- ment has this advantage, that the wing-like branches, which are spread apart by means of the screw, after their introduction into the vagina, readily retain their place, and that the patient can Fig. 78. Fig. 79. The Zwank and Schilling hysterophor, The same, without the covering. covered with rubber. remove or introduce the instrument herself. Still, even a pretty large specimen is sometimes expelled from the vagina, after it has slipped around obliquely, or it may recede so far posteriorly that the prolapse partially descends in front of it. Another dis- agreeable thing about it is the annoyance of the stem lying between the labia (it belongs to the class of stemless pessaries, in spite of its stem or handle, as the latter is merely for the accom- modation of the screw, and not for any purpose of an external support or fixation). The modifications of this instrument made by Eulenburg,3 Breslau, Savage, Coxeter, and others have not turned out to be improvements. Pessaries that receive their support from the outside of the body can often be used where those just described are impracti- cable, on account of their escaping from the vagina. On the 1 Gazette des hopitaux, 1852, No. 55. 2 Zwank, M. f. Geb., 1853, Bd. I., p. 215, 1854, Bd. 4, p. 184, and Hysterophor, etc., 2 Aufl. Hamburg, 1854. Schilling, Neues Verfahren, etc. Erlangen, 1855. C. Mayer, Verh. d. Ges. f. Geb. in Berlin, VIII., p. 5. Chieiri, Zeitschr. d. Ges. d. Wiener Aerzte, 1854. p. 533. Breslau, Scanzoni's Beitrage, Bd., IV., p. 275. a Zur Heil. d. Gebarmuttervorfalles, etc. Wetzlar, 1857. DISPLACEMENTS OF THE UTERUS. 205 other hand, they have the disadvantage of being burdensome on account of their bands, straps, and stems. Fig. 80. The Eoser and Scanzoni hysterophor. The best thing to use for the retention of the anterior vaginal wall, when this prolapses to a marked degree, is the Roser and Scanzoni hysterophorl (see Fig. 80). But the spring forming the curved arm must be select- ed to fit each individual case, for if the spring is too strong, the pad presses unduly against the soft parts, and if it is too weak, the pad is driven out of the vagina. Lazarewitscha re- commends a similar instrument, the stem of which is made of copper wire covered with rub- ber, and which can, therefore, be bent as required. If the posterior vaginal wall is the one that especially pro- lapses, or if the entire uterus descends evenly, the long extremity of a T-bandage may be passed between the thighs and padded at the point where it covers the vulva, so that the bandage mechanically prevents the Fig. 81. Scanzoni's bandage for the support of a prolapse. 1 Roser, Archiv f. phys. Heilkunde, B. X., p. 80, and Scanzoni, Lehrb. d. Krankh. d. weibl. Sex., 4 Aufl., 1 B. Wien, 1867, p. 150. 3 Coup d'ceil sur les chang., etc. Paris, 1862. 206 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. descent of the prolapse ; or a short stem may be fastened to the bandage, moving in a ball-and-socket joint, the upper extremity of which is button-shaped or is covered with a small sponge, and the prolapsed parts are thus supported. Such bandages are described by Seyfert1 and Scanzoni.2 Scanzoni's bandage is shown in Fig. 81. In the application of pessaries, we must never forget that they are all foreign bodies in the vagina, and that they, there- fore, all irritate. There is an immense difference, it is true, in the degree of this irritation. A good, well-fitting pessary increases the secretion of the mucous membrane but very little, especially if the decomposition of this secretion is prevented by frequent cleansing. Pessaries that are not well placed, and especially those that are too large, may cause peritonitis, ichorous inflammation, and the most extensive destruction of the soft parts. Von Franque cites a series of cases in which perforation into Douglas' space, the rectum, and the bladder took place. As a rule, pessaries only give temporary relief. Indeed, the vagina, the relaxation and width of which have either induced, or at least favored prolapse, only becomes wider and more re- laxed by their use. If prolapse is to be radically cured, its cause must be removed. The general principles, which must here guide us, have already been pointed out. It only remains to indicate more particularly the operative procedures by which those indi- cations are sought to be fulfilled. As regards the immediate reduction in the size and weight of the uterus, the shortest way to accomplish this is by amputa- tion of its lower portion. This operation, it is true, presents peculiar difficulties, in case of prolapse, as that part of the organ which can be removed without serious danger, viz., the vaginal portion, is very little developed, indeed has sometimes entirely disappeared. Attention has already been called to the fact that, as a rule, hypertrophy of the original vault of the 1 Prag. Vierteljahrsch., 1867, I., p. 97. 2Lehrb. der Kr. der weibl. Sexualor., IV., Aufl. I., p. 151. DISPLACEMENTS OF THE UTERUS. 207 vagina entirely destroys the conical shape of the vaginal portion of the uterus, so that the entire prolapsed part assumes a globular form. In other cases this conical form disappears, because the dragging of the vagina results in a complete ever- sion of the external os. For these reasons it is quite common, in cases of prolapse, to find that the vaginal portion of the uterus can no longer be defined, having become lost in the sur- rounding tissues. The question of whether amputation is practicable, or of how much can be amputated, must depend upon a careful examina- tion of each individual case. First of all, it must be accurately determined how far down the bladder reaches. Somewhat below this line the anterior lip may be cut off, the incision being carried somewhat obliquely inwards. It is a much more diffi- cult matter to avoid the retro-uterine fold of peritoneum, as we cannot possibly determine how far down it reaches, and it fre- quently descends to the lowest point of the posterior wall of the prolapse. Although not a matter of indifference, yet the wounding of this peritoneal pouch is not of positively unfavor- able prognostic significance, as the edges, if carefully brought together with sutures, readily unite. The particulars of the operation have already been discussed under the head of Cervical Hypertrophy and of Chronic Metritis." We will only here remark, in addition, that amputation of the vaginal portion is the surest and quickest way to secure a dimi- nution in the size of the uterus; and that the accomplishment of this end does not depend upon amputation of the largest possi- ble piece, as involution of the organ also follows the removal of comparatively small portions thereof. The prolapse itself is of course not cured by amputation of the vaginal portion of the womb, but one of the causes that has produced and maintained this condition is removed. In certain exceptionally favorable cases it is true that, after involution, a complete cure may be 1 In addition to the literature there cited, we may mention Carl Mayer, Klin. Mitth. a. d. Gebiete d. Gyn. Berlin, 1861, p. 33. Scanzoni, Beitr. z. Geb., IV., p. 329. Mar- tin, Mon. f. Geb., B. 20., p. 203. Bremn. Wien. med. Woch., 1859, Xo. 30. Munde (Braun), Am. J. of Obst., IV., p. 385. "Taylor, On Amput. of the Cervix Uteri, etc. New York, 1869. 208 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. effected by maintaining a recumbent posture, and observing other remedial measures as indicated above. Generally, how- ever, we are obliged to have recourse to other means, with the object of diminishing the relaxation of the uterine supports and restoring a resisting floor to the pelvis. Both indications may be fulfilled by operative procedures. As regards the first, we are confined to operations on the vagina. Changes in this part are often the cause of prolapse, and even when this is not the case, the width and laxness of the vagina, to say the least, encourage prolapse. Indeed, the attempt to cure prolapse by artificially narrowing the vaginal canal, is one of ancient date, and has been under- taken in two ways : either by endeavoring to produce a cicatri- cial contraction by the use of caustics, or by the excision of large pieces of vaginal mucous membrane. Girardin, Laugier, and others used the stick of nitrate of silver for this purpose ; Phil- lips used fuming nitric acid; Laugier, Yelpeau, Kennedy, and Dieffenbach, the actual cautery, applied lengthwise ; Colles and Simon the same, applied in rings. Chipendale even attempted to excite inflammation of the vaginal mucous membrane by the application of gonorrhceal matter. Marshall Hall was the first to introduce elytroraphy, that is, the narrowing of the vagina by cutting out pieces of mucous membrane, and stitching together the edges of the wound. He cut out long, oval strips from the anterior wall, introduced his sutures while the prolapse was out, then replaced it, and finally tied the sutures. Others, such as Dieffenbach, cut one or more strips out of various sides, and were followed in this practice by Velpeau, von Langenbeck, C. Braun, and others. This narrowing of the vagina at random is not a rational pro- cedure, as it can only now and then accomplish the desired end ; for even the narrowed vagina soon again protrudes through its distended mouth, and the lower part of the uterus crowds doAvn into the narrowed canal, which is exceedingly distensible, soon stretching it to its former size again. The only circumstances under which we may expect a satis- factory result from this operation, are when the vaginal prolapse was the primary one, and when a definite portion of the vaginal DISPLACEMENTS OF THE UTERUS. 209 mucous membrane has become so relaxed and stretched that tliere is actually no room for it in the vagina. This is occasion- ally the posterior, and often—in case of cystocele—the anterior wall of the vagina. The methods employed for decidedly nar- rowing the anterior wall rest, therefore, upon a rational basis, are sometimes indispensable, and, if the case is properly selected, accomplish all that they can accomplish ; that is, they prevent prolapse of the anterior vaginal wall, whereas they are not capa- ble alone of preventing uterine prolapse. Consequently, after their adoption, one must still employ means of retention or proceed to other methods of operation. The narrowing of the anterior vaginal wTall may be accom- plished in various ways. Sims l has projected some original methods of kolporaphia anterior. He intended to remove a considerable part of the wall Fig. 82. Narrowing of the anterior vaginal wall (kolporaphia anterior) according to Sims's method. a, orifice of the urethra ; b, os uteri. between the bladder and vagina, and then to close the extensive fistula by means of sutures. He found, however, unexpectedly, that he had only removed the vaginal mucous membrane, and then he drew the edges of the wound together. Subsequently, in order to render the operation less bloody, and to avoid the formation of deep-seated abscess, he only re- • Loc. cit., p. 299. VOL. X.—14 Fig. 83. Narrowing of the anterior yasrinal wall by freshening the entire surface and employing alternately superficial (c) and deep (d) sutuies. a, orifice of the urethra; b, os uteri. 210 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. moved a V-shaped strip (see Fig. 82), and then closed the wound, afterwards freshening a space at each of the open arms of the V, as shown by the dotted lines in Fig. 82. As Emmet' had ob- served that the cervix may crowd into the gap left at c, he fresh- ened this bridge too (so that the whole part denuded resembled an isosceles triangle, with the apex towards the vaginal outlet), and then brought the sides together. I prefer, in cases that demand narrowing of the anterior wall, to freshen the entire surface and bring it together with sutures, as is shown in Fig. 83. The bleeding can be held in control while freshening the surface, and is sure to stop on drawing it to- gether. The formation of abscess may be avoided by not merely passing sutures through the mucous membrane, as was done by Sims, but by introducing deep sutures between the superficial ones. I have only performed the operation in one case (see Fig. 74), but in this it accomplished all that could be expected of it. The prolapse of the anterior vaginal wall ceased, and the uterus could be held in position by a Zwank's pessary, which was im- possible previously, when the anterior wall descended like a bladder in front of the instrument. The uterus also became reduced in size from four and three-quarter inches to three and one-third inches. Even if the width of the vaginal entrance is not the cause of prolapse in certain cases, as we have seen above, it very materi- ally favors this condition, inasmuch as it admits of the escape of the uterus, which is disposed to prolapse, without further hin- drance. In former times the influence of such an enlarged vaginal entrance was over-estimated, and rupture of the perineum, with its attendant extension of the fissure of the vulva, was ranked as the most important etiological factor in the production of pro- lapse. It was very natural, therefore, that the attempt should be made to prevent the descent of the womb by narrowing the opening of the vulva. This was accomplished by the operation of eyisioraphy, that is, the freshening of the margins of the vaginal opening and uniting them by means of sutures. This 1 New York Med. Journ., April, 1865. DISPLACEMENTS OF THE UTERUS. 211 method was first introduced by Fricke. The edges of the labia majora are freshened, beginning behind and advancing forward, until, in old women, only a small orifice is left for the escape of secretions, while in others a conjugal opening is preserved in front. If the edges are thoroughly freshened, the operation suc- ceeds without any difficulty. What is accomplished by this operation is, that at first the uterus cannot escape; but it remains down, and rests on the bridge of integument as on a perineal bandage. This condition of things would be a great gain, if it were lasting. Gradually, however, the uterus pouches out the integumentary covering* forming a sort of perineal hernia of the size of the former pro- lapse ; or, not uncommonly, it crowds out at the opening which has been left. In some cases the support thus given, however, holds good for a long time, and takes the place of all other appliances. A procedure which is less to be recommended than that given above consists in closing the vulva by means of rings passed through its lips. Dommes combined beauty and utility when he united the labia by means of silver and golden rings. All such methods, even at best, can only prevent actual pro- lapse, they have no power to raise the uterus to anything like its proper position. In order to accomplish this we must aim not only to restore a longer perineum, but to construct a firm, thick, unyielding pelvic floor, capable of sustaining the weight of the uterus, and, in constructing this, so to narrow the vaginal canal as to render descent difficult. Such an operation is by no means to be con* fined to cases of old and extensive perineal rupture, but is also applicable where no rupture of the perineum has occurred, see- ing that in every case of complete prolapse the posterior vagi- nal wall and the entire floor of the pelvis have become in the highest degree relaxed and atrophied. Baker-Brown' first attempted to achieve this end by the fol- lowing operation. Beginning at the posterior commissure, he denuded a portion of the vaginal surface and introduced several quilled sutures and interrupted sutures, the latter, however, only 1 Surg. Pis. of Women, 3d ed. London, 1866, pp. 90 and 109. 212 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. through the perineum, so that the perineum was lengthened and the cicatrix extended only a short distance into the vagina. In case of cystocele, he furthermore removed from each side of the upper portion of the vaginal entrance a strip measuring one inch in length and three-quarters of an inch in width, and brought the edges of the mucous membrane together. This procedure is also quite insufficient, actually amounting merely to an elongation of the perineum, and therefore accom- plishing but little more than the operation of Fricke. The method adopted by Simon * is particularly complete, although others (Yeit, Hegar, Spiegelberg) adopted a combina- Fig. 84. Fig. 85. Hegar's perineauxesis. Simon's kolporaphia posterior. a, apex of the freshened space toward a and b, as in Fig. 84 ; c, deep, d, the os uteri; 6, its base at the frenulum; superficial, and e, perineal sutures. c, vaginal, d, perineal sutures. tion of the operations on perineum and vagina {episio-elytrora- phy) simultaneously with himself. Simon proceeds as follows in his kolporaphia posterior. He freshens a surface in the same way as Baker-Brown, except that he carries it further into the vagina, so that at the frenulum the surface denuded is from two to two and a quarter inches wide, and extends the same distance into the vagina, narrowing about a third of an inch at its further extremity. The two incisions are united above at an obtuse ' Prag. Vierteljahrschr., 1867, Bd. 3, p. 112, and von Engelhardt, Die Retention des Gebarmuttervorfalles. Heidelberg, 1871. DISPLACEMENTS OF THE UTERUS. 213 angle, the part denuded thus forming a pentagon. Simon does the freshening of the surface with a scalpel, operating through a fenestrated speculum. In freshening the upper angle an assist- ant draws down the parts by means of his finger in the rectum. In bringing the parts together (see Fig. 85), two sutures are first introduced at the apex, a, and then follow superficial and deep sutures alternately. The first, d, are entered close to the edge of the wound, are brought out again about a third of an inch from the point of entrance, and are then carried across to be similarly passed through the other edge of the wound. The deep sutures, c, are armed with two needles, each of which is introduced a little to one side of the median line, and carried outward to a point one-third of an inch beyond the margin of the incision. The perineal sutures, e, are introduced like the deep sutures, but they are brought out nearer the edge of the wound, and so obviate the necessity of superficial ones. In tying, two superficial sutures are tied first, and then the deep one lying between them. The subsequent treatment consists in quiet rest in bed, which must be continued for several weeks. The catheter is only to be used if difficulty is experienced in passing water spontaneously. It is not desirable to induce constipation; on the contrary, we should endeavor to secure light, thin stools. Hegar ' operates in a very similar manner in his uperineaux- esis," except that he freshens a triangular surface, or rather a sector of a circle, and introduces only deep sutures (judging by the diagram). He uses silver-wire sutures, which, however, are of no special advantage, as silk ones can be left in place an indefinite length of time, as is proved by the instances in which they are sometimes forgotten. By restoring a firm floor to the pelvis, and at the same time narrowing the vagina, excellent results may be secured; inas- much as the vaginal portion of the uterus remains above the upper part of the newly formed pelvic floor, a fact of which we were enabled to convince ourselves in the case of a woman who had been operated on by Simon, three years before, and who was 1 Huff el, 1. c, p. 31. 214 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. obliged to work hard. The uterus was found at about its nor- mal height, and very slightly retroverted. Breisky ' gives prom- inence to the idea that the bladder also finds support in the newly formed pelvic floor, and that thus the tendency to cysto- cele is abolished; as well as to the opinion that the acute angle at which the uterus and vagina stand to one another facilitates retention. The most radical operation for the cure of prolapse is ampu- tation of the entire uterus, which has recently been carried out by Choppin* and M. Langenbeck.3 The operation is justifiable in complications with a malignant new growth or gangrene of the organ. Aside from this, it can only be permitted very excep- tionally in case of an exceedingly large irreducible prolapse. ELEVATION OF THE UTERUS. An abnormally high position of the uterus is only of sympto- matic significance, as the organ is never spontaneously dislocated upward. The elevation is produced either because the uterus is pushed upward from below or drawn upward from above. It may be pushed upward by any tumor developed below it, such as an accumulation of blood in the closed vagina, hematocele, exudations, extra-uterine pregnancy, and other tumors, especi- ally those of a malignant character, developing themselves in the true pelvis or the vagina. The uterus is more frequently drawn upwards, either through very large tumors (ovarian cysts or subserous and interstitial fibroids) or through peritoneal attachments. The latter fix the organ especially far up, if they have occurred during the puerperal state, when the fundus still lies high in the abdominal cavity. In cases of uterine elevation the vagina is drawn out length- wise, so that its mucous membrane becomes smooth, and the reflected portion of it, covering the vaginal part of the uterus, is unfolded. The vagina then becomes funnel-shaped at its upper 1 Aerztl. Correspondenzbl. f. Bohmen, 1874. a Amer. Journ. Med. Sci., 1867, p. 567. 3 Memorabilien, 18 Juli, 1868. INVERSION OF THE UTERUS. 215 extremity, and in the depth of the funnel a little hole may be observed—the os uteri. In extreme cases, especially those associated with ovarian or fibroid tumors, the uterus itself, and especially the cervix, may become elongated ; indeed the latter may even be ruptured by the amount of strain brought to bear upon it. INVERSIO UTERI. Fries. Abh. v. d. Umk., etc., d. Gebarmutter. Munchen, 1804.—Crosse, An Essay, etc., Transact, of the Pro v. Med. and Surgical Assn. London, 1845. —Lee, Am. J. of Med. Sc, Oct., 1860, p. 313.—Gurlt, Mon. f. Geb., B. 16, p. 11.— Betschler, Breslauer klin. Beit. z. Gyn., I. Breslau, 1862, p. l.—v. Scanzoni, Beilr. z. Geb. u. Gyn., 1868, V., p. 83.—Freund, Zur Path. u. Ther. d. veralteten Inversio ut. puerp., etc. Breslau, 1870.— Thomas, Am. J. of Obst., II., p. 423.—Spiegelberg, Arch. f. Gyn., B. IV., p. 350 u. B. V., p. 118. As we here omit the consideration of recent cases of inversion occurring in the puerperal woman, our attention will be directed to old cases and to such as are developed in connection with abdominal tumors. Etiology. Inversion may be produced, though much more rarely than in the puerperal state, by tumors attached to the uterine walls, —not those polypi that grow by a narrow stem, but tumors attached by a broad base which encroach upon the uterine cavity ; or by those of a purely interstitial character (sometimes even very small in size). These growths may be fibrous or sar- comatous in nature. Inversion is doubtless brought about in this wise: the uterine foundation, or base of the tumor, which consists of normal uterine tissue, becomes atrophied (either dis- appearing or undergoing fatty degeneration) by means of the pressure which the tumor exerts. A gap is thus formed in the firm, contractile uterine tissue ; the tumor sinks into the cavity of the womb, and is driven towards the mouth, both by its own weight and by the contractions of the organ. The os then opens, and the tumor sinks into the canal of the cervix, and thus the adjacent portions of the uterine wall being drawn down, a com- plete eversion is gradually accomplished. In some cases, how- 216 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ever, after the tumor has sunk a certain distance into the cavity of the uterus, the inversion is rapidly accomplished by means of uterine contractions. Pathological Anatomy. Inversion of the womb is divided into three grades, as fol- lows : 1st. That degree of inversion in which the fundus still remains above the external os. 2d. That condition in which the fundus has passed through the os, but still remains within the vagina (Fig. 86). 3d. Prolapsus uteri inversi, when the inverted organ has escaped from the vagina. The uterus, turned inside out and lying within the vagina, pre- sents a rounded, sometimes quite swollen body, with a somewhat puffy, reddish or bluish surface (the inflamed uterine mucous mem- brane). At its upper portion the tumor becomes narrower, and forms a sort of pedicle lying between the lips of the os. These latter are dis- tinctly to be felt, for a complete inversion of the organ seems to be impossible,—the cervix, through which the inverted uterine body has descended, retaining, at least in part, its normal position. This is particularly true of the anterior lip. The cervix is completely involved in the inversion only when strong traction is made on the uterus; perhaps, in some exceptional cases also, through the weight of the tumor. After opening the abdominal cavity, on the dead subject, the site of the uterine body is seen to present a funnel-shaped depression, into which the tubes and ligaments of the uterus lead. In cases of long standing this funnel is very narrow (one-fifth of an inch at the outside), and the ovaries do not lie in it. Fig. 86. Inversion of the uterus. INVERSION OF THE UTERUS. 217 At a later period the uterus may undergo material changes ; a process of involution takes place, and the mucous membrane becomes smooth—more like a serous surface. Symptoms. In cases of uterine inversion dependent on the presence of a new growth, the hemorrhages which previously existed, and were caused by the tumor, continue, and, as a rule, debilitate the patient in the highest degree. Between the periods of hemorrhage an excessive mucous discharge is present. In addition to this, pain in the back and in the abdomen is frequent. So also are difficulties of micturition. Still, it is remarkable how the organism may accustom itself to such a serious disturbance. It occasionally happens that serious symptoms arise only at times, when the inverted organ escapes through the vulva. Contraction of the cervix, which engirdles the body, may produce gangrene, with its usual consequences. Diagnosis. Under ordinary circumstances the inverted uterus can be recognized as such with certainty. It is true that it bears a striking similarity to a polypus, and the history as well as appearance of the tumor are often not sufficient positively to settle all doubt. Careful conjoined manipulation, however (if necessary, under chloroform), must determine the presence or absence of the uterus in its customary place. If it is absent, one may, in cases that are not too unfavorable, be able to feel a funnel-shaped depression or cleft at its former site, and can sometimes distinguish the uterine appendages emerging there- from and spreading out like a fan. If the tumor is pulled down strongly, this funnel may also be made accessible to the finger introduced into the rectum. In drawing the uterus down another evidence is sometimes pro- duced which, alone, is capable of settling the diagnosis posi- tively : this is the disappearance of the lips of the os from 218 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. around the pedicle of the tumor, inasmuch as traction causes the lower part of the cervix to participate in the inversion. Exploration with the sound, too, must show that the pedicle of the tumor is everywhere continuous with the cervix, as it meets with resistance all the way around at the point of union, whereas, with a polypus, it should pass onward into the uterine cavity. Occasionally the uterine orifices of the Fallopian tubes can be seen, and the diagnosis thus verified. Prognosis. Even old inversions of long standing justify an unfavorable prognosis, as they give rise to so constant a loss of blood. Still, even very old cases may be reduced, and, after replacement of the organ, pregnancy, too, may supervene, as is shown by the cases of Tyler Smith and of Emmet. The spontaneous reduction of inversion is certainly very rare. One unequivocal instance of this kind has been observed by Spiegelberg, in which, after the patient had remained on her back for two weeks, during which time she suffered with severe diarrhoea, the womb was found to have returned to its normal position. Schatz explains this re-inversion as follows: During the quiet maintenance of the dorsal recumbent posture, the womb came to lie somewhat higher, so that the bands which pass down into the funnel were shortened ; during the existence of diarrhoea a strong downward pressure was exerted on the cervical ring, while the shortened uterine attachments admitted of but a slight dislocation of the body downwards. The cervix, then, being powerfully crowded down, while the fundus re- mained at about the same height, the latter finally slipped back through the former. Treatment. Inversion is removed by replacement of the parts, which in recent cases is easy, in old cases very difficult to accomplish. This may be attempted, while the patient is under the influence of an anesthetic, by pressing against the fundus with the INVERSION OF THE UTERUS. 219 fingers or a pestle-shaped instrument, at the same time that the funnel formed by the inverted organ is pushed downward by another hand applied to the abdominal walls. As a rule, it is a comparatively easy matter to push the fundus up as far as the external os, inasmuch as the uterus becomes soft and yield- ing under taxis; its further progress, however, is accompanied with far greater difficulty. The greatest variety of apparatuses have been introduced for the purpose of securing as powerful, constant, and effective pres- sure as possible. White,1 of Buffalo, makes pressure against the fundus by means of an instrument, the upper bowl-shaped end of which embraces the fundus, while the other end, provided with a strong spring, rests against the breast of the operator. Braxton Hicks2 uses peculiar-shaped rubber tampons, as does also Barnes, who likewise, urgently recommends incisions into the cervix. Noeggerath advises that one horn of the uterus be replaced first, whereupon the other readily follows. Emmet* has several times successfully accomplished a reduction in the fol- lowing manner : The hand, introduced into the vagina, takes the inverted uterus into the hollow of the hand, while the five fingers lie in contact with the point at which the organ is turned in. While the hand pushes the fundus up, the fingers are spread as forcibly as possible so as to distend the funnel. If by this means the fundus is carried above the plane of the os, the fingers crowd it up further, while the other hand, external to the abdomen, presses the ring of the cervix downward. If the attempt at manual replacement fails, it becomes neces- sary to call into action long-continued pressure upon the fun- dus through the vagina. This may be best accomplished by means of the colpeurynter. I myself5 accomplished reduction by this means in a case that had existed for two years, and in which the most energetic attempts at manual replacement had 1 Amer. Journ. Med. Sc, April, 1872, p. 391. 3 British Med. Journ., August 31, 1872. 3 Obst. Journ. of Gt. Brit , April, 1873, p. 1. 1 Amer. Journ. of Med. Sc, January, 1866, and Amer. Journ. of Obstet., II., p. 213. * Berlin klin. Wochenschr., 1868, No. 46. 220 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. failed. The colpeurynter, considerably distended with water, was kept continuously in the vagina, and for several hours of each day it was so far enlarged as to exceed in size the head of a new-born child. Emmet1 produced continued pressure against the fundus, already pushed up some distance, by closing the lips of the vaginal portion of the uterus, beneath the fundus, with silver- wire sutures. The administration of ergot, whereby Freund brought about re-inversion, after pushing the fundus up as far as possible, might prove dangerous, seeing that if it does not accomplish its object, strangulation of the fundus is likely to be the result. (In Freund's own case, the use of ergot at first led to the beginning of gangrene.) If the inversion is caused by a tumor, this should first be removed, whereupon reposition usually follows spontaneously within a few days. In Field's" case, however, in which the fibroid which had caused inversion was removed with the ecra- seur, the uterus did not return to its place until a rubber tampon had been used for twenty days. If all these means do not accomplish the end, and the annoy- ance caused by the inversion is very great, we may proceed to amputation, unless disposed, like Thomas, to perform gastro- tomy. Still, it should be distinctly remembered that, according to recent experience, replacement of the organ has been accom- plished in apparently hopeless cases, through perseverance and systematic effort, even though such a result is occasionally made impossible by the existence of firm adhesions within the funnel. The fact that an inversion has been of long standing is no argu- ment against persistent efforts at its reduction, as we have reports of cases where replacement has been effected after a dis- placement lasting for years (as long as fifteen years). Thomas caused pressure to be made through the vagina, on the encircling cervi- cal ring, pressing it up against the walls of the abdomen; then he cut down upon it, enlarged the ring by means of a dilator made for the purpose, and then, with great difficulty, replaced the womb. Recovery followed, in spite of a perforating 1 Amer. Journ. Med. Sc, Jan., 1868. 2 St. Bartholomew's Hosp. Rep., 1872. INVERSION OF THE UTERUS. 221 rent of the vagina, produced in the efforts of replacement, and in spite of consider- able hemorrhage outwards, into the cavity of the abdomen. In a second case in which he operated, the patient died of peritonitis. When, in any individual case, the dangers or annoyances of the condition are not too great, it is best to try to render them bearable without the aid of an operation. This is most readily accomplished at the beginning of the menopause, because then all coincident discomforts may, to a great degree, cease. The attempt may also be made by means of the chloride of iron, or other caustics, so to alter the uterine mucous membrane that the organ may lie within the vagina without hemorrhage or any con- siderable amount of secretion. Amputation of the uterus has been undertaken in various ways. In former times the ligature was uniformly employed, and the organ was gradually removed by this means. Of late, the removal has frequently been direct and immediate, usually by means of the ecraseur, though occasionally by the knife or scissors. The direct removal, however, is the most dangerous method, both on account of hemorrhage and because after the uterus is cut off the cervix turns in, so that the bleeding surfaces of the wound are directed inward toward the abdominal cavity. The best chances for recovery seem to lie in a combination of the ligature with subsequent removal of the organ. Adding some more recent cases to the statistics of Scanzoni, we have the following results: Total. Recovery. Death. Simple removal.......... 14 6 (43 per cent.) 8 (57 per cent.) Simple ligature.......... 26 19 (73 per cent.) 7 (27 per cent.) Ligature and removal..... 29 24 (83 per cent.) 5 (17 per cent.) The operation is accomplished as follows: a cord or wire is passed around the neck or pedicle of the tumor, lying in the vagina, and is drawn tight. This causes intense pain, and even produces evidences of shock and collapse, which not infre- quently necessitate the loosening of the ligature. (Sometimes this has been the means of first establishing the diagnosis of inversion, where, previously, the tumor had been mistaken for a polypus.) 222 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The uterus then swells considerably, and soon gives evidence of the beginning of gangrene, which we endeavor so to control by means of carbolic acid and chloride of iron as that it shall take more the form of dry mummification. According to the indi- cations of the case, the whole, or a part of the ligated portion, is removed within a few days, or may be left for ten or fourteen days. The longer it is allowed to remain, the more complete will be the peritoneal adhesion of the funnel, so that the cervix, even if it turns in, only stretches these adhesions. HERNIA UTERI. Klob, Pathol. Anat. d. weibl. Sex. Wien, 1864, p. 105. The non-pregnant uterus very seldom composes the contents of a hernial sac. Only two cases of crural hernia seem to be on record : one of Lallement's,1 in a woman eighty-two years old, and one of Cloquet's, in a new-born child, which Boivin and Duges repre- sent in PI. XL, Fig. 3, of their Atlas. Cases of inguinal hernia have been observed by Maret, Cho- part, Lallement, and Cruveilhier. The etiology of uterine hernia is most intimately connected with that of ovarian hernia (descensus ovariorum), to which we must here refer the reader, inasmuch as the dislocated ovaries drag the uterus after them. The diagnosis cannot be difficult, with careful palpation and the use of the sound. No especial therapeutics are to be thought of, as the uterus is irreducible. FIBROIDS OF THE UTERUS (MYOMA, FIBROMYOMA, LEIOMYOMA). Bayle, Cervisart Journ. de nu'rl., Ann. XI. Vendem. (1803, Oct.), and Diction, dessc. med. Paris, 1813, T. VII., p. 72.— Wenzel, Krankh. d. Uterus. Mainz, 1816. —P. U. Walter, Denkschr iiber fibrose Geschwiilste der Gebarmutter. Dor- pat, 1842.—Amussat, Me*m. sur lcs tumeurs fibr. de Tuterus. Paris, 1842. — Th. S. Lee. On Tumors of the Uterus and its Appendages. London, 1847.— Chiari, 1 Bull, de la fac. de medec, 1816, L, p. 1. FIBROIDS OF THE UTERUS. 223 Braun u. Spaeth, Klin. d. Geb. u. Gyn. Erlangen, 1852, p. 396.— Routh, Lettsomian Lectures, etc., Brit. Med. Journ., Feb.-July, 1864.—Sdxinger (Sey- fert), Prager Vierteljahrschr., 1868, 2, p. 93.—Klob, Wiener med. Woch., 1863, No. 35, etc., und Path. Anat. d. weibl. Sex. Wien, 1864, p. 149.— Virehow, Geschwiilste, 3 B., 1 H., p. 107, etc.—Kidd, Dublin Journ. of Med. Sc, Vol. 54, 1872, p. 132.—Goodell, Phil. Med. Times, May 1, June 1, 1872. Etiology. Myoma, or the round uterine fibroid, is a new-growth, of extremely frequent occurrence, resembling in its structure the uterine parenchyma, but developed within the latter as a round tumor. The declaration of Bayle, so often quoted, that fibroids are to be found in 20 per cent, of the women who die past the age of thirty-five, may be extravagant; still, Klob, too, estimates the frequency of fibroids, among women who die over the age of fifty, as reaching 40 per cent. Thus much is certain, that it is one of the most frequent diseases of the uterus. The Americans assert that fibroid tumors are very frequent among negresses and mu- latto women, and that even at an early age (twenty years) they are not rare. (Ovarian tumors and uterine carcinoma are said to occur but seldom among them.) If we add thirty-six of my own cases, of which I have accurate notes, to those collected by Chiari and West, we shall obtain the following results with regard to the age at which the patients came under treatment: Age 20 to 30. 30 to 40. 40 to 50. 50 to 60. 60 to 70. 70 to 74. Total. No. of cases.. 33 54 62 19 0 1 169 As these tumors often produce no symptoms until late, their origin must be dated back considerably ; still, they do not occur before puberty. Nothing at all is known with regard to the causes which determine or favor the development of fibroids. Undoubtedly some local irritation is at the bottom of it, but as to the vari- ety or the origin of this irritation, we are completely in the dark. Bayle considered abstinence from sexual indulgence and ster- ility as predisposing causes, but was evidently wrong with 224 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. regard to both. The great majority of women having fibroid tumors are married (among 514 cases treated by West, Dupuy- tren, Routh, and myself, 421 (= 81TV per cent.) were married); and undoubtedly a good many of those who were unmarried were still not shut out from sexual indulgences. The relation of fibroids to sterility is exactly the reverse ; sterility does not induce fibroids, but fibroids are often followed by sterility. Among 196 patients treated by Dupuytren, Malgaigne, West, McClintock, and myself, we find that, omitting twenty-seven unmarried women who had never borne children, 119 were fruit^ ful, and fifty sterile. Pathological Anatomy. Although composed of the same constituents as the normal uterine tissue, a fibroma or myoma does not, at the same time, represent a mere diffuse enlargement of the uterus, but develops itself as a distinct, round tumor, plainly separate from the par- enchyma proper. Microscopically the fibroid tumor consists of unstriped mus- cular fibre and connective tissue. If the former predominate, it may best be designated as a myoma, or, more accurately, a leiomyoma ; otherwise, as a fibro-myoma or fibroma. Both components are irregularly distributed. The muscular bundles are extensively interlaced with one another, and here and there amongst them are found bands of wavy connective tissue. The latter is, as a rule, firm, fibrous, almost cartilagi- nous ; in other cases, however, it may be loose. The arrange- ment of fibres is nearly concentric, so that the entire fibroid con- sists either in a single lobe or in several lobes combined. On section, the exposed surface is whitish, often reddish white or reddish gray. If it contains more tendinous tissue, the color, at certain points, will be a brilliant white. At the same time the cut surface appears lobulated, the pressure of the fibrous bands throwing up ridges upon it. As a rule, the uterus is hypertrophied, its walls are thick- ened ; sometimes, however, especially in subperitoneal fibroids, FIBROIDS OF THE UTERUS. 225 it may be thinned by reason of being drawn out in length; and in old women it may be greatly atrophied. Blood-vessels enter the tumor with the bands of connective tissue, though usually they are but few in number. It is exceedingly rare that any larger arteries dip into a fibroid. The tumor apparently lies as a foreign body within the mus- cular substance of the uterus, inasmuch as it is separated by a capsule of loose connective tissue, from the parenchyma of the organ, and can readily be enucleated. Still, its development always begins in the uterine tissue itself, as a local hyper- plasia, and it is not till later, when the well-defined tumor grows by the multiplication of the elements belonging to it, that it pushes the muscular fibres of the uterus apart, lies between them, and is capable of being separated from them and turned out. Nevertheless, a large fibroid is often continuously attached to the uterine parenchyma by quite a broad base. On the other hand, the tissue by which the tumor is attached to the uterus, and out of which it was, in fact, developed, readily atrophies; so that, then, the fibroid actually has no longer a continuous connection with the parenchyma of the uterus. In the latter case, the blood-vessels become obliterated at the same time with the pedicle, so that scarcely any vessels enter the sub- stance of such an isolated and embedded fibroid. As a rule, then, vessels of considerable size enter those fibroids which are intimately attached to the uterine substance, while those which are merely embedded therein are quite feebly vascular (the mucous membrane, even of the latter, however, majr bleed quite profusely). It is possible, however, for fibroids, especially of the large interstitial variety, to be so vascular that an actual cavernous structure is developed, resembling that at the seat of the placental attachment in advanced pregnancy. This form has been desig- nated by Virehow as Myoma telangiectodes, seu cavernosum. Cavernous spaces filled with blood are then developed, " colossal capillaries," having a lumen varying in size from that of a hemp- seed to that of a pea, between which, sometimes, there remain but narrow ridges of muscular tissue. In rare instances, the whole, or nearly the whole, of the tumor is converted into such a VOL. x.—15 226 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. cavernous structure; usually the disease is confined to certain portions of the growth. Leopold1 has described a colossal tumor of this sort, which had so enlarged the uterus that it resembled that of a woman in advanced pregnancy. According to Virehow, it is just in these cavernous myomata that we meet with an increase and subsidence of swelling. He explains this on the score of a greater or less supply of blood and the contrac- tion or relaxation of the muscular substance. The fibroid may also undergo other alterations, such as Softening. This may depend on a. Simple azdema; for the fibroid may become so highly cedematous as to give fluctuation and be mistaken for a cyst. On puncture, however, nothing is discharged, or but a few drops of serous fluid. In oedema, the muscular fibre atrophies. b. Fatty metamorphosis; the muscular cells undergoing fatty degeneration and being absorbed, thus establishing a pro- cess quite similar to that of puerperal involution. The tumor may thereby be materially diminished in size, and even entirely absorbed (see below). c. Myxomatous degeneration. Between the individual lobes of a compound tumor, as well as between the individual fibre- bundles of a single lobe, mucous tissue is to be found. By the destruction of the cells and the secretion of considerable quanti- ties of intercellular mucus, large collections of mucus may be formed, which create a semblance of degeneration. Induration. This takes place in connection with fatty metamorphosis, the muscular tissue undergoing fatty degeneration and the con- nective tissue becoming indurated. Perhaps the latter is the primary step, so that the entire process is to be regarded as an interstitial inflammation, and the fatty degeneration of the mus- cular fibres as the result of pressure produced by the cicatricial 1 Archiv f. Physiol. Heilkunde, 1873, p. 414. FIBROIDS OF THE UTERUS. 227 contraction of the connective tissue. The fibroid then becomes quite hard, tendinous, or cartilaginous. Calcification. The occurrence of induration, accompanied as it is by an' arrest of growth, is followed by the deposit of the salts of lime. The presence of lime, in irregular veins, is first observed in the middle of the tumor. At a later period the deposit may be more considerable, so that it is difficult to saw through the tumor, and maceration betrays the existence of something like a coral for- mation. The deposit of lime is seldom so complete that the section is smooth and admits of a polish. It is very exceptional for the process to begin on the outer surface, forming a shell. Calcareous degeneration occurs only in subperitoneal and interstitial fibroids. The latter variety may then be set free, in the manner described further on, and may be expelled as uterine calculi. As a general thing, calcareous' degeneration is met with only in the smaller interstitial tumors ; in very large ones it is extremely rare. Calcareous myomata, which have been set free within the uterus, have engaged the attention of physicians from the earliest periods, under the name of "uterine stones." Thus, Hippocrates states that a Thessalian maid, sixty years of age (who during her youth was subject to severe pain on sexual intercourse), was seized with pains similar to those of labor, after eating leeks, and that a rough stone was extracted from the vagina. Salins tells of an old nun who was delivered of a stone resembling a duck's egg in size and shape. Another class of cases, which undoubtedly belong in the same category, are to be found especially in older litera- ture. Louis ' knew of eighteen cases of uterine stone, and since that a number more have been observed, amongst others, by Velpeau, de Coze, Courty,2 Duncan,3 and Arnott.4 Saxinger6 reports a case in which the surgeon applied forceps and delivered a uterine stone of the size of a child's head. Henoque 6 demonstrated by ' Mem. de l'acad. de chir., 1753, T. II., p. 130. 2 Mal. de l'uterus, etc., 2d ed., p. 932, weighing 10 kilogr. s Edinburgh Med. Journ., August, 1867, p. 179. 4 Medico-Chirurg. Transactions, XXIIL, 1840. Stone of fifty pounds, which tore the rectum by its weight on the occasion of a falL 6 Loc. cit., p. 113. s Archives de Physiol., Juillet, 1873, p. 425. 228 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. a microscopical examination that a uterine stone obtained by Amussat, in 1829, was a calcified fibroid. In the Museum of Pathological Anatomy at Erlangen there is a very large submucous fibroid, measuring thirteen inches by eight and a half inches in diameter, which has become so calcareous throughout that a piece of the tumor which has been sawed out and macerated presents a structure similar to a coral. The specimen was furnished by Dr. Bohm, of Gunzenhausen, with the state- ment that the fibroid, weighing twenty-four and a half pounds, was taken from the body of an unmarried woman, sixty-one years of age, who had never borne children, and who died of marasmus. The tumor, which she first noticed at about the age of thirty, finally lay in a sacculated portion of the immensely distended abdominal walls, between the upper portions of the thighs, inclining particularly to the left side. Another variety of nutritive disturbance may arise when the fibroid is cut off from the source of its nourishment by suppura- tion of its bed. This occurs most frequently after traumatic injuries. A degeneration, which is partly fatty, partly gangren- ous, then takes place, and pieces of the tumor, or the whole of it, are expelled, accompanied by a fearful stench. A complete cure may be effected in this way, or death may ensue, with symptoms of septicaemia or of peritonitis, caused by the decom- posing fibroid, with or without perforation into the abdominal cavity. In addition to the simple fibroid, with its various alterations, some mixed tumors also occur, which are not without practical importance. The most frequent are cyst-formations in fibroids, which then constitute the myoma cysticum, or "fibrocystic tumor" of the English. These represent, not actual, newly formed cysts, supplied with a lining membrane, but merely gaps in the connective tissue, filled with serum. These are formed, during great oedema of the fibroid, by the tissue being driven apart at some points. For this reason, a large number of small cystic chambers are generally met with ; still, the centre of the fibroid may be occupied by a large cavity filled with fluid, which has been formed by the softening and gradual dissolving of the tissue lying between the smaller cysts. The several cavities are surrounded and limited by bands of muscular and connective tissue, which also sometimes stretch across them as trabeculse. In addition to these, however, cysts of apoplectic origin may occur, which are formed in the usual manner by the effusion of FIBROIDS OF THE UTERUS. 229 blood. These arise, if not exclusively, at least by far the most frequently, during pregnancy. The formation of cysts may also originate in masses that have undergone fatty degeneration, by their breaking down into a detritus that becomes fluid.1 The semblance of cyst-formation may also be produced through myxomatous degeneration of tissue. It is under the first form especially that colossal mixed tu- mors arise, belonging to the largest forms of abdominal growths that exist. They are soft, and contain a multitude of cysts of various sizes. Boinet,2 at the same time, is doubtless correct in his assertion that in some cases reported as "tumeurs fibrocystiques," these have been confounded with the more solid ovarian cysts which have grown fast to the uterus, as well as with fibroids that are surrounded by peritoneal adhesions, within which, as is so often the case, a con- siderable amount of yellow serum accumulates. It appears that Pean3 describes these serous accumulations lying on the fibroid within pseudo-membranes as " tumeurs fibro-cystiques proprement dites." Primary degeneration of fibroid tumors into carcinoma hardly ever occurs. Only one case, reported by Klob,4 is to be found in the whole field of literature, in which primary cancer originated in a fibroid. The metastatic development of carcinoma in a fibroid6 is also extremely rare ; whereas the secondary extension of a widespreading carcinoma to the fibrous growth is not quite so uncommon. The simple complication of fibroid of the body with carcinoma of the cervix, which Courty6 likewise considered extremely rare, is far more frequent; although the views of Simpson, who considers that the irritation of a fibrous polypus in the cervix may be the direct cause of carcinomatous degenera- tion, appear to have but little foundation. The transformation of a fibroid into a sarcoma, constituting a 1 Virehow, 1. c, p. 116, and Graily Hewitt, Pathol. Trans., XL, p. 173. 8 Gaz. hebd., 1873, No. 8. 3 Hysterotomie, etc. Paris, 1873, p. 88. 4L. c, pp. 163 and 188. 5 Benporath and Liebmann, Monatsschr. f. Geburtsh., B. 25, p. 50, saw secondary deposits in carcinoma of the vagina. 6 Mal. de l'uterus, etc., II. edit., p. 933. 230 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. myosarcoma, seems to be more frequent. The intercellular tissue then begins to proliferate, at first smaller, afterwards larger round cells, with large nuclei, appearing therein. These multiply between the bundles of muscular fibres, crowd the latter apart, and gradually cause them to disappear. On section, those por- tions which have undergone sarcomatous degeneration present a homogeneous, white, or yellowish appearance, and are softer. We cannot as yet determine how often this change, from a benign fibroid to a malignant sarcoma, takes place. There is no doubt that it may take place. For further particulars, see the section on sarcoma. Through softening of individual portions, and through apo- plectic effusions, cystic myosarcoma may arise. The degenerated tissue may, in itself, be so soft—myxosarcoma—that one re- ceives the impression of cysts filled with a mucous fluid. After these general observations on the mode of origin, the structure, and the alterations of fibroids, we have yet to consider the several varieties separately, and they will be found to pre- sent differences of great practical significance. In the first place, we distinguish fibroid of the body from that of the cervix, and divide the former into subserous, submucous, and interstitial fibroids, according as they lie more externally in the abdominal cavity, or encroach upon the cavity of the uterus, or, finally, remain situated within the parenchyma of the organ. Fibroid of the Body of the IT terns. a. The Subserous Fibroid. The subserous fibroid (see Fig. 87 and Fig. 89 SF), the ex- ternal or peritoneal polypus of Virehow, is by no means devel- oped exclusively from the outer layers of muscular fibres. As it grows outwards it naturally pushes the peritoneum before it. The pedicle varies in character. Either a continuous con- nection with the uterine parenchyma is maintained for a long time, in which case the fibroid usually grows fast; or the tumor separates itself early from the uterine wall, and then remains connected with the uterus only by a pedicle, which consists FIBROIDS OF THE UTERUS. 231 externally of peritoneum, internally of subserous cellular tis- sue. The tumor may also entirely separate itself from the womb. If such fibroids are developed from the lateral borders of the womb, they may remain entirely extra-peritoneal, inas- much as they grow between the two folds of the broad liga- ments. The complete separation of subserous fibroids is extremely rare; Virehow has never seen it, but Rokitansky mentions several such cases. Simpson ' also met with this condition several times. West2 observed one case, and Turner3 describes another in detail. Those fibroids, which are no longer continuously attached to the uterine parenchyma, undergo tissue-changes but very slowly; Fig. 87. Fig. 88. A large subserous fibroid, springing by a broad A submucous fibroid, which has obliterated base from the posterior wall o£ the uterus. the cervix. eo, external, o o, internal os. still they may again become richly supplied with blood, through adhesions which they form with neighboring organs, especially with the intestines and mesentery. 1 Obstet. Works, I., p. 716. 8 Frauenkrankheiten, 3 Aufl., p. 330. 3 Edinburgh Med. J., January, 1861. 232 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. If subserous fibroids grow very considerably, they may draw the uterus upward so powerfully that the cervix, in particular, is greatly stretched, and may even be entirely separated from the .body. Such cases are communicated by Rokitansky,1 Times,2 and Virehow.3 If the tumor, at the same time, turns on its axis, hgematometra or hydrometra may result.4 Less frequently the fibroid, by its weight, displaces the uterus downwards so far as to produce prolapse of the organ. Subserous fibroids quite commonly occur in numbers, so that it is exceptional to find solitary ones. The eruption of these tumors into neighboring organs, or outwards, will be treated of hereafter. b. The Submucous Fibroid. The submucous fibroid (see Fig. 88), growing inward into the cavity of the uterus, likewise does not, by any means, always arise from the tissue lying immediately beneath the mucous membrane, but often comes from the deeper parts, growing, by preference, towards the mucous membrane, which is pushed before it. Various tumors may result therefrom. The growth may permanently retain the character of a sub- mucous fibroid, by encroaching more and more upon the cavity of the uterus, while still remaining attached by a broad base, either being continuous with the uterine tissue at the point of attachment, or, if the pedicle has become obliterated, being sim- ply embedded in that tissue. The fibroid may, however, separate itself from the inner sur- face of the womb, like a polypus, its pedicle growing progres- sively thinner. These are the fibrous polypi, and their rela- tions to the womb may be of two kinds. In the majority of cases the pedicle, which consists of uterine tissue, is preserved, so that the tissue of the polypus and that of the uterine wall are continuous. Under these circumstances the pedicle usually 1 Handbuch d. Path. Anat. Wien, 1842, Bd. III., p. 547. a London Obst. Transact., II., p. 34. 3L.c,. p. 161. 4 Virehow, 1. c, p. 161, and Kuster, Berlin Beitr. zur Geburtsh. und Gynaek., I., 7. FIBROIDS OF THE UTERUS. 233 contains large vessels. The continuous connecting band of muscular tissue, may, however, atrophy, so that the pedicle consists merely of mucous membrane and submucous connective tissue. The fibrous polypus, which, on account of its practical im- portance, will be considered in a separate chapter, is at first round, like all polypi, but afterwards readily becomes pear- shaped, or at least oval. If compressed by the natural orifices of the organ, it may assume the form of an hour-glass. These polypi are usually tumors with a simple centre, so that it is but exceptionally that they exhibit a lobular structure. They almost always occur singly, that is, as polypi. Subserous and interstitial fibroids are frequently associated with them; the pressure of interstitial tumors, occurring at the same time, may flatten them considerably. They are softer than other fibroids, and undergo more rapid tissue-metamorphosis. They are not subject to calcareous degeneration. c. The Interstitial, Intraparietal, or Intramural Fibroids. Fibroids are designated as interstitial (see Figs. 89 and 90) when they constitute a portion of the wall of the uterus. At the same time they may project inwards or outwards, or in both directions. As a matter of course, transition-forms, from one of the three varieties of fibroid to another, also occur. The original connection between the new growth and the uterine parenchyma is maintained longer in interstitial tumors than in any other variety. As a rule, therefore, large vessels are developed within their substance, so that they are the seat of the most active tissue-changes, and generally grow the most rapidly. The uterus is usually hypertrophied,—it is not very uncommon, however, for it to be atrophied. During the cli- macteric years, and even earlier, in exceptional cases, it may have quite thin, relaxed walls. Even very large interstitial fibroids have sometimes only one centre ; very frequently, however, they are composed of several collections, so that they are then de- cidedly lobulated and uneven. The tumors occur most frequently in the posterior wall and 234 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. at the fundus. They may become very large. Walter1 saw one of 71 lbs., Binz,2 one of 62 lbs. These very large ones exist solitary; smaller ones usually occur in connection with other fibroids of the same or of different varieties. Indeed their aggregate number may be extraordinarily large. Kiwisch3 and Cruveilhier4 counted forty such tumors, and Schultze5 saw a uterus in the body of a woman, eighty-three years old, which contained at least fifty fibroids. Interstitial fibroids may project outward in the form of seg- ments of a globe. The larger ones also project regularly in- wards. The cavity of the uterus is thus lengthened and dis- Fig. 89. Fig. 90. JF, an interstitial, SF, a subperitoneal fibroid. An interstitial fibroid, with an os uteri that has been artificially dilated for diagnostic purposes. torted in the most varied manner, especially if several tumors project into it from different directions. By this means, as well as by projection outward, especially into the broad ligament, 1 L.c, p. 10. 2 Deutsche Klin., 1857, No. 30. 3 Klin. Vortr., etc., 4 Aufl., Bd. I., p. 449. 4 Traite d'anatom. pathol, T. III., p. 656. 6 Jenaische Zeitschr. fur Med. u. Naturw., 1870, Bd. V., p. 350. FIBROIDS OF THE UTERUS. 235 and by irregular hypertrophy of different parts of the uterus, this organ may undergo the most peculiar alterations in form. The cavity, which is irregularly distorted, is often extremely difficult to find. The tubes, too, which are often so far dislo- cated as both to lie on one side or to change sides, are hard to discover. The pressure which the fibroids exert on one another may also give the tumors themselves peculiar shapes, such as hemispheres, or even segments of spheres. The large size of these tumors greatly distends the abdominal walls, so that the abdomen equals or exceeds in size that of a woman in advanced pregnancy. Sometimes the belly is hugely pendent, or large hernial protuberances may be developed in its walls, in which the tumors lie. These sacs may become gangrenous through pressure, so that then the tumors lie fully exposed to the day. Scarcely anything has been known, hitherto, with regard to this rare complica- tion of large interstitial and submucous fibroids. Dull, in his Inaugural Disserta- tion (Zur Lehre von den Uterusfibroiden. Erlangen, 1872), which was never printed, describes two preparations to be found in the Institute of Pathological Anatomy at Erlangen, and collects several similar cases from the literature of the subject. One of these preparations (all notes of which during life are wanting) consists of an agglomeration of thirteen larger and smaller interstitial and sub- serous fibroids. The largest of these, springing by a pedicle from the light side of the fundus, had passed through a hernial opening of about twelve inches in cir- cumference into a large hernia of the linea alba, and within this hernia had attained the size of twenty-six inches in circumference. A smaller tumor lies below and to the left, in a smaller hernial sac, and is but slightly adherent to the hernial opening, whereas the larger tumor is completely adherent to its ring. Other subserous tumors are also crowding into this ring. The large fibroid shows marked oedema, with the development of pseudo-cysts. The second preparation shows similar conditions, only that here the skin cover- ing the hernial sac has become gangrenous. This specimen, according to the com- munication of Dr. Degen, in Fiirth, comes " from a woman sixty years old, in whom the first signs of a tumor in the abdomen had been observed twenty years before. Up to that time she had been well, had menstruated regularly, had never borne children. The tumor grew slowly. In 1852 a small umbilical hernia appeared, which, in spite of bandages, grew larger, bearing a relation to the growth of the tumor, which gradually crowded all the intestines out of the abdominal cavity. In consequence of this the woman frequently suffered from vomiting and disturbances of digestion. Menstruation continued regular and copious. In the summer of 1865 the lower portion of the very thin integument covering the um- 236 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. bilical hernia became gangrenous, so that finally the larger part of the tumor, which in the meantime had also protruded into the sac, became exposed to view. The woman died under hectic symptoms. The autopsy revealed nothing else of interest." The preparation shows an agglomeration of twelve tumors, of sizes vary- ing from that of a hickory nut to that of a fist, which so cluster around the uterus on all sides as only to leave a small part of its posterior wall free. The largest of the tumors is interstitial, the others more subserous. The uterus was so turned on its axis that the largest fibroid, which arose from the right posterior aspect, lay in the hernia, and was finally laid bare to view. Neuschler1 describes a similar case. It relates to a firm uterine fibroid, weigh- ing ninety-three pounds, four times the size of a man's head, which in the course of ten years had attained such a size that it caused the abdomen to hang down as low as the knees. In the year 1865 a gangrenous ulcer appeared at the most dependent portion of the abdomen, and soon terminated in death. The cases of Loir and of Dumesuil, cited below, are of a different character, as the perforation of the abdominal walls was not caused by gangrene due to pres- sure dependent on the weight of the tumor, but was caused by the action of an inflamed gangrenous tumor perforating outward. Fibroid of the Cervix. Fibroids of the cervix, which are far more rare than those of the body, may arise in the same three forms as the others. The submucous variety almost invariably assumes the form of a polypus, and, as such, very soon reaches the vagina, even though it may have originally arisen higher up in the cervical canal. In this case, too, the polypus, by its weight, may so far draw down the mucous membrane as that it shall appear to arise from the free edge of the lip. If the polypus attains a still greater size, it may itself become prolapsed, and lead to second- ary prolapse of the uterus.8 Interstitial cervical fibroids may attain a very considerable size. They cause a uniform swelling of one lip, so that the mucous membrane of the other lip encloses it in the form of a semilunar fold. These tumors may become so large that the body of the uterus constitutes only a small appendage to them, crowded away to one side. Large tumors of this kind are de- 1 Wiirtemb. Corresp.-Bl. 36, 2, 1866 ; see Schmidt's Jahrb., B. 133, p. 310. a Chiari, Klin. d. Geb. u. Gyn. Erlangen, 1852, p. 401. Barnes, London Obst. Trans., III., p. 211. Freund, Breslauer Klin. B., 3 H., 1865, p. 165, and Midler, Scan- zoni's Beitr., B. VI., p. 70. FIBROIDS OF THE UTERUS. 237 scribed by Wenzel,1 Furth,2 Boivin et Duges,3 Murray,4 and Virehow.5 In Figs. 91 and 92 we give two representations of fibroids of the cervix from the Museum of Pathological Anatomy at Erlangen, the one being given in life size, the other in half the natural size. The most rare form of cervical fibroid is that which grows outwards. Peritoneal polypi, properly speaking, consist only of those growths which arise from the posterior surface of the Fig. 91. Fig. 92, Fibroid of the cervix. Natural size. Fibroid of the cervix. Half the natural size. upper part of the cervix. Those arising further down, as well as on the sides, usually grow into the connective tissue lying about the vagina, and may be felt, as knotty tumor s, pushing forward the vaginal mucous membrane. Symptoms and Course. Fibroid tumors act in such entirely different ways, according to their location, that we must consider them separately. ' L. c, T. VII. and VIII. 2 Diss, inaug. Bonn, 1854, T. 1 and 2, in a parturient woman. 3 Atlas, PI. 21. 4 London Obst. Tr., VI., p. 184. 5 L. c, p. 219. 238 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Subserous fibroids have scarcely any different influence on the condition of the uterus than that exerted by other tumors originating in the pelvis. Very small subserous fibroids, there- fore, may be regarded with entire indifference, aside from the displacements to which they may give rise in the relaxed ute- rus. As they grow larger they act like other abdominal tumors. They crowd the uterus over to the opposite side from that on which they arise, or, when they become quite large, may also lift it quite a distance upward. The prominent symp- toms, then, are a feeling of weight, bearing down, and pain in the back. Pressure on the bladder, or the displacement of the same upward, very uniformly produces a frequent desire to pass water, although compression of the neck of the bladder or of the urethra may cause retention of urine. Defecation, too, may be mechanically hindered, especially when the tumor is wedged fast in Douglas's cul-de-sac. The effects of the pressure exerted by the tumor manifest themselves, on the part of the nervous system, by pain, and sometimes by paralysis of the lower extremities, and, on the part of the veins, by oedema. Ascites may supervene, partly as the result of the pressure and partly through the irritation which the tumor produces in the peri- toneum. This irritation very commonly gives rise to circumscribed peritonitis, resulting in adhesions between the tumor and neigh- boring organs. According to the situation in which the tumor is thus fixed, relief or aggravation of the symptoms may occur (the latter particularly if it is confined in Douglas's cul-de-sac). Indeed, if a tumor which is thus held fast in Douglas's space continues to grow, it may give rise to symptoms of complete incarceration. Chronic metritis often occurs as a complication, being caused by the pressure of the tumor, and giving rise to a variety of additional symptoms. Sterility may result, partly due to the metritis, partly to the narrowing of the uterine cavity by the mechanical pressure of the tumor; or it may depend on a closure of the tubes, caused by the attacks of partial peritonitis. The symptoms are usually aggravated during a menstrual FIBROIDS OF THE UTERUS. 239 period, by the swelling of the uterus and fibroid which then takes place. Hardie1 calls attention to the fact that at such times retention of urine sometimes occurs. Subserous fibroids usually so far separate themselves from their bed that no continuous connection any longer exists be- tween their parenchyma and the substance of the uterus. Their growth is then arrested either entirely, or nearly so, and they readily undergo retrograde metamorphosis. Fibrocystic tumors resemble the above variety in general, and yet, as they grow more rapidly and uninterruptedly, and to some degree at least contain fluid, they show more similarity to ovarian cysts. Submucous fibroids give rise to very early symptoms, because they distend the uterus itself. The stretching of the uterine mucous membrane which covers the tumor and is pushed for- ward by it in its growth, brings about leucorrhoea and hemor- rhages. The latter are entirely from the mucous membrane, and may, therefore, occur even when the fibroid is quite poor in vessels. They arise from the large, thin-walled veins which are distributed throughout the distended mucous membrane. Some- times they appear as menorrhagia, sometimes, however, they are independent of menstruation. They may be so great as to produce the highest grade of anaemia. Occasionally the hemor- rhage is almost uninterrupted. In the intervals beween the flow of blood a flow of serous fluid takes place, caused by irrita- tion of the distended mucous membrane. The causes of hemorrhage are more particularly treated of by Duncan2 He very properly calls attention to the fact that the tumor in itself is an irritant, causing increased congestion, and by its pressure, like every other tumor, being the means of impeding circulation. Furthermore, the menstruating or bleeding surface is increased by the enlargement of the uterine cavity, and the contractions which the tumor calls forth likewise produce hemorrhage by the violence they do to the mucous membrane. A partial hyperaemia, caused by impeded circulation, likewise takes place when the extremity of the fibroid reaches into the distended internal or external os uteri, inasmuch as this extremity is not exposed to the uniform pressure by the uterine walls to which the rest of the tumor is subjected. 1 Edinburgh Med. Journ., January, 1874, p. 581. 2 Edinburgh Med. Journ., January and February, 1867, p. 630. 240 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. However important all these influences may be, the most prominent cause, after all, is still the great distention of the mucous membrane by the tumor, in conse- quence of which the veins become enlarged, while their walls are made thinner and are more easily torn. Submucous fibroids are very liable to be accompanied by dys- menorrhoea, which sometimes (fortunately not often) reaches an enormous degree. It depends upon the fact that the tumor, diminishing the cavity of the uterus, offers a mechanical obstacle to the escape of the menstrual fluid. For the same reason sterility usually exists, the occurrence of pregnancy being extremely rare. When they attain a considerable size, then, submucous fibroids present the same manifestations as those which are sub- serous, the circumstance that, in the former case, the abdominal tumor is composed of the enlarged womb itself, not making any material difference. The shape of the uterus is materially modified. As its cavity is pretty uniformly distended, and its walls become hypertro- phied in the same manner, the organ assumes a strikingly round form. Even during their earlier history, submucous fibroids usually lead to such complete obliteration of the cervix, that, even while the external os remains closed, the cervix and body constitute but one cavity (see Fig. 88). At the climacteric period the disturbances grow less and may even entirely disappear; still, menstruation may often persist long, continuing after the age of fifty. Interstitial fibroids sometimes act more like subserous and again more like submucous tumors. The very little ones, if sit- uated in the anterior wall, produce anteflexion of the uterus, and if in the posterior wall, retroflexion ; as they become larger, however, a tumor situated in the anterior wall may induce retro- flexion of the organ. The more these tumors encroach upon the uterine cavity, the sooner will there be blennorrhcea and hemor- rhage. These conditions will both be particularly well developed if several growths have combined to lengthen and distort the uterine cavity. Under these circumstances the most violent dys- menorrhoea may arise. Partly by these means, and partly by dislocations or narrowing, that is, closure of the tubes, the FIBROIDS OF THE UTERUS. 241 meeting of sperm and ovum may be prevented, so that, here too, sterility is common. These tumors grow more rapidly than any other kind of fibroids, and may attain a colossal size. They will then, by their extent and weight, produce the same train of disturbances described above. If the tumor projects chiefly into the cavity of the uterus, this organ may be pretty uniformly enlarged. Very commonly, however, these growths project outward as well as inward, espe- cially if they are multiple, giving the most singular shapes to the exterior of the uterus and the most extraordinary irregulari- ties to its cavity. Cervical fibroids are not so frequently accompanied by severe hemorrhage, but are regularly associated with catarrh of the cervical mucous membrane. Dysmenorrhoea and sterility usu- ally exist, because the tumor blocks up the cervical canal. The termination of fibroid tumors, in the great majority of cases, consists in an arrest of growth. This arrest may even take place very early, especially in subserous fibroids. It is not an uncommon thing to find these little subperitoneal fibroids, about the size of a walnut, when making post-mortems, or in gynecological examinations for other purposes, or even in the examination of pregnant women. But even when the fibroid continues to grow, and gives rise to serious symptoms, this growth is ordinarily very slow, and is likely to terminate at the menopause, or even to recede from that time. Excepting the fibro-cystic variety, it is rare for these tumors to progress uninterruptedly in their growth and threaten life, as is so common with ovarian tumors. There can be no doubt that the recession, and even the com- plete disappearance of these growths, is observed. In making this statement, it is true, we practically regard all such tumors as having disappeared, which cannot be found on the most care- ful combined manipulation, even though anatomical search may subsequently reveal some cicatricial remains of connective tis- sue. Quite an array of instances of the complete, or almost complete, disappearance of fibroid tumors may be found in literature, in some of which the diagnosis may appear a little vol. x.—16 242 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. doubtful, but in the majority of which its correctness may be regarded as beyond question. Such cases are reported by McClintock (Clin. Mem. on Diseases of Women, Dublin, 1863, p. 141), J. Clarke (Transact, of a Soc. for the Imp. of Med. and Surg. Knowl., 1812, Vol. III.), Rigby, Ashwell (Lancet, Feb., 1854, four cases), M. Duncan (Edin. Med. Journ., Jan., 1867), Playfair (Lond. Obstet. Tr., Vol. X., p. 102), Brun- ton (ibid., Vol. XI1L, p. 282), Kidd (Dublin Journ. Med. Sc, Vol. 54, 1872, p. 133), Simpson (Dis. of Women, Edin., 1872, p. 693), Goodell (Phil. Medical Times, June 1, 1872, p. 323, two cases), Gueniot (Bull, de Therap., 1872), Depaul (two cases), Herpin, Behier (ibid.), Cazeaux (Bull, de la Soc. de Chir., 1857, p. 94), Courty (Traite Prat, des Mal. de l'uterus, 2d ed., p. 953),Velpeau (Schmidt's Jahrb., B. 151, p. 206), Pe"an (Gaz. des hop., Nov. and Dec, 1871), Hildebrandt (Berl. Id. W., 1872, No. 25), Routh (1. c, two cases), G. Braun (Wien. Med. W., 1868, Nos. 100 and 101; disappearance of a very large fibroid, under suppuration). Boinet (Gaz. hebdom., 1873, No. 18) is also convinced of the correctness of his diagnosis in three cases. Sedgwick (St. Thomas' Hosp. Rep., 1870, Case I.), Scanzoni (Lehrb. d. weibl., Sex., 4 Aufl., Bd. I., p. 252), Gassmann (Wiirtemb. med. Corresp.-Blatt, 1868, No. 19), and Kidd (Dublin Journ. of Med. Sc, Vol. 54, 1872, p. 144) saw fibroids disap- pear during the puerperal period. In one case, in which a woman was delivered of her fifth child, at seven months, suffering from severe hemorrhage, I was sure that I felt two moderately large interstitial tumors (the imprint of one of them could be distinctly seen on the placenta which had grown over it). Six weeks later no trace of these was to be found. Madge (Lond. Obst. Trans., XIV., p. 227), in a case pre- senting eight fibroids, saw several of them disappear entirely within a few months after labor, and others diminish in size. Here, then, are thirty-six cases, in which the disappearance of fibroids is pretty positively established. If we inquire under what circumstances and by what means their absorption was accomplished, we shall receive no very satisfactory answer. See- ing that fibroids, as a whole, exhibit the same structure as the normal uterine parenchyma, and as during the puerperal period this tissue undergoes an almost complete process of physiologi- cal absorption, one would conclude, a priori, that the fibroids, too, would be most readily absorbed during the same period. This, however, is not fully confirmed by experience, as only six puerperal cases are found among the thirty-six reported. A more important influence seems to be exerted by the occurrence of the menopause, and yet there are not a few younger women embraced in the above list. The most unreliable results seem to follow therapeutic interference. It is true that in very many FIBROIDS OF THE UTERUS. 243 of the above cases the women were under the treatment of phy- sicians. But whether the medicines administered contributed to the result, appears, in the great majority of cases, highly prob- lematic. The experience given above does, however, positively estab- lish the fact that even very large fibroids may entirely disap- pear (most readily after the menopause), even though this ter- mination is quite rare, in proportion to the frequency of their occurrence, and although we cannot bring therapeutic means to bear upon them with any degree of certainty. A complete cure (partial recovery by calcareous degeneration of the tumor has been spoken of above) may also take place in another way, viz., by the expulsion of the tumor. This process of expulsion is either an enucleation, whereby the tumor is, to a certain degree, turned out of the bed of over- lying mucous membrane in which it rests, or the coverings of the tumor become inflamed and suppurate, and the tumor, having been deprived of its nourishment and become gangrenous, is cast off. The process of spontaneous enucleation is, of course, a far milder one than that last referred to. It occurs most frequently in the submucous fibroids, but may also be met with amongst those that are interstitial. The mucous membrane becomes torn at the point where its extremity lies within the os, or it is worn off, or becomes gangrenous through pressure, and when an opening has thus been effected the mucous membrane draws itself back over the tumor, and thus uncovers an ever-increasing portion of the same. Contractions of the uterus, then, drive the fibroid completely into the vagina, and thence outward. This process, however, is often a dangerous one, inasmuch as the icJwle bed of tlte tumor may suppurate, and the tumor, being deprived of its nourishment, may become gangrenous. Even under these circumstances expulsion and complete recovery may be accomplished; in other cases, however, death may ensue from peritonitis or pyaemia. Instances of expulsion of fibroids, either unchanged or gangrenous, whole or in pieces, are reported by Pinault (Bull, de la soc. anat., 1828), Marchal de Calvi, (Aimales de la chir. franc, et (Strang., 1843, II., p. 385), Barth (Bull, de la soc. 244 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. anatomique, 1S50, p. 82), Willaume (Archives gen., XXIV., p. 249), Bernutz (Gaz. hebdom., 1866, p. 703), Depaul (Soc. de chir., 27 Mai, 1868), McClintock (1. c, Cases I., II, III., IV., VI., VII.), Baker-Brown (Lond. Obst. Trans., Vol., I., p. 330), Sedg- wick (St. Thomas's Hosp. Rep., 1870, Case II.), Hardie (Med. Times, July 6th, 1872), Whiteford (Glasgow Med. Journal, May, 1872), Ziemssen (Virchow's Archiv, 1859, Bd. 17, p. 340), Lumpe (Zeitschr. d. Ges. d. Wiener Aerzte, 1860, No. 29; sup- puration after the loss of chalky concretions), Chiari (Klin. d. Geb. u. Gyn., pp. 402 and 403), Freund (Bresl. klin. Beitr., H. 3, p. 143 and 147), Kiichenmeister (Oesterr. Z. f. pr. Heilk., 1869, No. 31), Roloff (Diss. Inaug. Greifswald, 1873), Saxinger (1. c, p. Ill), Kristeller (Berl. klin. Woch., 1872, No. 35), Schneider, Corresp.-Blatt schweiz. Aerzte, 1872, No. 16), Fredet (Annales de la soc. de med. de St. Etienne, 1865, p. 205); the tumor, which was mistaken by the midwife for a child's head, and by the physician for the breech, was seized with forceps and drawn out of the vagina. In exceptional cases a fibroid tumor may lead to perforation into other organs, causing destruction or gangrene of the inter- vening parts by pressure. Undoubtedly, as is claimed by Larcher,1 such perforation is often completed by means of uter- ine contractions. Perforation into the abdominal cavity, with fatal results, may take place, as is shown in the following cases: Viardin-Fourcade-Cruveilhier, (Bull, de la soc. anat. de Paris, 1834, T. IX, p. 43), Maslieurat-Lagemart (e. 1., 1836), Balard (Provine Med. and Surg. J., June, 1849), K Lee (Medico-chir. Tr., London, 1855, IX., 94), Maisonneuve (Mem. de la soc de chir., 1851, p. 267), Huguier (e. 1., 1857, VIII., p. 92), Jarjavay (see Guyon, Des turn. fibr. de l'uterus. Paris, 1860, p. 65), Larcher (1. c, p. 548), Hecker (Klin. d. Geb. II., p. 133), Demarquay (Soc. de chir. de Paris, 22 Juin, 1859; perforation of the anterior and posterior uterine walls. In front, adhesion to and perforation into the bladder,—behind, an opening into Douglas's space with fatal peritonitis). The case of Demarquay, with perforation into the bladder, is very similar to those of Lisfranc (see Th. S. Lee, 1. c, p. 67) and Fleming (see McClintock, 1. c, p. 27): " A calcareous fibroid, which arose from the anterior wall of the uterus, had forced its way into the bladder, by ulceration, and produced the worst symptoms of stone in the bladder." The inflamed tumor may also perforate through the anterior abdominal wall. Loir (Mem. de la soc. de chir. de Paris, 1851, T. II.), saw a gangrenous polypus work its way, by suppuration, through the anterior uterine wall and the linea alba. Dumesnil (Gaz. des hop., 1869, No. 6) observed quite a peculiar case, in which a tumor, which had broken through the anterior abdominal wall, grew in the form of a cone. The entire growth afterwards fell off spontaneously, the wound healed, and the woman recovered, a tumor as large as a fist remaining under the cicatrix. 1 Arch, gener., 1867, 2, pp. 545 and 697. FIBROIDS OF TIIE UTERUS. 245 Diagnosis. Subserous fibroids can rarely elude a search made by careful conjoined manipulation, as the tumor is usually felt, whether pedunculated or attached to the uterus by a broad base. Quite small tumors, up to the size of a walnut, if distinctly felt, can hardly be mistaken for anything else. If the fibroid is of about the size of the normal uterus, and rises by a broad base from the region of the internal os, lying either in front or behind, it may by mere vaginal examination very easily be mistaken for a retroflexed or anteflexed uterus. On more careful combined examination, however, tiie uterus may be felt in its usual position, or but slightly displaced. Still, under these circumstances, the question may arise as to which of the two tumors is the uterus. As a rule, this can be determined by the somewhat deviating form of the fibroid; the consistence of the two also usually varies—the fibroid being harder, the uterus softer. Should a doubt still remain, it can be settled by the sound. If the tumor is still larger, it may be confounded with quite an array of other conditions. This is particularly easy if it is held fast in Douglas's space by peritoneal adhesions. It may then bear a close resemblance to intraperitoneal exudation, or to retro-uterine haematocele. But the two latter are irregular in shape, they are not so round, and lie in full and firm contact with the pelvic walls. A fibroid tumor embedded in an exuda- tion may, it is true, present features which render it impossible to distinguish it from an old, thickened exudation. Fresh exu- dations, however, as well as haematocele, are softer, or at least more elastic, and present characteristic peculiarities as to their early history and subsequent course. An ovarian tumor may be bound down in Douglas's space in just the same way as a fibroid. As the former is almost always composed of cysts, its consistency is less firm; still, this sign may be shrouded by the presence of an exudation, and in excep- tional cases the fibroid itself might be quite soft. If it seems of urgent importance to establish the differential diagnosis, this 246 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. may be accomplished by an exploratory puncture with a small trocar, or, better yet, by the use of the aspirator. But it is not under these circumstances alone that ovarian and fibroid tumors may be mistaken for one another; the chances of error become greater when the tumors are very large. In general, ovarian tumors are not so intimately connected with the uterus, though they may, exceptionally, be bound closely thereto by peritoneal adhesions. Although ovarian cysts are characterized by their elasticity and fluctuation, yet once in a while we may have to deal with a solid ovarian tumor; and, on the other hand, fibroids may become soft by oedema, fatty degeneration, and especially cyst-formation. It may therefore prove impossible to determine the diagnosis between an ovarian tumor, held fast to the uterus, and a subserous fibroid with a narrow pedicle, or a large fibro-cystic tumor. Indeed, it is some- times a matter of great difficulty, even on.the dead body, posi- tively to establish the point of origin of the growth. We shall return to this question again under the head of ovarian cysts. Interstitial fibroids, if they are quite small, may be difficult of recognition. They may be diagnosticated when the uterus can be felt to be thickened, and when palpation or the use of the sound determines the fact that this thickening is partial; that it only involves one wall, while the other is thin and relaxed—such a marked contrast occurring only when one wall is the seat of a fibroid. Sometimes the way in which the hard- ness of the fibroid stands in relief against the soft and relaxed state of the uterine wall is exceedingly striking, so that then even quite small fibroids can be recognized with certainty. When tumors of this class grow larger, they usually cause irregularities in the external shape of the uterus. If it is pos- sible, as it usually is, to prove that the tumor is composed of the enlarged womb itself, it is difficult to refer the hard, irregu- lar growth to any other cause than the right one. If the inter- stitial fibroid is very large, and especially if the cervix lies far back and high up, it may be very hard to decide whether the uterus itself is enlarged, or whether it lies behind a large tumor; still, in cases of fibroid, the uterine sound usually shows decided lengthening and distortion of the uterine cavity. FIBROIDS OF THE UTERUS. 247 It is true, however, that in cases of large ovarian cysts, which are most likel}T to be confounded with the condition we are now studying, the womb may also be drawn out beyond its normal length. If the matter remains in doubt, and the body of the womb is so drawn up and back that it cannot be reached by the usual methods, Simon1 s plan of rectal palpation, with the whole or half of the hand, often settles it at once. In those rare cases in which an interstitial fibroid has not altered the external contour of the uterus, or at least has not so materially altered it but that it can be recognized with certainty on combined manipulation, great difficulty may be experienced in making a differential diagnosis between this and other con- ditions, which likewise produce uniform thickening of the organ. The subjects of haematometra and hydrometra will be con- sidered again when treating of the diagnosis of submucous fibroids, with which these are much more likely to be con- founded. Aside from them, the greatest difficulty will arise in differentiating between interstitial fibroids and chronic metritis or pregnancy. In chronic metritis the uterus is flatter, and at the same time tender to the touch ; in fibroids, it is round and not tender, as long as no inflammatory complications exist. Examination with the sound, too, may furnish valuable infor- mation ; in metritis, the sound readily passes up through the middle of the enlarged organ; in fibroids it passes with diffi- culty, and to one side of the centre. These tumors may be distinguished from normal pregnancy without trouble, even during the first half of the period, by the history, the consistency of the tumor, and the difference in the vaginal portion of the uterus, which is soft and spongy in preg- nancy, but hard in fibroids. Great confusion may arise in case of pregnancy with death of the embryo and degeneration of the ovum. Here, too, the sound passes the internal os with diffi- culty, and then turns to one side, continuing its way up between the ovum and the uterine wall. The uterus may be quite hard, though it is usually softer and flattened from before backward. The history of the case may leave us completely in the dark. In such a case, which fell into my hands, and in which the his- tory pointed strongly to retention of a blighted ovum, no alter- 248 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. native was left but to dilate the cervix with sponge-tents, and pass the finger into the uterus, whereupon it came into imme- diate contact with a fibroid (see Fig. 90) pushing inward through the left wall. The uterine bruit is of no great significance as affecting the differential diagnosis, as it is almost always present in preg- nancy, and not rare in case of fibroid tumors, occurring also very exceptionally in ovarian tumors. As regards diagnosis, submucous fibroids are to be put in the same category with those interstitial growths which enlarge the uterus uniformly, and may therefore easily be confounded with chronic metritis and pregnancy. But they possess one characteristic peculiarity, which is wanting in the two conditions just named, viz., that they soon cause a disappearance of the cervix, so that the tumor may be felt immediately above the external os. The various tests noted above likewise retain their significance. Submucous fibroids are most likely to be con- founded with atresia of the external os, with consecutive haema- tometra, as in this case, too, there is a disappearance of the cer- vical canal. But, as a rule, the history of the case, as well as careful sounding, will suffice to establish the distinction ; and furthermore, the fulness and tension are never so great in fibroid tumors (though it may be in malignant growths) as they uni- formly are in haematometra. It frequently happens with these submucous fibroids, that the cervix is sufficiently dilated to permit the passage of the finger, so that the tumor may be directly felt; and if this dila- tation is not constant, it is at least likely to occur during the menstrual period. This last circumstance is of great diagnostic importance, and should lead us, in all such cases, to make an examination during the menstrual flow. Fibroids of the cervix are usually easy of recognition, as the distention of one lip by a round, hard tumor is characteristic, and can hardly be mistaken. Prognosis. Although, fortunately, it is but seldom that fibroid tumors reach such a size as directly to endanger life, yet this does hap- FIBROIDS OF THE UTERUS. 249 pen now and then; sometimes, too, they may prove fatal in other ways, especially through hemorrhage, or through suppu- ration and ichorous degeneration. Usually, however, owing to the fact that these tumors are seldom radically cured, they constitute a life-long malady, not directly threatening life, but greatly interfering with its enjoyment, and sometimes seriously impairing the vital powers. A partial cure may take place spontaneously, through an arrest in growth or material diminution in size, the result of induration or calcareous degeneration. In very rare instances a radical cure has been effected through absorption or elimination of the tumor outwards. Treatment. Inasmuch as the causes which operate in the production of uterine fibroids are entirely unknown, we can, of course, insti- tute no rational prophylactic treatment. When a myoma has developed itself in the uterus, the first question for the practitioner to consider is, whether he shall confine himself to the treatment of the most urgent symptoms or aim at the removal of the tumor. In order to obtain a general view of the question, we will first consider the possibility of a radical cure and the various methods of attempting it. Although there is some opposition to this view, we may con- sider it as well established that fibroid tumors may entirely dis- appear spontaneously, therefore, of course, also under treatment (see page 241). But almost all are agreed that the influence of treatment in these cases is very problematic.1 The remedies most employed are iodine, iodide of potassium, bromide of potassium, chloride of calcium (especially by the English, who believe that it produces an atheromatous degeneration of the vessels), and ergot. Gueniot2 recommends arsenic and phos- phorus for the purpose of inducing fatty degeneration. Al- though, in some of the instances given above, the influence of 1 See the Brit. Med. Journ., 1871, p. 536, for a collection of the views of many of the most noted English gynecologists. 2 Medical Times, March 23d, 1872. 250 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. treatment cannot be disproved (we refer, above all, to the case of Hildebrandt), and although we may construct rational theories with regard to the method of this influence, yet, on the other hand, we should distinctly remember that all the means recom- mended usually fail, and that we have no internal treatment from which, in any individual case, we are justified in expecting good results, with the least degree of certainty. At the same time, the experiences of the past, especially Hildebrandt's observations on the hypodermic use of ergotine, should incite us to further attempts in this direction. Instead of Langenbeck's alcoholic solution (thirty-eight grains of aque- ous extract of ergot to two drachms each of dilute alcohol and glycerine), Hildebrandt uses the following : aqueous ex- tract of ergot, forty-six grains; glycerine and distilled water, each two drachms. He claims that the use of this solution, if the injections are made deep enough, is less liable to be followed by local trouble. A simple watery solution, equal parts of the aqueous extract of ergot and water, or one part of the former to two of the latter, may also be used, and a quarter or half a syringeful be injected at a time. Swiderski' recommends the following four solutions: 1. 2. 3. 4. Aqueous extract of ergot. . 38 grains. 31 grains. 38 grains. 15 grains. Alcohol.................139 minims. 92 minims. 46 minims. 27 minims. Glycerine................92 " 123 " 154 " 37 " Distilled water........... 68 Injections of ergotine have this unpleasant feature, that they are very painful, and cause a prolonged induration, or even abscess, at the site of puncture. According to Wernich, these disagreeable effects are less likely to follow the use of the ex- tract of ergot of the German Pharmacopoeia, which may be best employed in the form of a pure ten per cent, solution. Wernich" obtained a pure and very effective preparation, which caused scarcely any pain, and was rapidly absorbed, by taking powdered ergot, after it had been freed from fatty matters and 1 Berl. klin. W., 1870, Nos. 50 u. 51. *Berl. klin. W., 1874, No. 13, and Berl. Beitr. z. Geb. u. Gyn., B. III., H. 1, p. 71. FIBROIDS OF THE UTERUS. 251 those soluble in alcohol, extracting it with water, and then cleansing it from its mucilage and other impurities by filtering. This method, however, is tedious and troublesome, and the pre- paration, therefore, expensive. As yet, nothing very favorable has been reported with regard to the radical cure of fibroids by these injections. Bengelsdorf ' reports doubtful results (better ones in chronic metritis). Keat- ing and Ashhurst2 have had comparatively good results, and some favorable cases have also been reported to the Philadelphia Obstetrical Society,3 as well as by Goodell in his report to the Pennsylvania Medical Society on the progress of obstetrics and gynecology, 1873, p. 24. Electricity has also been employed to cause the absorption of fibroids. The radical removal of these growths may be accomplished, much more surely than by all these methods, in appropriate cases, through operative interference, although this is not unac- companied with considerable danger. Uterine fibroids may be reached in two ways, either through the vagina and cervix, or through the abdominal walls, by lapar- otomy. The first method is applicable to submucous tumors, the second to those that are subperitoneal; the interstitial variety have been attacked in both ways, either by attempts to enu- cleate them from within, and remove them through the vagina, or, having opened the abdominal cavity, to amputate the entire uterus with its new formations. The Eemoval of Fibroids through the Vagina, Amussat, Mem. sur l'anatom. pathol. des tumeurs fib., etc., 1842.—Atlee, Amer. Journ. of Med. Sc, Apl., 1845, and Oct., 1856.—Hutchinson, Med. Times, 1857, July and Aug.—Langenbeck, Deutsche Klin., 1859, No. 1.—M. Duncan, Edin- burgh Med. Journ., Jan. and Feb., 1867.-— Gusserow, Mon. f. Geb., B. 32, p. 83. —J. M. Sims, loc cit, pp. 90 et seq.—Thomas, Amer. J. of Obst., V., pp. 104 and 474.— Meadows, Amer. J. of Obst., V., p. 241, and Obst. J. Gt. Bt, I., p. 34. 1 Berl. klin. W.. 1874, No. 2. 2 Amer. Jour. Med. Sc, July, 1873, pp. 131 and 138. 3 Amer. Journ. of Obst., VI., p. 639. 252 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Enucleation through the vagina, after having been proposed by Velpeau, was first carried into effect by Amussat in 1840. In general, it is only applicable to submucous fibroids, at least it is only very exceptionally so to those that are interstitial. The operation is divided into several steps. First of all, the os uteri must be dilated as widely as possible. If the cervix is obliterated, this enlargement may be most readily accomplished by an incision; if it is preserved, dilatation by the sponge-tent may be employed, as extended lateral incisions through the entire length of the cervix, to the internal os, are decidedly dan- gerous. When one or more fingers can be introduced through the cervix to the tumor, a longitudinal or crucial incision into the mucous membrane of the tumor is to be made, and the same separated from the tumor as widely as possible by the finger. The detached end of the tumor is now to be firmly seized with the vulsellum forceps, and forcibly drawn down, while the fin- ger endeavors still further to detach it from its bed. If it has come down far, and passed through the dilated os, the last adhe- sions may be severed by the finger, the handle of the scalpel, curved scissors, or the knife. Great difficulties may arise if very considerable tumors, which have passed through the os into the vagina, show signs of stran- gulation within the true pelvis. Scarcely any alternative remains but to remove as much of the tumor as possible with the ecra- seur or the galvano-caustic wire loop, or by the knife and scis- sors. If this operation, which is certainly quite hazardous, is well borne, the cut surface soon shrivels up, and the tumor may disappear.1 The enucleation of interstitial fibroids is far more dangerous than that of the submucous, because the tumor is more difficult to reach, and because one cannot tell how near, or over what extent, it reaches to the peritoneum. The operation should, therefore, only be undertaken under favorable circumstances, that is, when the cervix is obliterated and the external os is open, or its edges sharp, when the tumor does not protrude out- wards into the abdominal cavity, and when symptoms arise 1 Spjiegdberg, Arch. f. Gyn., V., p. 100, and P. Miiller, e. 1., VI., p. 125. FIBROIDS OF THE UTERUS. 253 directly threatening life. It will be found best, then, according to the suggestion of Duncan, to undertake the enucleation of the tumor by various means, only, to a certain extent, inaugurating and assisting the efforts of nature to expel the growth. The os uteri is first incised some time after the capsule is split and, as far as possible, detached from the tumor. By the internal administration of ergot, and attempts at extraction, nature is aided in the gradual removal of the tumor thus loosened. If, however, the removal of its mucous covering causes gangrene of the fibroid, its extirpation must be speedily completed. It must never be forgotten that the operation is accompanied with great danger, so much so that Thomas, who is a decided advocate of the same, declares it to be more dangerous than ovariotomy; it is certainly more difficult. According to him, the operation is practicable only if the cervical canal is enlarged, and if either the uterus is so greatly displaced downwards that the os appears at the mouth of the vagina, or else the vagina admits the entire hand ; therefore, in effect, only in women who have borne children. A considerable number of those operated upon die of p_yaemia or septicaemia.1 Sometimes it is found impossible to complete the operation, as the tumor cannot be separated from the uterus ; this condition of things is, of course, extremely dan- gerous, if not absolutely fatal. If the enucleated fibroids are of very considerable size, their passage through the vagina may be a matter of some difficulty. Under these circumstances the obstetrical forceps may be of great service, being applied to the tumor as to the head of a child. Lateral incisions, to enlarge the outlet of the vagina, as in labor, may also be required. Cervical fibroids, being the most accessible, are the best adapted for enucleation. In rare instances a radical cure is effected by incising the capsule and detaching it from the tumor, or even by merely incising it, the tumor being then enucleated by the powers of 1 Hegar, Virchow's Archiv, B. 48, p. 332 ; Brown, Phila. Med. and Surg. Rep., 1871, No. 25; and Emmet, Amer. Jour, of Obst., IV., p. 725. In the latter case the tumor also projected outwards, and the autopsy showed that by its removal a hole had been left in the uterine wall, covered only by peritoneum. 254 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. nature, or, if it become gangrenous, being expelled. For this purpose Baker-Brown ! has cut large pieces out of the fibroid. The Removal of Fibroids by Laparotom U Koeberle, Gaz. med. de Strasbourg, 1864; and Documents p. servir a l'hist. de l'exist- ence des turn, fibr., etc. Strasbourg, 1865 ; and Oper. d'ovariotomie. Paris, 1865, p. 98.—Storer, Successful Removal of the Uterus and both Ovaries. Bos- ton, 1866.— Ceitemeiult, Essai surla gastrotomie dans les cas, etc Paris, 1866. —Boinet, Gaz. hebdom., 1873, Nos. 8, 13, 18, 19, 23, 28, 29.— Pean et Urdy, Hysterotomie, etc. Paris, 1873. The most favorable cases for laparotomy are those in which the fibroid is attached to the uterus by a well-developed narrow pedicle, in other words, cases of pure subserous fibroids. An incision is then made through the abdominal wall, the tumor is turned out through the opening, and the pedicle is treated according to the rules adopted in ovariotomy. The operation would not seem to be any more dangerous than that of ovario- tomy. But, unfortunately, pedunculated subserous fibroids seldom call for the operation, because their growth, as a rule, is quite limited. Gastrotomy is more frequently indicated in those sub- serous tumors that have a broad base of attachment, or in the interstitial fibroids, and most frequently demanded by the fibro- cystic tumors, whose growth is exceedingly rapid. In all these varieties the.operation is much more difficult and dangerous, because the tumor must either be detached from the uterus over a large surface, or the uterus and its appendages, in whole or in part, must be removed at the same time. In performing the operation, the abdominal cavity is opened by a long incision through the linea alba, then the size of the tumor is diminished as far as practicable by puncture of any cysts that may be present, and it is drawn out through the opening. Its connection is now severed at the narrowest point—■ in interstitial fibroids usually in the neighborhood of the internal os,—all necessary precautions being observed, as in ovariotomy, and the pedicle being variously treated, that is, being either i Obst. Trans., III., p. 67, and Surg. Dis. of Women, 3d ed., 1866, p. 240. FIBROIDS OF TIIE UTERUS. 255 included in the lower angle of the wound, or returned into the cavity of the abdomen ligated or cauterized. Heath and Charles Clay, in Manchester, were doubtless the first who removed uterine fibroids by laparotomy, in 1843 and 1844. Both patients died. An American, by the name of Bumham, achieved the first recovery, in 1853. Since that time the operation has been performed pretty frequently, sometimes intentionally, and sometimes under a mistaken diagnosis, the tumor being considered ovarian. Boinet collects the following operations: Among 42 laparotomies, with removal of the uterus, 32 deaths and 10 recoveries. Among 23 operations, with simple removal of the tumor, 15 deaths and 8 re- coveries. The last 23 may be divided as follows: 13 in which the tumor was pedunculated, giving 5 deaths and 8 recoveries; 10 of interstitial tumors or of tumors with a broad base, giving 10 deaths. Among 14 cases of laparotomy which were abandoned, unfinished, we have 5 deaths and 9 recoveries. Boinet, therefore, comes to the conclusion that laparotomy is justified, in uterine fibroids, only when the tumor is pedunculated. Demarquay endorses these con- clusions in his notice of Boinet's work, given to the session of the Acad, de Med. of the 29th of October, 1872, By the addition of new cases we arrive at the following statistics: Among 108 laparotomies for uterine fibroids there were 78 deaths and 30 recoveries (27,8U- per cent.). Of these, 73 operations, with removal of the uterus, gave 55 deaths and 18 recoveries (24-^0 per cent.); while 35 operations, without removal of the uterus, gave 23 deaths and 12 recoveries (34,% per cent,). According to these results, we must certainly thus far coincide with Boinet's verdict that in the case of non-pedunculatcd fibroids, at all events, we should only undertake an amputation, if very urgently indicated. Pean, however, even under these circumstances, reports 8 cases with 6 recoveries. Symptomatic Treatment. The symptoms dependent on an increase in size are: 1st. The same annoyances which all other large abdominal tumors cause by their weight and pressure on neighboring organs. These annoyances cannot be done away with otherwise than by the radical cure of the tumor, and they can be relieved only to a very slight degree. As a rule, we may be well content if we can prevent these symptoms from growing worse, by arrest- ing the progress of the growth. Even this only succeeds occa- sionally,—still, it should be tried. 256 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. It is of the greatest importance to remove all influences which induce an increased supply of blood to the genitals. Abstinence from, or at least restriction of, sexual intercourse is therefore imperatively demanded. As this can very seldom be attained while married people live together, it is doubly desirable to send women away to visit the baths. The blood-supply is also somewhat diminished, and the nour- ishment of the neoplasm therefore interfered with, by the fre- quent abstraction of blood through scarification. Cold cannot very well be applied as continuously as would be necessary in order to prove effective. The internal remedies to which has been ascribed the power of influencing the absorption of fibroids, such as iodine, bromine, and chloride of calcium, deserve but little confidence. It is of decided benefit to let patients make use of those baths which promote absorption. Amongst these may be reckoned waters containing carbonic acid, saline "baths, and probably also mud- baths. The best, however, are the saline waters, containing iodine or bromine, therefore Kreuznach,1 Miinster on the Stein, Adelheidsquelle and Krankenheil, near T61z, Sodenthal, near Aschaffenburg, Hall, in Upper Austria, etc. Of late, injections of ergotine have claimed special attention as a means of reducing the size of fibroids. Enough has been said on this subject, however, in a previous section. 2d. If the tumor lies in the true pelvis, symptoms of pres- sure on the other organs occupying that cavity, especially the bladder and rectum, will appear. These cases often improve quite materially if the tumor is pushed up into the false pelvis. The worst cases, in which the symptoms of compression are most urgent, and in which, therefore, the tumor is very large for the true pelvis, are the very ones in which it stays up, and the symptoms, which up to that time have been quite severe, are suddenly relieved. 3d. In such narrowing and distortion of the uterine cavity, as gives rise to uterine colic of the most painful description. In such cases it is but rarely that relief can be given by effecting a 1 Prieger, Mon. f. Geburtsh., B. I., pp. 183 and 241, and Michels, Die chron. Frauen- krankh, etc., im Bade Kreuznach. Berlin, 1869. FIBROIDS OF TIIE UTERUS. 257 change in the position of the tumor. Usually we are confined to the symptomatic treatment of the dysmenorrhcea. The symptom which most frequently and urgently demands relief is the hemorrhage, which is always greatest during the menstrual period, and is, therefore, a menorrhagia. Pest in the recumbent posture often fails to diminish the flow. In many cases a slight scarification, shortly before the menstrual period, is very effective in moderating the menstrual hyperaemia. The most important internal remedy is ergot, which may be given with very good success in the form of powder, eight grains every hour or two hours, or in decoction or infusion (from half a drachm to one and a half drachms of ergot in three fluid ounces of water), or injected subcutaneously in the form of ergotine (see page 250). The solution of chloride of iron, tannin, and other astringents may also be given internally. On the other hand, narcotics are also recommended by many to control hemorrhage; their mode of action doubtless being that, by paralyzing uterine contraction, they prevent the distor- tion and violence otherwise done to the mucous membrane, and the rupture of vessels which follows. (This appears to be in opposition to the recognized efficacy of ergot; still, a case will sometimes arise where ergot seems to increase hemorrhage, and then the drug doubtless acts more by producing contractions of the walls of blood-vessels, and perhaps, also, sometimes by virtue of the fact that strong contractions of the uterine muscu- lar tissue compress the bleeding mucous membrane). Opium, and more particularly tincture of Indian hemp, have achieved a high reputation under these circumstances. If we wish to secure the immediate arrest of a considerable hemorrhage, we may tampon the vagina. This, however, is purely symptomatic treatment, and is of no benefit for the future. Therefore the use of the sponge-tent is to be preferred, which also securely stops the hemorrhage, and likewise fre- quently diminishes its future violence, as well as occasionally operating in a strikingly favorable manner upon all the symp- toms. Still more decided measures against hemorrhage may be adopted by the use of intra-uterine injections, which should be Vol. x.—17 258 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. employed with all the precautions previously enjoined. Savage - injects the following solution, after dilatation of the cervical canal: Iodine.............................. 68 grains. Iodide of potassium.................. 116 " Alcohol............................ 18 fluid drachms Distilled water...................... 6 fluid ounces. or, also, the pure tincture of iodine. He, as well as Sims and G.' Braun, have seen very good results from this. According to the latter,2 adhesions take place between the two mucous surfaces. At all events, this iodine solution is to be preferred to that of chloride of iron, recommended by Routh and M. Duncan,3 be- cause the latter causes the formation of blood-clots which must be expelled with pain. Kidd4 refers to a case of fatal metritis after the injection of the chloride of iron. A very simple, quite safe method, and one which is often effectual against hemorrhage for a long time, consists in incisions of the os uteri, or—what is far safer—of the mucous membrane covering the tumor. Atlee b and B. Brown,6 have recommended this. The mouth of the uterus being dilated, and the enlarged organ being pressed downwards by an assistant, a bistoury—the lower part of which is guarded by having something wound about it—is introduced through the cervix, and as high as possible over the tumor, and as it is withdrawn a longitudinal incision, not too superficial, is made into the surface of the tumor. The hemor- rhage following the incision is very moderate, and the metrorrha- gia is often quieted for a time. The efficacy of this method evi- dently depends on the fact that the distended veins lying in the mucous membrane over the fibroid, and which cause the profuse hemorrhages, retract' and are obliterated by thrombi after the incision, and the tension of the distended mucous membrane is lessened.7 1 Sims, 1. c, p. 120. 3 Wien. med. Wochenschr., 1868, Nos. 100 and 101. 3 Med. Times, 11th Feb., 1871, p. 158. 4L. c, p. 137. B Transact. Amer. Med. Assn., 1853, p. 558. 6 L. c, p. 243. 7 Spiegelberg, Monatsschr. f. Geb., B. 29, p. 87. FIBROUS POLYPI OF THE UTERUS. 259 FIBROUS POLYPI. Aside from the literature referred to, under the head of fibroids, the following works may be mentioned : Lerret, < >bserv. sur la cure radic. de plusieurs polypes de la matrice. Paris, 1771.—Bidder, Anfangsgriinde der Wundarzneikunst, B. 1, p. 401.—Ilerbiniaux, Traite sur divers accouch. lab. et sur les polyjjes de la matrice, T. II. Bruxelles, 1782.—Nissen, De polypis uteri. Diss. Inaug. Got- tingen, 1789.—Mi issuer, Ueber d. Polypen, etc. Leipzig, 1820.—MaJgaigne, Sur les polypes de l'uterus. These. Paris, 1823.—Gooch, Ueber einige d. wicht. Krankh., etc. Weimar, 1830, p. 183. — Oldham, Guy's Hosp. Rep., April, 1844. —Hirsch, Ueber Histologic u. Formen der Uteruspolypen. Diss. Inaug. Gies- sen, IHo't.—Dyce, Edin. Med. J., Dec, 1867, p. 503.—Saxinger (Seyfert), Prager Viertelj., 1868, 2, p. 76.—Baler-Brown, Surg. Dis. of Women, 3d ed. London, 1866, p. 247.—Scanzoni, Sc.'s Beitrage, B. II. Wuizburg, 1855, p. 94.—Leberecht, Ueber 40 Falle von Gebarmutterpolypen. Diss. Inaug. Berlin, 1868.—M. Dun- can, Edin. Med. Journ., July, 1871, p. 1.—Hildebrandt, Volkmann's Samml. klin. Vortr., No. 47. Leipzig, 1872.— Madden, Obstet. J. of Gt. Britain, Oct., 1873, p. 468. Pathological Anatomy. As has been explained above, fibrous polypi are nothing else than submucous fibroids which project into the cavity of the uterus and have a narrow pedicle. The etiology and the general pathological anatomy of these tumors has, therefore, already been considered under the head of fibroid tumors, so that but a few words will now suffice. Fibrous polypi vary in size, attaining to the dimensions of a child's head and over ; they almost invariably occur singly, that is, as polypi; it is not unusual to find interstitial and sub- mucous fibroids associated with them. Polypi, as a rule, arise from the body of the uterus, which is almost always hypertrophied ; they are most frequently attached to the fundus, very rarely to the internal os or the cervix. In the majority of instances they retain continuous connec- tion with the parenchyma of the uterus by means of a fibroid pedicle (see Fig. 93), in which case blood-vessels always enter the substance of the polypus through the pedicle. If the pedicle atrophies, the vascular connection may still be maintained, or 260 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the vessels may be obliterated, so that then the polypus main- tains its connection with the interior of the uterine walls only by a duplicature of mucous membrane (see Fig. 94). The mucous membrane covering the polypus may undergo secondary changes of various kinds. At one time it may be greatly thinned by the pressure of the growing polypus, so that it constitutes quite an attenuated, smooth membrane, in which Fig. 93. Fig. 94. Uterine polypus whose pedicle is directly Uterine polypus without a fibrous pedicle. continuous with the parenchyma of the organ. the orifices of the uterine follicles appear as small openings, which may, however, be considerably enlarged if the membrane is greatly stretched. At other times the mucous membrane is tumefied, hyperaemic, and traversed by thin-walled veins. This tumefaction may attain a high grade ; the strangulated extremities of glands may undergo cystic degeneration ; indeed new-growths, having their origin in these glands, may give rise to peculiar, complicated tumors, described by Rokitansky as sarcoma or cystosarcoma adenoides uterinum. In that case the submucous connective tissue grows rapidly and extensively, with cellular hyperplasia, and prolonged, numerously branching, utricular glands grow into this tissue. These, by strangulation, may result in a number of small cysts, of various sizes, filled with a serous, mucous, bloody, or colloid mass. A papillary growth may, how- ever, originate in the walls of these cysts, pushing into the cav- ity of the glands, and it, in turn, may likewise lead to cyst- formation, so that very complicated forms of tumors may be the result. FIBROUS POLYPI OF TIIE UTERUS. 261 Symptoms. As long as polypi remain in the uterine cavity, they merely give rise, as a rule, to the same symptoms as submucous fibroids, that is, particularly, to blennorrhcea and hemorrhage. They soon dilate the internal os and thus cause the disappear- ance of the cervix. At a later date, the external os is also enlarged and the polypus escapes into the vagina, often very slowly, occupying several months in the process. During this gradual escape the polypus may be so tightly engirdled by the external os at some point, rarely at more than one point, that it assumes the form of an hour-glass. This process of the opening of the cervical canal, and especi- ally of the passage of the tumor through the external mouth, is almost always accompanied by severe pains in the back, like labor pains, which sometimes attain a very high grade. It rarely occurs quite unnoticed, and hemorrhages continue during its progress. Sometimes general constitutional disturbances appear early, such as hysterical manifestations of the most varied kind, or derangements of digestion ; the same symptoms, indeed, may arise as in early pregnancy—pigment-deposits in the linea alba and the areola of the nipple, swelling and the beginning of secre- tion in the breasts, also nausea and the like. A different train of symptoms appears when the polypus, lying in the vagina, attains such a size that it acts as a large tumor, filling the true pelvis. Aside from the feeling of weight in the pelvis, and dragging downward, tliere are the evidences of pressure on the bladder and rectum. The first causes frequent micturition, or even incontinence ; it may, however, result in the retention of urine and dilatation of the uterus, or even hydro- nephrosis. The pressure of the polypus on the nerves produces neuralgia in the lower extremities, and its pressure on the veins is followed by a varicose condition of these vessels and oedema. The vaginal mucous membrane is so irritated by the powerful distention to which it is subjected, that catarrh is a uniform result, often accompanied with copious secretion. The further history is various. Patients may be so exhausted 262 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. by the loss of blood and other fluids that they die of marasmus. It is rare for one to succumb to an acute hemorrhage. It appears possible for an adhesive inflammation to arise between the poly- pus and the vaginal mucous membrane, of sufficient extent to limit the hemorrhage. In other cases inflammation, or the stran- gulation of the pedicle by the os, may lead to gangrene, severing the pedicle and permitting the tumor to be expelled. The poly- pus itself, however, may also become gangrenous, and thus be expelled as a wdiole or in pieces. In that case there is danger of septicaemia. The possibility of perforation into other organs has been considered under the head of fibroids. Sterility, due partly to catarrh of the uterine mucous mem- brane, partly to the mechanical obstruction, is the usual, if not the uniform result of a polypus. If the latter has passed into the vagina, the act of coition itself may be rendered very difficult and painful, and be accompanied by hemorrhage. Diagnosis. The diagnosis is very difficult as long as the polypus has not escaped from the uterine cavity, or the cervix will not admit the finger (the latter is often temporarily practicable during the menstrual period). Up to this time it is only possible to deter- mine the uniform enlargement of the uterus, and to diagnosti- cate a submucous fibroid in the manner indicated above. If the symptoms demand more positive knowledge with regard to the method of its attachment, the cervix must be dilated with a sponge-tent, and the insertion of the tumor explored with the finger, or where it will not reach, with the sound. A good way of testing its mobility is to seize it with the forceps and turn it upon its axis, according to the advice of Scanzoni. If a polypus has passed into the cervix or vagina, there are usually no serious difficulties in the way of its recognition. The evidences distinguishing it from inversion have already been cited. They are to be distinguished from mucous polypi, which are smaller and arise from the cervix, by the great difference in their consistency, although, exceptionally, a fibrous polypus may be very soft. FIBROUS POLYPI OF THE UTERUS. 263 The same diagnostic sign holds good as applied to an ovum lodged in the cervix, as well as to a fibrinous polypus. Ulcerated spots at the extremity of the polypus, which admit the tip of the finger, like a fissured os, may, on a superficial examination, lead one to suspect prolapsus or descensus uteri,1 or the presence of a malignant growth. There may be great difficulty in determining the method or point of attachment in polypi of such size that the finger cannot be passed around the tumor. It may then be necessary to draw the tumor out to the vulva, or, where that cannot be done, to remove it piecemeal. Another error, with regard to the pedicle, may arise from mistaking a strangulated portion thereof, em- braced within the os, for the point of insertion. The differential diagnosis between these growths and poly- poid sarcomata can only be made by means of the microscope after their extirpation, inasmuch as they may both have pre- cisely the same history. Prognosis. If polypi are not removed by an operation, the prognosis is unfavorable, as the natural method of cure (expulsion by gan- grene) is rare and not without danger, and as the hemorrhages, which are very prostrating, do not cease spontaneously. Their removal by an operation improves the prognosis materi- ally, as it is usually safe, not very difficult, and followed by a radical cure. Treatment. The only rational treatment consists in a radical cure through removal of the polypus. The methods which accomplish this end in mucous polypi, such as cauterization, twisting, crushing, and tearing out of the growth, are not adequate in fibrous polypi. The most that can be expected from these methods is that occasionally a small 1 See the cases of Scanzoni, 1. c, p. 97, and Martin, Boston Med. and Surg. Journ., June 11, 1868. 264 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. fibrous polypus, which is not continuously attached to the uterus, may be twisted off.1 As a rule, other means have to be employed. The plan for- merly most in vogue was Ligation.—This is often very difficult to accomplish. If the polypus has escaped from the vaginal entrance, or can be drawn out so far that the pedicle is to be seen, the application of a liga- ture is easy. If, however, the pedicle lies high in the vagina or in the uterus, the application of the ligature can only be accom- plished by means of instruments (an immense number of which have been proposed for this purpose),2 and is very difficult. After the ligature has been drawn tight, it is not uncommon for severe pains to set in, or even for metritis and parametritis to arise; and a long time elapses before the gangrenous polypus falls off. During this time, aside from the annoyance caused by the decomposing polypus in the vagina, there is danger of septic infection. Owing to these objections, this procedure is now generally abandoned. The method most frequently employed at present is Excision.—This may be best accomplished by means of a pair of strong scissors (Siebold's) curved flatwise (see Fig. 95). It is well to draw the polypus as far down as possible. The opera- tion is, of course, easiest if the polypus lies outside of the vulva, so that the pedicle can be severed, by the knife or scissors, with- out any further ceremony. In other cases it is to be left in situ only if it is so small that the pedicle can easily be reached by the fingers, and by the scissors passed up along the fingers. If it is larger, so that there is difficulty in passing the fingers or scissors between the polypus and the vaginal walls, it must be drawn down to the outlet of the vagina. This may be done either by passing a ligature through it or by seizing its extremity with Muzeux' forceps, or, if the polypus is very large, b}^ the use of 1 Brown (Boston Gyn. J., Vol. II., p. 2) reports a case in which evulsion of a poly- pus was followed by fatal tetanus. It is true that dilatation of the cervix by sponge- tents had been accomplished. Porter Smith (Med. Times, 1861) also saw a case of tetanus after the use of the ligature. 2 Kilian, Die rein chir. Oper. d. Geb., II. Aufl. Bonn, 1856, pp. 230 et seq. FIBROUS POLYPI OF THE UTERUS. 265 obstetrical forceps. This latter proceeding, if the tumor is very extensive, may present the same difficulties as extraction of a child's head, so that prolonged traction, and even incisions into the external genitals, may be required. In the extraction of polypi, the uterus naturally descends low in the vagina. But this artificial prolapse does no mischief, if one is only careful not to leave a partial inversion as the result of dragging on the pedicle, so that, in fact, the upper part of the pedicle consists of an inverted portion of uterine wall. This inversion is not very easily accomplished, because the floor of the uterus is hypertrophied. When the pedicle is rendered accessible by these means, it should be cut off at its thinnest point. There is no need of making any special effort to cut it off as high up as possible, as the remaining portion of the pedicle shrivels, and never gives rise to any evil symptoms. The hemorrhage, as a rule, is very insignifi- cant, so that no subsequent treatment is required. If it should prove to be more serious, a tampon may be applied to the vagina. If the uterus cannot be drawn far enough down to make the pedicle of the tumor accessible, with- out the employment of too great force, and if it is impossible to reach the pedicle by passing around the tumor, the operation becomes a diffi- cult one. It then becomes necessary either to re- Siebold's scissors. move the tumor piecemeal, or to undertake what is known as " operative elongation." The removal of the growth by pieces may also become necessary, if it is so large that it cannot pass through the pelvic outlet. The tumors most easily removed, then, are those which are quite soft, as large pieces can be turned out of them by the hand, and thus the pedicle gradually reached. The operative elongation of polypi may be accomplished by making deep, lateral incisions, according to Simon ;' or, accord- » Monatsschr. f. Geb., B. 20, p. 467. 266 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ing to Hegar,1 by running spiral incisions over the tumor, carry- ing them pretty regularly as high up as the middle thereof, or even higher. The polypus is thereby lengthened, and its thickness so diminished that it is possible to press past and reach the pedicle. If the tumor is too large for the true pelvis, the operation becomes one of great difficulty. It must then generally be removed in pieces, which implies great danger of the patient sinking from exhaustion, from the effect of wounds made in effecting this purpose, as well as under the suppuration and expulsion of retained remnants.2 Byrne3 employs the galvano- caustic loop, cutting such large tumors through smoothly, and then extracting the pieces. If the polypus is still in the womb, and cannot be reached without dilatation, its removal, even if it is small, is difficult and dangerous. It should, therefore, only be undertaken if very urgent symptoms demand it; otherwise, it is better to wait until natural and artificial means have conspired to drive it into the vagina. In the operation the cervix must, first of all, be sufficiently dilated (by sponge-tents as well as through the draw- ing down of the polypus), the uterus must be forcibly pushed down by pressure on the abdominal walls, half the hand must be passed into the vagina, and then, the scissors being introduced and guided by two fingers, an attempt must be made to cut the pedicle, or to pass a wire over the polypus by a method about to be described. Various polyptomes have also been invented for this purpose, by Lever and Simpson,4 for example, most of which consist of hooks, sharp on their inner surface, which are to be passed around the pedicle, and thus cut it off. Aveling6 has introduced an instrument similar to Scanzoni's, by means of which the pedicle is embraced by a blunt hook, and a knife is made to slide forward and cut it. These instruments are not likely to 1 Monatsschr. f. Geb., B. 21, p. 220. 5 Walter, Dorpater med. Zeitschr., 1873, B. 4, H. 1, p. 1. 3 Amer. Jour, of Obst., Vol. VI., pp. 120 et seq. * Sel. Obst. Works. Edinb., 1871, p. 725. 6 London Obst. Trans., IV. FIBROUS POLYPI OF TIIE UTERUS. 267 prove of much practical value, as, in all cases in which they can be used, the same end could be attained by Siebold's scissors or the wire ecraseur. In view of the great loss of blood which patients have almost always undergone, it often becomes of the greatest importance to spare them even the small amount of hemorrhage which accom- panies an operation with the knife or scissors. It is then advis- able, especially in cases that have to be operated on in situ, and in which, therefore, the pedicle is more inaccessible and hemor- rhage less under control, to make use of the ecraseur or of the gal vano- cautery. The use of the chain-ecraseur is by all means and altogether to be prohibited, for even if one has a curved instrument and Sims"s chain-guard,1 it is difficult of application and is liable to amputate a considerable area of uterine mucous membrane. It is far easier to apply the thin wire belonging to the ecraseur represented in Fig. 48.* If this is well applied, it cuts the pedi- cle through smoothly, and hemorrhage is pretty certainly avoided. The loop employed in the application of the galvano-cautery is even more easily handled, as it is more pliable. The pedicle is slowly cut through, under the use of a moderate red heat. Symptomatic treatment is only called for if the polypus is inaccessible, that is, if it is hidden in the womb ; the rule then being to postpone any operation until the tumor shall have descended through the cervix. It is only under very urgent necessity that we should proceed to the artificial dilatation of the neck by sponge-tents and amputation of the tumor. Under these circumstances it is always a very difficult operation, and not without danger. The symptom which calls most urgently for relief is hemor- rhage. This may be best controlled by the use of ergot and of the cold douche, the relief given by a tampon being altogether transitory. The injection of solutions of chloride of iron should only be resorted to if everything else fails, as it may be followed by adhesions between the polypus and the uterine walls, which 1 Loc. cit., p. 79. 2 Braxton Hicks, Guy's Hosp. Rep. XIII., p. 128. 268 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. will greatly increase the difficulty of any subsequent operative procedure. If the polypus is accessible, it should be removed at once ; the postponement of an operation being but very exceptionally justified in case of extreme debility or of some inflammatory complication. Then hemorrhage may have to be controlled, for a time, by the use of the tampon, and the strength of the indi- vidual maintained by the usual means. Uterine Cysts. Aside from the pseudo-cysts, which may be developed in large fibroids by the separation of muscular fibres through an accumulation of serum, the development of cysts in the paren- chyma of the uterus is an occurrence of extreme rarity. At all events, very few cases of this kind are to be found in the litera- ture of the subject. What have been most frequently described as cysts, lying beneath the peritoneal covering of the uterus, are those accumulations of yellow serum which are not rarely devel- oped within an intra-peritoneal pseudo-membrane in the true pelvis. A case of considerable cyst-formation within the largely hypertrophied parenchyma of the uterus (not in a round fibroid) is described by Boinet.1 Demarquay2 reports a case in which the apoplectic origin of the cyst is hardly to be mistaken. Another case was operated on by Pean.3 Dermoid cysts also occur in the uterus. Among the recent observations of this subject are those of Wagener4 and Kiwisch.6 PAPILLARY TUMORS OF THE UTERUS. John Clarke, Transact, of a Soc. for the Improv., etc., 1809, Vol. III., p. 321.— Charles Mansfield Clarke, Observ. on Diseases of Females which are attended ! Gaz. hebdom., 1873, No. 13, p. 199. 2 L'Union med., 1868. 3 L'hysterotomie. Paris, 1873, p. 96. 4 Archiv f. physiol. Heilk., 1857, p. 247. B Klin. Vortr., etc., IV. Aufl., B. I., p. 456, cysts the size of a child's head, con- taining hair and teeth, on the inner surface of the womb, without any further par- ticulars. PAPILLARY TUMORS OF THE UTERUS. 269 by Discbarges. London, 1821, Part II., p. 57. — Thomas Saffeird Lee, loc. cit., p. 81.—Reneiud, London Med. Gazette, August, 1848. — Watson, Monthly J. of Med. Sc, October, 1849, p. 1183.—Virehow, Verb. d. pbys. med. Ges. in Wiirzburg, B. I., 1850, p. 106.—a Meiyer, Verb. d. Berl. Ges., f. Geb., 1851, H. 4, p. 111.— Mikschik, Zeitscbr. d. Ges. d. Wiener Aerzte, 1856, 12 Jahrg., p. 40.—Braxton Hicks, Guy's Hosp. Rep., 1861, VII., p. 241. Until quite recently, benign papillomata and cancroid forms of cancer have been confounded with one another, and, indeed, the two show great similarity in their method of origin and in their appearance on examination ; in fact, tliere can be no doubt that cancroid tumors sometimes spring from what were, origi- nally, benign papillary growths. It is, therefore, easy to under- stand why, since John Clarke first called attention to the "cau- liflower excrescence" of the vaginal portion of the cervix, there should have been conflicting views held with regard to the signi- ficance of the same, especially in a prognostic point of view. A rigid distinction must nevertheless be drawn between these two varieties. The simple branching and proliferation of the villi, causing them to project into the vagina, constitutes a per- fectly benign form of tumor, with no tendency to recur; while the cancerous character of the growth, with all the consequences therein implied, is assumed as soon as the epithelial layers lying between the villi begin to proliferate inwards towards the central structure of the uterus. This much, however, is certain, that the larger tumors, of the cauliflower variety, are far oftener malignant than benign. Etiology. Papillomata of the vaginal portion of the cervix are of two kinds, differing both in their origin and their course. The one variety is caused by the specific irritation of gonorrhoea! matter, just as pointed condylomata may be produced by the same cause in other places. The other variety is the simple papilloma, which is most readily produced by some continuous irritant, operating upon an eroded spot, and stimulating the denuded villi to proliferation. It must be admitted, however, that under these circumstances, too, the production of large papillary tumors is uncommon. 270 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Pathological Anatomy. Benign papillary growths, having none of the characteristics of a cancer, present themselves under the form of a somewhat pedunculated tumor, showing a bright red color in the specu- lum, and, in their structure, presenting a truly striking resem- blance to the fine branching of a cauliflower. The two forms of papillary growth, the pointed condyloma and the truly benign papilloma, are exactly alike as regards the finer tissue-changes which they present. These consist in a growth of the papillae or villi, which become hypertrophied either in the form of a long, club-shaped swelling, or of one with numerously branching extremities. The tissue of the papilla presents its normal components—delicate connective tissue, con- taining a loop of blood-vessels, often very branching. The papillae are covered with epithelium, which is generally also greatly hypertrophied, covering the papilla in thick layers. The substance of the uterus is perfectly normal; the epithelium lying between the papillae, therefore, does not penetrate into the substance of the organ, tliere to form cancerous nodules. Pointed condyloma of the vaginal cervix does not arise from one circumscribed point, but originates, in a diffuse manner, from various portions of the mucous membrane. It is uniformly found in connection with the same class of condylomata of the vagina or external genitals. At first the papillary growths are fine and tender, and the individual villi become thinner towards their free extremity. Later, however, the ends become more club-shaped, and are covered with an abundant whitish epithe- lium. The form of the growth is sometimes like a raspberry, sometimes like a cauliflower, and again like the comb of a cock. At times the epithelial deposit is so abundant that it fills the interspaces between the club-shaped extremities of the papillae, so that the surface of the growth assumes a uniform character. After persisting for some time, the pointed condylomata may assume a considerable degree of hardness. Benign papillomata, which are very rare in connection with the vaginal cervix, are always solitary, arising from a greater PAPILLARY TUMORS OF TIIE UTERUS. 271 or smaller portion of the mucous membrane. From this point they grow into the vagina, as a polypoid tumor, and may exactly resemble a tightly compressed, strongly proliferating, pointed condyloma. Cysts may also be developed in a papilloma, the strong pres- sure of the vaginal walls causing adhesions between the free, club-shaped extremities of the villi, and leaving free spaces between the latter, which are converted into cysts by a secretion of mucus.1 Symptoms. The most constant symptom is blennorrhea, which is pretty abundant in pointed condylomata, and often quite insignificant in a papilloma provided with a thick epithelial covering. If the loops, however, are thick, club-shaped, vascular, and but scantily covered with epithelium, quite a profuse watery flow may take place, which also sometimes alternates with hemorrhages. Undoubtedly papillomata which were originally benign may undergo carcinomatous degeneration, although this degeneration does not seem to be very frequent, at least in the larger tumors. Pointed condylomata may undergo a retrograde metamorphosis, whereby their vessels disappear and they shrivel. A natural cure may take place in non-specific condylomata by the suppu- rative destruction of the pedicle and the subsequent expulsion of the tumor. Diagnosis. The two varieties of non-malignant papillomata may be pretty certainly distinguished by their etiology and the method of their appearance. Simple papilloma occurs as a single tumor, while the pointed condyloma is only one of several evidences of irri- tation of the papillary body, which not only gives rise to nume- rous growths in the vaginal part of the cervix, but causes the same to appear in the vagina and on the vulva. The most important point in differential diagnosis lies in distinguishing these growths from the cancroid form of cancer. In the latter, the mucous membrane is early adherent to the 1 Rindfieisch, Monatsschr. f. Geburtsh., B. 24, p. 438. 272 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. subjacent tissue, as the epithelial depressions penetrate into the parenchyma of the vaginal part of the cervix. In benign papil- lomata, which only lie in or project from the mucous membrane, this is freely movable. The cancroid, therefore, seems to arise from the parenchyma of the cervix, while the benign papilloma merely constitutes an appendage to the mucous membrane. In watching the progress of the disease, it will be found that the purely papillary growths enlarge but slowly, while cancroids spread rapidly and ulcerate early. Prognosis. The system may be greatly weakened by the serous and bloody discharges spoken of above, the former of which are often exceedingly profuse. When the diagnosis is unequivocal, too, the possibility of transformation into carcinoma must ever be borne in mind, though it supervenes but rarely in large tumors, especially if they are specific in character. Treatment. The removal of the tumors, which is always indicated, may be undertaken with the curved scissors, or, in large tumors, may be effected, to very good advantage, by means of the wire ecraseur, or the galvano-caustic loop. The operation presents no difficulties, but care must be taken to remove the tumor close to its point of insertion. The stump may be cauterized with the hot iron, to arrest hemorrhage, as well as to destroy any can- cerous collections which may have been formed within the pedicle. CANCER OF THE CERVIX UTERI. Besides the literature given in the article on papillary tumors, refer to Wenzrl, Ueber die Krankh. des Uterus. Mainz, 1816.—Beycrle, Ueber den Krebs der Gebarmutter, 1818.—IT. J. Schmidt, Ges. obstet. Schriften. Wien, 1820, p. 110.—E. von Siebold, Ueber den Gebarmutterkrebs, etc. Berlin, 1824.— Teallier, Traite du cancer de la matrice, etc. Bruxelles, 1836 (Deutscb, Qued- linb. u. Leipzig, 1836).—Duparcque, Traite" des mal. org. simples et cancSr. de l'utgrus. Paris, 2d ed., 1839.—Montgomery, Dublin Journal, Jan., 1842.— Walshe, CANCER OF THE UTERUS. 273 Nature and Treatment of Cancer. London, 1846.—Th. S. Lee, On Tumors of the Uterus and its Appendages. London, 1847, p. 111.—Robert, Des affections gran., ulc. et carcinom. du col. de l'uterus. Paris, 1848.—Lebert, Traite prat, des mal. cancer. Paris, 1851.—Chiari, Braun u. Spaeth, Klin. d. Geb. u. Gyn. Erlangen, 1852, p. 673.—#. Wagner, Der Gebarmutterkrebs. Leipzig, 1858.—L. Mayer, M. f. Geb., B. 17, p. 241.—Tanner, On Cancer of the Female Gen. Organs. London, 1863.—Saxinger (Seyfert) Prager Viertelj., 1867, 1, p. 103.—Lusk, New York Med. J., Sept., 1869.—Blau, Pathol. Anat. iiber den Gebarmutter- krebs. Diss. Inaug. Berlin, 1870.—Fordyce Barker, Trans. N. Y. Acad, of Med., Feb. 18,1870 (see Amer. J. of Obst., HI., p. 519).—Gusserow, Volkmann's SammLklin. Vortr., 1871, No. 18. Etiology. The marked ratio in which the female sex is attacked by cancer is entirely due to the frequency of cancer of the uterus. According to Simpson, 61,715 women and 25,633 men died in England of cancer between the years 1847 and 1861. A third of all the women dying of cancer suffer from cancer of the uterus, while carcinoma of the mamma stands second on the list.1 The influences, however, which determine the dreadful fre- quency with which carcinoma is developed in the cervix uteri are practically unknown. North American authorities agree that negro women, in whom uterine fibroids are singularly common, are very seldom affected by carcinoma uteri, or, indeed, by any form of cancer. Thus Whitall, of New York, saw only two cases of malignant disease of the uterus among 2,000 colored women treated by him. According to the statistical statements of Chisolm, out of 4,052 whites, men and women included, 35, or 0.86 per cent., died of cancer; while of 10,828 blacks, men and women included, only 40, or 0.37 per cent.—less than half as many—died of the same disease. From these reports it also appears that in North America cancer is much more rare even among the whites than in Europe. As regards age, we find the frequency as follows, if, aside from our own observations, we group the figures of Lebert, Kiwisch, Chiari, Seyfert, Scanzoni, Lever, Lee, and Tanner (the 1 According to Hough, TancJwn, Simpson, Eppinger, WiUigk, and Wrany, of 19,066 women dying of cancer, almost exactly one-third had cancer of the uterus. VOL. X.—18 274 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. figures of Boivin and Duges must be set aside as untrust- worthy). Of 745 women affected with cancer of the uterus, there were : Under 20 yrs. 20-30. 30-40. 40-50. 50-60. 60-70. Over 70. 0 43(5.77#) 167(22.4;?) 312(41.9?) 155(20.8?) 62(8.32?) 6(0.8?) We get the following figures in 492 cases, as the results of post-mortems, from Hough, Blau, and Dittrich: Under 20 yrs. 20-30. 30-40. 40-50. 50-60. 60-70. Over 70. 0 22(4.47?) 107(21.75?) 133(27?) 153(31.1?) 53(10.77?) 24(4.87?) Here, then, the average is removed to a somewhat more advanced age, and this is explained in part by the fact that carcinoma uteri comes under the view of the pathologist later than under that of the clinical observer. According to these figures carcinoma uteri does not occur at all before puberty, or, in fact, before the twentieth year; its frequency then increases up to the fifth decennium, to fall again somewhat after the menopause. Still, according to these figures, we find even after the menopause a very considerable number affected with the disease, and the number is actually greater, since the absolute number of women of this age is materially less. This appears more markedly from the statistics of Glat- ter,' in which the number of women dying of cancer is compared with the whole number of those of the age in question. Accord- ing to these, there died in Vienna: Of cancer of the uterus, of women from 21-25 years old, 0.1$ ' . " it tl 26-30 1.05? 1 11 it 11 31-35 1.45? 1 11 (i II 36-40 3.64? 1 11 1 i'. i 11 ti n n tc II II II 11 41-45 46-50 51-55 56-60 ' 4.73? 6.62? 5.5? 3.96? I It t it (i it 11 11 61-65 66-70 2.04? 2.03? I It I! 11 71-75 0.91? t it it 11 76-80 0.66? It 11 It 11 over 80 0.36? 'V erteljahrschr. f. off. Gesundheitspflege, 1870, II. p. 161. CANCER OF THE UTERUS. 275 The climacteric period, then, furnishes the most considerable number of deaths from carcinoma uteri. After this the pro- portion only very gradually diminishes. Taken altogether, therefore, 2.5 per cent, of all women over twenty died of this disease. It has always been maintained that sexual indulgence, especially when excessive, favors the occurrence of carcinoma, and this neoplasm is, in fact, met with more frequently in married women. We find that of five hundred and thirty-one patients observed by Chiari, Seyfert, Scanzoni, West, Tanner, Gusserow, and myself, four hundred and forty-nine had borne children and only eighty two had not. A considerable number of instances of excessive child-bearing, too, is found among patients with carcinoma. Among my own there was one woman who had had thirteen and, another fifteen births. The influ- ence of regular sexual indulgence is most clearly traced in the comparative statistics of Glatter. According to these there were : Single. Married. Widows. Out of 1,000 Vienna women over 20 years old........ 459 408 133 " " " " with cancer of the uterus. 229 503 268 It is very evident from this how very much less frequent death from cancer of the uterus is among single women. It is still very doubtful if we should allow a knowledge of these facts to influence us in indicating traumatic irritation simply as the cause, if we consider that the state of rest, in which the vaginal portion constantly remains, is even in the most frequent practice of coitus and in labor relatively very seldom interfered with. Prostitutes have no special tendency to cancer of the uterus. The ungovernable sexual passion exhibited by many women with carcinoma is only the symptom of a uterine disease. It is also very striking that the uterine orifice is, like most other orifices,—as the lips, the pylorus, the caecum, and the rectum,—so often affected by carcinoma. Least of all does the influence of hereditary descent seem to be established by the statistics hitherto attainable, although we must allow that it has at least some slight foundation. Among three hundred and twenty-six cases collected by Gusserow1 (Gus- 276 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. serow, Tanner, Lever, Lebert, Scanzoni, and West), a hereditary character could be proved but thirty-four' times. According to Sibley, it could be proved eight times in one hundred and thirty- five ; according to Barker, thirty-six times in four hundred and eighty-seven cases ; taken altogether, seventy-eight times in nine hundred and forty-eight cases. Scanzoni lays great stress upon previous depressing states of the mind; at all events, their influence is very important, etio- logically, in individual cases. Pathological Anatomy. In the nomenclature of the malignant tumors of the cervix, such confusion and uncertainty prevails,—inasmuch as they comprise the malignant cauliflower excrescence of Clarke, the cancroid, the medullary cancer, and so on up to scirrhus,—that we must first of all explain ourselves as to the various forms of cancer. In the first place, we declare that we neither separate the malignant papillary tumors from cancroids, nor the latter from carcinomata. We follow the views of Waldeyer, who refers the origin of all the forms of cancer to the true epithelia, considering them all as epithelial tumors, which develop, with- out exception, from actually existing epithelium; and who, in the very rare cases where primary carcinomata have devel- oped in places where there is no native epithelial soil, regards them as arising from abnormally distributed remnants of the epithelial blastodermic membrane. They are thus sharply defined from the sarcomata, which are pure connective-tissue tumors. The carcinomata, then, are developed, by normal pavement or glandular epithelium penetrating with its ramifications into the depths of the tissues in all directions like plugs, destroying the other tissues by pressure, and forcing apart the bundles of con- nective-tissue fibres, so as to form for itself a framework of con- nective tissue, and an alveolar structure for the whole tumor. 1 Loc. cit, p. 121. CANCER OF TTIE UTERUS. 277 According, now, to the preponderance of either this connective- tissue framework—which is also partly a new formation from the irritated connective tissue—or the nests of cancerous epi- thelium, we distinguish the harder forms—scirrhus, and the softer—medullary cancer. Fig. 96. Fio. 97. Cancroid of the anterior lip. The same patient, fifteen months after the operation. A more strict separation of these forms is, from a clinical point of view, impracticable; for multiform and differing in appearance as are the forms which here present themselves, they still have precisely the same significance, very commonly in the same individual pass one into another at some place or time, and consequently must be considered as belonging together through- out. In the description of the separate forms we begin with malig- nan t pap illoma. This, at the beginning, bears great external resemblance to the benign papilloma, which has already been described; only the epithelial plugs sink more deeply into the tissue between the papillae so that epithelial cancer-nests are found beneath the 278 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. mucous membrane. If we make a cut through the tumor, par- allel with its attached surface, the sections thus obtained are not uniform, but we observe in them roundish spaces varying from a very small size to above that of a pea, and containing either a yellowish greasy mass, which can be squeezed out like a comedo, and consists of the compressed epithelial cells, or a juice of greater or less consistency, composed of cancer cells, in part undergoing fatty degeneration, and in part suspended in serum. These tumors form the majority of Clarke's cauliflower excres- cences. Fig. 98. Fig. 99. Large cancroid of the portio vaginalis. Great carcinomatous proliferation of the cervix and surrounding connective tissue. In other cases the papillary proliferation is much less marked. The individual papillae are only swollen into a club shape at their ends, not so as to form papillary tumors with abundant ramifications, but so that the surface of the mucous membrane merely acquires a somewhat granular appearance. In these cases the mucous membrane is seated firmly upon an infil- trated and hardened base, because, to be sure, the epithelium has gone on developing like plugs in the submucous tissue, and, CANCER OF THE UTERUS. 279 according to Waldeyer1 s striking expression, has nailed on the mucous membrane as if with tacks. As the cancer-nests become larger they break down, first in the middle, into a yellowish, greasy pulp, and the framework of connective tissue that lies between them becomes gradually gangrenous from the increasing pressure. An abscess thus forms directly under the mucous membrane, and soon breaks through it and discharges exter- nally, h'aving behind the characteristic cancerous ulcer. At the same time the process of epithelial proliferation encroaches also upon the normal tissues in the neighborhood, so that soon the vault of the vagina is also infiltrated, i.e., hardened and fixed in position. The cancer exhibits the cancroid form if the mucous mem- brane is irritated by the newly formed epithelial masses or involved in a papillary proliferation, so as to encroach to a marked extent upon the calibre of the vagina, and thus form a tumor springing from one lip, or from the whole vaginal portion, and which frequently has a distinct pedicle. But in case the epithelial plugs force their way at once deep into the normal tis- sues, so that it amounts less to a tumor formed upon the vaginal portion than to an actual cancerous transformation of the cervix and surrounding connective tissue, we then have the pure carci- nomatous forms. These again may, it is true, show great differ- ences. In the first place, the framework of connective tissue commonly preponderates over the epithelial plugs which pene- trate singly into the depths of the tissue. We have then to do with the harder or more scirrhous forms. As a rule, however, the epithelial proliferation soon increases to such an extent that the framework of connective tissue is very much thinned. When, however, the mucous membrane is broken through by the defunct cancer cells, thus forming the cancerous ulcer, then either a great proliferation of the cancer cells begins in the framework of newly formed, delicate, connective tissue, or the meshes of connective tissue early waste away, their contents escape, and lacunae of considerable size are formed. Here we have the various forms of medullary cancer. It is unusual, when the whole vault of the vagina, up to the sides of the pelvis, has become infiltrated, for the epithelial plugs 280 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. still to lie so far apart from one another that the framework of connective tissue influences the consistency of the tumor, in other words, that even at a late stage of the growth, it should maintain the character of a scirrhus. As a result of these conditions the external forms of carci- noma of the cervix may be very different. Sometimes we find great papillary tumors (see Fig. 98), in other cases large neoplas- tic growths are seated upon the smooth mucous membrane, and they have led to decided hypertrophy of the vaginal portion, or have already so involved the vault of the vagina in every direc- tion that it is no longer possible to distinguish the vaginal por- tion by the touch (see Fig. 99). The external appearance of the carcinoma will therefore differ very much, according to whether the neoplasm has developed considerably before breaking down, or whether the newly formed tissue has wasted away imme- diately, so that in the vault of the vagina we encounter nothing but a funnel-shaped crater. When the recent proliferations on the margins of the ulcer disappear immediately, the character of the neoplasm may be so little marked that it seems almost pos- sible to mistake the carcinoma for some merely extending or cor- roding ulcer, like the phagedenic ulcer already described (see Fig. 100). It ought to be prominently mentioned as highly characteristic of the wide propagation of cancer, that the new formation does not at all respect the limits of any definite tissue or organ. Con- sequently the disease remains confined to the parenchyma of the cervix for but a short time. Very often it encroaches upon the neighboring connective tissue, so that the boundaries of the cer vix are effaced by the uniform hardness, and the swelling of the cervix appears so marked only because the connective tissue at its sides is infiltrated in the same way. This infiltration per- meates the connective tissue up to the sides of the pelvis, and even at times the lymphatics, so that they are found choked with cancer cells. In an upward direction the proliferation advances uninter- ruptedly up to the vicinity of the os internum. Here it is not seldom arrested, so that occasionally the whole cervix is ulcerated away, while the neoplasm has attacked the body of the uterus CANCER OF THE UTERUS. 281 to only a very inconsiderable extent. In other cases, it is true, the body is also completely involved in the degeneration, so that it first becomes greatly hypertrophied and then gradually de- stroyed by ulceration. In fact, the process may even extend to the Fallopian tubes. Blau found that, in ninety-three cases, the neoplasm had passed above the os internum to the body of the uterus thirty-one times ; Wagner, in eighty-three cases, thirty- two times. It is possible, however, for metastatic nodules to form in the body without continuous connection with the cancer of the neck. Fig. 100. Fig. 101. Carcinomatous ulceration, which has de- Carcinoma of the cervix, with secondary stroyed the greater part of the uterus. extension to the vagina and rupture into the bladder. The process very commonly, and, as a rule, very early spreads to the mucous membrane of the vagina, though generally only to its upper third. The anterior vaginal wall chiefly shows the ten- dency of the degeneration to go downwards, and here the mass containing the urethra may sometimes be found infiltrated. Considerable tumors do not readily form on the vaginal mucous membrane, but it generally happens, especially if the mucous 282 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. membrane is much thickened, that ulceration takes place early. If the neoplasm has extended to the wall of the vagina, generally all the boundaries between the vagina and uterus have disap- peared, and one is inclined to estimate the vagina as too short, and to take all that is cancerous as belonging to the cervix, par- ticularly if the infiltration of the vaginal walls is so thick that its calibre has almost disappeared (see Fig. 101). Carcinoma of the anterior vaginal wall and of the anterior lip, when it goes deeper, is very apt to involve the bladder. Here it forms at first projections of the mucous membrane until this latter ulcerates and breaks down, and, if the carcinomatous tissue of the septum has been melted down, a great vesico- vaginal fistula is formed. According to Blau, this occurred twenty-eight times in ninety-three cases ; according to Eppin- ger, fourteen times in seventy-nine cases. The urethra, too, may be destroyed, so that tliere may be a urethro-vaginal fis- tula, either by itself or associated with the other. In other cases the ureters are attacked, and hydronephrosis results, either from this cause, or, more frequently, from the traction or pres- sure of neighboring cancerous nodules or inflammatory exuda- tions. Blau witnessed this result fifty-seven times in ninety- three cases ; Seyfert even maintains that death is due to uraemia in most cases of carcinoma uteri. Still more rarely does perforation of the rectum occur in the same way from the posterior vaginal wall; according to Blau, thirteen times in ninety-three cases; according to Eppinger, three times in seventy-nine cases. Thus from its breaking through into both organs a vast cloaca may be formed out of the three openings. As a rule, the carcinoma does not break through into the abdominal cavity, because inflammatory thickenings and adhe- sions form at those points of the peritoneum towards which the proliferation extends, and do not permit the actual perforation to take place. Consequently in carcinomata, which have ad- vanced far in an upward direction, we find very many cicatricial adhesions bridging over the anterior and posterior excavations of the peritoneum, and gluing the appendages of the uterus together, and to the intestine and mesentery. In these pseudo- CANCER OF TIIE UTERUS. 283 membranes are often found areas of pasty, circumscribed oedema, which appear like large yellow cysts in the membranes. In other cases, however, the carcinomatous nodules also develop directly in the abdominal cavity, or there are open communications between the ichorous cavity of the vagina and the abdominal cavity. The degeneration may also extend laterally to the connective tissue, the muscles, the periosteum, and even the bones of the pelvis, so that the whole of the true pelvis may appear filled with carcinoma. It also attacks other organs, such as the nerves, the veins, and especially the lymphatic glands. Going upward, the carcinoma may not merely attack the body of the uterus, the tubes and ovaries, but even the adherent omentum and the intestine, so that portions of the latter, and not the rectum only, may open into the general cloaca. The body of the uterus and the tubes are, as a rule, attacked from continuous extension only, but the ovaries by metastasis. Thus, in the most advanced cases, there may come to be one great ichorous cavity, into which the bladder and rectum open, and in which every trace of the uterus has disappeared. Those parts of the walls of this cavity which do not show evidences of carcinomatous infiltration are frequently covered with diph- theritic deposits. Secondary carcinomata in other organs are not rare ; they occur most frequently in the inguinal, lumbar, and retro-peri- toneal glands, also in the ovaries, liver, and lungs, and excep- tionally in almost all the other organs. Among 292 cases collected by Arnott, Wrany, Blau, Kiwisch, Lebert, and Wagner, carcinomata of the ovaries are mentioned fifty-one times, and of the liver twenty-four times. As opposed to various reports, secondary carcinoma of the mamma is very rare ; among the 292 cases it occurred but three times. Symptoms. The malignancy of carcinoma of the cervix is enhanced by the fact that the beginnings of the tumor usually furnish no symptoms whatever, so that the trouble is almost always discov- 284 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ered too late; only in malignant papilloma does blennorrhcea occur early, and sometimes there is also bleeding. In the other forms of cancer, however, the discharge at the begin- ning is very slight, so that the disease, in the absence of all other alarming symptoms, usually first comes to the know- ledge of the physician when the carcinoma has broken down, and the cancerous ulcer has actually formed. Then appear an abundant blennorrhcea and attacks of metrorrhagia. The latter are first noticed only as an increase of the normal menstruation, but subsequently at other times also. It is not unusual for the first sign noticed to be a discharge of blood after coitus. The hemorrhages may be entirely wanting, especially in the scirrhous forms; but they are, as a rule, present, and may be of such an extent as to result in the most extreme degree of anaemia. Still, death scarcely ever occurs as the immediate result of hemorrhage. The first considerable blennorrhcea generally shows itself after the first hemorrhages, although slight mucous discharges, not sufficient to attract the attention of the woman, have preceded them. The blennorrhcea may, as in the papillomata, be almost purely serous, and of a stale but not offensive smell; but so soon as a cancerous ulcer is formed, the secretion becomes more sus- picious ; its color becomes darker from the admixture of frag- ments of gangrenous tissue—gray, yellowish, greenish, brownish, or even black,—and there is an offensive and sometimes a truly horrible smell. In the beginning the pain is apt to be very slight or wholly absent, especially if we remember that there are pains in the back and a feeling of pressure in the belly in almost all diseases of the uterus. More severe pain sets in when the infiltration has extended to the connective tissue of the pelvis, and, in fact, it usually is worse the larger and harder the growths become ; so that we find the severest pains in those carcinomata in which the ulceration is slight and occurs late, and when infiltrations of a board-like hardness fill the whole pelvis. To be sure, this is not invariable, so that we occasionally meet with the most intense pains in cases where the cancer consists almost wholly of ulcerated surfaces, and the reverse is also true. CANCER OF TIIE UTERUS. 285 To these pains, which are dependent on the growth of the carcinoma itself, and which are often of a piercing, lancinating character, are added those referable to peritonitis from the for- mation of inflammatory adhesions, so soon as the neoplasm encroaches upon the peritoneum. Uterine colic may also be very troublesome. Sometimes exceedingly violent pains of this kind, occurring at intervals, may be occasioned by the new growth constricting the cervical canal, so that the secretions of the uterine cavity are retained. A slight degree of haema- tometra or hydrometra may even be caused by occlusion of the cervix. The peculiar hardness of the abdominal integuments, so char- acteristic of the later stage of carcinoma, is caused in great part by the pain. The muscles at that period are constantly on the stretch, and the intestine somewhat distended, so that the integ- uments present a peculiar sensation of rigid hardness. The appearances which remain to be mentioned are developed by the advance of the disease to the neighboring organs. Car- cinoma quite regularly extends to the anterior wall of the vagina, and thus approaches the bladder. As a consequence of the irri- tation of the mucous membrane of the bladder, pain and burn- ing on urination are apt to supervene. Retention of urine in the bladder is rare, but hydronephrosis, with consecutive affec- tions of the kidneys, is a very frequent occurrence. The ureters are very apt to be narrowed, partly by carcinomatous growths and partly as a result of flexures and constrictions due to the processes going on around the uterus. If the mucous mem- brane of the bladder is involved in the degeneration, we have catarrh or diphtheria of the bladder, and, after the ulceration of the neoplastic masses, a vesico-vaginal fistula, with its sad consequences. The carcinoma also not infrequently passes over to the rec- tum. Even before that, we may have obstinate constipation, as well as catarrh of the large intestine, if considerable tumors nar- row its calibre. If perforation takes place, we generally have as a result the formation of a cloaca—as a fistulous opening into the bladder is usually formed before this occurs. The general condition may be excellent at the beginning of 286 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. the disease, especially up to the period of ulceration. Gradu- ally, however, it becomes very bad, in part from the loss of blood and nutrient fluids from the cervix, but in great part, also, from the disturbances in the intestinal canal, which are the constant accompaniments of carcinoma. In some cases obstinate constipa- tion is present, while in others, generally beginning in the later stages, there is profuse diarrhoea, together with very great loss of appetite, and quite commonly vomiting. The latter symptom may depend upon various causes, among which Gusserow especialty calls attention to the nauseating discharge and the uraemia caused by the constriction of the ureters. If the pain deprives the patient of rest at night, if the blennorrhcea is very profuse, and if the hemorrhages are abundant, the most marked cachexia .will be established, with extreme emaciation and oedema. The majority of the patients die slowly of marasmus, associ- ated sometimes with uraemia and septic conditions. Very often an intercurrent peritonitis or some disease of the respiratory organs closes the scene.' The duration of the disease is very difficult to estimate, be- cause of its latency in the early stages, and at all events it varies greatly. According to Arnott, the averaged uration of carcinoma is 53.8 weeks, of cancroid 82.7. West and Lebert assign fifteen and sixteen months as the mean duration, while other English, and especially American authors, give much higher numbers. Thus, according to Simpson, carcinoma lasts from two to two and a half years, and according to Barker for three years and eight months ; in fact, the latter tells of a patient with carci- noma, in whom he made the diagnosis eleven years before, and who is still able to go to church and to the opera, although the uterus is almost completely destroyed.2 For Germany these high 1 According to Blau, out of ninety-three patients, forty-eight died of marasmus, twenty-seven of peritonitis, eleven of pneumonia, three of pleuritis, three of embolism of the pulmonary artery, and one each of pyelonephritis, fatty degeneration of the heart, gangreno of the lungs, and pyelophlebitis. 2 The courtesy of Prof. Barker enables us to state that the patient referred to in the text died in October, 1874, or twelve and a half years after the diagnosis of cancer was made. Bladder and rectum were thrown into one common cloaca with the vagina. —Trans. CANCER OF THE UTERUS. 287 averages are certainly not appropriate ; we are obliged to assume with Gusserow that carcinoma of the cervix leads to death in from twelve to eighteen months after the first symptoms. Diagnosis. Properly speaking, the diagnosis is attended with difficulties only in the first stage, when the carcinoma is not yet broken down ; for, up to that time, it is difficult to distinguish it from homologous hypertrophy of the vaginal portion. The following indications are important for the differential diagnosis between these two conditions: The consistency of carcinoma is unyielding, although not always very hard, while old connective-tissue growths are occa- sionally harder, although they always remain somewhat elastic. In the same way the latter affect the tissue of the cervix quite uniformly, while the inelastic hard nodules, lying in approxi- mately normal tissue, are characteristic of carcinoma. We must, of course, guard against mistaking the nodules for swollen follicles, which may feel like them. The state of the mucous membrane is characteristic of the heterologous growth, for, unless ulcerated, it appears to be firmly attached to the subjacent tissue, and not movable upon it. In" Waldej^er1 s words, "it is fastened by the epithelial plugs to the subjacent tissue as if with little nails." Further than this, carcinoma is very early found not to be confined to the cervix, like simple hypertrophy of the cervix, but involves the connective tissue of the vault of the vagina, so that the boundaries of the cervix appear completely obliterated ; while, on the other hand, in simple hypertrophy, the cervix, though thick, is still clearly perceptible, and can be felt dis- tinctly defined from the surrounding connective tissue. Spiegelberg' calls attention to the different behavior towards the sponge-tent in these two conditions, for while the sides of the cervix, when simply hyperplastic, will soften and yield under its action, they remain completely unaltered when the seat of carcinomatous degeneration. 1 Arch. f. Gyn., Bd. III., p. 233. 288 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. In the matter of diagnosis it is not unimportant to bear in mind that we very rarely have an opportunity to see carcinoma at so early a stage; consequently in doubtful cases we are almost invariably dealing with benign changes. Besides, carcinoma of the cervix may exceptionally occur in quite a different way. Thus Hegar1 observed that the carcinomatous degeneration, in a patient sixty-eight years old, had produced such an hypertrophy of the cervix that the vaginal portion protruded to the extent of three centimetres (1-J- in.) outside of the vulva, while the mucous membrane was wholly intact. The soft consistency of the tumor was suspicious, as well as its rapid development at so late a period of life. At the autopsy of a woman on whom ovariotomy had been performed, I have myself accidentally discovered a medullary carcinoma in the upper part of the cervix. This, being in great pait broken down, formed a cavity over which the mucous membrane of the cervix passed smoothly, while the vaginal portion remained completely normal. The ovarian tumor did not contain a trace of a suspicious neoplasm, while a gland in the broad ligament, and the retroperitoneal glands were infiltrated with carcinoma. The ulcerated carcinoma, which almost exclusively comes under the attention of the physician, presents no further diffi- culties in diagnosis. Only occasionally will ulcerating fibroids or polypi be con- founded with cancer, a mistake only to be guarded against by very thorough examination. The question how far the carcinomatous infiltration has al- ready extended is usually very difficult to determine, for fre- quently the first epithelial forerunners, or sometimes even larger growths, have gone very much further than was believed on examination. In the connective tissue of the pelvis, particularly, will the neoplasm often be found to have gone much deeper than the appearances indicated. Prognosis. Unfortunately we shall scarcely ever be mistaken in any single case, in which the diagnosis is well established, if we regard, the prognosis as absolutely unfavorable; for a cure by nature unaided hardly ever occurs, and even after operation 1 Virchow's Archiv, 1872, Bd. 55, p. 245. CANCER OF TnE UTERUS. 289 recovery is extremehy rare, though it may be because patients are operated on too late. In addition to this, the condition of the patients is always a very deplorable one, and is often unex- pectedly prolonged and accompanied by intolerable pain, by almost complete loss of sleep, by shocking emaciation, and by a smell which is intolerable not only to those around, but to the patient herself. In other cases, again, a sudden death by perito- nitis or pneumonia brings the wished-for end of these intolerable sufferings. " Treatment. As a matter of course, the radical removal of the carcinoma is to be aimed at in the first place, although unfortunately this is very seldom accomplished. This must be done entirely by oper- ative means, for up to the present time we know of no internal remedies capable of changing this abnormal direction of the cell- growth, for even cundurango is being forgotten again. And besides, at the very beginning of the carcinomatous growth, when we have to do with a decidedly local disease, no result is, a priori, to be expected from internal remedies acting through the general system. The operation is done from the vagina.' The most is to be expected from it when we have to deal with a pedunculated tumor springing from the vaginal portion, which has not yet penetrated far into the substance of the lip ; for instance, a can- croid or the malignant form of cauliflower excrescence described by Clarke. (See Fig. 96.) In such cases it is undoubtedly our most urgent duty to remove the tumor as quickly as possible, that is, while the patient is still in good health. The operation is most conve- niently done when the uterus can be drawn so far down as to bring the seat of the amputation in front of the vulva. Of course this artificial prolapsus can be made use of only in cases where the carcinoma is implanted on the cervix by a pedicle, 1 We need not speak of the operative treatment by the removal of the whole uterus by laparotomy, as, of course, this operation can be done only when the vaginal portion at least can be left behind, while in carcinoma thia is the very part affected, and the one which must first be removed. VOL. X.—19 290 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. and the vault of the vagina is wholly free, and even then only when the uterus yields to moderately strong traction exercised by a noose of thread, or, better, by the double forceps of Muzeux. The uterus is then held in a fixed position by a force applied above the site of the incision, the tumor cut off with the knife or scissors, and the wound thoroughly cauterized with the hot iron. This last we are absolutely required to do, although we believe that we have operated in perfectly healthy tissue, for microscopic cancer-nests may have pushed quite far into tissue otherwise healthy. If the operation has to be performed in situ, it is best to divide the cervix by the wire ecraseur or the galvano-caustic loop, unless we wish to employ the sharp spoon, to be presently described ; for the chain ecraseur must decidedly be rejected, as it is apt to tear off at the same time the neighboring mucous membrane. The operation, however, cannot be performed, under these circumstances, with the knife and scissors, without con- siderable loss of blood, and this, as a rule, must be strictly avoided. The cut surface, even when made by the wire, and when it does not bleed, must likewise be cauterized with the hot iron. It is true that cases very rarely make a perfect recovery, even when operated on under these conditions. The following cases of complete recovery after operation on pedunculated carci- noma have been witnessed: Ziemsse^Virchow's Archiv, 1859, Vol. 17, p. 333 (death from pneumonia after seventeen years); C. Mayer, Langenbeck, Martin, M. f. Geb., Vol. 18, p. 16 ; Mikschik, Zeitschr. d. Ges. d. Wiener Aerzte, 1856, p. 52 (death from cancer of the stomach after ten years); Simpson, Clin. Lee. on Diseases of Women. Edinb., 1872, pp. 178 and 199 (destructive cauterization by sulphate of zinc); Boul- ton, e. 1., p. 201 (destroyed by chloride of iron); Barker, loc. cit. (acid nitrate of mercury); Weatherby, New Orleans J. of Med., Oct., 1869; Mettauer, Boston Med. and Surg. Jour., March 10, 1870 (acid nitrate of mercury); Scharlau, Berl. Beitr. z. Geb. u. Gyn., II., p. 23; Martin, Berl. klin. Woch., 1873, No. 28 (two cases); Byrne, Amer. Jour, of Obstet., V., p. 727, and VI., p. 112; and my own case, represented in Figs. 96 and 97. If the disease has advanced further, so that the neoplasm has gone high up in the cervix, or has extended to the connective tis- sue of the vault of the vagina, the chances of preventing relapse CANCER OF THE UTERUS. 291 by a radical removal are very slight. Still, in view of the dread- ful prognosis of an advancing carcinoma, it appears to be our urgent duty always to make a new attempt at complete extirpa- tion of the cancerous infiltration in all cases that offer any pros- pect of improvement. It is so much the more indicated because, even in case of further development of the carcinomatous por- tions which are left behind, a very complete removal of the degen- erated masses, with subsequent cauterization, has a decidedly favorable effect upon the course of the disease. Xot only is there a cessation of the hemorrhages and ichorous discharge for a con- siderable time, and also, in some cases, a remission of the pain, but if the removal and cauterization have been thorough, the new growth, as a rule, makes slower progress. The knife and scissors certainly are not alone sufficient for such a thorough extirpation, for the neoplasm penetrates into the healthy tissue in wholly irregular processes. The best mode of operating is to remove as much of the tumor as possible by some one of the methods in use, and then to endeavor to destroy the remaining parts by caustic. With the view of destroying, at the same time, as little healthy tissue as possible, we must select such caustics as act particularly upon epithelial formations, upon the carcinomatous masses in fact, and less upon connective tissue. As such an article Simpson' formerly made use of sulphate of zinc. Skene2 recommends the chloride of zinc, of which he makes up a paste with starch, and inserts small pieces of this, when dried, into incisions in the dis- eased parts. I have been employing, for over a year, the local treatment by means of an alcoholic solution of bromine, as proposed by the English; it has produced such admirable results that I can recommend it with the fullest confidence. I use this treatment in all cases in which the destruction of tissue is not already too considerable, because this caustic, as shown by the investigations of Henneberg,s has the property of acting with especial destructiveness upon the cancer-nests, and because I have seen relatively superior results from its use. ' Med. Times, Jan. 17, 1857. * Amer. Journ. of Obsts., II., p 218. 3 Dis. inaug. Erlangen, 1874. 292 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Routh' first recommended the alcoholic solution of bromine against carcinoma uteri, in 1866. He mixes ten parts of alcohol with one part of bromine (which must be done carefully for fear of explosion), soaks tampons with this solution, and applies them to the cut surface, leaving them pressed against the part for forty-eight hours. Wynn Williams 2 employs one part of bromine to five of alcohol, and in case of a superficial carcinoma applies this mixture, with a tampon of cotton, to the ulcerated spot, or, in case of more solid growths, injects it into the tumor itself. In the former case he covers the tampon with india-rubber, and allows it to remain for a variable length of time—from ten minutes to two hours,—after which he uses vaginal injections of the bromine solution very much diluted. He protects the organs of smell by small pledgets of cotton soaked in a solution of soda. The strong solution gradually loses its color, but, according to Wynn Williams, does not lose its efficacy, a statement which my own experience forces me to consider highly questionable. Where the carcinoma is more advanced, we proceed with the operation in the following manner: If the carcinomatous infiltration of the cervix and its sur- roundings no longer permits of the artificial prolapsus, the oper- ation must be performed in situ. If tumors of considerable size are present, they must be removed as thoroughly as possible by the scissors, the wire ecraseur, or the galvano-caustic loop. In the absence of such tumors, and where we are dealing more with cancerous ulcerations than with a new growth, or where perhaps the degenerated cervix forms such a short stump that it cannot well be got at, we can employ, with great benefit, Simon's sharp spoons (see Fig. 102) to scrape away as much of the neo- plasm as possible. In cases in which the carci- noma has rather a medullary character, this makes very thorough w^ork, so thorough, in fact, that we cannot employ the hot iron after- wards, as we may have already forced our way with the spoon into dangerous proximity to the bladder, rectum, and peritoneum. I have pene- Simon's sharp spoons. trated so far with the spoon that the newly formed excavation was for a considerable space separated from the bladder, as well as from the rectum, only by the intact 1 Lancet, 1866, II., No. 17; London Obst. Tr., 1867, Vol. VIII., p. 290; and Brit. Med. Jr., Feb. and March, 1870. a London Obst. Tr., Vol. XII., p. 249. CANCER OF THE UTERUS. 293 mucous membranes of those organs. But if the connective-tissue constituents are more largely present in the neoplasm, we cannot so well scrape away the masses with the spoon, for the connec- tive tissue of the tumor offers the same resistance as the normal tissues. In these cases, especially if it is easy to feel portions of the neoplasm that have been left behind, I employ the hot iron in the most thorough way immediately after the extirpation. One iron after another (ordinarily from twenty to thirty) is applied to the parts that are left, until all the diseased tissue seems to be burnt away, and a deep crater made in the cervix. So soon as the eschar begins to separate, the concentrated alcoholic solution of bromine (one part bromine to five of alcohol) is applied to the wound, so as to destroy, as far as possible, the remaining cancer-nests which have entered the healthy parts. A tampon of cotton, well soaked in the solution, is pressed against the wound, and retained in place by another tampon covered with bicarbonate of soda. The bicarbonate of soda neutralizes the bromine which escapes, and thus prevents any excoriation of the vaginal walls. Still it is not necessary to guard with too great care against the sound parts being moistened by the bro- mine solution, for it only burns the mucous membrane, and never causes any deeper destruction. Whilst formerly I al- lowed the bromine tampon to remain for but a short time in con- tact with the surface of the wound, I now allow it to stay for twenty-four hours. If sizable knobs of the cancer are still left behind, or if new growths show themselves, I inject the bromine solution with a hypodermic syringe, furnished with a long needle, directly into the parenchyma of the neoplasm, in exactly the same way as it has long been recommended to do with acetic acid or nitrate of silver in solution. After this, quite large pieces of the neoplasm are cast off in a gangrenous state. I repeat the application of the caustic at intervals of at least eight days, and between times use injections of a weak solution of bromine—say of bromine one part, alcohol five, dis- tilled water five hundred. Sharp spoons have formerly been employed for other purposes, as by Sedillot for scraping out carious bones, and by Volkmaun for scraping away ulcers. Reca- 294 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. mier proposed his curette for scraping away simple granulations from the inner surface of the uterus. Sir James Y. Simpson, too, according to a note by Alexander R. Simpson, the editor of the Clinical Lectures on Diseases of Women, was in the habit of scraping away, with the finger-nails or a curette, carcinoma which was already far advanced, so as to check the local progress of the neoplasm, and enable patients to recover from the exhaustion caused by the discharges. Lately Simon has recommended a set of sharp spoons, of various sizes, for scraping away car- cinoma from the cavities of the body; and we must admit that this process is one easily employed, certain, and comparatively free from danger, for the spoons scrape away only the carcinomatous and not the healthy tissue. Munde * also has made favorable experiments with them. It still remains uncertain whether a radical cure will be effected more frequently by the proceeding we have described than by the methods hitherto in vogue. In one case (see Figs. 96 and 97) the patient recovered, and has as yet, after a year and a quarter, had no relapse, though, to be sure, being a cancroid, which was pedunculated, and sprang from the anterior lip, it presented a favorable opportunity. In another case, in which the infiltration had already in part extended to the pelvic con- nective tissue, the patient died from a peritonitis unconnected with the operation, and at the autopsy no further trace of can- cerous structure was found under the microscope. In the cases which I have since treated in this way, it is true I have not again obtained a perfect cure, but in all of them the degeneration had already extended high up in the cervix and far into the pel- vic connective tissue. This much, however, is certain from what I have seen, namely, that the bromine solution has a most excellent local effect. I have even attained a perfect local cure in the above- mentioned case, where an enormously broad wound was made with the sharp spoon, extending to the bladder and rectum, so that on examination with the speculum nothing but healthy mucous membrane was to be seen, while, however, the neoplasm was still advancing in an upward direction. Such a local result cannot be too highly esteemed, for the hemorrhages and fetid discharge cease, and, as a result, the nutrition is essentially improved, and the strength increases. 1 Berl. Beitr. z. Geb. u. Gyn., 1872, B. I., p. 17. 8 Amer. Jour, of Obst., V., p. 309. CANCER OF THE UTERUS. 295 I am therefore most decidedly in favor of a thorough oper- ation, even in cases where we cannot hope to remove all the diseased tissue, and I cannot agree with Spiegelberg' that the depressing influence of the operation is greater than the advan- tage gained by it; on the contrary, I consider the operation as precisely indicated by the hemorrhages, for generally the very moderate loss of blood during the operation is less than other- wise occurs in the space of a few days, and the spontaneous hemorrhages are with greater certainty checked for a consider- able time by the operation. Even by simple amputation, with subsequent energetic appli- cation of the hot iron, extraordinary results are often obtained, for the intense cauterization may so change the character of the tumor that actively growing and rapidly ulcerating forms of medullary cancer become firmer scirrhous forms. To this end it is, of course, necessary that the hot iron be vigorously used, so that the wound may heal with a firm cicatrix, for the iron, when only superficially used, merely acts as a new excitant to increase the luxuriant growth. Still better results have been attained by the after-treatment with bromine, for in this way the chances of radical removal are improved, and, in any event, the local healing takes place with wronderful rapidity. This treatment is no longer applicable when the destruction has made marked progress, particularly if perforations into the bladder or rectum are already present or threatening. In such cases, as well, of course, as in those where operative treatment is not considered to be indicated, or is not consented to, we must meet the symptoms in another way. The most dangerous ones are the hemorrhages, and these can only be averted for any length of time by operation. If that is out of the question, a solution of the chloride of iron is the most efficient resource. The most convenient and energetic way of using this is simply to pour the fluid into a milk-glass speculum, in the upper end of which the cancerous growths are engaged, and allow it to act for some minutes. Inconsiderable hemor- 1 Arch. f. G., Vol. V., p. 411. 296 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. rhages may be arrested by the injection of cold water and vine- gar ; the advantage of this proceeding being that patients can use it themselves. The same is the case with diluted solutions of chloride of iron. Even suppositories of tannin may check slight hemorrhages. The internal administration of chloride of iron, ergot, and the like, is of but little use in these hemorrhages, and the use of the tampon is not to be recommended, because it is generally effective only so long as it remains in position, and because it increases the ichorous discharge. Very imperfect success attends the effort to disguise the offensive smell of the ichorous discharge by means of substances with an agreeable odor. It is decidedly moderated by taking pains to syringe out the vagina frequently, so that the secretion does not stagnate. If we employ disinfecting substances for this purpose, such as bromine, carbolic acid, or permanganate of potash, we may succeed, even in extensive ulceration, in making the condition of patients endurable in this respect. The bad effects which follow the excoriation of the vulva and inner sur- faces of the thighs by the fetid secretion, are prevented no less by these injections than by the closest attention to cleanliness and by lukewarm sitz-baths. Pain, which is the most unendurable symptom present in many cases, is in general to be treated in the ordinary way. Still, it is well not to accustom patients to the use of morphine until as late as possible, for the most incredible quantities of this drug are often required when the later stages of the disease are much prolonged. Besides the internal and subcutaneous use of morphine, rectal suppositories containing it are particularly recommended, or small clysters (of about one and a half fluid ounces) containing from ten to fifteen drops of the tincture of opium. Chloral, too, will often procure a quiet night's rest. In these very cases of carcinoma of the uterus, iodoform has been recommended by Demarquay, Barker,1 and Volker.4 Sup- positories made up according to the formulas mentioned are to be inserted into the vagina. 1 Loc. cit. Iodoform, gr. x. ; but. cacao, 3 i. ; glycerine, gtt. v. 3 Bull, gen de therap., 1869, Dec. 15. Iodoform, gr. viij. ; but. cacao, 3 ijss. CANCER OF TIIE UTERUS. 297 It is moderately useful in some circumstances to allow vapor of chloroform or carbonic acid gas to flow into the vagina. It is particularly important in cases where considerable can- cerous masses encroach upon the calibre of the rectum to exer- cise continual care to secure soft faeces. Attention must also be paid to the urinary secretion. When the quantity of urine is remarkably small, before vomiting occurs, I recommend the drinking of large quantities of carbonic-acid water, or order other diuretics. The loss of strength and the establishment of the cancerous cachexia may often be long prevented if we are careful to secure good nutrition by moderate exercise, by stay in the fresh air, and invigorating food, and, at the same time, to check the loss of nutrient fluids through hemorrhagic and serous discharges, in the ways already recommended. CARCINOMA OF TIIE BODY OF TIIE UTERUS. Simpson, Edinb. Med. J., April, 1864, and Select. Obstet. and Gyn. Works. Edin., 1871, pp. 763 and 768.—Szukits, Zeitschrift d. Ges. d. Wiener Aerzte, 1857, p. 414.—Strobel, Ein Fall von Carcinom des Uterusgrundes. Diss. Inaug. Er- langen, 1857.— Wagner, Der Gebarmutterkrebs. Leipzig, 1858, p. 122.—Fbrster, Scanzoni's Beitr., 1860, IV., p. SO.Saxinger, Prager Vierteljahrs., 1867, 1, p. 118.—Blau, Einiges pathol.-anat. uber den Geb;'irmutterkrebs. Diss. Inaug. Berlin, 1870 (Fall 17, 32, 33, 34, 51, 88).— Spiegelberg, Arch. f. Gyn., Bd. VI., p. 123. In the first place, we will remark that it is extremely difficult to present a picture of carcinoma of the body which shall be at all trustworthy, from the very few observations we have which are to be depended on. Besides two, observed by myself, I have hunted up from the literature of the subject a series of cases which seem to be trustworthy, and from them I sketch the features of the disease. Etiology. It is certain that carcinoma of the body is of extreme rarity, compared with that of the cervix. It is very difficult to speak more fully about its frequency, because, on the one hand, the reports of observers differ very much, and, on the other, the more 298 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. frequent sarcoma of the body of the uterus has not seldom been confounded with carcinoma. Szukits asserts that out of four hundred and twenty cases of carcinoma of the uterus, treated in the female division of the hospital at Vienna, only one was found in the body, while Blau describes six out of ninety-three cases. Inasmuch as the rarer cases come more frequently under the observation of clinical teachers than ordinary ones do, the reports of autopsies only are useful in determining the frequency of this neoplasm. If we add together the numbers given by Blau, Eppinger, Szukits, Lebert, and Willigk, we find that of 686 carcinomata of the uterus, thirteen, or not quite two per cent., had their seat in the body. Carcinoma of the body is, far more than that of the cervix, a disease of advanced life, since in the great majority of cases it first occurs after the menopause. I find that in eighteen well- marked cases, in which the ages are given, no single case was younger than forty years ; only six were between forty and forty-nine ; nine between fifty and fifty-nine, and three between sixty and seventy. A very important etiological difference from carcinoma of the cervix, moreover, consists in this, that, like sarcoma, the malignant disease of the body occurs with striking frequency in nulliparous women. Out of thirteen cases, in which statements are made on this point, five had never borne a child ; one had borne a child once ; three, twice; one, three times, and three are simply indicated as multiparse. Pathological Anatomy. Carcinoma of the body of the uterus is met with under two different forms. It occurs either in circumscribed roundish foci in the parenchyma of the uterus, or as a diffuse carcinoma- tous infiltration, which gradually involves the whole body and fundus. The round nodules of the first form are of the size of a hazel-nut, a walnut, or larger ; they very readily become soft- ened, and, when broken down from necrosis, sometimes perfo- rate into the cavity of the uterus, where they can be felt as friable masses, and are gradually cast off. Sometimes they make their way outwards, instead of inwards, and then the per- CANCER OF THE UTERUS. 299 foration is very commonly preceded by adhesions to adjacent organs, or may be shut in by pseudo-membranes. On the other hand, acute peritonitis, from perforation, often occurs with a fatal result. There may, however, be adhesion to and perfora- tion into various parts of the intestine or into the bladder; in fact, by these excluding pseudo-membranes a completely new, sac-like space may form between the posterior wall of the pel- vis and the symphysis, in which lie the broken-down masses shut out from the abdominal cavity, so that gradually almost the whole body of the uterus may be destroyed, and in its stead may be found a newly formed cavity, with gangrenous contents. The diffuse infiltration of the body of the uterus (see Fig. 104) undergoes destructive disintegration much less readily, so that here we find a much greater formation of carcinomatous tumors. Still, the mucous membrane of the uterus being forced together from every direction, soon becomes necrotic, and thus the starting-point of the suppuration and necrosis of the neo- plastic masses is the uterine cavity. Carcinoma may extend, secondarily, by direct propagation, to the cervix, as well as to all the rest of the neighboring organs, such as the peritoneum, bladder, intestine, tubes, or ovaries. There are also frequent metastases to other organs, especially the vagina, the glands, and the ovaries. Symptoms. As in the case of carcinoma of the cervix, the first symptom is apt to be a hemorrhage. Besides this, there is almost invari- ably an offensive discharge, sometimes abundant and watery, in other cases more puriform. But the discharge may also be like the washings of meat, and not in the least degree fetid, and the hemorrhages and discharge may even be almost completely absent. The secretion becomes most offensive when the softened carcinomatous nodules are emptying themselves into the cavity of the uterus, and being gradually expelled from it, as they are by pains resembling those of labor. The pains, too, may behave in various ways. In many cases 300 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. they are wholly wanting, or there are no pains which are at all peculiar to carcinoma, but only such as are caused by other uterine tumors: especially pains in the back, and often severe pains in one or both of the lower extremities. The paroxysms of pain of great intensity, occurring at a certain hour of the day, which Simpson represents as characteristic of carcinoma of the body of the uterus, are not, strictly speaking, frequent; they are to be considered as uterine colic, called forth by the abnormal Fig. 103. Plo> 104 Carcinoma of the body, which has increased Carcinoma of the body. The case shown in Pig. 103, after the sxze of the uterus uniformly. the suicide of the patient, which occurred two months later. a, carcinomatous new formation: b, breaking down of the same; c, nodules of cancer projecting somewhat out- wards ; d, lower border of the new formation ; e, lower part of the cervix in normal condition; /, vagina. contents of its cavity. These contents may consist of cancerous masses discharged into the cavity of the uterus, though the new growth itself may also act as abnormal contents, distending the organ powerfully by its development; or the canal of the uterus may be so obstructed by the neoplasm that the secretion of the mucous membrane is retained. To these are subsequently added the pains of peritonitis, CANCER OF TIIE UTERUS. 301 which arise if the neoplasm invades the serous investment of the uterus. On examination, the uterus is found, even at the beginning, moderately enlarged (see Fig. 103); later on, single, knob-like I prominences may make their appearance on it, or it may no longer be distinctly outlined, owing to the numerous adhesions with the neighboring organs. The increase in size is generally but moderate, but it may attain a size equal to that in the later period of pregnancy. On internal examination, the cervix is usually found to be unaltered; but it may also be permeable, or at all events be capable of being easily dilated, so that in such a case the carcin- omatous masses always present in the cavity may be felt, and portions removed. The reaction upon the general condition often does not occur till quite late, so that in the beginning the nutrition may be per- fectly good. Diagnosis. Great difficulties are often presented in recognizing the new growth as malignant, unless fragments of the tumor have escaped from the cavity of the uterus. If we have uniform enlargement and no fetid discharge, the tumor can be easily distinguished as a fibroid. Yet, in the case represented in Fig. 103, in which there was no offensive discharge, I was able to fix upon the diagnosis of a malignant neoplasm, because the uterus, uniformly enlarged, exhibited a very remarkable, tense, firmly elastic dis- tention, such as I had never felt with fibroids, but only in haematometra and hydrometra. Now, inasmuch as the latter could be excluded with certainty, and as I could assume a priori that a malignant neoplasm would distend the uterine walls more forcibly than a benign one, I diagnosticated a sarcoma ; at the autopsy, however, which was made at quite an early stage, owing to the suicide of the patient, the carcinomatous infiltra- tion was found which is shown in Fig. 104. It still further indicates a malignant neoplasm if the uterus, having at first been uniformly enlarged, acquires irregular pro- tuberances and contracts adhesions with neighboring organs. 302 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The diagnosis becomes easier if a fetid discharge sets in. Nevertheless, the diagnosis of a malignant neoplasm is not even then certain, for we may have to deal with a fibroid undergoing destructive degeneration ; and even if everything is in favor of the malignancy of the tumor, still sarcoma of the mucous mem- brane of the uterus may furnish perfectly analogous symptoms, so that carcinoma cannot be diagnosticated positively until pieces of the growth can be placed under the microscope. Treatment. These patients, being doomed to certain death, are only to be treated symptomatically, for the seat of the evil cannot be reached. At all events, it must for the present be left wholly undecided whether and how far the extirpation of the uterus by laparotomy is justifiable when the diagnosis is established with certainty at an early stage. Such a procedure is rational, if the new growth has attacked the body only, since then we may hope to remove the malignant neoplasm completely by an operation which, while certainly dangerous, is not necessarily absolutely fatal. The discharge, if fetid, cannot be deprived of this quality, so that we are limited here to the protection of the vagina and external genitals from the irritating effect of the ichorous secre- tion by means of purifying injections. In many cases, however, it becomes our duty to assist the efforts of nature to expel the masses which have escaped into the cavity of the uterus, by dilating the cervix with sponge-tents, and by removing any portions of the neoplasm within reach by the finger or the sharp spoon. In this way a remission of the worst symptoms, such as the ichorous discharge, the pains and hemor- rhage, is often secured, and a week, or even a month, of steady improvement gained. SARCOMA OF THE UTERUS. Mayer and Virehow, M. f. Geb., Bd. 13, p. 179.— Virehow, Die krankhaften Ge- schwiilste, Bd. II., p. 350.—L. Mayer, M. f. Geb., Bd. 17, p. 186—Hardy, SARCOMA OF THE UTERUS. 303 Dublin Journal, May, 1864.—Ahlfeld, Wagner's Archiv f. Heilk., 1867, p. 560. — Veit, Frauenkrankheit., 2 Aufl., p. 413.— West, Lectures on Diseases of Women. London, 1864.—Langenbeck, M. f. Geb., Bd. 15, p. 173.—Sclyphas- sowsky, Virchow-Hirsch'scher Jahresbericht liber 1868, p. 604.—Gusserow, Arch. f. Gyn., Bd. I., 2, p. 240, and iiber Uteruscarcinom in Volkmann's klin. Vortr., No. 18, p. 117.—Hegar, Arch. f. Gyn., Bd. n., p. 29.— Winkel, Arch. f. Gyn., Bd. III., p. 297.— Spiegelberg, Arch. f. Gyn., IV., pp. 344 and 351.— Chrobak, Arch. f. Gyn., IV., p. 5±$.—Rabl-Ruckhard, Berlin. Beitr. z. Geb. u. Gyn., Bd. I., H. 2, p. 7G.—Kunert, Ueber Sarkoma uteri. Diss. Inaug. Breslau, 1873, and Arch. f. Gyn., Bd. VI., p. 111.—Miiller, Arch. f. Gyn., Bd. VI., p. 126. Sarcoma of the uterus occurs in two forms, which are quite distinguishable from one another in their pathological anatomy as well as clinically, and we agree with Waldeyer in regarding it as a pure connective-tissue tumor. One form is sarcoma of the mucous membrane, which forms diffuse growths whose tendency is to encroach upon the cavity of the uterus, and the other is sarcoma of the uterine parenchyma, which develops in a way precisely similar to myoma and polypi of the uterus, and which we shall consequently designate as fibroid sarcoma. Sarcoma of the Mucous Membrane. Etiology and Mode of Occurrence. The causes of its formation are completely unknown. We find in the literature of the subject sixteen cases which undoubtedly belong in this category, in which the nature of the tumor was fully established by microscopic examination. Still to this neoplasm belong by far the greatest number of those not very rare cases in which villous papillary "cancer-masses " have either been removed from the cavity of the uterus or found in it. Typical cases of this kind are to be found, e.g., in Simpson.1 Sarcoma seems to occur at every period of life from puberty onwards. Among the sixteen cases just mentioned tliere was one patient of fifteen years and one in her twentieth year, three were between thirty and thirty-nine, four between forty and fortv-nine, five between fifty and fifty-nine, and one each of 1 Diseases of Women, p. 764, Cases I. and II. 304 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. sixty and sixty-one years. Among fourteen patients, where the history touched upon this point, eight (!) had never borne a child. Pathological Anatomy. The sarcomatous proliferation appears in these cases to spring from the submucous connective tissue of the cavity of the uterus, or, as in the sixth and eighth of Spiegelberg's cases communicated by Kunert, from the cervical mucous membrane. Under the influence of a new growth of small, round, rarely spindle-shaped cells, a soft, flabby, or villous tumor develops, which grows inwards into the cavity of the uterus. Thence it may be expelled into the cervix or vagina by the contractions of the uterus. It generally ulcerates only at a late stage, and per- haps only in consequence of the pressure exerted by the uterine walls. -Sarcoma of the mucous membrane may, however, destroy the wall of the uterus secondarily by further proliferation and by destructive pressure upon it, or even by direct infection. Gusserow's1 case is very strange, and it certainly belongs here, and not to the next variety. In that case a soft neoplasm, springing from the uterine mucous membrane, grew through the upper wall of the uterus (apparently by infection of that part) into the abdominal cavity, wThere, separated from the other organs by an enveloping sac,' it broke down, and ultimately perforated into the intestine and through the abdominal walls. The formation of metastases is rare. Symptoms. Here, too, the first symptoms consist of hemorrhages and a watery discharge. The latter may be astonishingly abundant, but it is only toward the last that it has a very offensive smell. In the first stage it is more like the washings of meat, stale or slightly offensive. The pains may be entirely absent or quite insignificant. Only when the uterus prepares for the expulsion of the new •Loc. cit., p. 242. SARCOMA OF TIIE UTERUS. 305 growths, do pains like those of labor set in in the back and abdomen. On examination we find the uterus moderately enlarged, some- times only slightly thickened, the cervix usually closed. This latter may, however, open enough to allow of the passage of the finger, and to permit us to feel the soft masses of the tumor in the uterine cavity, or these may themselves project in considera- ble masses through the dilated cervix into the vagina. In the latter case, the uterus may even be secondarily inverted, as shown by cases of this kind reported by Langenbeck and Spie- gelberg. Diagnosis. The diagnosis cannot be established with certainty until masses which have been expelled or have scaled off can be placed under the microscope. Still, in view of the infrequency of car- cinoma, we shall not be likely to go astray in our diagnosis, if, with moderate enlargement of the uterus and a discharge of blood, or one resembling the washings of meat, we feel soft masses of tumor through the dilated cervix—provided we can exclude a retained placenta, with which it might very easily be confounded. Without a thorough microscopic examination it is also difficult to avoid confusion with benign Iryperplastic growths of the uterine mucous membrane, which present a tissue like the decidua, very similar histologically to carcinomatous tissue. Such tissue as is due to development of the uterine glands also presents an appearance under the microscope more resembling carcinoma. Such cases have been described by Slavjansky and Duncan' and by Gusserow.3 Prognosis. The prognosis is indeed fatal in every case, although, by removing the soft tumor from the uterus, we may avert the bad s^ymptoms for a considerable time and retard a second formation 1 Edinb. Med. Journ., Aug., 1873, p. 97, and Obst. Journ. of Gt. Brit., Nov. 1873, p. 497. ■ Loc. cit., pp. 246 and 247. VOL. X.-20 306 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. of the masses. If the cervix is closed, it must be dilated arti- ficially, and as much as possible of the growth removed with the fingers, the curette, or the sharp spoons. Sarcoma of the Parenchyma of the Uterus. Etiology and Mode of Occurrence. The formation of the fibroid sarcoma appears to be due in some way to the presence of a round fibro-myoma or a fibrous polypus. At any rate, it not unfrequently proceeds from a degeneration of these. Under what conditions this occurs, how- ever, is wholly unknown to us. From the mere fact of its similarity in external character to the myomata, it has also been regarded as a recurrent fibroid. Fibroid sarcoma does not occur by any means so exclusively in advanced life as does carcinoma of the body of the uterus ; but in this, too, it has much greater analogy to the fibroid. We find that among eighteen patients one was indicated as young, two were between 20 and 29, five between 30 and 39, eight between 40 and 49, one between 50 and 59, and one was over 60 years old. Among fourteen patients three had never borne a child, three had had one child, and three others three children each; there was one who had had two children, one five, and one six, and two were simply indicated as multiparae. Pathological Anatomy. The fibroid sarcoma has the same predilection for the body of the uterus as the fibro-myoma, yet it may also, like the latter, arise from the cervix. It forms round or cylindrical tumors of considerable size, which are quite constantly seated in the sub- mucous tissue. The tumor is soft, and usually springs with a broad stem from the parenchyma of the uterus, with which it is continuous; upon section the cut surface appears pale, moist, and homogeneous, and reflects the light uniformly. All forms of sarcomatous polypi not having a very broad pedicle probably SARCOMA OF TIIE UTERUS. 307 always spring from degenerated fibrous polypi; at all events in the two cases referred to below I found the pedicle almost purely fibro-myomatous, with scarcely any suspicious admixture. On microscopic examination, we find the tumor either com- posed largely of the normal constituents of the fibro-myoma, with here and there, scattered throughout the mass, centres of cell-growth (round, or, in this form, very frequently spindle- shaped cells); or these centres of cell-growth constitute the entire mass of the tumor, being separated from each other by only scanty trabeculae of connective tissue. The tumors have no tendency to break down, although, like the fibrous polypi, they may be spontaneously expelled. Con- sequently they sometimes attain a very considerable size. In a case wdiich is still under my observation, where the diagnosis is scarcely open to question, although not yet confirmed by micro- scopic examination, the tumor reaches from the entrance of the vagina to above the navel. These tumors may extend by con- tinuity to the surrounding tissues and also, by metastasis, involve the lymphatic glands or other organs. Symptoms. In its symptoms the fibroid sarcoma entirely corresponds to the fibrous polypi; in fact, the resemblance in its whole charac- ter may be so complete that the homogeneous appearance of the section of the tumor may be the first thing to call attention to its malignant nature. Tliere are hemorrhages, as a rule, occurring either as menor- rhagia or metrorrhagia, and besides these, not infrequently other discharges, generally resembling the washings of meat, but at times somewhat purulent. This discharge has of itself no ich- orous offensive character, though it may become fetid, just as in the case of fibrous polypi, if the mucous membrane ulcerates. The tumor is not necessarily characterized by pain, so that sometimes its whole course is painless. But pains like those of labor usually occur in the back and loins when the uterus endeavors to expel the polypus. In the case mentioned above, when the tumor had attained an enormous size, there occurred 308 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS paroxysms of the most intense pain, which, however, were due to attacks of uterine colic caused by retention of the purulent secretion of the uterine cavity. Fio. 105 FIG. 100. Sarcomatous polypus (,SP) lyin The general condition after the operation was good; the pulse being 76. From the third day, however, the condition became worse, the wound gaped at the upper part and discharged thin, offensive secretion. The patient died on the eighth day. At the autopsy the pleuritic exudation of the left side was found to be discol- ored, offensive, and decomposed. There was also an abundant, sanious, and some- what offensive secretion in the abdominal cavity. The whole wall of the peritoneum was thickened from chronic inflammation and fibrinous deposits, the latter being partially detached. All the abdominal organs, especially the liver and spleen, were covered with thick, callous peritoneum. The case is diagnostically interesting, inasmuch as the peritoneal fluid very closely resembled cystic fluid, and because the thick, fibrinous masses, which had gravitated towards the true pelvis, suggested the diagnosis of extensive adhesions in the true pelvis. Ovariotomy may also become a really life-saving operation when sudden enlargement follows hemorrhage into the cyst, with the onset of acute manifestations of anaemia and peri- tonitis. * Spencer Wells 3 on two occasions arrived too late to operate under just such conditions, death having already oc- curred. Wiltshire,4 however, was enabled to save his patient by ovariotomy. The accompanying peritonitis is to be diagnosticated in the usual manner, especially by the tenderness of the abdomen, the elevated temperature, and a gradually accumulating exudation in the abdominal cavity. 1 Virchow's Archiv, B. 58, p. 35. 3E. 1., B. 59, p. 156. 3 L. c, p. 264. 4 Pathol. Trans, of London, Vol. XIX., p. 295. OVARIOTOMY. 411 In cases of suppurating cysts, also, tliere is tenderness; but it is limited to the cyst itself. The pulse is frequent and small, and the temperature exhibits evening exacerbations. Moreover, the cyst grows rapidly, and feels unusually hard in consequence of the increased tension. The rapid emaciation of the patient is also striking. The diagnosis of adhesions is, as a rule, very difficult to estab- lish. Those still in the true pelvis are the easiest to diagnosti- cate, and they are also by far of the greatest importance. If the pelvic entrance is felt to be uniformly filled with a firm mass, which adheres fast to the sides of the pelvis, and which is closely connected with the sides of the uterus, and if the latter organ is immovably fixed, extensive adhesions to the uterus and its neighboring organs are evidently present. Moreover, an unusu- ally high position of the uterus, as well as a decided elongation of its cavity, indicates that the tumor is adherent to the uterus ; for the pedicle, as a rule, is so long that the uterus remains in its normal position; at the same time this should not prevent us from performing the operation of ovariotomy, provided the uterus is fairly movable, and the pelvic entrance is not occluded by firm products of exudation. If, on the other hand, the uterus lies low down, is readily movable, and of normal length, and only the lower portion of the tumor can be felt in the superior strait of the pelvis, all thoughts of firm adhesions in the true pelvis may be excluded. The same indications are also valuable for determining the length of the pedicle, inasmuch as it is long under the latter conditions and short under the former. The determination of the presence of adhesions in the ab- dominal cavity itself is more difficult, but at the same time much less important. The history of the case must be taken into consideration, if the question is raised whether adhesions will be found during the operation. If the tumor has developed slowly and imperceptibly without inflammatory manifestations, if it has imperceptibly risen into the false pelvis as it in- creased in size, then it is likely that there will be no adhesions, even in the case of large tumors. If, on the other hand, unques- tionable symptoms of peritoneal irritation have appeared dur- 412 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ing the course of the disease, the existence of adhesions may be premised. Palpation also may furnish indications, inasmuch as the abdominal wall can be made to slide over the tumor, if there are no adhesions with the anterior abdominal wall. In cases, how- ever, of very great tension this indication may be indistinct; and it has no bearing on cases in which adhesions exist poste- riorly. If crepitation is felt on palpation, or a friction sound be heard on auscultation, the existence of firm adhesions may be safely excluded ; although, as the first of the two cases reported by me clearly showed, adhesions may become developed. The Operative Procedure. Before the operation is commenced the necessary preliminaries should be thoughtfully and carefully considered. In the first place, the operation should be performed in a healthy locality; best in a private house, or at least in a small hospital in which no infectious diseases prevail. The apartment should be large, light, easily ventilated, and free from all unne- cessary furniture. The bed should be prepared in as simple a manner as possible. The most suitable one is an iron bedstead, with a horse-hair mattress, and at most a small feather-bed. It is well to place two beds, exactly alike, near each other, so that the patient can be changed without any trouble. It is extremely desirable to have an intelligent, painstaking, self-sacrificing attendant—one competent to record the tempera- ture and use the catheter. For some weeks before the operation the patient, especially if not accustomed to keep her chamber, is to be treated as an invalid, in order to accustom her somewhat to that mode of life. Spencer Wells makes it an especial point that the opera- tion should not be performed on a patient who only passes but a little concentrated urine, until a considerable daily urinary secre- tion has been established by the administration of a lithium salt. In order to judge of individual deviations of temperature and pulse it is advisable to take regular morning and evening obser- vations for some days before the operation. OVARIOTOMY. 413 The chamber in which the operation is to be performed should be well warmed, but not too hot. Spencer Wells does not approve of keeping the apartment filled with steam,—a point on which English surgeons formerly laid great weight. The operating-table should be placed opposite a window, so that the operator, standing at one side of the table, may have the full advantage of the light; and, above all things, it must not be too wide, as it is very inconve- nient to operate over a broad table. A mattress should be placed upon the table, and the patient should be chloroformed while lying upon it. Spencer Wells warmly recommends chloromethyline as an anaesthetic ; he has used it in two hundred cases of ovari- otomy, and always with good results. Vomiting and sick headache, so common with chloroform, are exceptional with chloromethyline. The instruments (including those rare- ly required) should lie on a table near the operator. But few instruments are necessary for ordinary, uncomplicated operations : a sharp, bellied scalpel to divide the abdominal wall, a director to use in slitting up the peritoneum, forceps, Muzeux's double hooks or Nelaton's toothed forceps (Fig. Ill), by means of which the walls of the cyst may be firmly held, a very thick trocar for emptying the cyst, a clamp for fastening the pedicle in the wound, and, finally, ligature forceps, needles, and the best of ligature silk of different thicknesses. In more difficult cases it will also be necessary to have fine cauterizing irons, a clamp, armed with a poor conductor of heat, for restricting the action of the cautery iron, a wire ecraseur, and any other instruments that the circumstances of the case may require. Fig. ill. Nfilaton's forceps for seizing the walls of the cyst. 414 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. As to the trocar, it is well to use the one mentioned by Spen- cer Wells, which seizes the cyst externally by means of hooks, or else Veit's trocar, in which the hooks spring out from the inside (Fig. 112). Fio. 112. Veit's trocar, with the hooks extended for holding the walls of the cyst. There are a great many varieties of clamps. A good clamp must be able to hold its position well, even on delicate struc- tures, but must not have so sharp an edge as to cut. The pres- sure must not be unequal at both ends of the clamps, as is the case with clamps constructed on the principle of a pair of com- passes, but the two arms should work parallel, and the clamp should be so constructed that it will not allow the stump, when grasped, to spread out laterally to too great an extent. These requisites are best exemplified in the clamp devised by Atlee,1 in which the branches work parallel to each other, and the spreading out of the stump sideways is prevented by lateral needles ; and also in the clamp recently employed by Spencer Wells, by which the stump is pressed together concentrically. Fig. 113 represents the old, and Fig. 114 the new, clamp of Spencer Wells.2 The clamp used in connection with the application of the actual cautery, the so-called " cautery clamp," is employed to arrest hemorrhage from adhesions; but it is also applicable to the stump. In using it, the clamp is fastened provisionally either to the stump or to the mass of adhesions, the tumor is then burnt through with the hot iron, and finally the single 1 Amer. Jour. Med. Sci., April, 1871, p. 353. 3 Other clamps have been described by Storer (Boston Gyn. Jour., Vol. I., p. 212; III., p. 7 ; and VI., p. 265), by Leizareioitch (Boston Gyn. Jour., Vol. III., p. 85), and by Dawson (Amer. Jour. Obstet., IV., p. 304). OVARIOTOMY. 415 blood-vessels are separately cauterized with pointed cauterizing irons. In order that the iron should not burn too deeply, which it is especially important to avoid in cases of adhesions with the intestines, the upper surface of the clamp is covered with some poor conductor of heat, like ivory. The clamp protects the remaining portions, and the arrest of hemorrhage is far more certain than if each blood-vessel were separately cauterized, inasmuch as the blood-vessels are compressed by the clamp throughout a considerable extent. Fro. 113 Fig. 114. The old clamp of Spencer Wells. The handles can New clamp of Spencer Wells. The handles can be removed. be taken off, so that only the compressing ring • remains on the stump (see Fig. 115). We now pass to the technical details of the operation, and shall first describe it as it is usually performed in a simple, uncomplicated case. The operation is performed with the patient lying upon her back, in an easy position. All other positions, as for example the half-sitting one (Spiegelberg) or the lateral posture (Nuss- 416 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. baum), which have been recommended with a view of prevent- ing the escape of the cystic contents and blood into the abdomi- nal cavity, are unnecessary, inconvenient, and may readily lead to prolapse of the intestines. The English operators very conveniently cover the -patient with a rubber cloth, in which a large round opening has been cut out to accommodate the enlarged abdomen. The edges of this opening being fastened to the abdomen in a water-tight man- ner by means of strips of adhesive plaster, the fluids from the abdominal cavity and from the cyst, and also the blood, all flow down upon this rubber cloth, and thus the patient is protected from a wTetting. The bladder having been emptied with the catheter, the operator takes his position on the right side of the patient, and, with a strong knife, divides the abdomen through the linea alba. Only a short incision is made at first, from seven to fourteen centimetres in length, especially if it is known that the tumor is composed of but few solid parts ; the incision can readily be enlarged, if, during the course of the operation, it appears to be insufficient. The incision is so made that its lower angle is about five centimetres above the symphysis pubis. The abdom- inal wall should be divided gradually, the superficial layers being divided by separate strokes of the knife. First comes the external skin, then the subcutaneous connective tissue with the adipose layer, which varies greatly in thickness, and finally the fascia, which is loosely connected with the peritoneum ; after the fascia has been divided, the distended peritoneum appears in view. Before the abdominal cavity is opened, care must be taken that all hemorrhage has ceased. The hemorrhage is very slight, as a rule, and is controlled by ligating the small divided branches of the epigastric artery; the bleeding from the larger veins, if it has been found necessary to divide them, may be arrested by torsion or ligature. The next step is to raise the peritoneum with the hooked for- ceps, make a small opening in it, and then divide it upon the director throughout the entire length of the external incision. The bluish, glistening surface of the cyst, which now appears in the wound, is punctured with a large trocar, and the cyst OVARIOTOMY. 417 emptied of its contents. While the tumor is undergoing col- lapse, the assistants must press the abdominal wall closely upon it, so as not to allow the intestines or omentum to fall between the walls of the abdomen and the cyst. When the cyst is nearly empty, it is gradually dragged through the wound, either by means of the trocar, or by Muzeux's hooks or Xelaton's forceps ; a manoeuvre readily accomplished if it is empty and there are no adhesions. During the with- drawal of the cyst the remainder of its contents are emptied, so that the collapsed envelope of the cyst, when entirely with- drawn, is only connected by its pedicle with the organs in the true pelvis. The clamp is to be fastened closely around the pedicle, just beneath the tumor, and then the latter is to be cut off in such a manner that a short stump will still project beyond the clamp (if the tumor is cut close to the clamp, the pedicle may be- come withdrawn out of its grasp). If no blood or cystic con- tents have escaped into the abdominal cavity during the operation, sutures are to be ap- plied ; before doing this, how- ever, two fingers should be in- troduced into the abdominal cavity for the purpose of ascer- taining whether the uterus and the remaining ovary are in a normal or nearly normal con- dition. In applying the sutures the needles are to be passed through the entire thickness of the abdominal wall, so as to include the peritoneum, which is an important point. A suture is applied at the lower part of the abdominal wound, and then the pedicle, held firmly outside by the clamp, is to be pressed down against this suture, and a second suture placed directly VOL. X.—27 Fig. 115. The abdomiual wound after the operation. The pedi- cle lies inclosed within the clamp, at the lower angle of the wound. 418 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. over it. The remaining portion of the w^ound is to be united in the usual manner. If the skin gapes between the sutures, super- ficial stitches should be taken between the deep ones. The abdo- minal wound is thus completely closed, and the pedicle, firmly held by the clamp, lies at its lower angle (see Fig. 115). The operation then being finished, a greased cloth and a piece of flannel are placed over the wound. Very frequently, how- ever, the course of the operation is not so simple, as many seri- ous complications may render it much more difficult. In the first place, it may be difficult to recognize the perito- neum, as such, after making the incision through the abdomen. This may happen : 1. AVhen there is marked ascites ; after we have cut down to the peritoneum, this membrane may be forced forward by the free abdominal fluid and protrude into the wound, just like the wall of a cyst; 2. When the inflamed and thickened peritoneum has become unrecognizable in cases of chronic peritonitis ; 3. AVhen the peritoneum and the wall of the cyst have be- come adherent in the region of the incision. In such cases the fascia may be mistaken for the peritoneum, and the latter for the sac of the cyst, and in the belief that the peritoneum is already divided, the operator may actually begin to tear away the peritoneum from the anterior wall of the abdo- men. This is always an exceedingly disagreeable accident, although a case reported by Spiegelberg shows that the torn surfaces may again become adherent. It is therefore preferable in doubtful cases to cut through the supposed or true cyst. If the actual cyst has been cut through, tliere is no harm done, since, owing to the firm adhesion between the surface of the cyst and the peritoneum, the cystic contents cannot escape into the abdominal cavity, and the adhesions can be readily torn away when the cyst has been emptied, and in cases of very extensive adhesion are removable only in that way. If, however, the case is one of ascites, the operation has been performed in the only proper manner. In case adhesions are found throughout the whole extent of the incision, the incision is then to be lengthened until we find a OVARIOTOMY. 419 spot where the peritoneum and cyst are not united together. The separation of the adhesions is commenced at this point. This separation of the adhesions is to be performed, when they are loose, by introducing the hand between the cyst and the peritoneum, and simply separating the parts from each other. Even extensive adhesions can often be detached in this way without difficulty. If, however, there are some firm adhesions, especially on the posterior wall of the cyst, they may be disregarded until the cyst has been emptied. In tearing away firm adhesions, especial care must be taken that no portion of peritoneum and omentum, or, what is much less likely, of the intestine, is removed with them. It is better practice to leave portions of the cyst walls adherent to these organs. Only firmly adherent portions of the omentum may be excised when requisite ; but then care must be taken, of course, to arrest the hemorrhage from them. As a rule, however, it is better to dissect them up from the surface of the cyst. In case the multilocular cyst is not wholly emptied by the trocar, an effort should be made to reach the septa of the con- tiguous larger cysts with the canula, in order to penetrate them. If this effort is unsuccessful, and the tumor still continues to be very large, the remaining cysts must be punctured by another trocar, or by the same one ; great care being taken, in the latter instance, that the cystic contents do not escape into the abdom- inal cavity through the opening made by the first puncture. It is very desirable that the tumor should be drawn out through a small incision, inasmuch as the prognosis is rendered much graver in cases of very large incision. In five hundred cases of ovariotomy Spencer Wells had a mortality of 23.4 per cent, among cases in which the incision did not exceed six inches in length, and a mortality of 40 per cent, where it exceeded six inches. On the other hand, however, the forcible withdrawal of the tumor must be avoided, inasmuch as the crushed edges of the abdominal wound heal badly. It is better to continue the incision to the navel, and, under certain circumstances, even higher up, and to the left of the navel (on account of the round ligament of the liver). 420 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. "While the tumor is being gradually drawn out, the remaining adhesions are put upon the stretch and must now be separated. It is always best to separate them from the surface of the cyst by the fingers, the finger nails, or the handle of the scalpel. If this does not succeed, they must be divided, and the bleeding central ends either cauterized or ligated. If there are only insignificant vessels in the adhesions they can be simply divided either with a knife-like cauterizing iron or with the glowing platinum wire ; but if large vessels course in the adhesions, they should be burnt through upon the cautery clamp ; and the arrest of the hemorrhage is not absolutely cer- tain even by this procedure. The cauterized parts, if they do not bleed, are to be replaced in the abdominal cavity, and no apprehension need be entertained concerning them. If the divided adhesions have been ligated en masse, or each vessel has been ligated separately, it is better to cut off the ligatures short and to let the ligated portion fall back, unless it can be brought near the incision, which can readily be done, as a rule, in the case of the omentum. We shall recur to the fate of the cauterized places and the ligatures in the abdominal cavity, when we come to speak of the treatment of the pedicle. The omentum, lying apron-like upon the tumor, is not unfre- quently adherent to the cyst throughout a great extent. As its separation from the cyst will unavoidably entail tearing and extended injury to the free edge of the omentum, it is best, in these cases, to treat the omentum in the same manner as the pedicle, that is, to let it heal in the upper angle of the abdominal wound. It can be fastened in this position either by means of a clamp or by sutures. The serous surface of the omentum then unites with the cut surface of the peritoneum. Gusserow in one case allowed the omentum to hang loosely outside, whence it gradually underwent retraction into the abdominal cavity without becoming gangrenous ; this proced- ure, notwithstanding the recovery which followed, is scarcely worthy of imitation. In removing the tumor it should be held firmly, so that its weight shall not drag too much on the pedicle or on any adhe- sions which may exist. OVARIOTOMY. 421 Methods of Treating the Pedicle. The pedicle, which consists of the broad ligament, the Fallo- pian tube, the ovarian ligament, and, as a rule, the round liga- ment also, and which always contains large arteries, and fre- quently very greatly developed veins, can be treated in various ways. The older operators, such as McDowell and Clay, passed a ligature around the pedicle, and then allowed it to return into the abdominal cavity, the ligatures being left protruding from the lower angle of the wound. The lower part of the incision was left open for the removal of the ligatures and the distal end of the ligated pedicle, and also for the escape of the secre- tions from the wound. This method of treatment has justly been abandoned, al- though it cannot be denied that Clay and Koeberle obtained excellent results with it. Curtis,1 and also Storer,2 have recently again allowed a portion of the wound to remain open. At present it is usual to adopt either the so-called extra-peri- toneal method, which consists in allowing the pedicle to heal in the abdominal wound, so that the abdominal cavity remains completely closed and the place from which the tumor was detached lies outside the peritoneum ; or else the intra-peritoneal method, in which the pedicle, after being treated in various ways, is allowed to return within the abdominal cavity, which is then to be completely closed. The extra-peritoneal method was first employed by Stilling, in Cassel,3 in 1841, and the intra-peritoneal method by ^Nathan Smith, of Baltimore, in 1821. Tiie Extra-peritoneal Method. A clamp is placed around the pedicle, in the manner already described, and firmly secured; after which the tumor is cut off so as to leave a small portion in front of the clamp. In order 1 Boston Gyn. Jour., TV. p. 201. 2 E. 1., p. 258, and Vol. V., p. 144 3 Holscher's Annalen, 1841, pp. 261 and 393. 422 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. that this projecting portion shall not become ichorous, it is painted over with chloride of iron, so that it may become per- fectly desiccated. Instead of the clamp, other extra-peritoneal methods have been employed. Koeberle secured the pedicle with the " serre- noeud," ' and Scanzoni and Neugebauer have followed his prac- tice. By others the pedicle is stitched into the wound, or secured there by means of a transfixing needle. The external fixation of the pedicle, however, is best and most conveniently accomplished by means of the clamp. The Intra-peritoneal Method. The essential element of this method is to devise some means of safely preventing subsequent hemorrhage, without at the same time so altering the pedicle as to excite local inflammation. The actual cautery and the ligature concur in attaining this end. The actual cautery is especially warmly recommended by Baker Brown ; Spiegelberg uses the galvano-cautery. The fear that the gangrenous eschars, replaced within the abdominal cavity, may excite peritonitis, seems to have little foundation ; it is much more likely to become encapsuled by means of a circumscribed inflammation, as shown by the good results of various operations, and also by the experiments made on animals by Spiegelberg, Waldeyer,2 and Maslowsky.3 The reproach is better grounded that cauterization does not surely prevent subsequent hemorrhage, especially from the large vessels ; and the combination of ligation of the larger vessels with cauterization of the pedicle seems to involve serious danger, ' Serrenoeud is a surgical instrument consisting of a steel rod, at one end of which is a steel plate pierced by two holes. A wire is passed through one of the holes, and, forming a loop, is returned through the other. Both ends of the wire are then secured to a movable slide, which can be drawn downwards by the turning of a handle placed at the lower end of the steel rod. In this way the size of the loop is gradually dimin- ished, jus* as is the case with the loop formed by the chain of an ecraseur.—Trans- lator's Note. 2 Virchow's Arch., B. 44, p. 69. s Berlin, klin. Wochen., 1868, No. 18. OVARIOTOMY. 423 because gangrene of the ligated portion more readily occurs under these circumstances. For these reasons the ligature, as specially recommended by Tyler Smith, is to be preferred. The pedicle is ligated in its entire mass, or, what is better, in separate portions, and the larger vessels are secured by separate ligatures, and then the ligatures are cut off short and the pedicle is allowed to drop back. The healing goes on around the ligatures, and covers them up, or they may even1 undergo a partial absorption, as shown by the case of Bautock ;2 and the hemorrhage is arrested more securely than by cauterization. The hemorrhages, which quite often take place (according to Spencer Wells, in about one-third of the cases) from the stump of the pedicle, even after it has healed, and which may give rise to hematocele, are not in any way dependent upon this method of treatment, being in reality menstrual in nature. With a view of rendering the ligated stump less irritating to the peritoneum, Maslowsky8 has proposed, under the name " sero-plastic " method, to dissect a flap-like piece of peritoneum from that portion of the tumor which is to be cut off, and to cover the pedicle with it before replacement. The use of catgut for ligatures is also recommended. The employment of the ecraseur for cutting through the pedicle offers no safeguard against hemorrhage, and so crushes the tissues that it is not to be recommended. Simpson has used his favorite procedure, acupressure, for the intra-peritoneal securing of the pedicle and the arrest of the hemorrhage from it. This method scareel}^ finds any imitators. Torsion of the vessels also, as recommended by Beebe,* affords too little safety. The extra-peritoneal method possesses such superior advan- tage's, all things considered, that, if the pedicle is not too short and broad, the use of the clamp is most worthy of recommen- dation. In this method the pedicle lies outside of the abdominal 1 Spiegelberg and Walrfeycr. 1. c. 2 London Obstet. Trans., XIV.. p. 2. 3 Medic. Centralb., 1868, No. 56. 4 Amer. Journ. of MeJ. Sci., April, 1871, p. 353. 424 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. cavity, always permits the control of any inflammation, suppura- tion, or hemorrhage that may occur, and is not left, as it were, to its uncertain fate in the abdominal cavity. The strain upon the uterus is not of any consequence, if the pedicle is not too short. The clamp also has its disadvantages. It may happen, for instance, that a coil of the intestine surrounds the pedicle, and the bowel will thus be rendered impassable, or a hernia may readily be developed at the lower angle of the wound, where the pedicle has united with the surrounding parts. The disadvantages of the clamp become more apparent when the pedicle is short, as then it cannot be held fast in the lower angle of the wound without considerable traction being exerted on the uterus and its neighboring organs. It may then occasion severe pains or give rise to peritoneal irritation, or even to tetanus. As far as present experience goes, the extra-peritoneal treat- ment with the clamp is therefore most to be recommended, when the pedicle is tolerably long. If the pedicle is short, it is cer- tainly best to ligate it with catgut in several portions (the larger vessels separately), to cut the ligature short, and allow the stump to recede. Cauterization alone does not seem to occasion perito- nitis readily, yet it does not protect safely from subsequent hem- orrhage ; but used in connection with the ligature it may readily give rise to peritonitis. The method of performing ovariotomy recently described by Miner, of Buffalo,1 and to which he has given the name of " ova- riotomy by enucleation," deserves careful investigation. Miner starts from the opinion that the vessels are spread out only over the superficial surface of the cyst, and that none but capillary vessels enter the true cyst wall. For this reason he goes deep down, where the pedicle spreads over the cyst wall, and enucle- ates the tumor by separating this vascular extension of the pedi- cle from the surface of the cyst. He follows the same plan with the adhesions, and in this manner performs an almost bloodless operation without danger of subsequent hemorrhage.2 1 Amer Jour. Med. Sci., Oct., 1872, p. 391. 2 The following named surgeons have operated successfully, according to Miner's method: Knight, Amer. Jour. Med. Sci., 1872, p. 434 ; Logan, e. 1., July, 1873, p. 122; OVARIOTOMY. 425 Procedure in Cases in which the Second Ovary is diseased. After the tumor is separated from the pedicle the other ovary is to be felt for, and if it is healthy it is not to be meddled with. If, however, it too has degenerated into a decided tumor, it should be extirpated in precisely the same manner as the first one. The treatment of its pedicle also does not differ essenti- ally from the plan recommended above. If it is long, and can easily be brought into the abdominal wound, it should be placed either in a second clamp, or else ligated in several portions, and then secured to the first clamp. In case, however, it cannot be brought into the abdominal wound, it should be treated by one of the intraperitoneal methods. It is a more difficult question to decide what ought to be done when cystic degeneration is just beginning in the second ovary. On the one hand a relapse is threatened, which, as it may render a repetition of the operation necessary, Avill expose the patient a second time to the danger of the operation. On the other hand, however, the danger of the operation in hand is considerably increased by the removal of the second ovary, as is shown by the experience of Spencer Wells, who had a mortality of 24.44 per cent, in single ovariotomies, and a mor- tality of 44 per cent, in double operations. Moreover, it is to be borne in mind that the removal of but one completely degener- ated ovary is a very different thing from the simultaneous re- moval of the second also, which, although somewhat diseased, is yet able to perform its functions ; for the double operation deprives the patient of her sexual characteristics. For this latter reason it is a matter of great difference whether the operation is performed on a woman who has passed the climacteric period, or on one who is still menstruating. A young woman who has ceased menstruating is to be put in the same class with the former, since it may be assumed that the other ovary is so dis- organized as no longer to possess any tissue capable of perform- ing the functions of this organ. Bumham, Bost. Med. and Surg. Jour., July, 1873 ; Mursick. Amer. Jour, of Med. Sci., Jan. 1874, p. 119 ; and Craig, unsuccessfully, Amer. Jour. Med. Sci., Jan., 1874, p. 286. 426 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. If, however, the patient is still menstruating, the idea of sim- ultaneous removal of the second ovary is contra-indicated, unless it is at least three or four times the normal size. Moreover, as already remarked, it is not absolutely certain that a return of the disease will take place, simply because the remaining ovary contains small cysts. The patient might, there- fore, be unnecessarily mutilated. In case, however, a relapse should really occur, the danger from the repetition of the opera- tion is scarcely any greater than the increase of danger which would result in the first place from attempting to remove the second ovary at the first operation. A case reported by Spencer Wells, is extremely instructive in this connection. In 1864 he performed ovariotomy on a young unmarried girl, nineteen years of age. After the removal of the degenerated right ovary, he discovered that the left ovary was nearly twice the normal volume, and contained two cysts of the size of cherries. After some hesitation he decided not to remove this ovary, and merely emptied the two cysts. The patient recovered, was married in August, I860, and up to July, 1871, had been confined four times. Sometimes the uterus, also, is found enlarged, especially if the operation has been performed, knowingly or unknowingly, on a pregnant woman. The prognosis in these cases, hoAvever, is scarcely more unfavorable, and the pregnancy usually con- tinues undisturbed. In other cases the uterus is found enlarged, OAving to the presence of an interstitial or subserous fibroid. One ought to hesitate before attempting to remove this tumor, even though it should be connected with the uterus by a pedicle, inasmuch as it grows slowly, as a rule, or may even remain sta- tionary; and its simultaneous removal adds greatly to the danger of the ovariotomy. After the tumor has been removed and the pedicle treated in the proper manner, the next thing in order is the " toilet of the peritoneum," which is of very great importance in all cases in which a foreign substance (cystic contents or blood) has escaped into the abdominal cavity. The soiled intestines should be dried with large, clean, and new sponges, and the anterior and posterior surfaces of the uterus cleansed as carefully as possible, as well OVARIOTOMY. 427 as the posterior abdominal Avail as far up as the kidneys, and especially all places at which adhesions have been separated. Spencer Wells lays a piece of sponge betAveen the edges of the incision, so that no fresh blood from the Avails of the wound can floAv into the abdominal cavity, and leaves this in position until the sutures are applied. The application of the sutures is best performed in the fol- loAving manner: tAvo straight or slightly curved needles are threaded Avith a good silken thread, and then each needle is passed through the opposite sides of the abdominal Avail, from within outAvards, in such a manner that the peritoneum is firmly included in the suture. After the sutures are all applied, the surfaces of the wound are again cleaned and the knots tied. The pedicle is sewed in pretty closely, but not so closely as to be strangulated. If the skin then gapes, in cases of thick abdominal Avails, superficial sutures should be inserted between the deep ones. The inclusion of the peritoneum in the sutures is very important. In this way only can the two serous surfaces be brought in contact throughout their entire extent. They unite very quickly with each other (they have been found united within tAventy-four hours, in a case subjected to autops}-), and the closure of the abdominal cavity is then again completed. An oiled piece of cloth and a flannel binder serve for the dressing. The drawing together of the wound by means of adhesive plaster is usually unnecessary, though it is Avithin the range of possibility that the still tender uniting surfaces may separate, especially if there be marked meteorismus or vomiting. The best AA-ay to apply the adhesive plaster is to lay long strips of it (close together and parallel) on that portion of the bed Avhich corresponds to the patient's lumbar region, and then, the patient being laid upon these, the tAvo ends of each strip are crossed over the anterior abdominal wall. After-Treatment. The after-treatment should be purely symptomatic. If the patient is in a state of collapse after the operation, or if the extremities are cold, heated bottles should be applied to the feet 428 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. and Avine should be administered. If the patient is restless, or suffering from severe pain, morphia should be administered sub- cutaneously, or opium be given by the rectum. The catheter should be passed at least every six hours, "and in such a way that the position of the patient may not be disturbed. The sutures should be Avithdrawn gradually, from the third to the fifth day. The clamp and the pedicle which is attached to it fall off, as a rule, from the seventh to the tenth day ; occasionally they become detached as early as the third or fourth day, and some- times not until the fourteenth day, or even later. Too early a spontaneous detachment, or too early an artificial removal of the clamp is unfavorable, for the stump of the pedicle may then become retracted deeply into the wound, or may even fall back into the abdominal cavity within the first few days after the operation. The following accidents after the operation evince danger: In the first place, hemorrhage is to be feared; and it may take place from the pedicle or from the torn adhesions. Hem- orrhage from the pedicle is readily arrested, in cases treated by the extra-peritoneal methods, by the application of the chloride of iron or the actual cautery; internal hemorrhage, liOAvever, from the retracted pedicle, or from the adhesions, is a very unfavorable occurrence, since the application of ice to the abdomen affords very doubtful assistance, so that occasionally nothing remains to be done, in case of continuous hemorrhage, than to reopen the wound and to search for the source of the bleeding. Peritonitis also is a source of great danger ; yet, as a rule, it is wholly circumscribed, provided no septic infection has occurred, and none of the various fluids has escaped into the abdominal cavity during the operation. In fact complete union by adhesion may take place in the peritoneal wound in the shortest possible period of time, without any untoward symp- tom, and without fever or pain. A severe traumatic peritonitis should be treated in the customary manner, with opium, leeches, and ice. Where peritonitis is the result of septic infection it has a far OVARIOTOMY. 429 graver significance. To prevent this infection the greatest pos- sible pains must be taken in cleansing the hands, the instru- ments, and all the utensils used in the operation; and to avoid leaving any secretions in the abdominal cavity, as they readily undergo decomposition. The gangrenous stump of the pedicle within the clamp may also give rise to the danger of infection during the few days immediately following the operation. In order that no ichorous secretion from the stump may Aoav into the abdominal cavity, care must be taken that the abdominal walls are stitched tightly round the pedicle, and the mortifying stump must be painted with chloride of iron so that it may de- siccate and dry up. It is very important to be able to remove the secretion which frequently accumulates in the abdominal cavity, and which is liable to undergo decomposition. This is practicable Avithout further interference, if the operation has been performed by the method of Clay and Koeberle, who keep the communication open between the lower angle of the wound and the pedicle by means of ligatures, the serrenoeud, or the introduction of a glass tube, so that the secretion may be withdrawn by suction. As complete closure of the abdominal cavity is not practicable in these cases, this procedure is not to be recommended. Peaslee' first proposed to wash out the abdominal cavity through the wound, in order to remove the decomposing intra- peritoneal fluid, and Sims J has extended this proposition. Sims regards the majority of fatal cases after ovariotomy as of septic origin, and considers all reddish serum in the peritoneal space as tending to a fatal termination; he therefore advises that in every case a canula should be introduced into the deepest portion of Douglas's cul-de sac, in order to facilitate the discharge of secre- tion, and to insure the possibility of making an injection into the abdominal cavity. There can be no question but that Sims's idea is too one- sided ; for although I agree entirely with him in the view that infection is the most frequent cause of death (I believe that the better results in England are partly due to the fact that the 1 Amer. Jour Obstet., Vol. III., p. 300 ; and Ovarian Tumors, p. 509. 2 New York Medical Journal, Dec, 1872, and April, 1873. 430 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. accidental diseases of wounds are rarer in England), septicemia does not by any means originate exclusively in the peritoneal exudation, and is not always prevented by its removal; and, moreover, small quantities of reddish serum' or fibrinous exuda- tion are not so absolutely dangerous as Sims has represented. The possibility of being able to remove an intra-peritonea exudation, which has accumulated after the operation, is ahvays of the greatest importance, and it may be accomplished withou very great difficulty or danger, if only proper provision has been made for it during the operation. If this has been neglected, the operative removal of the exudation presents great difficulties, inasmuch as either the closed wound must be re-opened, or Douglas's cul-de-sac must be punctured. The puncture of the latter, however, is easy and safe only when it protrudes as a tumor into the vagina ; but this occurs only when the exudation is no longer free, but is encysted ; in such a case the puncture is no longer necessary, and therefore the opening of Douglas's cul-de-sac during the ovariotomy has certainly a great advan- tage, and should at least be recommended in all cases in which there is reason to fear considerable peritoneal exudation on account of peritoneal irritation already existing or resulting from the tearing of extensive adhesions. The safest way to provide for the discharge of the secretion is the simple puncture of Douglas's cul-de-sac, or the insertion of a canula which leads from it into the vagina. The simple punc- ture is wholly inefficacious, inasmuch as the wound will soon unite again ; and it has yet to be decided by actual experience whether or not the end of the canula lying in the abdominal cavity does not soon lose its free communication Avith the abdo- minal cavity by inflammatory adhesions which form about it. If it is thought desirable, at the time of the operation, to make provision in the safest manner possible for Avashing out the abdominal cavity and for drainage of any exudation that may take place, the plan, recommended by JVIursick,1 of introducing stout silken threads, or that devised by Nussbaum,"'1 of using a drainage tube, may be considered as the best. These are to be 1 Amer. Jour, of Med. Sci., Jan., 1874, p. 119. 2 Bayerisches arztl. Intelligenzbl., 1874, No. 3. OA'ARIOTOMY. 431 passed through the peritoneal cavity in such a manner that Avhile one end protrudes from the lower angle of the abdominal wound, the other passes out through the cul-de-sac of Douglas into the vagina. The peritoneal cavity can then be washed out Avith pure water, or with a very weak solution of carbolic acid at about the temperature of 97° Fahr., as often as may be desirable. A fatal termination from incarceration of the bowel is much less frequent. This accident results very exceptionally from the wound; it is occasioned much more frequently by the pedicle. Death may be prevented by the establishment of a fecal fistula or an artificial anus. In a case which I had the opportunity of seeing and which was operated on by Veit,1 death occurred on the twenty-second day after the operation, from perforation of the intestines. The perforation occurred in the following man- ner : the omentum had become united by adhesions to the peri- toneum, the left abdominal wall, and the adjacent surface of the cyst; after the operation the portion of the omentum torn off from the cyst became adherent to the upper angle of the abdo- minal incision, and in this Avay the intestine was subjected to such tension in opposite directions—the omental portion pulling it one way, and the portion adherent to the peritoneum restrain- ing it in the other—that perforation finally ensued. The prognosis of the operation varies to a remarkable degree. It depends chiefly upon the patient's general strength, the simple or complicated relations of the tumor, and also upon the skill and experience of the operator. The results of many operators show that the prognosis is more favorable than in other capital surgical operations, as, for example, the larger amputations, dis- articulations, and resections. Spencer Wells, in 500 cases of ovariotomy, had 128 cases of death, and 372 cases, or 74.4 per cent., of recovery; Keith's results exhibit 84 recoveries out of his last 100 cases. Ovariotomy through the Vagina. Thomas2 recommends the removal, in suitable cases, of small 1 Berlin, klin. Wochenschr., 1868, No. 21. 2 Amer. Jour. Obstet., III., p. 186, and Dis. of Women, p. 724. 432 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ovarian tumors through the vagina. In these cases of "vaginal ovariotomy" the cul-de-sac of Douglas is opened per vaginam, the cyst is punctured, and the sac is then drawn out, ligated and excised, after which the pedicle is replaced. DERMOID CYSTS. Kohlrausch, Midler's Archiv, 1843, p. 365.—Steinlein, Zeitschr. f. rat. Medicin, B. IX., p. 146.—Lebert, Prager Vierteljahrschr., 1858, 4, p. 25.— Heschl, Prager Vierteljahrschr., 1860, 4, p. 36.—Klob, Pathol. Anat. d. weibl. Sex., p. 365.— Pommier, Quelques consider, sur les kystes dermoides de l'ovaire. Strasbourg, 1864.— Waldeyer, Archiv f. Gyn., B. 1, p. 304. Etiology. The occurrence in ovarian tumors of elements of the external integument, with hair, teeth, and bones, has always attracted the attention of physicians. Formerly these cases were considered as a sort of imperfect ovarian pregnancy, which was supposed to occur either with or without sexual intercourse. It is only recently that light has been thrown on these abnor- mal formations. His' at flrst entertained the view that the Wolffian duct was formed by a folding-in of the horny layer; but this view, which was again advocated by Hensen,2 was after- ward discarded. Very recently, hoAvever, His3 has modified his views, in which modification Waldeyer4 concurs, so that they now believe that the first rudiment of the genital organs is devel- oped from the axial cord of His, in the formation of which the upper germinal layer also participates; and that the horny layer contributes chiefly to its formation. From this we can understand how formations of the external skin can originate from parts of the upper germinal layer which have not contrib- uted to the formation of the ovary, and how fat, bones, teeth, etc., can be produced from parts of the middle germinal layer which also participated in the folding-in of the axial cord. 1 Archiv f. mikrosk. Anatomie, I., p. 160. 2 E. 1., p. 502. 3 Unters. iiber die erste Anlage des Wirbelthierleibes, I. Leipzig, 1868, p. 225. 4 Eierstock u. Ei., p. 111. DERMOID CYSTS OF TIIE OVARY. 433 Accordingly, the first trace or rudiment of dermoid cysts is ahvays congenital. Their further development, as a rule, begins after puberty, but in exceptional cases even earlier. Mears,' for example, has successfully removed a dermoid cyst by ovario- tomy from a child six years and eight months of age ; and Spencer Wells2 has removed one in the same manner in a child eight years old. Pathological Anatomy. The tumors are chiefly small, not exceeding the volume of an orange, and only very exceptionally reach the volume of a man's head. They are distinguished by the fact that their inner surface is covered Avith a formation perfectly analogous to that of the external skin. This inner surface of the cyst-wall, which is either smooth or uneven in places, with isolated prominences or even actual protuberances, exactly resembles in its structure the epidermis. Superficially we find thick horny layers of pavement epithelium, whose nucleated, flattened, and finally rounded cells follow each other in exactly the same manner as is seen in the outer skin as far as to the rete Malpighii. Under the epidermis is found a connective tissue resembling that of the cutis, which, hoAA-ever, does not always exhibit papillse, and in no instance papillae arranged as regularly as in the cutis of the skin. But a fatty layer corresponding to the panniculus adiposus is always found beneath the cutis, upon Av\hich the external connective- tissue envelope of the cyst rests. The resemblance of this formation to the external skin is still further enhanced by the growth within them of hairs which spring from distinct hair follicles. Largely developed sebaceous glands often open into these hair follicles, and also into the free cavity of the cyst. Even sweat-glands are found in certain cases. From these sebaceous and sweat glands secondary cystic formations may proceed, as Ave are taught by the interesting tumor examined by Friedlander:3 from the former, retention- 1 Philadelphia Med. Times, Nov. 1, 1871, No. 27. 2 Obstet. Jour. Great Brit., April, 1874, No. 69. 3 Virchow's Arch., B. 56, p. 365. VOL. X.—28 434 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. cysts are developed by the accumulation of horny epithelial cells; and from the latter, cysts, of which some are as large as the fist, lined with ciliated epithelium and with sero-mucous contents, which press the dermoid wall of the cysts inwards. As a rule the hairs are long, and usually reddish or blonde in color. They are also very frequently found exfoliated in large quantities, and rolled into a ball in the contents of the cyst. I have myself seen a free ball of hair as large as a man's fist. The cystic contents consist of a fatty, gruel-like mass, formed of the exfoliated epithelial cells and the secretion from the seba- ceous glands. Cholestearine crystals are also found in them, often in such considerable quantities that the entire contents glitter. Bamberg1 found oxalic acid in the cystic contents, large quantities of tyrosine and leucine (doubtless produced from the decomposition of the epithelium), urea, and appa- rently xanthine or some similar substance. In addition to these customary formations, even bones and teeth are not infrequently found in dermoid cysts. The bones are formed in the connective tissue in various shapes, which exhibit, however, the attributes of true bone. They are interpreted as alveolar processes, or as jaws, whenever, as is not unfrequently the case, teeth are found in them. These latter have the normal structure of teeth, although, as a rule, exhibiting but rudimentary forms. Sometimes the enamel is wanting. In Rokitansky's museum there is a preparation in which a milk-tooth has become atrophied from the root to the crown by an advancing permanent tooth. Teeth occur, more- over, free in the connective tissue, with the crown projecting into the cavity of the cyst, or entirely enclosed by connective tissue. They may be present in great numbers. Thus, in a case reported by Schnabel,2 more than one hundred teeth of all sorts were found in three pieces of bone ; and Paget found even three hundred. In rare instances gray cerebral substance, and sparse, trans- versely striped muscular fibres have been found on the inner wall of the cyst. 1 Obser. aliquot de ovarii tumor. Diss. Inaug. Berol., 1864, p. 15. 2 Wiirtemb. Correspondenzbl., 1844, 10. DERMOID CYSTS OF THE OVARY. 435 Combinations of multilocular cystomata AAuth dermoid cysts are also found. Such cases have been described by Eichwald,' Martin,2 and Kreis,3 and one has been carefully examined histo- logically by Flesch." The opinion of Flesch that the cystoma is gradually transformed into a dermoid cyst can scarcely be entertained. The rarity of the simultaneous occurrence of the two is opposed to this idea, and rather favors the view that it is a pure complication. In the case reported by Pommier,5 bilat- eral dermoid cysts Avere found, the one on the left side being complicated with carcinoma. Heschl,6 too, found carcinoma in the wall of a dermoid cyst. Symptoms and Course. Dermoid cysts very often remain stationary, and are then undiscovered during life. In many instances, however, they may rapidly undergo further development from some precise period, so that they grow rapidly, and behave, clinically, just like cystomata. Sometimes they discharge themselves into neighboring or- gans, most frequently into the rectum or the bladder. In the latter case atheromatous masses and hair, and even fragments of bone, are found in the urine. (In the case reported by Blick and Winge,' the cyst had apparently grown into the bladder, its contents had been discharged, and its inner Avail had become everted, so that it finally formed a polypoid tumor, covered with hair, Avhich projected into the bladder and excited excruciating pain). They may also break through the abdominal wall, and occasionally through the vagina. Perforation into the abdom- inal cavit}7" is fortunately rare. Simultaneous rupture into several organs may also take 1 Wiirzburger med. Zeitsch., 5, p. 422. 3 Berl. klin. Wochenschr., 1872, No. 10. 3 Correspondenzbl. schweiz. Aerzte, 1872, No. 100. 4 Verhandl. der physikal-med. Gesellsch. in Wiirzburg, 1872, B. 3, p. 111. BL. c, p. 39. 6L. c p. 58. 7 Schmidt's Jahrbuch, 1871, B. 151, p. 294. 436 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. place. Larrey1 saw a case of rupture through the abdominal Avails and the bladder; and the case of hydatid pregnancy of the ovary described by Greenhalgh,2 in which the cyst commu- nicated with the rectum, bladder, and navel, belongs to this category. The diagnosis, before puncture, can only be that of an ovarian cystoma, since the mode of development as well as the consistency of the growth may be exactly the same as in a cys- toma with thick colloid contents. The treatment is also the same as for cystoma. Ovariotomy is indicated in cases of rapid growth. SOLID TUMORS OF THE OVARY. Fibroids. Thomas S. Lee, On Tumors of the Uterus and its Appendages. London, 1847, p. 224.—Kiwisch, Klin. Vortr., II., 2. Aufl., 1852, p. 188.—Rokitansky, Lehrb. d. pathol. Anat., 3. Aufl., 3. B., p. 423.—Klob, Pathol. Anat. d. weibl. Sexual- org., p. 339.— Virehow, Geschwiilste, in., 1, p. 222.—Scanzoni, Krankh. d. weibl. Sexualorg., 2. B., 4. Aufl., 1867, p. 127.—Ingham, Amer. Jour. Obstet., VI., p. 106. —Spencer Wells, Diseases of the Ovaries, 1872, p. 49.—Leopold, Archiv f. Gyn., B. VI., H. 2. Fibroids are seldom found in the ovary, but they may in exceptional cases attain a very great size. Simpson has a pre- paration of the kind which weighs fifty-six pounds; and Spie- gelberg3 describes a fibroid (probably a fibro-sarcoma) of the ovary which had acquired an enormous volume. The abdomen measured 103 cm. (41 inches) in length, and its greatest circum- ference was 150 cm. (60 inches), the tumor itself weighing 30 kilogrammes (80 lbs). The tumor was richly supplied with large vessels, running free from the abdominal Avail to the tumor, and a vessel as large in size as packing-thread protruded from the wound made by the puncture. Ovarian fibroids do not develop from a definite point, as uterine fibroids do, so that they do not lie so circumscribed in 1 Spencer Wells, 1. c, p. 65. 8 Lancet, Nov. 22, 1870, p. 741. 3 Monatsschr. fur Geb., B. 28, p. 415. FIBROIDS OF THE OVARY. 437 the tissue, nor are they so easily enucleated ; but they resemble more a uniform hypertrophy of the ovary, in which the con- figuration and normal relation to the broad ligament are toler- ably well preserved. This latter fact is of great importance as a means of distinguishing them from cystomata. The difference in the manner of insertion is best expressed by the schematic illustration made by Leopold. Fig. 116 represents a fibroid, Fig. 116. Fig. 117. Formation of the pedicle in the ovarian Formation of the pedicle in the ovarian fibroid. cyst. t, Fallopian tube; m, mesovarium. t, Fallopian tube. Avhich is connected by a short but broad mesovarium (m) with the posterior surface of the broad ligament. The Fallopian tube (t), which courses in the broad ligament, retains its normal mobil- ity. In cystomata (Fig. 117), on the other hand, the ovary becomes distended into a round tumor, over which both folds of the broad ligament pass continuously so that the tube lies close to the cyst. While, therefore, the pedicle in the ovarian cyst is formed from the broad ligament itself, in solid tumors it is formed from the short and broad mesovarium, which penetrates into the hylus. Exceptionally, other cysts as well as solid tumors may so grow into the base of the broad ligament that a pedicle is altogether wanting. In other respects the external appearances of ovarian fibroids do not differ, as a rule, from those of uterine fibroids. It is still doubtful Avhether only true fibromata occur in the ovary, or myo«fibromata also, since it is extremely difficult to decide, even in the cadaver, whether the fibroid has originated from the 438 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. uterus or from the ovary. A fibroid, for instance, which arises from the uterus, may occupy the same position that an ovarian fibroid would, and the ovary may be so atrophied from pressure, or be so closely incorporated with the tumor, that it appears to form a part of it. It is, therefore, still a matter of doubt Avhether the true myo-fibromata do not always arise from the uterus ; the true fibromata alone being of ovarian origin. Virehow con- siders that myo fibromata occur in the ovary, but that the smooth muscular fibres are only sparsely found in them. It is very rare, indeed, that a fibroid appears simultaneously in both ovaries. Waldeyer * saw one case of ovarian fibroid which had a com- plete osteoid structure; and Kleinwachter2 performed Cesarean section on account of a bony tumor, of which but a small por- tion was fibrous. Cysts may also occur in the neighborhood of a fibroid, in which case, the fibroid may be said, as a rule, to be complicated with cysts of the Graafian follicle. Eokitansky and Klob have described the development of small fibroids from a corpus luteum. Jenks3 also has reported a similar case. The symptoms are only such as occur in general from the development of any tumor in the true pelvis, and therefore pre- sent nothing essentially characteristic. In rare instances the fibroma may suppurate. Cases of this kind have been reported by Kiwisch and Safford Lee.4 Roki- tansky6 reported a case of suppuration, after delivery, of a fibroid as large as a goose's egg. The diagnosis can hardly be determined with certainty. The origination of the tumor in the ovary is to be diagnosticated in the manner previously mentioned, yet the differential diagnosis from a uterine fibroid must always be doubtful, as is evident from what has already been said. If it is believed that the tumor arises from the ovary, it can be distinguished from a cys- 1 Archiv f. Gyn., B. 2, p. 440. 8 Archiv f. Gyn., B. 4, p. 171. »Amer. Jour. Obstet., VI., p. 107. 4 L. c, p. 226. » 6 L. c, p. 424. CARCINOMA OF THE OVARY. 439 toma by its hardness, its slight mobility, and its gradual growth; and from cancer by its gradual growth and symmetrical surface, and by the circumstance that it can be isolated. The prognosis is more favorable than in other ovarian tumors; for fibroids grow but slowly, as a rule, or may even remain Avholly stationary. Ossification also is to be regarded as a favorable termination. The treatment is for the most part purely symptomatic. Ovariotomy, which is more dangerous than in cystomata, is some- times to be performed, if necessary, on account of the size of the tumor. Carcinoma of the Ovary. Forster, Verh. d. Wiirzburger phys. med. Ges., B. X., p. 24.—Klob, Pathol. Anat. d. weibl. Sex., 1864, p. 369.— Waldeyer, Arch. f. Gyn., B. I., p. 307.—TJiomas, Amer. Jour. Obstet, IV., p. 76.— Spencer Wells, Diseases of the Ovaries, 1872, p. 54.—Leopold, Arch. f. Gyn., B. VL, H. 2. Etiology. Primary ovarian carcinoma is very rare, and usually attacks both ovaries (we except secondary cancer, which presents no points of special interest). Moreover, it does not occur with especial frequency in elderly women, but evinces, as it appears, a peculiar predilection for younger subjects, and may even occur before puberty. Pathological Anatomy. Carcinoma occurs in the ovary in two different forms. It may appear as a diffuse infiltration of the stroma, so that the entire ovary is transformed into a cancerous mass covered with peritoneum and retaining very nearly the form of the ovary. The ovary, degenerated in this manner, may attain the size of a man's head. It very rarely happens that one or more cancerous nodules are formed in the otherwise healthy tissue, which grow very large, and thus transform the ovary into a nodular tumor. In addition, there are also cancroid forms, wdiich in many cases proceed from the papillary growths of a cystoma; but they 440 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. may also occur independently of any such origin. These push their way (without forming adhesions) into the abdominal cavity, and, if they suppurate, may lead to fatal peritonitis. Ovarian carcinoma, in its first origin, is always to be referred to the epi- thelial constituents of the gland and consequently to the folli- cles, or at least to the rudiments of follicles. Since a true cystoma, as a new glandular formation, consists of a proliferation of cells and growth of the stroma through the epithelial cells, it cannot be a matter of surprise that transitional and mixed forms should occur, which may be designated by the term cystoma carcinomatositm. Such cases have been seen by Bruch,1 Spiegelberg,2 and Wagner,3 and, in a bilateral case, in an insane patient, by myself. Ovarian carcinoma always severely irritates the peritoneum, and thus uniformly occasions marked ascites, and not infre- quently limited acute peritonitis. In many cases the chronic peritonitis is well characterized by abundant exudation, exten- sive thickening, or reticulated tracings on the peritoneum. The cancer readily encroaches on the neighboring organs, especially in cases of circumscribed nodular formations, and spreads through the pedicle to the pelvic connective tissue or penetrates the mucous epithelium of the ovary, and then grows, fungus-like, into the abdominal cavity. Symptoms. In the beginning there are no other symptoms but such as occur in benign enlargements of the ovary. Later, however, the tumor undergoes rapid development, with symptoms of chronic peritonitis; the patient's condition then becomes truly pitiful, until finally death ensues from peritonitis, marasmus, intestinal stricture, etc. Diagnosis. At first nothing can be determined save the existence of a hard tumor of the ovary ; and the existence of a tumor on both ' Zeitschr. f. rat. Medicin, 1849, B. 8, p. 125. 3 Monatsschr. f. Geb., B. 14, p. 200. 'Arch. d. Heilk., V., p. 92. SARCOMA OF THE OVARY. 441 sides indicates, at most, a cancer rather than a fibroid. Soon, however, the depraved general condition, and the accumulation of fluid in the abdominal cavity, with a disproportionately small tumor, suggest the suspicion of cancer. (Edema of the lower extremities is also one of the earliest symptoms. Further, the tumor is sensitive, and also spontaneously painful. If the tumor increases rapidly in size, while the general condition grows Avorse and the ascites increases, the diagnosis can hardly be longer doubtful. In the two cases of uncomplicated ovarian cancer which I have seen, it was a characteristic feature that in an evi- dently ovarian tumor the new groAvth had progressed from the base of the tumor to the pelvic connective tissue, and thus ren- dered the tumor immovable. Treatment. Although ovariotomy might possibly be indicated in the very commencement, while the diagnosis of malignant disease is not yet certain, the best course to pursue is to simply alleviate the sufferings of the patient as much as possible, as the symptoms call for it, until certain death finally terminates them. Sarcoma of the Ovary. Wilks, Pathol. Trans. London, X., p. 146.— Virehow, Geschwiilste, I. p. 369.—Hertz, Virchow's Archiv, B. XXXVL, p. 97.—Szm'minski, Diss, inaug. Breslau, 1872. —Lobeck, Winkel, Benchte u. Studien, etc. Leipzig, 1874, p. 353.—Beigel, Krankh. d. weibl. Geschlechts. Erlangen, 1874, p. 440.—Leopold, Archiv f. Gyn., B. VI., H. 2. Sarcoma, which very rarely occurs in the ovaries, and, when it does, appears as a spindle-cell sarcoma, usually affecting both sides, is developed from the connective-tissue stroma of the ovary, which contains small, short, spindle-cells even in its nor- mal condition. The blood-vessels are especially apt to become markedly developed, so that the tumor presents a cavernous appearance. Moreover, the larger Graafian follicles are also apt to increase in size, and may thus occasion a complication of cys- tic formation with sarcoma. Still more complicated forms of 442 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tumors occur. Thus Spiegelberg1 has described a cancerous myo-sarcoma2—a sarcomatous degeneration in a stroma consist- ing of mucous tissue—with distinct epithelial alveoli in certain spots. The sarcomatous tumor, which, like the fibroid, forms a tol- erably uniform hypertrophy of the ovary, may attain a very large volume, although the tumor described by Clemens s as a medullary sarcoma, and which weighed eighty pounds, hardly belongs to this class. The course of the disease seems to be tolerably rapid, and the prognosis is as unfavorable as in carcinoma. The diagnosis is difficult. Rapid growth, early ascites, and sensitiveness merely indicate the malignancy of the tumor, so that the absence of metastases and a somewhat more marked mobility are the only signs of value in distinguishing the growth from carcinoma. The treatment recommended for carcinoma holds good here ; but the prospect of a radical cure may be considered as some- what better, inasmuch as sarcoma does not so continuously invade the connective tissue. Papilloma of the Ovary. Gusserow and Eberth, Virchow's Archiv, B. XLIIL, p. li.—Klebs, Handbuch d. pathol. Anat., 4. Aufl., p. 794. In very rare cases a cauliflower-like, papillary growth, covered with a cylindrical or stratified pavement epithelium, proceeds from the surface of the ovary. In the very interesting case reported by Gusserow and Eberth, the disease had led to exten- sive ascites, and rupture of the umbilicus, with prolapse of the bowel. Tuberculosis of the Ovary. This disease appears to be exceedingly rare,4 and has no prac- tical significance. J Monatsschr. f. Geb., B. XXX., p. 380. i Myxo-sarcoma ?—Translator's Note. 3 Deutsche Klin., 187:1. No. 3. 4 Klob, Pathol. Anatom. d. weibl. Sex., p. 372, and Spencer Wells, 1. c., p. 64. HYDROCELE OF TIIE ROUND LIGAMENT. 443 DISEASES OF THE UTERINE LIGAMENTS, AND OF THE ADJACENT PORTIONS OF THE PERITONEUM. DISEASES OF TIIE LIGAMENTA ROTUNDA. Rau, Neue Zeitschr. der G., B. 28, p. 289. The ligamenta rotunda represent a continuation of the super- ficial muscular layer of the uterus ; hence affections of the latter organ may be imparted to these ligaments very directly. The round ligaments have a very important diagnostic value in cases of malformation, since they always serve as a guide to the boundary between the cornua of the uterus and the Fallo- pian tubes. When the uterus and tubes are Avanting, either upon one or both sides, the round ligaments are also absent. Moreover, they participate in enlargements of the womb. This is evidenced most strikingly in pregnancy, when they be- come hypertrophied to large, hard cords, which can be felt at the sides of the uterus—most distinctly in primiparse, in whom they readily contract. But it is only the tumors of the ligamenta rotunda which have any real practical importance, inasmuch as it is possible to mistake them for herniae. This hardly applies, however, to the varices of the round ligaments, though Boivin and Duges ' have figured a case where very marked varicosities of both ligamenta rotunda simulated double inguinal hernia. Hydrocele of the round ligament is much more apt to give rise to mistakes. HYDROCELE OF THE ROUND LIGAMENT. Regnoli, Archives geher., 2 serie, T. V., 1834.—Sacchi, Oesterreich. Jahrb., 1833, B. 14.—Pol ant, Prager Vierteljahrschr., 1845, I., p. 125.—Bends, Hosp. Moddel- elser, B. V., H. 3, 1853.—Auhenas, Des tumeurs de la vulve. These. Stras- bourg, 1860, p. 44.—Hart, Amer. Jour, of Obst., Vol. IV., p. 15.—Hennig, Zeitschr. f. Med., Chir. u. Geb., 18G8, No. 6. 1 Atlas PI. 32, Fig. 3. $ 444 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Besides the simple cedematous swelling of the connective tis- sue surrounding the ligaments, which also is doubtless often described as hydrocele, there are two forms to be distinguished —an extraperitoneal and an intraperitoneal. The former devel- ops in the gubernaculum Hunteri proper (which afterwards in women becomes the ligamentum rotundum), beginning Avith a neAv formation of cysts, or, if the gubernaculum is originally a hollow canal, as C. H. Weber claims, the preservation of this canal may be the first step in the development. The intraperitoneal hydrocele owes its origin to the develop- ment of a true processus vaginalis peritonei, which occurs excep- tionally in females and extends through the inguinal canal to the mons veneris. In case the canal of this process is obliterated only at the internal inguinal ring, the original intraperitoneal portion of the canal may become a hydrocele. I have myself seen a case in which the serous contents could be emptied into the abdominal cavity, so that, in this case, the communication between the processus vaginalis and the abdominal cavity must have remained open. Hydrocele has the appearance of a soft, translucent swelling, which may attain the size of a hen's egg, and it has repeatedly been mistaken for hernia and operated upon. PERIMETRITIS OR PELVEO-PERITONITIS AND PARAMETRITIS. Grisolle, Archives gener. de med., III. Ser., T. IV., 1839.—Meirchal de Calvi, Des absces phlegmoneux intrapelviens, 1844.—Nonat, Gaz. des hop., 1850, No. 25, and 1859, No. 125, and Traite prat, des mal. de l'uterus, etc. Paris, 1860, pp. 232, 710.— Valleix, Union med., 1853, No. 125.—Gallard, Gaz. des hop., 1855, No. 128, and Annales de Gynecologie, Fevrier, 1874.—Becquerel, Maladies de l'uterus. Paris, 1859, T. I., p. 438.—Bernutz et Goupil, Archives gener., 1857, Mars-April, I., pp. 285, 419, and Clinique med., II., p. 1, and Bernutz, Archives de Tocologie, Mars, 1874.— Aran, Bulletin de therap., 1859, Juillet-Aout, and Lecons cliniques, p. 653.—Bennet, On Inflammation of the Uterus. London, 1853, p. 225.—Peaslee, Edinburgh, Med. Jour., July, 1855.—Ch. Bell, Edinb. Med. Jour., Oct., Dec, 1856, and January, 1857.—Simpson, Med. Times, July- August, 1859; Edinb. Monthly Jour., December, 1852; Sol. Obst. Works, 1871, p. 811.—Matthews Duncan, A Practical Treatise on Perimetritis and Parametritis. Edinb., 1868— Klob, Wiener Med. Woch., 1862, Nos. 48, 49, and Pathol. Anat. d. weibl. Sex., p. 392.—Noeggerath, Die latente Gononhoo PERIMETRITIS, PELA'EO-PERITONITIS. 445 im weibl. Geschl. Bonn, 1872.—Brown, Amer. Jour, of Med. Sci., July, 1872, p. 56.—Smith, Boston Gyn. Jour., Vol. VII., p. WZ.—Aitken, Edinburgh Obst. Tr., Vol. II., p. 77.—Spiegelberg in Volkmann's Samml. klin. Vortr . No. 71. Concerning the relation of perimetritis—inflammation of the pelvic portion of the peritoneum (hence, more properly, pelveo- peritonitis)—to parametritis—inflammation of the subperitoneal connective tissue—there have been very diverse opinions. Au- thors have frequently become so prejudiced in favor of one of these diseases as to deny the existence of the other. The dis- pute has been most vigorous amongst the French, among Avhom more particularly Bernutz, Goupil, and Aran contended in favor of pelveo-peritonitis, while Nonat and, in England, Simpson wrere the advocates of parametritis. It is not easy to decide the question, because it is difficult to make the diagnosis with absolute certainty in any given case during life, and the opportunities for autopsies in cases of these affections are comparatively rare ; and even post-mortem it may be difficult to discriminate between the two diseases, because intraperitoneal exudations may be invested with false mem- branes, which sometimes acquire a remarkable similarity to the peritoneum. I am of the opinion—as will be more fully indicated in what follows—that parametritis is a connective-tissue phlegmon, which is due to an infection with septic material; hence, that it is common in the puerperal state, but at other times is tolerably rare, and that perimetritis is a partial peritonitis, which may be, and frequently is, induced by the most diverse causes. Leaving out entirely the puerperal inflammations, we shall endeavor to describe the two conditions separately, first con- sidering perimetritis, Avhich, in fact, is commoner and of more importance outside the puerperal state, and afterwards taking up parametritis. PERIMETRITIS, PELVEO-PERITONITIS. Etiology. A whole series of causes of the most various description are capable of producing pelveo-peritonitis. Sometimes the disease 446 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. springs from a parametritis, through an extension of the inflam- mation to the peritoneum—a very common event in childbed. It is especially apt to occur as a complication in a variety of uterine affections. Thus it is particularly liable to be associated Avith metritis or endometritis. It occurs next in frequency in conjunction with dilatations of the womb, as in haematometra and fibroids; further, in connection with displacements, but above all in inversion and prolapse, though it may also be asso- ciated Avith the versions and flexions. Malignant growths of the womb, if far advanced, invariably lead to perimetritis. Inflammations and enlargements of the ovary are less apt to be accompanied with inflammation of the pelvic peritoneum. Yet the disease is developed invariably after rupture of small ovarian cysts or abscesses, and also when a copious hemor- rhage has followed the bursting of veins, or, exceptionally, the rupture of a Graafian follicle. It is a very frequent complica- tion of large ovarian tumors. Not infrequently perimetritis proceeds from changes in the Fallopian tubes. Enlargements or growths of the tubes may cause it, or an escape of blood from the ostium abdominale ; but it is especially apt to be an accompaniment of inflammation of the mucous membrane of the tubes, in consequence of an exten- sion by contiguity of the inflammatory process through the ostium abdominale on to the adjacent peritoneum, or else through the escape at this opening of the products of inflamma- tion—catarrhal secretion or pus. This is often the way in which pelveo-peritonitis is produced in gonorrhoea. Great Aveight was formerly assigned to this etiology by Bernutz, and recently Noeggerath has given it a special importance. Giles J also attri- butes the frequency of pelveo-peritonitis, together with the benign course it pursues, in prostitutes, to gonorrhoea.2 Noeggerath, of New York, holds that gonorrhoea in men is incurable; that when it is apparently healed it has only become latent, and, in case of marriage, it is invariably communicated to the wife. The latter contracts an inflammation of the mucous membrane, which extends from the entrance of the vagina to the ovaries. Noeggerath follows out this view very closely. He meets the objection, that, con- 1 Brit. Med. Journal, 1871, p. 539. 2See also Meicdonald, Edinb. Med. Journ., June, 1873, p. 1086. PERIMETRITIS, PELVEO-PERITONITIS. 447 sidering the commonness of gonorrhoea in men (eighty per cent., according to him and Ricord), all the wives should be diseased, with the reply: "And they all are diseased. It has come to such a pass that young ladies are afraid to get married, because they know that all of their married acquaintances were made ill directly, and never again recovered." Gonorrhoea in women, according to him, occurs in the form of an acute perimetritis (sometimes puerperal), a recurrent perimetritis or an ovaritis. But the catarrh of the Fallopian tubes plays the most important part in the affection. A sudden escape of but a few drops of the inflammatory secretion (occasioned by a contraction of the tubes) may give rise to any of the various forms of perimetritis, including even the rapidly fatal, acute peritonitis. Sterility, also, is very commonly due to a latent gonorrhoea, and, in the event of conception, abortion, premature delivery, and perimetritis during gestation are exceedingly apt to follow. Noeggerath's assertions are undoubtedly extravagant, yet we are forced to admit that the chronic inflammatory conditions of the genital organs—the endometritis, metritis, and perimetritis—are only too apt to be the result of gonorrhoeal infection. We should certainly doubt whether catarrh of the Fallopian tubes is an invari- ble occurrence in gonorrhoea, and hence question its etiological significance with regard to perimetritis. It is our conviction that endometritis often gives rise to metritis, and this again to perimetritis. Pelveo-peritonitis may occur also in connection with dis- orders of menstruation—sometimes Avith dysmenorrhoea, and sometimes Avith suppression of the menses. But in suppression the primary occurrence is undoubtedly the acute inflammation of the uterus and its peritoneal covering, and the suppression is merely the first symptom of this affection. Again, traumatic influences may be the cause of the inflam- mation of the pelvic peritoneum. B1oaats upon the abdomen or accidental wounds are occasional, though rare, causes; in the majority of cases the trauma is owing to surgical procedures— particularly bloody operations, the introduction of the sound, or of intra-uterine pessaries, and the like. Coitus also has been assigned as one of the causes of perimetritis; still, in the case of young wives or of prostitutes, the question will arise as to whether the affection may not possibly be due to gonorrhoeal infection. Finally, we must call attention to the fact that chronic inflammation of the pelvic peritoneum may be owing to certain processes which are associated with a chronic peritonitis, but which are entirely independent of the genital system. The most 448 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. noticeable of these processes are the tuberculous or carcinoma- tous new formations in the peritoneum or omentum. With respect to differential diagnosis, these diseases have a very im- portant bearing upon gynecology. The following table, which shows the etiology in 99 cases of pelveo-peritonitis, is given by Bernutz ; but its value is merely relative: 43 cases of perimetritis occurred in puerpera, 28 after gonorrhoeal infection, 20 were menstrual, and ' 3 were due to excess in venery, 2 were due to syph. disease of cervix, 2 were due to introduction of sound, 1 was due to the vaginal douche. 8 traumatic, of which *0j Pathological Anatomy. Perimetritis is an inflammation of the pelvic portion of the peritoneum, and may develop under various forms. In the lighter forms of the inflammation no alterations what- ever are left in the parts attacked, or else there remain merely slight deposits or thickenings in the peritoneum. But the production of pseudo-membranes is very apt to give rise to adhesions betAveen different organs contained in the true pelvis. Very frequently the Fallopian tubes and ovaries are displaced — usually backwards — and become adherent to the uterus or to the peritoneum lining the posterior pelvic wall. Very often, too, adhesions extend from the uterus posteriorly, or from its sides ; they occur less frequently in front of the womb. Furthermore, some portion of the pelvic peritoneum may become attached to organs situated higher up, more particularly the bowel or the omentum. Sometimes these adhesions are extremely fine and delicate, embracing the organs like a spider's web. In other cases broad, thick pseudo-membranes are produced, which form bridges from one organ to another, or closely invest the uterus and contiguous organs. Where several layers of false membrane are superim- posed, one above the other, large quantities of yellowish serum PERIMETRITIS, PELVEO-PERITONITIS. 449 may collect between them. Something like this occurs when Douglas's cul-de-sac is bridged over and entirely cut off from the general abdominal cavity. BetAveen the separate pseudo- membranes, and in the situations where bridges are formed, a thin, yellow serum is secreted, thus practically forming cysts. When such cysts are situated in Douglas's cul-de-sac, and the serum continues to be exuded, they may attain the size of a very large tumor (see Fig. 118). They may be situated else- where, however, and then consist usually of rather flat, serous ex- udations lying between the mem- branes ; though, if the secretion continues, they may afterwards become round and simulate true cysts. In case the peritonitis is pretty severe, a serous fluid, or a fibrin- ous and thicker exudation, or in still worse cases a purulent secre- tion, is poured out into the free cavity of the abdomen. This exudation collects in the most dependent portion of the peritoneal cavity—in the region of Douglas's cul-de-sac. So long as it remains fluid it acts in the Same Way as a fold Of tile inteS- Pelveo-peritonitis serosa of Douglas's cul-de-sac. tine in this situation would. When the bladder and rectum are empty (see Fig. 53, p. 160), a large space is left between the posterior Avail of the uterus and the anterior wall of the rectum, which is normally filled with coils of the intestine; but if an exudation is present it occupies this space, since it is heavier than the bowel, and the latter therefore floats upon its surface. But so long as the exudation remains fluid it recedes into the general cavity of the abdomen directly the bladder or rectum begins to be distended, and the uterus and rectum approach each other. Hence it is just as impossible to feel a free fluid exuda- tion in Douglas's cul-de-sac, by means of the combined method VOL. X.—29 0323 450 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. of exploration, as it is the empty bowel, for they both recede at once before the exploring finger. Therefore Douglas's cul-de- sac will be filled with the exudation only according as the dis- tention of the bladder and rectum permit. This continues so until the exudation thickens—becomes inspissated or solidified. Then it no longer alters its position, and, inasmuch as it does not recede before the finger, it can be felt (see Fig. 45, p. 98). But the same effect may be produced by a perfectly fluid exudation when it is so enclosed above by false membranes as to be pre- vented from receding into the rest of the abdominal cavity. In this case, if the fluid continues to be exuded within the enclosed space, another symptom is superadded: since the walls of the cavity in which the exudation is confined are distended equally in all directions, the floor of Douglas's cul-de-sac is forced downwards, the rectum compressed, and the uterus crowded forwards against the symphysis pubis, and a large, elastic, retro-uterine tumor is formed, which strikingly resembles the bloody tumor of haematocele (see Fig. 118, p. 449). In cases where Douglas's cul-de-sac has been obliterated, or when, under any circumstances, in an enclosed space near Douglas's pouch, a certain degree of exudation continues, other portions of the peritoneum may be pushed down before it, since the normal peritoneum yields more readily than the inelas- tic pseudo-membranes. Under these conditions tumors occur at the sides or in front of the uterus, which extend far doAvn- wards, and may have just the situation of exudations of para- metritis. If the exudation arising from the peritonitis is very copious, it may fill the entire lower portion of the abdominal cavity, extending up above the fundus uteri to the bladder, or even to the anterior wall of the abdomen, while the intestines float upon its surface. It may even then become enclosed by false mem- branes and undergo resorption. With regard to the ultimate results of the various forms which the products of perimetritis assume, we observe that the simple inflammatory thickenings of the peritoneum as well as the adhesions, as a rule, sustain no further changes ; though it appears that the adhesions between different organs may become PERIMETRITIS, PELVEO-PERITONITIS. 451 thinner and more attenuated, and perhaps in certain instances are entirely reabsorbed. The yellow serous exudation lying between the pseudo-mem- branes or in Douglas's cul-de-sac may remain for a long time stationary ; extravasations of blood may take place, however, into the collections of serum, or suppuration may occur second- arily. In other cases, after the lapse of a considerable period, complete resorption takes place. The fibrinous, and also the purulent, exudations generally yield, after the cessation of the inflammatory action, to a more or less complete resorption; yet circumscribed and enclosed deposits of pus may persist for a considerable length of time, or they may eventuate in pelvic abscesses, which in the worst cases undergo decomposition and induce general peritonitis. As a rule, however, the abscess perforates externally or into internal organs. AVhen it breaks externally, the opening is most usually in the flexure of the thigh, between the external and internal inguinal rings. It may also perforate at the side of the anus, or at the upper and inner part of the thigh, or even through the obturator foramen. In rare instances the abscess is evacuated through the foramen ischiaticum and the glutsei muscles. Very large abscesses may break above the crest of the ilium, or, still higher up, in the back. Perforation internally takes place most commonly per rectum, next per vaginam, and only occasionally into the urinary blad- der. Since the abscess is invested by firm adhesions, which are constantly increasing in thickness, it is rare for the discharge to occur into the abdominal cavity, and when it does, is followed by immediate death or by a subsequently fatal peritonitis. It is extremely uncommon for the abscess to perforate the uterus. But, furthermore, there may be several openings. Duncan reports a case where the pus opened simultaneously into the bladder and rectum. Simpson' saw a recto-vesical fistula—an extremely rare occurrence, of course, in women—which resulted from a double perforation of an abscess. In another case, observed by the same author, a rectovesical fistula' passed 1 Obstet. and Gynecol. Works. Edinburgh, 1871, p. 812. 2 Ibidem, p. 816. 452 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. through the ovary. Moreover, Simpson reports instances of double perforation, causing vesico-uterine and utero-intestinal fistulse. Klob' observed a fatty degeneration of the external muscular layer of the uterus, which was a secondary change due to peri- metritis, and resembled the fatty degeneration of the cardiac muscle in pericarditis. Symptoms and Course. Perimetritis, which is nothing more than a partial peritonitis, may be either acute or chronic. The chronic form develops in connection with a number of affections of the uterus which occasion a long-continued irrita- tion of the peritoneal covering. Thus, it may be associated with hsematometra, with fibroids, with displacements, with carci- noma, with dysmenorrhoea, as well as with enlargements of the Fallopian tubes and ovaries. Moreover, inflammations of the womb, or the escape of pus or blood through the ostium abdom- inale of the Fallopian tube is not foUowed by acute peritonitis always, but a chronic inflammation of the pelvic peritoneum is not infrequently the result. Hence it is that a chronic pelveo- peritonitis is very commonly produced after gonorrhoeal infec- tion. Under these circumstances the course of the disease is very protracted. The patient never manifests any marked signs of acute fever, though the date of inception of the disease can usuaUy be fixed with certainty. In some rare cases all symp- toms whatsoever—even pronounced abdominal pain—may be wanting; occasionally a frequent desire to micturate is the only symptom of the commencing disease. Much more com- monly patients complain of feeling ill from the very start, though perhaps never confined to their beds. Incessant pain in the abdomen harasses them from the beginning of the disease; they are conscious of an inability to apply themselves to any occupation requiring the least exertion; they are annoyed by chronic constipation or persistent diarrhoea. On account of the 'L. a, p. 397. PERIMETRITIS, PELVEO-PERITONITIS. 453 disorders in the intestinal canal, together with the loss of appe- tite, which is often very marked, they become greatly emaciated. As in chronic metritis, temporary exacerbations are of very frequent occurrence, and these are often, though not necessarily, connected with the menstrual periods. The discomfort which the disease occasions is in many cases, however, extraordinarily slight, and even where there are con- siderable adhesions in the true pelvis it may only amount to occasional pains in the abdomen, which are the most annoying to the patient during muscular exertions which cause an increase in the abdominal pressure and occasion an unusual displacement of the womb. Coition, too, is often rendered painful by chronic perime- tritis. This is partly due to the augmented sensibility from the increased hyperaemia of the parts, but it is chiefly to be ascribed to the traumatic influence—the stretching of the adhe- sions about the uterus. The traumatic effect is most obvious when the womb is fixed low in the pelvis. Such a case came under my observation where vaginismus was also present, and since the entrance to the vagina was sufficiently capacious, I was obliged to attribute the latter condition to the severe pain excited during coition, the pain proceeding from the uterus. But not infrequently pelveo-peritonitis develops in a decid- edly acute form. This is most commonly the case in the puerperal variety, with which, however, we are not here con- cerned ; it is next most frequent in all cases where it occurs as an extension from a primary parametritis, and particularly, therefore, in consequence of certain therapeutic measures, such as injections, the introduction of sponge-tents, sounds, or intra- uterine pessaries, and also after bloody operations. Moreover, perimetritis may occur in connection with endometritis and me- tritis, and particularly in consequence of the free escape of pus or blood at the abdominal orifice of the Fallopian tube. Conse- quently it is not so very rare for the acute forms of the inflam- mation to occur also in gonorrhoea. Perimetritis may occur, too, in consequence of exposure to cold—more particularly at the time of the menstrual period when suppressio mensium usually accompanies it. 454 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The symptoms in these cases are those of an acute partial peritonitis. It commences with a chill or with rigors, or both may be wanting ; the temperature rises, the pulse becomes more frequent, and severe spontaneous pains occur over the lower region of the abdomen, together with decided tenderness on pressure. There may be considerable meteorismus, and vomit- ing also. On making an examination at the commencement of the acute affection the abdomen is found so sensitive to pressure that it is impossible to employ the combined method of explo- ration with any satisfaction. The examination per vaginam reveals no other alterations than elevated temperature, swollen mucous membrane and vaginal pulse. The vaginal pulse per- tains by no means to any one particular affection (and this fact merits especial attention, for Nonat regards the vaginal pulse as characteristic of phlegmonous tumors); but it is most commonly met with in connection with tumors of the uterus or of the adjacent organs—pregnancy, fibroids, ovarian tumors, etc.— though it is also sometimes present in inflammations of the womb and its appendages—metritis, peri- and parametritis. The course pursued by the acute pelveo-peritonitis is subject to the following variations: Xot very infrequently the inflam- mation extends to the whole peritoneum, and then we have all the effects of a general peritonitis, and consequently the issue is most commonly fatal. But the inflammatory action may be lim- ited, and merely such changes are left as are induced by the inflammation; or the disease lapses into chronic inflammatory processes, which are very persistent, and not infrequently are associated with relapses of the acute inflammation. After the acute period of pelveo-peritonitis has expired, or where the course of the affection is chronic from the commence- ment, an examination will afford very interesting results, which will be of great variety, depending upon the changes which have taken place. If the adhesions and pseudo-membranes are not very dense they cannot be distinctly felt, though their presence may be clearly evinced in their effects. This is especially the case when organs accessible to the touch in the true pelvis, which are other- PERIMETRITIS, PELVEO-PERITONITIS. 455 Avise movable, become fixed in one position, as is the case with the uterus most commonly, though the ovaries may also be so affected. Another effect of the adhesions, which can be detected by palpation, is produced when organs which are ordi- narily inaccessible to the touch, because they recede at once before the exploring finger (such as the folds of the intestine and also the omentum), are bound down in one position, so that they can be palpated. We then feel high up in the pelvic strait an indistinct resistance, a diffuse, soft tumor, whose exact situa- tion and size cannot be accurately estimated. The consistence of the tumor varies considerably, according to the degree of dis- tention of the bowel. If the latter contains only gas, a very indistinct resistance is perceptible; although no tumor can be detected in the combined method of exploration, the fingers can- not be brought so nearly together as usual. But if the firmly adherent coils of the intestine are filled wuth fecal matter, diffuse tumefactions are felt, the precise size and limits of AAdiich cannot be well determined by palpation. These tumors, which are formed by the bowel when adherent to the genital organs, should be thoroughly understood, for they are exceedingly characteristic. The bowel can be felt under these circumstances, because the adhesions bind it firmly to the genitals ; otherwise it would recede before the finger. Serous transudations between pseudo-membranes can be felt the same as the real exudations. The latter, as already pointed out above, cannot be felt as a distinct tumor so long as they remain fluid, any more than we can define by palpation a free dropsical effusion in the peritoneal cavity, because the free fluid immediately yields to the palpating finger. But the case is altered so soon as the exudation is pre- vented from receding through its becoming solidified, or through its enclosure in a capsule of false membrane. Directly this has taken place, we are enabled by means of the combined method of exploration to detect a well-marked tumor, the size, location, and boundaries of which may be accurately ascertained. In the great majority of cases intraperitoneal exudations are found in Douglas's cul-de-sac, since this situation, both in the erect and recumbent postures, forms the most dependent part of the abdom- 456 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. inal caviry, into Avhich the fluid therefore naturally flows. Here, after it has stiffened or become enclosed in a membranous capsule, it forms a retro-uterine tumor of varying size, and in case the exudation is continued Avithin the enclosed cavit}', it may attain an enormous magnitude (see Fig. 118). In cases AA'here Douglas's cul-de-sac has previously been oblit- erated, or when under any circumstances membranous cavities form in other situations, we may have intraperitoneal tumors situated at one side of the uterus. The exudations then are ahvays situated high up at first, where they are inaccessible to an exploration through the vagina only, and sometimes they lie above the true pelvis, or laterally in the iliac fossa. As a rule, they are not very large, and are rather flat. But when there is a continued exudation in such an enclosed space at the side of the uterus, the tumor increases in size, crowds the ligamentum latum either forwards or backwards, and presses the peritoneum which forms the floor of the caAdty downwards. In this way tumors are formed which may project far dowmvard along the side of the uterus into the true pelvis, haAung all the appearance of exudations due to parametritis. In fact, they may be taken for the latter In the cadaver even, since the false membrane may be mistaken for peritoneum, and the small portion of the perito- neum, which has been forced downward and become altered in its appearance, may be regarded as the newly formed wall of the abscess. The excavatio vesico-uterina is very rarely protruded downward in this way. Perimetritis with exudation may vary also in its ultimate results. Entire resorption of the intraperitoneal adhesions and exudations is, to say the least, rare. In all cases the pelvic organs remain attached to each other, causing permanent dis- placement, or the organs contained in the true pelvis remain immovably fixed in permanent positions. Occasionally, how- ever, the adhesions become attenuated, or are so stretched by the continued traction that the displacement is gradually over- come and an almost normal mobility is recovered. A common effect of perimetritis is sterility. The direct causes of it are contraction or occlusion of the FaUopian tubes, the enclosure of the ovaries in exudations, and also displace- PERIMETRITIS, PELVEO-PERITONITIS. 457 ments of the womb. Should conception occur, the adhesions, even though very dense and firm, will gradually yield to the slowly enlarging uterus. In very rare cases only, when the adhesions are perfectly rigid, the womb is prevented from enlarging, and abortion results. The effect of the adhesions upon the position of the uterus is generaUy shown in a lateral displacement, in which position it is often immovably fixed; though in many cases the gradual stretching of the adhesions—seldom, probably, a total separa- tion—enables the uterus to resume its former perfect mobility. After the exudations have been entirely reabsorbed, the same effects are left as are produced by the adhesions, for in the for- mer case, also, the only result is that the organs implicated remain bound together. The exudation may, however, re- main for years unchanged, aftei its fluid portions have been re- moved, the absorbent action leaving the solid parts unaffect- ed. In still other cases sup- puration takes place, and the abscess leads to the various issues described above. The intraperitoneal exuda- tions, though as a rule they do not attain any very considera- ble magnitude, may exception- ally be of very great bulk ; but, in contradistinction to the eXUdationS Of parametritis, Large intraperitoneal exudation, which in the lowest -^ portion of the abdominal cavity has solidified. tliey dO not CrOWd the UterUS u, uterus, the location and size of which cannot be made out; D, Douglas's space, filled up with exuda- tO the OppOSlte Side, but fill ti011? r- rectum, which lies in the centre of the exuda- out the lower portion of the abdominal cavity so evenly—since they are at first fluid and only gradually thicken—that the upper portion of the true pelvis seems as though it were entirely occupied by a hard, solid mass. The exudation extends up the pelvic waUs on all sides, and 458 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. so surrounds the uterus that it can no longer be separately felt, and the whole pelvic entrance is so occupied that only a narrow opening in the rigid mass is left for the rectum (see Fig. 119). We would call attention particularly to the fact that in cases where the perimetritis has originated in an extension of the inflammation from the pelvic connective tissue, intra- and extra- peritoneal exudations frequently occur together. Diagnosis. It is generally easy to diagnosticate perimetritis, since, when the inflammation is recent, the tenderness on pressure, which is either diffused over the lower portion of the abdomen or con- fined to one spot, constitutes a sure sign of inflammation of the peritoneum. After the acute inflammation has subsided, the tenderness still remains for some time, and this, in connection with subsequent results of the inflammation, will suffice to indicate the diagnosis. The presence of the ordinary adhesions may be recognized by the marked immobility of the uterus or of one ovary ; the stronger adhesions can frequently be felt as bands which are sensitive to the touch. It is more difficult to diagnosticate an adhesion of the intes- tines to the genital organs. This condition is most liable to be mistaken for simple fecal accumulations in the bowel, since they also may render the intestine immobile and thus simulate tumors. The adhesion may be inferred from the local tender- ness and from the extreme hardness which remains after the boAvel has been wholly evacuated. With regard to the effects produced by exudations, we have already spoken of them at sufficient length in describing the symptoms. They are so characteristic that they can be con- founded with those of few other tumors. The tenderness with which exudations are accompanied, their lack of, or at least imperfect, mobility, and their rather irregular shape, are gene- rally sufficient to render them quite unmistakable. Very old exudations only, which have lost their sensitiveness, have par- PERIMETRITIS, PELVEO-PERITONITIS. 459 tially recovered their mobility, and are occasionally attached to the uterus by a sort of pedicle, may be confounded with fibroids or ovarian tumors. It is possible to distinguish them, not only by taking into account the history of the case, but by means of the irregular shape of the former, and also by their greater consistence, which even surpasses that of the fibroids, old exu- dations often becoming as hard as a board. We shall speak of the differential diagnosis between retro- uterine exudations and hematocele retro-uterina when we come to speak of the latter affection. It may be exceedingly difficult sometimes to decide the ques- tion whether the exudation is intra- or extraperitoneal,—in other words, whether it is a peri- or a parametritis. Ordinaril}r, to be sure, the points of distinction between these tumors are suffi- ciently characteristic. In parametritis the tumor can be easily reached by the vagina, unless it is situated in the fossa iliaca; and moreover, it is on one side, either in close proximity to the lateral border of the uterus, or separated from it by a distinct furrow. Very rarely is the tumor in front of or behind the womb. In perimetritis the tumors, as a rule, are retro-uterine, and may then, like those of the other variety, protrude far down into the vagina. When they are situated laterally they are usually so high up that it is impossible to reach them from the vagina, But, as pointed out above, an intraperitoneal exudation which is enclosed in a membranous capsule may carry the peritoneum far downwards and protrude into the vagina, and, under these circumstances, may produce precisely the effect, so far as position and size are concerned, as the extraperitoneal exudations. Moreover, after suppuration has taken place, the question as to whether the abscess when it first developed was intra- or extraperitoneal, is often a matter of considerable doubt. The difficulty of making the differential diagnosis is also increased from the fact that in primary peritonitis the peri- toneum may lie in the centre of the exudation—an exudation of perimetritis lying above and an exudation of parametritis beloAv. If, on puncturing an elastic pelvic exudation, a stream of 460 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. thin serum is obtained, the exudation invariably pertains to perimetritis. Prognosis. Inasmuch as perimetritis may lead to a general peritonitis, it is always a dangerous affection. The danger is most imminent in the acute form. But also chronic perimetritis, which is not apt to become general, may yet, in consequence of the adhesions being torn, or from the resulting hemorrhage, be followed excep- tionally by a general inflammation. The hemorrhages from the adhesions may occasionally give rise to hematocele. Furthermore, perimetritis may be the cause of displacement of the pelvic organs, and thereby of dysmenorrhoea and ste- rility, together with the rest of the ordinary symptoms and consequences of displacements of the uterus. Laceration and stenosis of the bowel, with the consequences, may be caused by the adhesions attached to the intestine. The abscesses also may be attended with serious dangers; not so much on account of the rare occurrence of a perforation into the abdominal cavity, as because of the liability that the inflammatory action in the abscess may lead at any moment to a general peritonitis. The latter may be owing to a perforation into the bowel, which permits the escape of faeces and intestinal gas into the cavity of the abscess, as illustrated in two cases observed by Duncan ; this is, however, contrary to the view maintained by Dupuytren. Treatment. Concerning the prophylactic treatment, which consists in avoiding all of the causes of perimetritis detailed above, it is unnecessary to speak further. The acute perimetritis is to be treated as a partial peritonitis, in the usual strictly antiphlogistic manner: internally, opium to keep the bowels quiet, ice-bags upon the abdomen, and, in case of severe pain, leeches in the groins. If this treatment controls the inflammation, and the fever PERIMETRITIS, PELVEO-PERITONITIS. 461 subsides, it is only necessary—beside providing for free defeca- tion, which may be done by means of enemata or mHd aperients —that perfect rest be enjoined. If in chronic perimetritis there is considerable sensitiveness, we shall find that, even where the complication of chronic metri- tis is wanting, rehef will be afforded by scarifications of the vaginal portion of the cervix. Moreover, warmth and moisture —the so-called fomentations of Priessnitz applied to the abdo- men, together with lukewarm hip-baths at a temperature of 95° F.—are often surprising alleviatives. If the condition has become very chronic, it may be stiD possible to effect a tolerably complete resorption by means of the above fomentations (which should be employed for a long period and be allowed to remain on during the night), by the use of somewhat warmer hip-baths [increase the temperature cautiously !] and by the iodide of potassium. At the same time it is of great importance to prevent any long-continued over- loading of the bowels. Even very old exudations, which have persisted without change for years, are not unfrequently made to undergo by this treatment, to say the least, a partial resorption ; or, if not, they may yield to the stimulated absorbent action excited by the mud-baths, especially those which contain iodine and bromine —such as the baths at Kreuznach and Miinster on the Stein; at Tolz; at Hall, in Upper Austria; at Sodenthal, near Aschaf- fenburg, etc. The abscesses should only be opened when they cause a marked protrusion. They are slow to heal, since the walls of the enclosed intraperitoneal cavity are often rigid, on account of the false membranes, and come together with difficulty, the purulent secretion continuing for a long time. When the abscess has perforated the bowel, the discharge may last for years, the narrow communication with the intestine only closing temporarily. So soon as the cavity of the abscess begins to be distended with pus, the opening is made pervious again, and from time to time repeated discharges of pus take place into the bowel. 462 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. PARAMETRITIS. Etiology. As already stated above, I regard parametritis—the "pelvic cellulitis" of the English—as a phlegmon of the pelvic con- nective tissue, which is invariably the secondary effect of the resorption of septic matters. For this reason parametritis is of pretty rare occurrence, excepting in the puerperal state. Aside from this, it is most common after traumatic operations upon the vagina or cervix. Thus all cutting operations, as well as the dilatation of the cervix with sponge-tents (which abrade the mucous membrane and expose it to the danger of absorbing the foul secretions), may lead to parametritis. Generally speak- ing, it is Hable to occur in all cases where the epithelium is destroyed and septic matter is brought into contact with the exposed subjacent connective tissue. Purely traumatic operations, in which tliere is no infection of the wounds, give rise, not to parametritis, but to perimetritis. Pathological Anatomy. Parametritis is a phlegmon (the acute purulent oedema of Pirogoff) in the connective tissue of the pelvis. It occurs more particularly about the upper portion of the vagina, between the layers of the broad ligaments, and thence extends upwards into the fossae iliacae, and posteriorly as far up as the kidneys. Exudations between the uterus and bladder, or between the bladder and anterior wall of the abdomen, are met with rarely ; neither is the phlegmon apt to extend to the short, unyielding connective tissue which unites the peritoneum with the body of the uterus. In the phlegmonous process the connective tissue becomes infiltrated with a gelatinous, fibrinous exudation which is also more or less cellular in its composition. In exceptional cases the pus corpuscles may be so numerous as to flow together and form an abscess. Parametritic abscesses have, in general, the same ultimate PARAMETRITIS. 463 results as those due to perimetritis—in fact, after suppuration has taken place it is generally too late to decide whether the disease is owing to an intra- or an extraperitoneal process; nor is it practically very important, since the perimetritic abscesses are also shut off from the general cavity of the peritoneum by firm investing membranes. It appears as though abscesses of parametritis were more apt to perforate externally in the groin, while those of perimetritis, into the internal organs. Freund1 has described, under the name of parametritis chronica atrophicans, a peculiar form of chronic parametritis, which he supposes, in many instances, constitutes the anatomical basis of hysteria, and which he is very particular to distinguish from the puerperal parametritis. In this affection an inflammatory hyperplasia of the pelvic connective tissue takes place, the consequence of which is a cicatricial shrinking of the tissue. On account of the compression to which the veins are subjected, disorders of the circulation occur, and the final result is a high degree of atrophy of the pelvic connective tissue, as well as of the entire genital tract; in this way such a condition of the genitals is produced in women not much over thirty as we ordinarily find only in women who have passed the age of fifty. The symptoms of the affection consist of pains in the deeper region of the pelvis, taediurn coitus, and, above all, hysterical manifestations. With respect to the etiology, Freund regards the disease as attributable to over- irritation of the genital nerves, with excessive losses of secretion. Symptoms and Course. Parametritis is almost invariably acute, resembling in the mode of its development the acute form of pelveo-peritonitis. It is frequently accompanied with exudation. The disease begins with a sudden attack of fever (occasionally with a chill), and its further course is marked by a high tempera- ture, and increased frequency of the pulse. In very rare cases the inception of the disease is not distinctly marked. There is a feeling of discomfort, with languor, loss of appetite and pains in the pelvis, and, on making an examina- tion, the exudation is discovered. The pain is owing to the implication, or at least to the asso- ciated irritation, of the peritoneum. Not infrequently pains 1 Monatsschr. f. Geb., B. 34, p. 380, and Verh. der Rostocker Naturforscherversam, 1871, p. 63. 464 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. occur in one lower extremity, in consequence of the pressure of the exudation upon the nerves; occasionally there is an enforced position of flexion or adduction of the thigh, which is character- istic ; furthermore, pains in the lower part of the back, pain during defecation, and disorders connected with the bladder, are frequent symptoms of the pelvic tumor. Upon examination an exudation is found, which is situated on one side of the uterus, either in close proximity to it, as though projecting from its lateral margin, but usually separated by a well-marked furrow, or else somewhat removed from it; and not infrequently it extends up into the iliac fossa. If the infiltration is only slight in amount, and merges gradually into sound connective tissue, simply a diffuse resistance can be detected, which is situated at one side of the womb. But if the infiltration is more considerable, and the process has become circumscribed, Ave find a well-defined tumor, which, as a rule, can be distinctly felt from the vagina, and sometimes it pushes the roof of the vagina on one side down before it. Frequently only one side is affected, though not very rarely the disease occurs on both sides. The tumor is movable only when it is perfectly circumscribed, and lies quite close to the uterus, and even then it is but slightly so, and can only be moved in con- junction with the Avomb, as though it formed a sort of appendage to it. The size and extent of the tumor are extremely variable. Sometimes only a slight tumefaction is found in the ligamentum latum, or exceedingly small sensitive deposits, like tubercles, occur at the side of the womb. But in other cases the whole upper portion of the pelvis seems to be filled up with the exu- dation. The consistence of the tumor is, at first—while it is still very sensitive—pretty soft. It becomes tender after the acute process has subsided, and finally, after it has become perfectly inspis- sated, it may become as rigid and hard as a board. When an abscess forms, the region becomes sensitive again and somewhat soft, as though cedematous, until the whole mass has suppurated, when the entire tumor becomes elastic or fluctuates. The characteristic location for the exudation of parametritis PARAMETRITIS. 465 is on one side, as described above. In very rare cases, and Avhere the exudation is slight in amount, its seat may be in the retro- uterine connective tissue, which lies between the cervix and upper portion of the posterior wall of the vagina, on the one hand, and the floor of Douglas's cul-de-sac on the other. Still more rarely is the tumor of parametritis found beneath the excavatio vesico- uterina, or underneath the place Avhere the peritoneum is reflected from the bladder on to the anterior Avail of the abdomen. The further course of the affection is, in the majority of cases, chronic ; the inflammatory process becomes limited, and the exudation becomes inspissated and gradually undergoes resorp- tion. Yet there is always the danger that the inflammation may extend to the peritoneum lying over the affected connective tis- sue, and so a general peritonitis ensue. In case the infection has been exceedingly severe, the result may be a necrosis of the inflamed connective tissue. But, as a rule, the inflammation becomes limited, the fever subsides, the painfulness diminishes, and the hitherto soft, some- what ill-defined exudation becomes hardened, and assumes defi- nite limits. Under these circumstances the usual result is that the tumor is gradually reabsorbed, the process being accom- panied, in the larger exudations, Avith well-marked hectic fever, and finally the tumor disappears entirely. In other cases the exudation remains stationary, and a large solidified tumor of great hardness continues for some time to occupy the cavity of the pelvis; nevertheless, a partial resorption may occur at a very late period. If an abscess is developed, the tumor begins to increase in size again, and its former sensitiveness returns, while, meantime, there is a reneAved occurrence of the remittent fever. These symptoms continue until the abscess has perforated externally, or into the cavity of some IioIIoav organ. The position of the uterus may be altered in various ways. In the case of the large exudations the womb is crowded to the opposite side; later, as resorption proceeds, it is gradually drawn over to the side of the exudation, and for a time is held firmly in this position, until by degrees its normal position is resumed, and its former mobility returns. vol. x.—30 466 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Diagnosis. Parametritis can only be diagnosticated through the presence of an exudation, for the tenderness proceeds from the perito- neum, which lies above the inflamed connective tissue. The diagnosis of an inflammatory exudation is not generally difficult, yet it may be a matter of great difficulty to decide the question as to whether the exudation is intra- or extraperitoneal. We have already referred to this at some length in connection with the diagnosis of perimetritis. But aside from this, the exudations of parametritis are most liable to be confounded with uterine fibroids; but the fact that the former are not, as a rule, round, but rather flat, the mode of their inception, their tenderness and lack of mobility will suffice to distinguish them. Moreover, there is a difference in their consistence, for the exudations, in the beginning and also after suppuration has taken place, are softer than the fibroids, but when they have become solidified they are much harder than the latter. They also present characteristic marks of dis- tinction in the courses Avhich they pursue. The exudations grad- ually groAv harder and smaller, or if they increase in size, it is only in connection with febrile symptoms and increased sensi- tiveness, and even then they do not increase in size so gradually nor so uniformly as the fibroids. But where a fibroid, which is situated low down, becomes inflamed, the diagnosis may be ren- dered extremely difficult. The exudations are still less liable to be confounded with ovarian tumors, on account of the lower positions in which the former occur, their immobility and their different consistence (unless in the stage of suppuration). But, on the other hand, if the ovarian tumor is confined in one position, Ioav doAvn, at one side of the uterus, and there becomes inflamed, the diagnosis will be difficult. An exudation may be distinguished from an extra-uterine pregnancy, which occasionally has a similar location, by observ- ing the subsequent course. RETRO-UTERINE HEMATOCELE. 467 Prognosis. Parametritis is not of itself a disease which threatens life, yet on account of the infection which causes it, we can never be sure that an extension of the disease to the peritoneum, or some other consequence of the infection, may not lead to a fatal termination. But after the inflammation has become limited, the prognosis is decidedly favorable, for if appropriate means are employed resorption invariably takes place, and we may anticipate a per- fect restitutio in integrum. Treatment. With regard to prophylaxis, we here simply observe that it consists in the avoidance of infection. A recent parametritis—so long as the process has not ex- tended to the peritoneum—demands hardly anything more than rest. Mild aperients are indicated to keep the bowels open. Great relief is obtained by the application, over the abdomen, of the so-called fomentations of Priessnitz. If the tenderness is gone, and the tumor has become hard, resorption may be stimulated by means of hip-baths, with warm Avater or with the mother-water of Kreuznach, and by the inter- nal use of the iodide of potassium. By these means, or through a course of treatment in the iodine or bromine mud-baths, exten- sive and old exudations may frequently be compelled to yield to a complete, or at least to a partial resorption. The English recommend especially the good effects derived from the external application of blisters. If suppuration has commenced, it is unnecessary to take any pains to find the pus, since the abscess is not apt to perforate into the abdominal cavity, but generally breaks at some favor- able point. As a rule, the abscess need not be evacuated until it can be reached Avithout incurring any great danger or diffi- culty. RETRO-UTERI XE ILEAIATOCELE. Vigues (N'laton), Des tumeurs sanguines, etc. These. Paris, 1850.—ttlaton, Gaz. des hop., 1S31, No. 16, and Nos. 143-143; !So2, Nos. 12 and 16, and 1853, No. 468 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. 100.— Fenerly, De l'hematocele rfitro-uterine. These. Paris, 1855.—Laugier, Gaz. des hop., 1855, No. 27.—Gallard, Union med., No. 134, 1855, and Archives gCner., Oct.-Dec, I860.—Gallard etc., Bulletin de la soc. anatom. de Paris, Avril, 1858, p. 157.—A. Voisin, De l'hematocele rgtro-uterine. These. Paris, 1858. Trans, into German by Langenbeck. Gottingen, 1862.— Bernutz et Goupil, Clinique med., T. I. Paris, 1860.—Trousseau, L'Union med., 1861, Nos. 153-155.—Engelhardt, De l'hematocele retro-uterine. These. Strasbourg, 1856.—Puech, Journal de Bruxelles, XXXI., p. 44, Juillet-Nov., i860.— Dolbeau, Med. Times, Febr. and March, 1873.—M. Duncan, Edinb. Med. J., 1862.—Tuckwell, On Effusion of Blood in the Neighbourhood of the Uterus, etc. Oxford and London, 1863.—Beirnes, St. Thomas's Hospital Reports, 1870.— Meadows, London Obst. Tr., XIII., p. 140, and p. 170, and Amer. J. of Obst, Vol. VL, 1874, p. 659.—Snow-Beck, London Obst. Tr., XIV., p. 260.—Lee, Amer. J. of Obst., Vol. VL, p. 193.— Crede, M. f. Geb., B. 9, p. 1. — Ott, Die periuterinen und retrovag. Blutergiisse. Diss, inaug. Tubingen, 1864. —Breslau, Schweiz. Z. f. Heilk., 1863, B., II., p. 297.—Ferber, Schmidt's Jahrb., 1864, B. 123, p. 223, B. 135, p. 321, and 1870, B. 145, p. 39.—Roedelheim.er, Wiir- temb. Correspondenzbl., 1867, Nos. 12, 13.—Schroder, Krits. Unters, uber d. Diagn. d. Haemat. retr., etc. Bonn, 1866, and Berl. klin. Woch., 1868, No. 4, etc.—Olshausen, Arch. f. Gyn., B. I., p. 24.—Kiichenmeister, Prager med. Viertelj., 1870, B. I., p. 31, B. II., p. 45.— Weber, Berl. klin. Woch., 1873, No. l.—Frdnkel, Prager Viertelj., 1872, 4, p. 46. Definition and Mode of Occurrence. Nelaton, who in 1850 first described haematocele as a special form of disease, defined it as the formation of a tense, bloody tumor in Douglas's cul-de-sac, which crowded the uterus against the symphysis pubis. Subsequently the term was given a more general signification, and every bloody tumor in the pelvis was designated as an haematocele; in fact, the application was so enlarged as to embrace all hemorrhages into the abdominal cav- ity (Barnes, for instance, applied the term to hemorrhages due to rupture of the uterus) under the name of intraperitoneal haematocele. But so general a use of the term haematocele must of necessity detract from a clear apprehension of the differ- ent diseases thereby designated; for what resemblance is there betAveen the haematocele of Nelaton and a free hemorrhage into the abdominal cavity, which causes immediate death ! Now since Nelaton's bloody tumor represents a special, well-defined form of disease, which has a great practical importance of its RETRO-UTERINE HEMATOCELE. 469 own, it is absolutely necessary, in order to prevent a complete confusion of terms, to retain the above definition of haematocele retro-uterina intraperitonealis: a bloody tumor situated in Douglas's cul-de-sac, which crowds the uterus forwards. We wiU here remark that in order to distinguish them we shall designate all extra-peritoneal hemorrhages as thrombi or haema- tomata. Haematocele is not apt to occur in women who have pre- viously been perfectly healthy ; the great majority of them have had children and have suffered from puerperal diseases, espe- cially perimetritis. Moreover, disorders of menstruation have very frequently preceded the hemorrhage. The bloody tumor is most common during the period of greatest sexual activity— from the ages of twenty-five to thirty-five approximately. We shall not here discuss the particular causes of the hemor- rhage, since it is necessary first to become acquainted with the pathological anatomy, and, more particularly, with the sources from which the hemorrhages may proceed. There exists a great diversity of opinion among gynecolo- gists as regards the frequency of haematocele, and this in itself is an evidence of the difficulty of the diagnosis. It is my own opinion that haematocele is a disease of pretty rare occurrence, and while Scanzoni's statement, that he has seen only two cases in a practice of tAventy years, is certainly very remarkable, I am fully convinced that, on the other hand, such statements as that made by Seyfert—that the relative frequency of haema- tocele is to be reckoned at five per cent, of all diseases—and that of Olshausen (who puts the ratio at four per cent.) are, in a measure, founded upon erroneous diagnoses. According to my own experience, including those cases where only certain condi- tions were found which in all probability had resulted from pre-existing haematoceles, this affection constitutes about 0.7 per cent, of all diseases—that is, seven cases of haematocele occur in every thousand patients. Pathological Anatomy. Haematocele intraperitonealis consists almost invariably of a retro-uterine, enclosed tumor, situated in Douglas's cul-de-sac. 470 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. It is necessary to the definition of haematocele that the tumor should be shut off from the rest of the abdominal cavity, for free hemorrhages into the cavity of the peritoneum never cause a tense, elastic tumor, Avhich is capable of crowding the uterus forwards ; but when blood escapes into the free cavity of the abdomen, it forms simply a pool of blood in the most dependent portion of the abdominal cavity, which may, hoAvever, after- wards become enclosed in an inflammatory, newly formed, mem- branous capsule. The tense, elastic tumor which croAvds the uterus forwards may occur in two ways. 1. It may be developed where a pseudo-membranous cavity, shut off from the general cavity of the peritoneum, existed prior to the hemorrhage—that is, a cavity whose Avails lie in contact with each other (the same as we speak of the pleural cavity, for instance). While the posterior wall of the uterus and the ante- rior wall of the rectum lie in close relation to each other, Doug- las's cul-de-sac becomes bridged over above. Now, in case a hemorrhage occurs from some place situated below this mem- branous bridge, the blood is effused into the enclosed space, dis- tends its walls, and so forms a tense tumor which crowds the uterus fonvards. Here- belong, also, those cases where the hemorrhage takes place into a previously existing retro-uterine tumor with fluid contents. The tumor then, all at once, becomes greatly distended, and its contents are changed to a mixture of serum, or pus, and blood. 2. But haematocele may also develop in cases where Doug- las's cul-de-sac is not enclosed by membranes at the time the hemorrhage occurs. In all such cases, no matter whence the blood is derived, the tumor is not tense at first, and does not press the uterus forwards, but it merely forms a pool of blood in the most dependent portion of the abdominal cavity, the folds of the bowel floating upon its surface. The pool of blood changes with every change in the patient's position, though it always fills the region of Douglas's cul-de-sac, since both in the erect and recumbent posture this forms the most dependent part. But so long as the blood remains fluid it only occupies Doug- las's cul-de-sac in the same manner as the folds of the intestine RETRO-UTERINE HEMATOCELE. 471 that is, it is only when the bladder and rectum are empty, and the posterior wall of the uterus and anterior Avail of the rectum are separated from each other, that any considerable amount of blood can descend between these organs; but as soon as the blad- der and rectum begin to fill, and the capacity of Douglas's space is diminished, the fluid blood re- cedes, partly or almost entirely, into the rest of the abdominal cavity. It acts in the same Avay also when a digital examination is made. The fluid blood cannot be felt as a tumor any more than it is possible to feel the bowel when lying free in Douglas's cul- de-sac. If the blood has coagulated or become enclosed in pseudo-mem- branes, though it forms a percep- tible retro-uterine tumor, it still lacks the characteristic features of an haematocele. The tumor will be of considerable size if, at the time when it became firm, the bladder and rectum were nearly empty, Avhile if these organs were then full, merely a thin layer of blood will separate the uterus from the rectum. This bloody tumor is distinguished from true haematocele in that its Avails are not tense, that it does not crowd the uterus for- wards, and that it only occupies so much of the true pelvis as the condition of the organs there permits. Therefore, the chief symptoms of haematocele are wanting, viz., those which depend upon the effects produced by the pressure of the tumor upon the organs of the true pelvis. True haematocele is produced by a free hemorrhage into the cavity of the abdomen only when the blood is derived from some spot deeply situated, and when the hemorrhage is either slowly continued or repeated at intervals. A single hemorrhage, if it occurs in the free cavity of the Yia. 120. Hematocele retrouterina intraperitonealis. H, The bloody tumor. 472 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. peritoneum, can never present the features of haematocele, for the reason given above; but when the effused blood is inclosed afterwards in a membranous capsule, which forms, in conse- quence of the irritation excited in the peritoneum by the bloody effusion, and the hemorrhage then still continues, or is repeated, the new hemorrhage does not take place into the free cavity of the abdomen, if it proceeds from a place which is situated below the membranous investment, but into the enclosed cul-de-sac of Douglas. Hence the conditions are now just the same as in the case where Douglas's cul-de-sac is shut off primarily. The blood extravasated from the vessels distends the newly formed invest- ing membrane, compresses the rectum, causes the floor of Doug- las's cul-de-sac to protrude downwards, and crowds the uterus against the symphysis. But if, on the contrary, the hemorrhage occurs from some spot lying above the investing false membrane, no haematocele is formed, but only a second pool of blood, which lies above the first, the latter having already been enclosed in a membranous capsule. It is this requirement that the source of the hemor- rhage should lie below the fundus uteri, which alone confers upon haematocele the right to be ranked among the gynecologi- cal diseases, for then the hemorrhage must proceed from some of the organs of the true pelvis. Only in exceptional cases (particularly in prolapse of the womb) is the first hemorrhage ever so considerable in amount that the pool of blood rises above the fundus uteri; then the adhesive peritonitis, which encloses the blood in pseudo-mem- brane, occurs above the fundus, and extends on to the bladder, or as far as the anterior wall of the abdomen. If the hemor- rhage is continued, or is repeated after the investment has taken place, a haematocele results which reaches above the uterus as far as the anterior abdominal wall.1 Let us now consider somewhat in detail the sources from which the blood, of which the haimatocele consists, may be derived. As we have already seen, the hemorrhage must come from organs of the true pelvis. Hemorrhages from parts situated 1 Martin-Magron and Soulie, Gaz. des h6p., 1861, No. 14. RETRO-UTERINE HEMATOCELE. 473 higher up may doubtless give rise to effusions into the perito- neal cavity, which may be fatal, and they may produce a coagu- lum of blood in Douglas's cul-de-sac, but can never cause the characteristic tumor which crowds the uterus f onATards. The hemorrhage in haematocele, therefore, may proceed from the Fallopian tubes, from the ovaries, from the broad ligaments, or from other portions of the pelvic peritoneum. 1. Hemorrhage from the Fallopian tubes may take place, In consequence of a tubal pregnancy terminating in rupture, in which case the resulting hemorrhage or peritonitis is generally fatal immediately. But if Douglas's cul-de-sac has already been shut in by pseudo-membrane prior to the occurrence of the rup- ture, or if the blood is so slowly effused that the membranous capsule is formed while the hemorrhage still continues, or finally, if, after the hemorrhage has ceased, the blood is enclosed in false membrane, and fresh hemorrhages occur subsequently, the consequence is the production of a retro-uterine haematocele. A few hematoceles formed in this way have been observed upon the cadaver. It is not improbable that the haematocele origi- nates in this manner oftener than is generally supposed, and for the reason that the existence of a tubal pregnancy in this affec- tion is frequently not recognized. Such may perhaps be the case in many of those instances (which are frequent enough) where tliere has been a cessation of the menses for several periods previous to the occurrence of the haematocele, and the patient has at first been under the impression that she was pregnant. Moreover, hemorrhages from the Fallopian tubes are not rare in connection with haematometra. There is obviously in this case a primary hemorrhage within the canal of the tube, and the blood, escaping through the abdominal orifice, or through a rupture, gains access to the cavity of the peritoneum. But this rarely gives rise to a haematocele, and probably for the reason that, as a rule, only a small quantity of blood escapes at the ostium abdominale at a time, and at each escape the blood becomes invested in false membrane immediately, so that in the vicinity of the tubal orifice a number of peritoneal thickenings are produced, each of which contains a small quantity of blood. In exceptional cases a hemorrhage may take place into the 474 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. canal of the Fallopian tube during menstruation, and thence into the peritoneal cavity. Yet the hemorrhage is generally too slight in such cases to cause haematocele. Tubal hemorrhages are especially apt to occur, after ovariotomy, from the cut end of the tube, which is included in the pedicle, and, together with the latter, is replaced in the abdominal cavity. 2. Hemorrhages from the ovaries do not occur in normal ovulation, for there is either no hemorrhage at all in the Graafian follicle, or at the most but a very slight one. But in exceptional cases a more considerable hemorrhage may occur, or some vessel, perhaps in a varicose condition, may be ruptured elsewhere dur- ing ovulation. At other times hemorrhages from the ovaries are more rare, unless due to ovarian diseases. The hemorrhage is then most apt to occur when varicose vessels cover the surface of the ovary, or when its stroma has become softened and somewhat disintegrated, in consequence of inflammation, and is, at the same time, decidedly hyperaemic. Moreover, there are certain other pathological conditions, such as the presence of small cysts, which predispose to the occurrence of hemorrhage. Very frequently the ovarian hemorrhage occurs, in the first place, in a Graafian follicle, in a small cyst, or in the stroma of the ovary, thus forming a bloody cyst, which is ruptured, and the blood escapes into the peritoneal cavity. 3. Hemorrhages from the broad ligaments are rare ; yet we occasionally find the peritoneal coating so thinned over thick varicose veins in the broad ligaments, that, should the veins burst, the hemorrhage would naturally escape into the cavity of the peritoneum. 4. Hemorrhages from the serous coating of the pelvis are pretty frequent causes of haematocele. Under these circum- stances the process is very similar to that which takes place in the pachymeningitis hemorrhagica,1 first described by Dolbeau2 and Virehow.3 The very vascular pseudo-membranes which are formed in pelveo-peritonitis may both serve to hem in Douglas's 1 Ferber, Arch. f. physiol. Heilk., 1863, III., p. 431. 8 Gaz. des hop., 18G0, No. 35. 3 Die krankh. Geschw., 1863, B. I., p. 150. RETRO-UTERINE HEMATOCELE. 475 cul-de-sac, and to supply the blood which forms the haematocele. Frequently, also, the hemorrhage takes place into a pre-existing, enclosed membranous space, which is filled with clear serum, the bloody effusion dilating its cavity still more. A very pretty instance of such a secondary hemorrhage from the walls of the cavity, in a pelveo-peritonitis serosa, is reported by Crede.1 On puncturing the tumor in Douglas's cul-de-sac a clear serum was poured out first; then serum mixed with blood; and finally, pure blood; and on reneAving the puncture, two days later, pure blood was discharged in such amount that the operation was not ventured again. Though the hemorrhage may take place at any time from the above sources, and without any especial occasion presenting itself, yet it is particularly apt to occur in the event of such general or local causes intervening as tend to promote the lia- bility of blood-vessels to rupture. In this connection a general predisposition to hemorrhages is of no little importance, whether OAving to morbid conditions of the vascular walls generally, or to the presence of scorbutus, purpura, or a hemorrhagic diathesis; also in phosphorus poisoning, where there is a fatty degeneration of the vascular walls, hemorrhage may occur in the tissue of the ovary, and, a rupture taking place, the blood escapes into the peritoneal cavity.5 Moreover, physical exertions or sudden jars may occasion rupture of the distended vessels. Furthermore, the local tendency to hemorrhage is increased by any hyperaemia of the pelvic organs, such as may be induced after exposure to cold (causing a congestion of all the internal organs), but particularly through sexual excitement. Of espe- cial importance also is the physiological congestion which takes place at the time of menstruation. In the cases described by the French, the cause is not infrequently attributed to coitus exercised during the menstrual period. Symptoms and Course. It is rare that haematocele occurs suddenly in women who 1 Monatsschr. f. Geb., B. 9, p. 1. 3 Wegner, Virchow's Arch., B. 55, 1872, p. 12. 476 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. have previously been healthy. Generally various ailments have been complained of for a long time before. In most cases signs of chronic peritonitis have existed before- hand, perhaps for years, with pains in the abdomen and back, together with various difficulties connected with the intestinal canal; also irregularities of menstruation often precede the affection, especially metrorrhagia, indicating a chronic condition of plethora in the organs of the true pelvis. It is doubtful as to what significance is to be attached to the amenorrhoea which, in a strikingly large number of cases, precedes the occurrence of the haematocele for from two to three months, and often leads women to believe that they are pregnant. We have already above alluded to the probability of a tubal pregnancy existing in many of these cases, and that its rupture may be the cause of the haematocele. But though haematocele is often preceded by the various dis- orders just described, it nevertheless also develops suddenly as an acute disease. Marked fever occurs, which is seldom ushered in with a chill, but frequently by repeated rigors. The tempera- ture is not generally much elevated, and sometimes at least it becomes normal again very soon after the commencement of the disease. The other more prominent symptoms of haematocele are mainly referable to three sources—namely, to the partial peri- tonitis, to the internal hemorrhage, and to the pelvic tumor formed by the accumulation of blood. The partial peritonitis may be of very different grades of intensity. Sometimes the peritonitic pains are extremely severe, and there may be considerable tympanites, or vomiting even, while in other cases all signs pointing to an acute though partial peritonitis are lacking. This is more especially apt to be the case when the hemorrhage has occurred into a cavity already enclosed; but even then the stretching of the walls of this cavity causes such an irritation of the peritoneum that spontaneous pain and considerable tenderness on pressure are never absent. The tenderness is evinced when an examination is made of the lower part of the abdomen, and it may be also extreme when the tumor is touched through the vagina. RETRO-UTERINE HEMATOCELE. 477 The symptoms of the internal hemorrhage also vary in their degree of severity. The patient becomes suddenly pale, the pulse is small and weak, a sense of weakness or of faintness is felt, and sometimes complete syncope ensues. Moreover, a large tumor is developed in Douglas's cul-de- sac (see Fig. 120), which, by its pressure upon, neighboring organs, gives rise to various other symptoms. 1. Thus, the rectum may be pressed upon. In consequence of this, defecation becomes difficult, particularly if hardened masses of faeces have to pass the sensitive tumor, when the pain sometimes becomes excessive. The compression of the rectum, in conjunction very likely with an extension of the inflamma- tion from the adjoining parts, causes the production of a catarrh of the rectal mucous membrane. 2. Pressure upon the bladder causes an increased desire to micturate, and, less frequently, retention of urine. Very fre- quently urination is painful. 3. Pressure upon the nerves gives rise to pains and to abnor- mal twitching of the inferior extremities. It is rare that the veins are so pressed upon as to cause oedema. 4. The uterus is crowded hard against the symphysis pubis. The engorgement of the womb with blood, Avhich is produced in consequence of this, together with the hyperaemia which pervades all of the pelvic organs, may doubtless be regarded as the cause of the bloody discharges which so frequently occur, and which occasionally amount to a profuse hemor- rhage. The tumor that develops in the abdomen, and which is some- times noticed by the patient herself, may be clearly demon- strated by palpation through the abdominal Avails and by explo- ration through the vagina or rectum. It is situated behind the uterus, and crowds the Avomb forwards, and generally some- AAdiat upwards. If examined externally, Ave find either in the mesian line, or most commonly on the left side, more rarely on the right, a roundish tumor which projects above the symphysis, and under certain circumstances may reach as .high as the umbilicus. In some instances large tumors are felt on both sides, Avhich are joined by a middle piece. Unless the tender- 478 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ness is too great, the uterus can generally be felt in the shape of a little tumor lying in front of the larger one. When an examination is made per vaginam, the finger impinges directly upon a large round tumor, which is situated not far from the vaginal entrance, occupies nearly the whole of the true pelvis, and so crowds the uterus against the sym- physis that the cervix is felt lying close to its posterior surface. The uterus may be forced so high up that the external os can scarcely be reached. The size and spherical shape of the tumor can be best appreciated from the rectum. The tumor lies inva- riably just behind the uterus, though it often extends a little to one side, and is in immediate relation with the upper part of the posterior wall of the cervix. We may easily convince ourselves, by means of the combined method of examination, that the tumor which is felt externally, and that which occupies the true pelvis, are one and the same. The tumor is ahvays very sensi- tive, and most markedly so when examined per rectum. The tumor has generally an elastic feel, but seldom presents any fluctuation. In the case represented in Fig. 120, I could feel a peculiar crepitation, like that produced in crushing a snoAv-ball, which was caused by the coagula being pressed together. Gradually the consistence of the tumor undergoes a decided alteration. The tumor becomes hard and irregularly nodulated, while, meantime, the tenderness slowly disappears. Not infrequently, in making an exploration per rectum or per vaginam, the finger suddenly encounters a markedly softened spot in some part of the tumor, and immediately sinks in so deeply that it gives an impression as though the tissue had been perforated. This is the spot where the future perforation is to occur. The large tumor does not always recede immediately after the first examination; sometimes it gradually increases; more frequently the increase is sudden, occurring by separate incre- ments. We attach an especial importance to the combined method of examination, on account of the affection of the body of the uterus ; for this portion of the Avomb can ahvays be felt in the form of a tumor lying in front of, but separate from, the larger RETRO-UTERINE HEMATOCELE. 479 one, though occasionally the haematocele lies in intimate con- nection with the entire posterior surface of the uterus. If the sensitiveness is very great, the examination may be possible only \AThile the patient is under the influence of chloroform. Although the most characteristic condition of things found on examination is that described above, certain modifications may occur. One of the most common of these arises when Douglas's cul-de-sac has been previously obliterated, for then the bloody tumor forms higher up, and the protrusion into the upper portion of the vagina is Avanting. I have observed such an instance in a married lady, tAventy-eight years of age, who for four and a half years had been sterile. At the age of fif- teen she had a very severe at- tack of typhus while in Munich, which was followed by peritoni- tis, with perforation of pus in the region of the umbilicus. For eight weeks this lady had re- garded herself as pregnant, when suddenly she was attacked Avith Ha3matocele with d™^1^^ sealed up. intense Dain in the abdomen. «. Uterus; h, hematocele; d, obliterated in- ± ferior portion of Douglas's space. On making an examination I found the condition represented in Fig. 121. Behind and above the uterus, which was strongly anteflexed, a great tumor had formed. The history of the case, the result of the examination, and the subsequent course, rendered it probable that, in con- sequence of the former peritonitis, the lower portion of Doug- las's space had been sealed up, and that a tubal pregnancy, terminating in rupture, had caused the production of a bloody tumor in the pseudo-membranes higher up. If Douglas's cul-de-sac is obliterated entirely, it is possible for an ante-uterine haematocele to occur, of which we shall treat separately hereafter. 480 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The course pursued by an haematocele is decidedly chronic, since the tumor remains, as a rule, for quite a long time sta- tionary, and, in fact, as we have already seen, additions may be made to its size afterwards, through recurrences of the hemor- rhage. Since the painfulness also continues, and in case the tumor has increased in size, may even be augmented, the condition of the patient becomes, in the more severe cases, exceedingly dis- tressing. The sensitiveness of the abdomen, the pain in the back, the incessant bearing down, and the disorders in the rectum and bladder, torment the patient extremely. The mere loss of blood through the internal hemorrhage is hardly ever of itself a matter of any serious moment, though signs of anaemia, or even syncope, may follow. But it is only in such individuals as are already greatly debilitated that any serious danger need be apprehended from the hemorrhage merely. The peritonitis, also, is seldom attended with danger to life at its first invasion. The ultimate result varies according as resorption or perfo- ration takes place. In the most favorable event resorption occurs, and the tumor gradually decreases in size, becoming harder and someAvhat nod- ular. Meantime the cervix recedes more and more from the symphysis towards the middle of the pelvis, the distressing symptoms gradually diminish in violence, and very slowly—in the course of months—the haematocele disappears, leaving only a remnant behind, which consists of a hard, retro-uterine tumor, which remains firmly attached to the uterus. The womb never regains its normal mobility. If perforation ensues and the blood is evacuated, an inflam- mation of the walls of the haematocele first takes place; neAv inflammatory symptoms are developed; one spot becomes soft- ened and is finally broken through. Most commonly the perforation takes place through the rec- tum. It is preceded by signs of intestinal catarrh, but never- theless occurs suddenly, with a profuse diarrhoea, and the dis- charge of masses of black, friable matter. Immediately after the RETRO-UTERINE HEMATOCELE. 481 first discharge the patient's condition is markedly alleviated, and continues to improve with the further evacuation of the contents of the tumor, which often lasts for a considerable time. As the evacuation proceeds, the tumor diminishes in size, and gradually wastes away until the perforation is closed, and only a vestige of the tumor is left behind, with the obliterated Douglas's cul-de- sac. But the perforation may also result in an ichorous inflam- mation, terminating in death. Perforation into the vagina is of much rarer occurrence, and Avhen it occurs is accompanied with vaginal catarrh. There may also be a simultaneous perforation into both vagina and rectum. But one case, according to Ott,' has been recorded of perfora- tion into the bladder, and in this a perforation through the abdominal walls was threatened at the same time. Perforation into the peritoneal cavity is very rare. The result is then unavoidably fatal, unless the blood which escapes is perfectly fresh. In all these cases there is the danger that either while the perforation is taking place, or during the gradual evacuation of the cavity, the walls of the cyst may suppurate, and the con- tents become decomposed. The usual result, under these cir- cumstances, is death from peritonitis or exhaustion. Sometimes, also, the cavity of the abscess remains open,, in which the pus collects until it is expelled through the narrow fistulous opening of the perforation, and in this way repeated discharges of pus may occur from time to time through the rectum. Diagnosis. The condition found on examination in haematocele is so remarkable and so characteristic that the disease suggests itself directly. Therefore, inasmuch as the physical examination in conjunction with the facts presented by the history of the case are fully competent to establish a positive diagnosis, we may confine ourselves to the consideration of the points of dif- ference which exist between hematocele and the conditions which are more or less apt to be confounded with it. 1 Revue elinique hebdomad, de la Gaz. des hop., 1861, p. 53. VOL. X.—31 482 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. We come first to speak of perimetritis, which, under certain circumstances, can only be distinguished from haematocele by an exploratory puncture ; for, certain forms of perimetritis exhibit precisely the same features as the disease which we are consider- ing. The differential diagnosis will most depend upon the anam- nesis—upon the ascertainment of certain facts in the history of the case. A very acute development of the large tumor, the sudden onset of the symptoms, together Avith the occurrence of an acute anaemia, are points in favor of haematocele. Moreover, the course pursued by the two diseases is different. The haema- tocele, unless perforation takes place, grows smaller and harder, does not present a uniform consistency, and becomes nodulated; while the serous peritonitis may, for a long time, remain un- changed, and the perimetritic abscess perforates. Yet a fibrinous exudation, on the other hand, may follow exactly the same course as that pursued by an haematocele. The peculiar crepi- tation, Avhich is sometimes imparted to the finger by the coagu- lated blood, appears to be a rare feature of the disease. Haematocele is peculiarly liable to be mistaken for retro- flexio uteri gravidi, in cases where (as not infrequently happens) the patient has before been laboring under the impression that she was pregnant. The examination per vaginam shows a very striking resemblance. In retroflexion we may feel, on external examination, the greatly distended bladder, which could not be mistaken for the tumor of haematocele, and besides, in the case of the latter disease, the fundus uteri will be felt pressing against the anterior abdominal wall. But in order to establish these points with certainty it may be necessary, on account of the fre- quently excessive sensitiveness of the patient, to make the exam- ination under chloroform. Ovarian cysts, also, or uterine fibroids, which have become engaged in Douglas's cul-de-sac, may give rise to an inflamma- tion in their vicinity, and produce almost precisely the effect of a haematocele; yet their course and mode of development are essentially different. In case of necessity the question may be decided by an exploratory puncture. Extra-uterine pregnancy in Douglas's cul-de-sac is very rare, but for this very reason may render the differential diag- RETRO-UTERINE HEMATOCELE. 483 nosis all the more difficult, and, furthermore, many of the anam- nestic points may show a marked degree of similarity. The tumor, to be sure, develops slowly in extra-uterine pregnancy; but this fact does not always clearly appear, and we are obliged to resort to the exploratory puncture. It is also important to note the fact that in extra-uterine pregnancy the uterus shoAvs a very considerable enlargement, which could only occur, in con- nection with haematocele, as an accidental complication. Retro-uterine carcinomata may usually be recognized with- out difficulty, by means of the anamnesis, by their gradual devel- opment and nodulated form, and by the various signs of malig- nant disease. To ascertain whence the hemorrhage proceeds is a still more difficult task than to make the differential diagnosis of haemato- cele. In the majority of cases it is mere matter of conjecture, though, to be sure, under certain favorable circumstances, this conjecture may be rendered tolerably plausible. Thus, in one case Avhich I observed, it was believed that the diagnosis of a tubal pregnancy could be made with considerable certainty, since the history of the case favored it, and a tumor which was distinct from the haematocele could be felt in the region of the Fallopian tube. Where there have been previous attacks of perimetritis, or if an enclosed serous exudation, known to have existed before, becomes suddenly increased in size, it is natural to refer the haematocele to a haemorrhagic pelveo-peritonitis. If, on a former examination, small ovarian tumors have been discovered, the inference arises that the source of the hemor- rhage exists in the ovary. In the absence of all local indica- tions, but with well-marked varicose veins in the loAver extremi- ties, one might surmise that the rupture of a varicose vein in the broad ligament was the cause of the trouble. Prognosis. Haematocele is always a very serious affection, partly on account of the decided derangement of health which is sure to follow in time, but likewise by reason of the danger to life; moreover the after-effects of haematocele are often of a serious nature. 484 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Death is an exceptional result, and is most generally caused by suppuration of the tumor, together with the development of putrefactive changes in the contents. Among the ill effects of the haematocele may be mentioned the permanent displacements of the uterus, recurrent attacks of perimetritis, and sterility, which latter is due generally to adhesions about the ovaries and occlusion of the Fallopian tubes. Yet conception is by no means an impossibility after the occurrence of haematometra. Haema- tocele very rarely occurs a second time. Treatment. Generally speaking, the treatment of haematocele must be expectant, depending entirely upon symptomatic indications. When the tumor has first developed, the external application of cold is the measure of chief importance. For this purpose ice- bags may be applied to the abdomen ; sometimes the introduc- tion of bits of ice into the vagina also affords relief. Two indica- tions are met by means of the application of cold, viz., to restrict the partial peritonitis within circumscribed limits, and secondly to moderate the internal hemorrhage. Local depletion is but exceptionably applicable, and only to those cases Avhere the peritonitis threatens to become general and wdien the hemor- rhage into the retro-uterine tumor has produced no symptoms of anaemia. In case there are no especially urgent symptoms pres- ent, it is only necessary further to insist upon absolute rest, to pass the catheter if required, and to administer such mild laxa- tives as will prevent the passage of any large, hardened masses of faeces by the side of the tumor, which might cause increased irritation and aggravate the pain. When the haematocele follows its typical course, further treatment, aside from the administration of narcotics to quiet the pain, is entirely unnecessary; for, as a rule, the contents of the tumor become inspissated, and all but a small remnant of the haematocele is reabsorbed. Since the issue in resorption is the most favorable one, the artificial evacuation of the tumor can only be warranted in the presence of a special indication. Such an indication may arise ANTE-UTERINE HEMATOCELE. 485 from the immense size of the tumor or from the occurrence of suppuration or putrefaction of its contents. With regard to the first of these indications, the distress occasioned by the pressure of the tumor may be so great that it becomes necessary to reduce the size in order to obtain any relief. But even in such cases the operation should be delayed as long as possible, lest a fresh hemorrhage should take place while the tumor is being emptied. Since, in all such cases, the contents of the tumor are still fluid, the puncture should be made with the finest possible trocar, and under all the precau- tions which will prevent the admission of air into the cavity. If air is admitted suppuration and decomposition ensue, but they may also follow a spontaneous perforation. Under these circumstances the entire mass of blood must be evacuated. This can only be accomplished by making a Avide incision into the tumor, which protrudes into the vagina, and by then removing the clots with the finger. A solution of carbolic acid is after- wards injected into the cavity to cleanse its walls, and in order to avoid, if possible, the threatened peritonitis or pyaemia. If the blood has perforated spontaneously, and no inflamma- tory signs have appeared in the contents of the tumor, we should be cautious about hastening the evacuation of the blood, since by this means air or intestinal gas may easily gain access to the cavity and render decomposition unavoidable. If perforation into the rectum is threatened, the treatment should be purely expectant; if the tumor is about to break into the vagina, a puncture or a cautious incision may be made at the place where the perforation is most imminent. ANTE-UTERINE HEMATOCELE. By the term ante-uterine haematocele we designate a bloody tumor lying in the peritoneal fold between the uterus and the bladder. A bloody tumor may develop in this situation under differ- in"- conditions. In the first place, it may form a portion of a lar^e retro-uterine tumor, the effused blood being enclosed in pseudo-membranes Avhich extend over the uterus on to the ante- 486 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. rior wall of the abdomen. The vesico-uterine cul-de-sac is then also filled with blood. It is very rare that the ante-uterine haematocele develops as in a case reported by G. Braun,1 where the hemorrhage escaped into the peritoneal pouch lying in front of the uterus, this pouch having been previously bridged over by false membrane. Such cases are extremely rare ; in the first place, because perito- nitic adhesions are of far less fre- quent occurrence in front of the uterus than behind it, and sec- ondly, because the Fallopian tubes and the ovaries, which often give rise to hemorrhages in the retro- uterine space, are not apt to be so displaced as to lie in the vesico- uterine cul-de-sac. I have myself seen an exceed- ingly interesting case of ante- uterine haematocele,2 in which the large bloody tumor (see Fig. 122) was developed in the follow- ing manner: The hemorrhage was due to the occurrence of rupture in a tubal pregnancy; but, since the anterior wall of the rectum lay closely adherent to the uterus, the blood flowed into, and became coagulated in, the hollow formed between the empty bladder and rectum, this hollow forming the most dependent portion of the abdominal cavity, inasmuch as Douglas's cul-de- sac had been obliterated. Pig. 122. Haematocele ante-uterina. v, Uterus; t, foetal sac in the tube: be. blood ooagula; fb, fluid blood. THROMBUS OR HEMATOMA OF THE CONNECTIVE TISSUE (HEMA- TOCELE EXTRA-PERITONEALIS). Effusions of blood into the pelvic connective tissue aside 1 Wiener med. Wochenschr., 1872, Nos. 22 and 23. ■ Arch. f. Gyn., B. V., Heft. 2. CYSTS OF THE BROAD LIGAMENT. 487 from those due to traumatic -auses, are very rare excepting in childbed. They may occur in any situation in the connective tissue, depending upon the occasioning cause and the source of the hemorrhage. They do not conform therefore to any cer- tain rules, and may give rise to tumors of the most various de- scription. TUMORS OF THE PELVIC PERITONEUM AND PELVIC CONNECTIVE TISSUE. Cysts. Spencer Wells, Diseases of the Ovaries, p. 30.—Atlee, Ovarian Tumors, etc., p. 107. —Peaslee, Ovarian Tumors, etc., p. 99.—Bantock, Obstet. Journ. of Gt. Brit, May, 1873, p. 124.—Koeberle, Ibid., September, 1873, p. 422. A number of pedunculated or non-pedunculated cysts not infrequently occur in the vicinity of the Fallopian tubes. Other cysts develop from the parovarium, the ducts of which are lined with ciliated epithelium ; yet all the cysts which occur in the broad ligament can scarcely be derived from the par- ovarium alone, but some of those which lie near the uterus doubtless proceed from that portion of the Wolffian body which originally belonged to the kidney, and vestiges of which remain, according to Waldeyer,l in the shape of little canals filled with epithelial cells, which lie between the parovarium—the sexual part of the Wolffian body—and the uterus. These cysts of the broad ligament generally remain small, but exceptionally they may become as large as ovarian tumors. As a rule, they have thin walls (Spiegelberg2 found smooth muscular fibres in them), and are lined internally with cylindri- cal epithelium, which is occasionally ciliated. They are not gen- erally pedunculated, but spring from the broad ligaments in the form of sessile growths, and lie either in close proximity to the ovary or are distinctly separated from it. The Fallopian tube is usuaUy lengthened and curved over them. Their contents consist of crystal-clear serum, with a low spe- 1 Eierstock und Ei., p. 142. 2 Spiegelberg, Arch, f. Gyn., I., p. 482. 488 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. cific gravity (1.004-1.005) and contain no albumen, or else but a very slight amount. They do not appear to fill again, as a rule, after they have once been punctured. Myoma, Fibroma, and Fibro-Myoma. The tumors of this description doubtless originate as tumors of the uterus, which have grown in between the layers of. the broad ligament, and the peduncle has afterwards become de- tached from the womb. According to Virehow,1 however, myo- mata may also develop in the uterine ligaments originally. Schetelig" describes a cysto-fibro-myoma, which probably originated in the uterus, although it was not connected with it. Carcinoma and Tuberculosis. These diseases present nothing characteristic in their features, since they merely represent affections of the peritoneum of the pelvic region. DISEASES OF THE VAGINA. Malformations. The vagina, like the uterus, is developed from the tAvo canals of Miiller, whose coalescence begins in the upper portion of the vagina. All of the malformations of the vagina are produced in consequence of the destruction or imperfect development of one or both of Midler's canals, or are due to the failure of their coalescence. This subject has already been touched upon in speaking of the malformations of the uterus. Complete Non-development and Rudimentary Formation of the Vagina. Kussmaul, Von dem Mangel, etc., der Gebarmutter. Wiirzburg, 1859.__Klob Pathol, der weibl. Sexualorg., p. 412. Practically these two conditions are equivalent to each other 1 Geschwiilste, III., 1, p. 221. 2 Arch. f. Gyn., B. I., p. 425. MALFORMATIONS OF THE VAGINA. 489 and, as a rule, the one is not distinguished from the other ana- tomically; yet bands of connective tissue, which run in the course of the vagina, must be regarded as a rudimentary vagina, the same as in the case of the uterus. Malformation of the vagina may occur in connection with complete non-development or rudimentary formation of the ute- rus, or it may occur independently of either of these conditions, the uterus being normal. Those portions of Midler's canals, out of which the vagina is developed, may be only partially obliterated, and consequently we sometimes meet with merely a blind pouch in the situation of the vaginal portion of the cervix, or there may be only a very shallow cul-de-sac just back of the hymen. In still other cases the vagina is only wanting in the middle, so that the two open ends are separated merely by a membrane of various degrees of thickness. Sometimes the latter is exceedingly thin, and it may be perforated by various-sized openings. The instances in which the upper and lower blind pouches overlap each other to a certain extent without joining, are doubt- less to be explained on the supposition that in one of Midler's canals the upper portion was obliterated, while in the other it was the lower portion. Vagina Unilateralis. If only one of Midler's canals is developed, while the other remains non-developed, or in a rudimentary state, there is, mor- phologically speaking, but a half-vagina. The fact that this malformation has hitherto received no attention is owing to the difficulty of demonstrating its presence with any certainty ; for such criteria as are available in this connection with regard to the uterus (the form and mode of attachment of its appen- dages), are, in the case of the vagina, entirely lacking. It is probable that in the great majority of cases of uterus unicornis, but one of Midler's canals has developed in the region also of the vagina. Doubtless many of the cases of partial duplication of the vagina are to be regarded simply as instances of partial develop- ment of one of the halves. 490 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Vagina Septa. When the whole vagina is double tliere is always a double uterus, and, generally, a double hymen is found. When one of the vaginal canals is closed below, haematometra is developed on that side. The two vaginae do not always lie exactly side by side; according to Dohrn, the left canal of Miiller lies a little in front of the other. When the duplication of the vagina is partial, it generally affects the lower portion (the upper remaining single), owing to the fact that the coalescence begins at the top. Yet it is not rare in connection with a double uterus to find the upper part of the vagina double (the septum being continued into the vagina), wdiile, below, the coalescence has taken place. In other cases isolated septa or bridge-like bands are stretched across the vagina, these being the remnants of a former partition (in many cases, too, they may be owing to foetal adhesions which have afterwards been stretched). If a double vagina occurs in connection with a single uterus, one of the halves is always rudimentary. Congenital Smallness of the Vagina. A congenital, abnormal narrowness of the vagina is most apt to occur in a marked degree in conjunction with various malfor- mations of the uterus, but more particularly with the fcetal and infantile varieties. A narrow vagina, occurring in connection with a uterus unicornis, is probably always a vagina unilateralis. An abnormal shortness of the vagina may be produced, also, in consequence of some special error of development. An operation is indicated in case of occlusion of the vagina only when a haematometra has developed, for the internal geni- tals are generally so malformed that it is useless, with any other object in view, to attempt the formation of a vagina artificially ; and moreover, unless the uterus is present to afford a guide to the operation, tliere is great danger of serious damage being done. INFLAMMATION OF THE VAGINA. 491 The bridge-like bands of the vagina, as well as the partial duplications, are only to be operated upon when they cause inter- ference with cohabitation or with parturition. The congenital narrowness of the vagina forms an obstacle to cohabitation only, but it is generally overcome by the repeated efforts of the male ; but, if necessary, compressed sponge may be introduced, as would be especially indicated in the event of a partial narrowing. Atresia of the Vagina. Atresia, with resulting haematometra, has already been de- scribed under atresia uterina. INFLAMMATION OF THE VAGINA.—VAGINITIS, COLPITIS, ELYTHRITIS. Kolliker and Scanzoni, Scanzoni's Beitrage, II., p. 128.—Tyler Smith, Pathol, and Treat, of Leucorrhoea. London, 1855.—Hennig, Der Katarrh der weib. Ge- schlechtsorgane, 2. Aufl., and the literature cited under Endometritis. Acute Catarrhal Inflammation. Etiology. The most frequent cause of acute inflammation of the vagina is gonorrhoea. Besides this, traumatic influences of every de- scription may give rise to it. Under certain circumstances coitus may be reckoned among the traumatic influences. But the latter also arise frequently in connection with various sur- gical procedures, such as cauterization, too cold or too hot injec- tions. Pessaries may also produce them, or putrid or other discharges. Acute catarrh may be developed during menstruation, par- ticularly if at the same time the patient be exposed to injurious influences, such as cold especially. Not infrequently the acute catarrh represents merely an exacerbation of a chronic catarrhal affection. Finally, the acute form of vaginal catarrh may occur in con- nection with the acute exanthemata, and particularly measles. 492 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Acute colpitis is by far most common in Avomen at the age of greatest sexual activity; but traumatic agencies may pro- duce it even in children, and, not rarely, it is met with after the menopause. We have observed it in one case where the uterus was completely atrophied, and where it was impossible to attri- bute it to the cause assigned by Hildebrandt, namely, to a patu- lous condition of the vulva, facHitating the intrusion of dust and cold air. Pathological Anatomy. The signs of an acute catarrh present themselves in this af- fection. The mucous membrane is reddened, swollen, and has a soft, velvety feel. The prominent folds are greatly swollen, forming ridges, upon whose summits a considerable injection is found, or even hemorrhages, or the epithelium is so easHy wounded that a free bleeding readily takes place. The mucous follicles of the vagina are swollen up in the form of little cysts. At the beginning of the catarrh the secretion of the vaginal mucous membrane is diminished ; later it becomes increased, and has a muco-serous or a purulent character. The colpitis due to gonorrhoea differs in no essential respect from the other form, excepting that it is apt to be associated Avith a catarrh of the urethral mucous membrane, and an inflam- mation of the follicles about the orifice of the urethra. More- over, suppuration of the glands of Bartolini is of frequent occur- rence in gonorrhoea. While the ordinary acute colpitis extends usually over the whole vagina, the gonorrhoeal catarrh is often confined to the lowest portion; yet circumscribed inflammations may occur also in the cul-de-sac of the vagina, owing to the extension of an inflammation from the uterus. There is also a very peculiar form of colpitis which occurs in just the upper portion of the vagina, and has been described by Hildebrandt,1 and designated by him as vaginitis ulcerosa adhassiva. In it the mucous membrane is deprived of its epithe- 1 Monatsschr. f. Geb., B. 32, p. 128. INFLAMMATION OF THE VAGINA. 493 lium at the upper part of the vagina, and presents an excoriated appearance, with slight papillary hypertrophy. The conse- quence of this inflammation is the adhesion of the vaginal por- tion of the cervix to the lateral wralls of the vagina, so that the vaginal cul-de-sac is completely obliterated, and the os is then felt at the apex of the funnel-shaped upper portion of the vagina. I have myself observed the results of this process; in one case the superior portion of the vagina Avas completely occluded, and in another instance there was a partial occlusion beloAV the vaginal portion of the cervix. Neither of the patients had ever borne children, and the affection had doubtless been con- tracted previous to the marriage. In one of the cases the result- ing haematometra perforated during the wedding trip, and was discharged through the vagina. In a third case, a uniform sten- osis occupied a good portion of the upper half of the vagina. The right side of the vaginal arch was adherent, Avhile the left formed a blind pouch. Symptoms. The acute catarrh may begin with decided febrile symptoms. It runs its course in a period of some Aveeks, if the proper treatment is pursued, and terminates in recovery. Otherwise, it lapses into a chronic blennorrhcea, as it is especially apt to do in the gonorrhoeal form. In the severer cases, besides the discharge, pains in the abdo- men are complained of, which are occasionally of an exceed- ingly distressing nature. A continual sensation of bearing down is present, and sometimes spasmodic contractions of the constric- tor cunni occur, with tenesmus of the rectum and bladder. Treatment. As a rule the treatment can be mainly expectant. A slight diversion may be created by way of the intestinal canal, and decomposition of the secretion is obviated by means of very cau- tious injections at a temperature of about 95° F. At the same time care should be exercised in the avoidance of unfavorable 494 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. influences, and absolute rest is to be enjoined. In case spas- modic pains exist, great relief is derived from Avarm hip-baths. Croupous and Diphtheritic Inflammation of the Vagina. Etiology. Croupous and diphtheritic membranes may develop upon the mucous membrane of the vagina in two ways: they may occur only at certain points, in consequence of local injuries, while the rest of the mucous membrane is barely affected with a catarrhal inflammation, or they may appear in the form of a croupous or diphtheritic inflammation, which involves the Avhole of the mucous membrane, or at least its greater upper or loAver portion. Isolated membranes may occur in all those cases in which the vaginal walls are exposed to the irritation of ichorous dis- charges, such as are present in carcinoma of the uterus or in ulcerating fibroids and polypi. Or they may be caused by pes- saries which have been left in the vagina for an undue length of time. Again, in prolapse of the vagina or uterus, membranous deposits may develop upon ulcers, which form in parts exposed to external injuries. Moreover, it is not uncommon to see firmly adherent diphtheritic deposits in cases of vesico- or recto-vaginal fistula, where the urine or faeces remain long in the vagina. A croupous or diphtheritic inflammation of the greater por- tion of the vagina occurs, excepting in gonorrhoea (in which, by the way, it is very rare) and during the puerperal state, only in connection with the acute infectious diseases—measles, small- pox, typhus, and cholera. Pathological Anatomy. Where the affection of the mucous membrane is limited, we find whitish membranes in spots of moderate extent, which may be easily separated from the mucous membrane, or are firmly adherent to it. The rest of the mucous membrane appears about normal, or is merely affected with a slight catarrh. , The general diphtheritis of the vagina presents a much severer character. The swelling of the mucous membrane is very great INFLAMMATION OF TIIE VAGINA. 495 and the septum recto-vaginale may have the appearance of a large tumor, occluding the passage of the vagina, and the mucous membrane of the cul-de-sac may swell up even with the vaginal portion of the cervix, so that the finger cannot pass beyond the os. White and green diphtheritic membranes cover the vaginal mucous membrane to a greater or less extent, and a purulent secretion, with a foul, cadaverous odor, flows from the vagina. In diphtheritis of the upper part of the vagina, the vaginal portion of the cervix is involved; the swelling of the mucous membrane covering it increases its circumference, and the lining membrane of the cervix is swollen up in thick ridges. I have seen the cervical mucous membrane so swollen as to protrude from the external os, and to the touch appear like a mucous polypus as large as a walnut. In the healing process, which advances very slowly, considerable strictures may be pro- duced, and the vault of the vagina may become adherent to the vaginal portion of the cervix. Symptoms. The symptoms are very like those of the severer forms of the acute catarrh. Fever is present only at the commencement; the symptom Avhich elicits the greatest attention afterwards is the discolored, bloody-purulent discharge, with its abominable odor. In addition to this, there are pains in the pelvis, bearing-down sensation, and spasms of the constrictor cunni and other muscles of the perineum. The diphtheritic exudations which occur in connection with the putrid discharges in carcinoma or fistulae occasion no special symptoms. Diagnosis. Generally the form of the inflammation is diagnosticated in the discovery of the membrane. In case a diphtheritis of the upper portion of the vagina is very severe, it may present pre- cisely the same features as would be exhibited by an ulcerating carcinoma or mucous polypus of the cervix which gives rise to a putrid discharge, inasmuch as the diphtheritis transforms the vaginal portion of the cervix into a shapeless tumor. The ques- 496 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. tion must be decided by a careful examination, and, in case of necessity, by watching the further course of the affection. Treatment. Naturally the most important point in the treatment is to remove the cause. If this is quickly done, as is possible in the case of ulcerating polypi or forgotten pessaries, recovery fol- lows immediately, attention being paid merely to cleanliness. Moreover, in all cases attention to the latter requirement, together with the application of a solution of carbolic acid, always effects a cure ultimately, though the mucous membrane may continue to granulate for some time, and considerable cica- tricial contractions may be left behind. The latter result is best obviated by the insertion of greased tampons between the contracting walls of the vagina. PERIVAGINITIS PHLEGMONOSA DISSECANS. Marconnet, Virchow's Archiv, B. 34, 1 and 2.—Minkiewitsch, Ibid., B. 41, p. 437. Three cases of this affection have been described ; its etiology is unknown. In Marconnet's two cases there was a suppurative inflammation of the submucous connective tissue which caused the separation of the entire vagina, including the mucous mem- brane and muscular layer, and the vagina was expelled in con- sequence, in the shape of a perfect tube, together with the mucous covering of the vaginal portion of the cervix. Healing followed with suppuration. The case of Minkiewitsch was of a more malignant character. In this instance also the vagina was expelled in toto, but the patient died, and at the autopsy the posterior vesical and ante- rior pelvic walls were found gangrenous. CHRONIC CATARRH OF TIIE VAGINA.—FLUOR ALBUS.—LEUCOR- RHffiA. Etiology. Chronic catarrh of the vagina is an exceedingly common CHRONIC CATARRH OF THE VAGINA. 497 affection. Sometimes it is the sequel to an acute colpitis, and both to the benign and the malignant varieties; but much oftener it occurs as an independent disease. A long-continued hypersecretion of the vaginal mucous mem- brane may be owing to climatic influences or to anomalies of the constitution. It is of especially frequent occurrence in connec- tion with chlorosis. But every local irritation to which the vagina is subject may give rise to a catarrhal secretion. Among such irritations may be reckoned too frequent coitus, which in newly married women, not before accustomed to it, is a very common source of chronic catarrh. Next, a whole series of operative procedures belong here; but, above all, the employ- ment of too hot or too cold injections. Vaginal pessaries in- variably irritate the mucous membrane, and those which are constructed of good materials and properly adapted differ in this respect from the others only in degree. The vagina is exposed to a very continuous irritation when in prolapse of the uterus and vagina it comes to lie outside the vulva between the thighs (but, on the other hand, a long-continued catarrh may lead to hypertrophy and relaxation of the vaginal waUs, and so be the cause of the prolapsus). Moreover, affections of the uterus—particularly inflamma- tions, though also displacements and new-growths—may readily cause a catarrh of the vaginal mucous membrane. Finally, it may be produced where tliere is an engorgement of the blood-vessels of the lower half of the trunk, such as may occur in consequence of diseases of the liver, lungs, or heart, or through the presence of abdominal tumors. But large-sized tumors in the true pelvis may also, by means of the local irrita- tion which they excite, give rise to a hypersecretion of the vaginal mucous membrane. Pathological Anatomy. We not infrequently find in cases in which the vaginal catarrh has become decidedly chronic—that is, has lasted for months—the same alterations in the mucous membrane as we meet with in the acute catarrh ; this seems to be particularly the case in gonorrhoea. We then find marked injection, and vol. x—32 498 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. occasionally ecchymoses at the top of the swollen ridges of tin4 mucous membrane, and purulent secretion. If these changes have receded, or in case they were never very marked, the mucous membrane feels smooth, firm, and rigid. Its color is brownish red or a slate gray ; sometimes it is studded with irregular spots of pigment—the remains of hemorrhages in the mucous membrane. The characteristic mark of the chronic catarrh is the secre- tion. It always has an acid reaction, and is frequently merely the physiological secretion much increased—that is, it is thick, whitish, and creamy, and consists of exfoliated pavement epi- thelium, together Avith a few mucus corpuscles. The latter are, in other cases, mingled with the secretion in larger amount, and pus corpuscles may be superadded ; occasionally the secre- tion may become almost entirely purulent. Not infrequently Ave find the trichomonas vaginalis and fungus spores in the catarrhal secretion. Symptoms. When the affection pursues a very chronic course, the dis- charge is the only symptom. This may, however, be exceed- ingly troublesome, or even pernicious to health if it is very profuse, since it erodes the vulva and thighs, and induces gen- eral disturbances of nutrition. The latter manifest themselves in very different degrees. Many women become veiy much reduced in health through a long-continued, though only slight discharge, vdiile others present a flourishing appearance Avith a profuse blennorrhcea. If the chronic catarrh has caused a relaxation of the vagina, a certain degree of prolapse results, which occasions bearing- down pains, as well as the annoying sensation of a foreign body in the vulva. The course is exceedingly chronic. A leucorrhoea may last for years, or even for a lifetime. Treatment. For the sake of moderating the hypersecretion an endeavor should always be made to obviate the causes upon which it depends. CHRONIC CATARRH OF THE VAGINA. 499 Thus, in chlorotic patients the administration of iron will not infrequently cure the leucorrhoea by itself, without local treatment. The' removal of an ill-adapted pessary, or, on the other hand, if there is a prolapse of the vagina, the introduction of a suitable ring may be followed by the complete disappear- ance of the secretion, or at least moderate it to a large degree. Furthermore, the treatment of any coincident uterine disease, especially the cervical catarrh, is important in this connection. With regard to the local treatment, simple cleanliness will often accomplish the desired result, since when the secretions lie for a long time stagnant in the vagina, they become them- selves a source of irritation to the mucous membrane. The in- jections which this treatment necessitates should, of course, be made in a very cautious manner—that is (aside from taking care to introduce the instrument employed carefully), they should not be made with too forcible a stream, and should be neither too cold nor too warm. A temperature of about 95° F. may be commenced Avith, and then gradually and cautiously lowered. In the event of the colder injections not being well borne, as not seldom happens, they should be refrained from. Injections Avith the waters of alkahne springs, such as Ems and Neuenahr, prove especially efficacious. These simple measures, however, are resisted by the more in- veterate catarrhs, and it becomes necessary to add some astrin- gent to the fluid injected, such as tannin, alum, chloride of iron, nitrate of silver, etc. Should injections not answer the purpose—the injected fluid not reaching the whole surface of the vagina—other methods of application may be employed Avith advantage. A very effectual method, and one which is particularly adapted to the application of concentrated solutions, consists in introducing the glass speculum so as to bring the vaginal por- tion of the cervix into view, and then, after pouring the fluid into the speculum, drawing the latter slowly out, by which means the solution is brought gradually into contact with every portion of the vaginal mucous membrane. This method is more effectual than Avhen the solution is applied through the specu- lum Avith a brush. Small tampons of cotton, or small sponges 500 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. which have been saturated with the astringent, may also be intro- duced into the vagina. For this purpose Scanzoni recommends a drachm tannin to an ounce glycerine. Even' glycerine alone has a desiccating effect upon the mucous membrane, since it abstracts its watery portions, and while remaining in contact with it occasions an increased serous discharge. The cotton tampons may also be sprinkled with powdered alum or smeared with an astringent ointment (eighty grains of alum to an ounce fat, according to Hildebrandt). A very excellent application also consists in the introduction into the vagina of little balls of cacao-butter and tannin (four grains of tannin and forty-six of cacao-butter in each ball). The warmth of the body gradually melts the cacao, and the tannin contained in the liquid fat is brought extensively into contact with the vaginal waUs. PROLAPSUS VAGINAE. Vid. literature cited under Prolapsus uteri. Etiology. A primary vaginal prolapse may be produced by all those conditions which cause an elongation of the vagina, if at the same time they are associated with a relaxation of the vaginal mucous membrane and of the organs in its vicinity. A slight degree of prolapse, a protrusion of the vaginal mucous membrane through the orifice of the vagina, may, it is true, be produced by a simple lengthening of the vagina without any relaxation. The most perfect instance of this is seen in pregnancy. The vagina becomes then so much elongated that, although its upper portion is displaced backwards and upwards,' yet in many cases its anterior wall, and not infrequently both the anterior and posterior, are protruded beyond the vaginal orifice. It is especially in chronic catarrh that the vagina becomes at the same time both hypertrophied and relaxed, and is also then less firmly united than usual to the subjacent tissues. Hence it is very common in catarrhs of long standing for the anterior and posterior walls of the vagina to project into the vaginal orifice. PROLAPSE OF THE VAGINA. 501 The vagina is apt to be prolapsed, too, in old women, in con- nection with the loss of adipose tissue and the relaxation of the tissues generally, and this would be still more common were not the prolapse in a certain measure counteracted by the senile atrophy of the vagina. In prolapse of the vagina it is always the anterior or pos- terior wall which is affected, and never the lateral walls. This is readdy explained by the accompanying figure, (see Fig. 123), which represents the transverse section of the vagina, according to Henle. The lumen of the vagina is filled up by the coUapsed anterior and posterior walls, so that it is only FlG- 123- i.1 i*i i it Shape of the vagina in tiiey winch can become prolapsed. transverse section, -p. . _, after Henle. But the anterior and posterior walls differ from „, Anterior, h, Pos. one another in certain essential respects. The anterior vaginal wall is more liable to a slight degree of protrusion through the rather narrow orifice of the vagina, on account of the direction of the vaginal canal, while the posterior wall is exceedingly apt to become prolapsed whenever the peri- neum is shortened (see Figs. 69 and 70, page 190). Yet, the total absence of the perineum, as in the case of cicatrized large perineal ruptures, is not in itself sufficient to produce pro- lapse of the posterior vaginal wall, but there must be also a relaxation of this wall. So long as the vagina is normal it does not become prolapsed, even in exceedingly large ruptures of the perineum, and indeed the cicatricial contraction which takes place in connection with the healing of the rupture tends to counteract the production of a prolapse, inasmuch as the pos- terior wall of the vagina is thereby greatly shortened. The condition of neighboring parts—the pelvic connective tissue, the bladder and the rectum—has an exceedingly import- ant bearing upon the displacement of the vagina. If the vagina is united Avith the parts in its vicinity by means of short unyielding connective tissue—as it is normally— it is impossible for a prolapse to take place so long as these organs are in a normal condition. But if the connective tissue is spongy and can be easily stretched, the vagina sinks down somewhat, so that its cul-de-sac disappears; instead of ascend- 502 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ing to envelop the cervix, the vagina begins to descend directly from the external os. Such a condition of things is particularly common after the puerperal stage, and occurs also in old women. If, then, at the same time, the posterior vesical and anterior rectal walls are relaxed, as is very commonly the case, they also participate in the downward tendency (see Fig. 71, page 190). In other cases, however, under favorable circumstances (that is, in a relaxed condition of the vagina), the displacement of the bladder and rectum may occur primarily. Where the habit exists of long retaining the urine, or where there is habitual constipation, the anterior or posterior wall of the vagina is gradually pushed forward before the distended organ, lower and lower in the vaginal canal; in this way diverticula of the blad- der and rectum are formed, and when these have attained a certain size, they can no longer, usually, be perfectly evacu- ated ; then, in consequence of the continual weight of their contents, the vaginal mucous membrane is displaced still farther downwards. In rare cases also the posterior vaginal wall may gradually become protruded in consequence of an abnormal pressure in Douglas's cul-de-sac, produced by the bowel or by the presence of ascites or of tumors. A primary prolapse of the vagina may, by means of the downward traction which it exercises upon the uterus, lead to descent and final prolapse of the latter organ, but only when the connections of the uterus with its neighboring organs are abnormally relaxed. In the absence of relaxation the uterus is unable to follow in the direction of the downward traction, and consequently supravaginal hypertrophy of the cervix results. Conversely, prolapse of the uterus may be the primary event, and the vagina may be inverted by the descending uterus. The upper portion of the vagina, which envelops the lower segment of the uterus, then appears first in the opening of the vulva. Practically, however, this does not occur just in this way, since when the connections of the uterus are relaxed the vagina, as a rule, is also not firmly united with its surroundings. There- fore, generally, the descent of the uterus is coincident with the PROLAPSE OF THE VAGINA. 503 prolapse of the vagina, so that the lower portion of the vagina protrudes beyond the vaginal orifice, while the upper portion is inverted by the descending uterus. Pathological Anatomy. Inasmuch as a relaxed vaginal mucous membrane is a condi- tion necessary to the prolapse, we invariably find the evidences of catarrh. This catarrh is then aggravated by the external injuries to which the protruding portions of the mucous membrane are exposed, until finally, through the action of the air and con- stant friction, the peculiar alter- ation takes place which was be- fore described under prolapse of the uterus. A special consideration is due the displacements of neighboring organs, which are apt to be asso- ciated with prolapse of the va- gina. Any considerable prolapse of the anterior wall of the vagina is always accompanied by a cys- tocele (see Fig. 71, on page, 190). This becomes especially marked Avhenever the abdominal pressure is much increased, and above all in very corpulent women. In such cases Ave often find in the orifice of the vagina a tense, elastic Simple rectocele. tumor, as large aS an Orange, r, The dilated diverticulum of the rectum. Avhich cannot be kept back by any mechanical means. The highest degree of displacement of the bladder (Avhere the entire bladder is contained in the pro- lapse) occurs only in connection with coincident prolapsus uteri. Rectocele may exist in a marked degree without any prolapse of the uterus, in rare cases even without any sinking of the uterus Avhatever; yet, unless the Avomb is abnormally fixed in 504 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. its position, its descent soon follows, in consequence of the con- stant traction upon it. Fig. 124 represents a case of simple recto- cele. The patient herself stated that faeces and flatus escaped into the prolapse. On percussion it was everywhere tympanitic. Figs. 125 and 126 likewise represent a very high grade of recto- cele, together Avith slight cystocele and incomplete prolapse of the uterus. Fig. 125. Fig. 126. Descent of the uterus, with moderate cystocele (c) Anterior view of the case represented in Fig. 125. and a large rectocele (r). The protrusion downwards of Douglas's cul-de-sac is desig- nated as enterocele vaginalis when bowel is contained in it, and ovariocele vaginalis when it contains an ovarian tumor. The bowel may exert a considerable degree of pressure upon the pos- terior wall of the vagina. Fehling1 has recently reported a case in which the patient, in attempting to replace the large pro- lapse of the vagina, ruptured the posterior vaginal wall at the cul-de-sac, and died in consequence of the protrusion of intestine which could not be reduced. 'Arch. f. Gyn., B. VI., p. 103. PROLAPSE OF THE VAGINA. 505 Symptoms The symptoms caused by prolapse of the vagina are very sim- ilar to those of prolapse of the uterus. Occasionally they are only trivial, but pains in the back and the sensation of bearing down are very commonly present. The sensation of a foreign body in front of the vulva becomes very annoying, and a trouble- some discharge takes place. On making an examination we find a tumor between the labia. It can be easHy ascertained whether it belongs to the anterior or to the posterior wall of the vagina. If it proceeds from the former we always find a furrow below the orificium urethrae running along the ramus of the pubic arch, though it may be only slight; while in any considerable prolapse of the posterior waU the fossa navicularis will be almost entirely effaced, and the perineum merges directly, without any interven- ing furrow, into the prolapsus. The finger can be passed in between the two walls of the vagina so as to reach the uterus, which is usually situated low down. To the discomfort occasioned by the prolapse directly are superadded disorders due to the cystocele or to the rectocele ; the former consist of pain and urgent desire to micturate, and the latter depend upon the mechanical distention of the pro- lapsed part by means of gas or faeces, and frequently also upon irritation of the rectum. Diagnosis. It is very easy to ascertain that the prolapse belongs to the vagina both by sight and by touch. We can determine the con- dition of the uterus by means of the combined method of exam- ination. The cystocele may be recognized by introducing the catheter through the bladder into the prolapse of the anterior vaginal wall, and the presence of a rectocele may be ascer- tained by passing the finger into the rectum and then hooking it into the diverticulum. Prognosis. The prolapse of the vagina is not dangerous in itself, but 506 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. extremely tedious, and, as a rule, it is more difficult to treat than a prolapse of the uterus. The treatment has already been considered sufficiently in speaking of prolapsus uteri. CYSTS OF THE VAGINA. Heming, Edinburgh Med. Journ., Jan., 1831.—Ladreit de la Charriere, Archives gener., 1858, Vol. I., p. 528.—Sdxinger, Spitalzeitung, 1863, No. 39.— Veit, Frauenkrankheiten, H. Aufl., 1867, p. h^.— Winkel, Archiv f. Gyn., B. II., p. 38B.—Kaltenbach, Archiv f. Gyn., B. V., p. 138. Etiology. With regard to the origin of the vaginal cysts but little is positively known. A true hyperplasia of the connective tissue' probably takes place only in consequence ol pretty severe bruis- ing of the parts and from extravasations of blood. Gotthardts gives an account of a cyst which had probably developed from a puerperal thrombus. The first of the cases described by Eustache3 was also doubtless a blood-cyst. Moreover, in some cases, the cystic development depends per- haps, as Veit supposes, upon a dilatation of the canals of Gart- ner—the primitive urinary passages—the persistence of which, however, in the human female can be verified only in very rare instances. The great majority of the vaginal cysts undoubtedly originate in occluded follicles of the vaginal mucous membrane. Pathological Anatomy. The vaginal cysts usually occur singly; rarely several are found together in groups. They proceed most commonly from the anterior or posterior wall, and, as a rule, are situated in the lower tliird of the vagina. They vary greatly with regard to 1 Kaltenbach thinks that in the first place accumulations of cells occur in the con- nective tissue, and from these the cysts lined with pavement epithelium are developed. 2 Wiener med. Wochenschr., 1869, No. 94. 3 Montpellier Med. Juin, p. 499. CYSTS OF THE VAGINA. 507 their contents; sometimes containing clear serum, sometimes a reddish or brownish chocolate-colored, or even greenish fluid, and the contents may also be thick and tenacious. I have my- self ' seen a case of colpohyperplasia cystica in a pregnant woman where the contents of the exceedingly numerous small cysts were gaseous. (Inasmuch as this variety occurs only in pregnant women, it need not here be considered.) The walls of the cysts may also vary considerably; some- times they are thick and tough, sometimes quite thin and tender. We find, occasionally, pavement epithelium on the inner surface of the cyst; in other cases there is no epithelial lining whatever. Hall Davis2 reports a case in which the cyst had drawn out the mucous membrane in the form of a polypus, so that a pear-shaped tumor hung in the vagina. Symptoms. No symptoms whatsoever are produced by the smaller cysts; the larger ones give rise to a catarrh of the vagina, and if situated low down produce the sensation, which always accom- panies tumors in the vaginal orifice, of bearing down. More- over, coitus may become painful or even be rendered impossible. The cysts rarely grow so large as to occasion any hindrance to the passage of urine3 or to interfere with parturition.'1 The cysts pursue a decidedly chronic course; they grow very slowly, and generally remain small or attain only a moderate size. Diagnosis. There is no difficulty in the diagnosis, since the fluid contents of the cysts are indicated by their elastic consistency, and they could be mistaken for ovarian cj^sts or for a cystocele only in the event of a very superficial examination. 1 Deutsches Arch. f. klin. Med., 1874, p. 538. 2 London Obstet. Tr., Vol. IX., p. 32. 3 Betz, Memorabilien, 1870, No. 3. 4 Peters, Monatsschr. f. Geb., B. 34, p. 141. 508 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Treatment. By puncture or simple incision the contents of the cyst should be evacuated (in one case where the woman was preg- nant I have seen abortion follow the puncture!); and, should the cyst fill again, the puncture is to be repeated, and iodine may be injected, or, a piece of the wall of the cyst having been excised, the inner surface may be cauterized. If the sac is so thick that it is possible to enucleate it, its complete extirpation is advisable. FIBROIDS OF THE VAGINA. T. S. Lee, On Tumors of the Uterus, etc. London, 1847, p. 245.— Virehow, Ge- schwiilste, B. III., Abth. I., p. 220.—Greene, British Med. Jour., 1870, May 14.— Barnes, London Obstet. Tr., Vol. XIV., p. 309. Vaginal fibroids or fibro-myomata are rare. Sometimes they become tolerably large, and are comparatively soft. I have seen a vaginal fibroid as large as a walnut, which was situated in the right side of the vaginal cul-de-sac, and was merely covered by the thin mucous membrane. It occurred in connection with a uterine polypus the size of a child's head. There was nothing to justify the supposition that the fibroid had originated in the cervix. The fibroids give rise to symptoms only when they attain a considerable size, and then their effects are purely mechanical, causing irritation of the vagina and compression of the rectum. Their extirpation is not particularly difficult. POLYPI OF THE VAGINA. Gremler, Preuss. Vereinsz., 1843, 33.—Scanzoni, Lehrb., 4. Aufl., 2 B., p. 259.— Ollivier, Gaz. des hop., 1862, No. 95.—Hoening, Berl. klin. Wochenschr., 1869, No. 6.—Jacobs, Berl. klin. Woch., 1869, No. 25.—Byrne, Dublin Quart. Jour., CIL, May, 1871, p. 504. The polypi are always fibroids with narrow pedicles. They may become very large. As soon as they come to lie in the ori- fice of the vagina they produce great discomfort, even when only of moderate size. As they enlarge they expand the vagina, CARCINOMA OF THE VAGINA. 509 and may cause ulceration of its mucous membrane, together with symptoms of compression of neighboring organs. Their treatment requires an operation the same as that em- ployed in large uterine polypi, yet their removal is generally easier, for the reason that the pedicle is more readily accessible. CARCINOMA OF THE VAGINA. Dittrich, Prager Vierteljahrschrift, 1848, 3, p. 102.—C. Mayer, Verhand. d. Berliner Geb. Ges., IV., p. 112.—Martin, M. f. Geb., B. 17, p. 321.—Baldwin, Phila. Med. Times, December 15, 1870.—Godell, Boston Gyn. Jour., Vol. VL, p. 383. —Eppinger, Prager med. Vierteljahr., 1872, B. 2, p. 9.—Parry, Am. Jour, of Obstet., Vol. V., p. 163, and Phila. Med. Jour., 1873, Feb. 1. Pathological Anatomy. Primary carcinoma of the vagina is very rare. With the secondary form, which is so commonly met with as the result of an extension from the cervix on to the upper portion of the vaginal cul-de-sac, we are not here concerned. The carcinoma may either occur as a diffuse infiltration of the vaginal mucous membrane, the normal mucous membrane being replaced by irregular hyperplastic growths, which sometimes render the entire walls of the canal rigid, or a circumscribed tumor may be developed, which, springing from a single spot, projects into the vagina in the shape of a hemisphere. The vaginal carci- noma may also extend secondarily to the neighboring organs. I have myself seen a case where in all probability a primary cancer of the vagina was the source of a local infection of the posterior lip of the cervix, brought about very probably by its rubbing against the vaginal tumor. The patient was a woman, forty-one years of age, who had had seven children, and once had aborted. The carcinoma formed a large tumor, which projected from the posterior wall into the vagina. While the vaginal cul-de-sac was entirely free, the posterior lip of the cer- vix appeared eroded, somewhat fissured, friable, and suspicious-looking. The mucous membrane of the rectum was freely movable over the tumor. Three and a half months after excision had been performed by Veit, a relapse occurred, which involved the posterior lip most markedly, together with the entire vault of the vagina and its posterior wall. The symptoms are quite similar to those of cervical carci- noma. In addition to the pain, which may be very slight, there 510 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. is a discharge of blood and offensive serous matter. Occasion- ally the symptoms of a tumor in the vagina become prominent, such as pains in the back and a sensation of bearing down. Later, manifestations of the cancerous cachexia are superadded. The treatment is the same in principle as that employed in cervical carcinoma. An operation is not only indicated in those cases where a complete extirpation of the new growth is to be expected, but it often proves to be a better way of controlling the foetid discharge and hemorrhage than by an excision, either with the knife, scissors, ecraseur, galvano-cautery, or with sharp scoops followed by cauterization of the base. SARCOMA OF THE VAGINA. Meadows, London Obstet. Tr., Vol. X., p. 141.—Smith, Am. Jour, of Obstet., Vol. III., p. 670.—Frau Kaschewarowa, Virchow's Archiv, B. 54, p. 73.—Spiegelberg, Archiv f. Gyn., B. 4, p. 348. The same two forms of sarcoma occur in the vagina as in the uterus, namely, in the form of a diffuse infiltration of the walls or in that of a circumscribed tumor resembling a fibroid, or occasionally more in the shape of a polypus. The symptoms of sarcoma, therefore, may either resemble those of carcinoma, or those of the benign tumors of the vagina. Operative treatment is necessary, particularly in the fibroid form, and it is worthy of note that in one instance a perfect recovery was observed by Spiegelberg. TUBERCULOSIS OF THE VAGINA. Klob, Pathol. Anat. d. weibl. Sexualorg., p. 432. Only two cases of this affection have been described (by Vir- ehow and Klob); in these, tubercles and tubercular ulcers were found upon the vaginal mucous membrane, in connection with tuberculosis of the urinary organs, and of the liver, lungs, and bowels. FOREIGN BODIES IN THE VAGINA. 511 FOREIGN BODIES IN TIIE VAGINA. Klob, Path. Anat. d. weibl. Sexualorg., p. 432, and Hyrtl, Topogr. Anatom., 4. Aufl., B. 2, p. 167. From a practical stand-point, pessaries are among the most important foreign bodies found in the vagina. With only mod- erate pressure they cause thickening of the epithelium, and if the pressure is more considerable ulceration may be produced. When they press continuously upon one spot for a long time they gradually erode the mucous membrane, and may cut deep furrows into the subjacent cellular tissue. Granulations growing through the opening of the pessary may even completely embed one side of the instrument. The ulceration may also lead to perforation into the bladder or rectum. Where a uro-genital fistula exists, calculi may occasionally be found in the vagina as foreign bodies. Furthermore, there are abundant instances on record AAdiere foreign bodies of the most diverse description have been intro- duced purposely into the vagina, sometimes by the patients themselves, for the sake of masturbation, and sometimes malici- ously by other persons. Among the foreign bodies of this class, such articles as pomade pots, curling sticks, needle-cases, drink- ing glasses, pine cones, and the like, are mentioned in the litera- ture of the subject. Pearse * found a thread-spool in the vagina of a woman thirty-six years of age, which had been tliere for twenty-two years, and had produced a urethro-vaginal fistula. It is remarkable that the woman had been twice married Avithout the presence of the foreign body ever having been suspected. But probably the strangest foreign body ever discovered in the vagina was one found by me—a cockchafer lying beside a pomade pot. ENTOPIIYTA AND ENTOZOA. Donne, Recherches microscopiques sur la nature, etc. Paris, 1837.—Kolliker u. Scanzoni, Scanzoni's Beitr., 1855, II., p. 128.—Kiichenmeister, Woch. d. Zeit- schr. d. Ges. d. AViener Aerzte, 1856, No. 36.—L. Mayer, Mon. f. Geb., B. 20, 1 British Med. Jour., June 28, 1873. 512 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. p. 2.— Winkel, Berl. klin. Woch., 1866, No. 23.—Haussmann, Die Parasiten d. weibl. Geschl., etc. Berlin, 1870. Apthaphytes (oidium albicans) are not infrequently found upon the mucous membrane of the vagina. Sometimes they give rise to no symptoms whatever, but in other cases they cause a redness of the mucous membrane, together with a rather free discharge, and sometimes an exceedingly annoying itching. The trichomonas vaginalis, an infusorium which is met with often enough in the vagina, is of no importance whatever. In Httle girls the oxyuris vermicularis sometimes finds its way into the vagina from the rectum, and produces violent itch- ing. INJURIES OF THE VAGINA. It is rather uncommon for the vagina to meet with an injury, excepting during parturition or through surgical procedures. Serious wounds have sometimes been made by the horn of a cow or by faUing upon some sharp-pointed object. Thus, James1 reports a case where a woman was impaled upon the prong of a hay fork, which passed between the cervix and rec- tum, and penetrated the body as far as the ribs. The case ter- minated in recovery. Gotthardt2 met with a case of spontaneous rupture from a fall. We have already considered sufficiently the injuries to the vagina produced by pessaries. Injuries to the vagina are most frequent during parturition. We can only speak here of the effects which they leave behind. These may consist in a marked stenosis or even atresia of the vagina, or, occasionally, in other deformities of the vagina and vaginal portion of the cervix. Thus in one case I have seen the vaginal portion, which had been torn off transversely from the cervix, heal in such a way that when the sound was passed into the external os it came out at the transverse fissure that still remained unhealed. Of all the forms, however, of solution of continuity in the vagina, by far the greatest importance attaches to those fistulse 1 Boston Gyn. Jour., Vol. III., p. 175. 8 Wiener med. Wochenschr., 1869, No. 94. URO-GENITAL FISTULA. 513 of the vagina, which communicate with neighboring organs ; and, inasmuch as we also include here fistulae AAdiich do not pertain to injuries of the vagina, we shall proceed to speak of the uro- genital fistulae in general. Uro-Genital Fistulse. F. C. Naegele, Erf. und Abh. a. d. Geb. d. Krankh. d. weibl. Geschlechts. Mann- heim, 1812, p. 367'.—Dieffenbach, Oper. Chirurgie, I p. 546, and Preuss. Ve- reinsz., 1836, Nos. 24, 25.—Jobert, Lancette francaise, 1834, No. 102, etc. ; Gaz. med. de Paris, 1836, No. 10, etc.; Gaz. des hop., 1850, No. 54; and Traitg des fistules, etc. Paris, 1859.— Wutzer, Organ f. d. ges. Heilkunde, II, 4. Bonn, 1843, and Deutsche Klinik, 1849, Nos. 3, A.—Chelius, Ueber d. Heil. d. Blasen- Scheidenfisteln durch Cauterization. Heidelberg, 1844.— Von Metzler, Prager Viertelj. f. prakt. Heilk., 1846, B. 2, p. 126.—Marion Sims, Amer. J. of Med. Sc., January, 1852, p. 59, and Silver Sutures in Surgery. New York, 1857.— Roser, Archiv f. phys. Heilkunde, 1854, p. 576.—G. Simon, Ueber d. Heil. d. Blasenscheidenfisteln. Giessen, 1854; Deutsche Klinik, 1856, Nos. 30-35 ; M. f. Geb., B. 12, p. 1 ; Scanzont's Beitr. B. IV., p. 170; Ueber d. Operation d. Bla- senscheidenfistel, etc. Rostock, 1862; Prager Vierteljahrschrift, 1867, B. 2, p. 61; Deutsche Klinik, 1868, Nos. 45, IQ.—Esmarch, Deutsche Klinik, 1858, No. 28.—IF. A. Freund, Breslauer klin. Beitr., 1862, H. 1, p. 33.— Rose (Wilms), Chariteannalen, B. XL, p. 79.— Baker Brown, Surg. Diseases of Women, 3 ed., p. 133, and Lancet, March, 1864.— Bozeman, Louisville Review, January, 1856, and New Orleans Med. and Surg. J., March and May, I860.— Vlrich, Zeitschr. d. Ges. d. Wiener Aerzte, 1863, H. 2-4, and AVoch. d. Ges. d. Wiener Aerzte, 1866, Nos. 1-10.— Heppner, M. f. Geb. B. 33, p. Q5.—Kalte?ibac7i, in Hegar's Sterblichkeit wahrend Schwang., etc. Freiburg, 1868.— Weiss, Prager Viertelj., 1872, B. 3.—Karl Braun, Wiener med. Woch., 1872, No. 34.— Emmet, Amer. J. of Med. Sci., October, 1867, p. 313, and Vesico-vaginal Fistula, etc. New York, 1868.—Spencer Wells, St. Thomas's Hospital Reports, 1870.— Hayes Agnew, Lacer. of the Fern. Perineum and Vesico-Vaginal Fistula. Phila- delphia, 1873. History. During almost the whole of the first half of this century the vesico-vaginal fistulae were considered as among the very Avorst difficulties to remedy. Cauterization effected a cure only in very exceptional" instances, and the operation of freshening the edo-es and applying sutures was unsuccessful, as a rule, even in the most skilful hands (Wutzer and Dieffenbach). A decided advance in the operative treatment of these fistulae has been vol. x.—33 514 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. made by Sims and Simon. The most valuable part of their achievements consisted in making the fistulae more perfectly accessible. The great merit due to Sims, and the good results attainable by the "American method," are by no means to be ascribed, as claimed in America and England, to the use of the silver-wire suture, but almost exclusively to the invention of the duck-billed speculum, and to the facility thereby afforded for paring the edges more perfectly, and for the more accurate adjustment of the sutures. Through a modification of the spec- ulum Simon has succeeded in making the most deeply situated fistulae perfectly accessible, and by improving, and, more especi- ally, by simplifying the method of freshening the edges and of applying the sutures, not to mention certain improvements in the after-treatment, he has so perfected the operation that there are very few fistulae now which cannot be made to close by healing. Etiology. By far the most common cause leading to the production of uro-genital fistulae arises from bruising of the soft parts during parturition, in consequence of which gangrene ensues": If, in cases of narrow pelvis, but also, exceptionally, where other disproportionate dimensions exist (such as may arise from the great size or false position of the foetus, from a frontal presentation, etc.), the labor is protracted, the compression of the maternal soft parts between the presenting portion of the foetus and the pelvic bones may be so great as to cause mortifica- tion, in consequence of which a slough is formed which separates in the course of a few days, leaving a communication between the urinary organs and the genital canal. The long duration of the pressure is especially important, since a momentary squeezing of the soft parts, even though very severe, is not apt to produce mortification, while a pressure which is very long continued does not need to be so very great to produce the injurious effect. A very severe pressure hardly ever takes place before the waters have escaped, for until then the force acting directly upon the child is very slight. Hence, labors which are very URO-GENITAL FISTUL.E. 515 long protracted after rupture of the bag of waters, the head pre- senting, rank first in importance in the causation of fistulae. From what has been said it is readily seen that fistulae are most apt to originate in the natural course of labor. Much more rarely are they attributable to instrumental aids ; in fact it may even be said that the majority of fistulae are owing to the neglect or too late performance of an operation. Fistulae are seldom produced by the pressure of the forceps or of the cephalotribe alone, unless the blade which produces the fistula lies unusually far forwards, and the operation is inor- dinately prolonged. But those instruments which compress the head (among which in difficult cases the forceps must unques- tionably be included) may indirectly do damage by so squeezing the head together laterally that the pressure of the latter upon the soft parts covering the anterior wall of the pelvis is greatly increased. If the head yields to the traction of the forceps, and the extraction of the child is hot long delayed, this brief increase of the pressure will still be less dangerous than if the head were suffered to remain fixed in one place; but if the forceps are applied unsuccessfully, and the head remains fixed in position, notwithstanding forcible tractions are made, the parts Avhere the pressure occurs will be completely crushed. Other causes than the above give rise to fistula much more rarely. Occasionally, the Avail intervening between the urinary and genital canals may be lacerated during labor, or it may be cut through by one of the rather sharp blades of the forceps stand- ing out someAvhat from the child's head. Moreover, it may be torn through by a sharp, cranial bone projecting from the skull of the child after perforation has been performed. Occasionally attempts at introducing the catheter result in a perforation. Other traumatic causes may produce a fistula, as, for exam- ple, a fall upon some sharp-pointed object, or certain gynecolo- gical operations such as opening a haematometra. Again, pessaries may give rise to a perforation from the vagina into the adjoining IioIIoav organ, Avhile calculi in the bladder may cause it from the other direction. Thus Simon ' 'Arch. f. klin. Chirurg., 1870, XII., p. 573. 516 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. operated upon a very large fistula in an eight-year-old girl, which had been caused by a calculus. It is very seldom that a parametritic abscess which perforates both ways leaves a communication between the two organs. It is also very rare for ulcerations of the vesical mucous membrane to cause a perforation into the vagina. Lawson Tait' reports three such cases, of which two were under treatment at Simpson's clinic. The ulceration which leads to perforation into the vagina develops in the course of a chronic catarrh, and, accompanied by extreme tenesmus, may extend so far as ulti- mately to destroy the greater portion of the vesical mucous membrane. The production artificially of a vesico-vaginal fistula, with the object of curing this condition, as well as for the treatment of chronic cystitis generally, through preventing any stagnation of the urine, was recommended, before Simpson, by surgeons in America. It was first performed, in the male, by Willard Parker (1850),5 then by Emmet3 and by Bozeman.4 I have myself observed one case of perforating vesical ulcer, in which the perforation developed almost under my very eyes, having been preceded for some time by ardent desire to mictu- rate, together with the presence of albumen, pus, and blood in the urine. The patient became cachectic, and soon afterwards died outside the hospital. An autopsy was not permitted. We will here merely allude to the fistulae which not infre- quently develop in connection with extensive corroding carci- noma of the cervix. Pathological Anatomy. The fistulae which are caused during parturition may, depending upon the position which the several organs occupy at the time the pressure is exerted, affect the two canals in the most various situations. It is the position of the organs, and not the different heights at which the pressure takes place, that 1 Lancet, 1870. 1 New York Journal of Medicine, Vol. XVI. 8 Am. Practitioner, February, 1872. 4 Am. Jour, of Obstet., Vol. III., p. 636. URO-GENITAL FISTULAE. 517 produces the great variety in the situations of uro-genital fis- tulae. Almost without exception the pressure occurs at the superior posterior border of the symphysis, or rather at the bony prominence lying near the pubic articulation ; only very excep- tionally does it take place against the side of the pubic arch. Now the fact that, while the situation of the pressure nearly ahvays remains the same, so many organs are nevertheless impli- cated by it, depends upon the great variations in the relative position which the bladder and genital canal may assume to one another during delivery. The bladder, as a rule, is so situated as to rest upon the pos- terior superior angle of the symphysis, so that in the great majority of instances a vesical fistula is developed. But some- times the bladder, when distended, rises so high above the symphysis that the orificium urethrae does not lie beloAv but behind the symphysis, and hence the urethra becomes exposed to the pressure, in consequence of which a vagino-urethral fis- tula results. But the bladder may also in rare instances lie so deep in the true pelvis that its summit falls below the point of pressure. In this case, of course, a urinary fistula cannot be produced ; but, if tliere is sufficient pressure to crush the tissues, it is the peritoneum which is involved and a peritoneal perforation is the result. But the different parts of the genital canal are subject to sim- ilar variations in their position during delivery. The fistula never leads into the cavity proper of the uterus, since at the time when the pressure takes place the internal os ahvays lies high above the symphysis. The anterior wall of the cervix may, however, lie within the constricted portion of the canal, and, in the case of a decidedly small pelvis, may be caught and crushed between the head and the pubic arch. In this event a communication. is formed be- tween the bladder and cervix. The crushing of the soft parts, which causes mortification, generally takes place after the pains have already been energetic for some time, and the external os has receded over the head of the child, bringing the vaginal Avail, consequently, into contact 518 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. with the posterior superior border of the symphysis. A vesico- vaginal fistula is then formed. Of course the very edge of the anterior lip of the os may be involved in the pressure, and a certain portion of it may also become crushed. After what has been said, it will be understood in what mani- fold forms the uro-genital fistulae may occur. To briefly recapitulate, the commonest form is the communi- cation between the bladder and the vagina—the vesico-vaginal fistula. Urethral fistulae occur only exceptionally. The vesico vaginal fistula may be seated high up in the vaginal cul-de-sac ; if it is situated so high up that the anterior lip of the os, which in other respects remains sound, forms its posterior edge, it is designated as superficial vesieo-utero-vaginal fistula. If the anterior lip of the os is also in part destroyed, so that the vesical fistula opens both into the cervical canal and into the vagina, it is termed deep vesico-utero-vaginal fistula. If, when the injury occurred, the external os was situated below the point of pressure, a vesico-cervical fistula is produced, the vagina remaining intact. Still another form of the uro-genital fistulae may very rarely occur, namely, when neither bladder nor urethra is involved, but an opening is made into the ureter. According as it communi- cates with the vagina or with the cervix, a uretero-vaginal or a uretero-uterine fistula is developed. In very rare instances vesico-rectal fistulae have been observed in women. Simon1 saw a case following a difficult labor. The upper two-thirds of the vagina was occluded. Vesico-rectal fis- tulae are doubtless more frequently due to the simultaneous perforation of parametritic abscesses into the bladder and the rectum, two instances of which are reported by Simpson.3 The fistulae differ from one another somewhat, according to the organs which they implicate. The vesico-vaginal fistulae almost always consist of simple roundish openings, Avhose edges are occasionally quite thin and sharp, but in other cases everted, thickened, and callous. Their 1 Arch. f. klin. chir., B. 15, p. 111. 8 Obstet. and Gynecol. Works. Edinburgh, 1871, pp. 814 and 816. URO-GENITAL FISTULA. 519 shape is mostly roundish or oval; less frequently crescentic or slit-shaped. Their size is very variable ; sometimes they are so small that they can scarcely be found, in other cases the intervening wall between the bladder and vagina is almost Fig. 127. Fig. 128, Vesico-vaginal fistula. Superficial vesico-utero vaginal fistula. u, Uterus; S, vagina; B, bladder. entirely destroyed, the two hollow organs forming virtually but a single cavity. Where the fistula is not very small the vesical mucous membrane is apt to protrude through the perforation into the vagina. Fig. 129. Fig. 130. Deep vesico-utero-vaginal fistula. Vesico cervical fistula. The urethrovaginal fistulae are likewise of variable size, the opening being sometimes very fine, and at other times almost the entire posterior wall of the urethra being destroyed. In the uretero-vaginal fistulae the opening is situated high up in the vagina, on one side, and is always very small. 520 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Stricture or occlusion of the urethra may occur as a com- plication of the fistula, induced in consequence of disuse, or caused by the same injury which led to the development of the fistula. In the same Avay constriction or atresia of the vagina may be associated with the fistula, so that an exceedingly compli- cated state of things may be produced. Symptoms. Immediately after delivery there are no characteristic symp- toms, for the simple reason that the fistula has not yet devel- oped. The symptoms which present themselves are ordinarily such as are wont to occur after difficult labors accompanied by injuries of the soft parts. Retention of the urine is very com- monly present, and often persists for a long time. But this is in no way characteristic, since it is quite apt to occur in puer- peral women, and furthermore, is wanting in many cases where a fistula has developed. An incontinence due to a paralysis of central origin is exceedingly rare. The really characteristic symptom is the continual escape of urine through the vagina, and this does not make its appearance until the slough, into which the bruised tissue has been trans- formed, has separated. Several days always elapse before this takes place, so that an involuntary discharge of urine cannot be expected before the third day. It is not unusual to find that so long as certain positions of the body are quietly maintained, the urine remains in the blad- der. This is either owing to the fact that the edges of the fistula (which in this case is usually slit-shaped) are brought closely together, or else that the orifice of the fistula is obstructed by the posterior vaginal wall or by the cervix. Under these cir- cumstances the urine may be evacuated naturally. The urethrovaginal fistulae have far less serious conse- quences, since the urine is retained normally; it is only during micturition that, instead of flowing through the orificium ure- thrae, it escapes by the fistulous opening into the vagina. Where only one uretero-vaginal fistula exists, the urine URO-GENITAL FISTULA. 521 secreted by one kidney is evacuated normally, while that from the other dribbles involuntarily through the fistula. In consequence of the involuntary discharge of urine the patient suffers great annoyance and distress. She is constantly wet, and the continual dribbling of the acrid urine over the vulva and the skin of the thighs produces cutaneous inflamma- tions. In addition to this, a strong odor of urine is emitted from the patient's person, which excludes her from society, and compels her to lead a tormented, pitiable existence. The capacity for conception, however, is not materially im- paired. These women not infrequently become pregnant; gesta- tion runs its normal course, and the labor does not differ from what, in view of the disproportionate dimensions, Ave should be led to expect. Diagnosis. There is no difficulty in recognizing the vesico-vaginal fis- tulae, provided a thorough examination is made. Tolerably large fistulae may even be felt with the finger, and if a metallic catheter is also introduced into the bladder, the hole may be discovered wdien the fistula is quite small. Where the fistulae are very minute, the sense of sight must be brought in to aid the diagnosis. Sims' s speculum is introduced, and the anterior vag- inal wall is carefully inspected, the folds and hollows being exposed to view by means of sharp hooks. In case the fistula cannot be discovered in this manner, as happens only when it is extremely fine and so situated as to be somewhat concealed, recourse must be had to injections of the bladder with colored fluids (milk, India ink, etc.). But notwithstanding the diagnosis is generally so simple, and though by means of Simon's specula it is possible to de- termine the location, size, and other characters of the fistula so accurately, yet, in complicated cases, especially where there is a stricture of the vagina present at the same time, it may be a matter of considerable difficulty to ascertain the precise condi- tion of things. The difficulty is greatest when the vagina is closed just beyond the vaginal orifice, and the obstructing wall is perforated with one or more small openings through which the 522 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. urine flows. Under such circumstances it may be almost impos- sible to ascertain what the condition is in the upper portion of the vagina and in the bladder. Moreover, it may be a difficult matter to determine what the state of the uterus is, whether it also is occluded (for this has an important bearing upon the operation), and the question is rendered all the more difficult from the fact that the menses often remain absent after severe puerperal processes. In one case of this sort I found two open- ings in the occluded vagina from which the urine flowed, and one of them conducted into the upper portion of the vagina Avhere there was a communication with the bladder, while the other led into the bladder directly. The fact that the uterus was pervious could only be ascertained, after repeated trials, by directing the sound, which had been introduced into the rectum, against the external os. It is possible to distinguish the urethral fistulae, on account of their being situated low down, and because the urine can be evacuated through them voluntarily. Fistulae of the ureter may be recognized from the fact that the probe passes in the direction of the kidney, and because when colored solutions are injected into the bladder, colored urine does not flow from the fistula. When the latter is closed up, violent symptoms of acute hydronephrosis at once super- vene, Avhich disappear again so soon as the fistula is again made pervious. Prognosis. Generally speaking the prognosis is not unfavorable. Not infrequently recent fistulae heal spontaneously. After the slough into which the bruised wall has been transformed has separated, the edges of the wound begin to granulate from the lines of demarcation, and thus, under favorable circumstances, may fill up the perforation. This process appears to take place more readily in vesico-uterine fistulae, since then the fistulous passage is of some length and the granulations therefore have a better chance of closing it. I have seen such a case occur after a frontal presentation, where the fistula healed rapidly during childbed. URO-GEXITAL FISTULiE. 523 In other cases a comparatively natural cure may take place, in that through the same process by which the fistula was caused the vagina may be occluded, an atresia vaginae being produced beloAv the fistula. Then, of course, the urine, and the menstrual blood too, must seek exit by Avay of the urethra. But if it is a tolerably old fistula it is not apt to heal natu- rally, at least the vesico-vaginal fistulae with sharp edges are not; nevertheless the irritation caused by the uterus, the pres- ence of urinary concretions, or the forced passage of a urinary calculus, may occasionally provoke the development of granu- lations, and in this way cause a closure of the fistula. A mo- mentary disappearance of the Aoav of urine, caused by obstruc- tion of the fistula by a calculus, is of no especial importance. At the present day, by virtue of the modern operative treat- ment of fistulae, the prognosis is favorable even in old cases ; for fistulae that cannot finally be closed after repeated attempts are extremely rare. It is true, however, that the prognosis of the operation depends largely upon the skHl and practice of the operator. Treatment. In recent cases, if the walls of the fistula are still granulating, Nature's efforts to close the wound are to be assisted. This may be done by introducing the catheter and leaving it in the blad- der, so that the urine may not collect there; in this way the flow of urine through the fistula may in great measure be pre- vented. The union of the edges of the wound can often be pro- moted by introducing into the vagina a suitable tampon, which tends to force the sides of the fistula into coaptation. If the fistula is pretty old, and its edges have completely cicatrized, it can only be closed by converting its edges into raw surfaces again. This may be accomplished in two ways. In the first place, the edges of the fistula may be stimulated to granulate by means of cauterization, so that the fistula will again have the same chance of healing as at the commencement of the puerperal state. But the larger the fistula, so much the less prospect is there of the granulations closing the wound. Therefore it is only in the case of quite small fistulae that cauterization with the 524 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. nitrate of silver or the hot iron merits a trial, and even then it often enough fails. But tliere is a decided objection to severe cauterization of the edges of the fistula, inasmuch as the sur- rounding tissue is thereby converted into a hard cicatrix, which greatly diminishes the chances of success in the more radical method of cure, which we shall now proceed to describe. This method consists in freshening the edges of the wound and uniting them by means of the suture. Simon has brought this operation to a remarkable degree of perfection; and in describing the technical points of the method we shall, in the main, follow his directions. An extremely important condition to the success of the operation consists in exposing the fistula to view to the fullest possible extent. The patient lies in an exaggerated lithotomy position; the legs are held by two assistants, and are strongly flexed on the body, so that the vulva is well elevated. Then, by pressing the posterior wall of the vagina as far back as possible with the duck-billed speculum, and the lateral walls (which are still somewhat inclined to fall inward) being kept back by bent spatulae, and finally that portion of the anterior Avail which lies below the fistula being lifted up by means of a flat-shaped speculum, the fistula will be fully exposed to view, or, at any rate, Avith the aid of little hooks, it may be rendered perfectly accessible. When the fistula is situated pretty low down, and the uterus is very mobile, the former may sometimes be brought down in front of the vulva by forcibly dragging down the womb. I operate invariably with the patient under the influence of an anaesthetic; for although the operation of preparing the edges and of applying the sutures is not very painful, yet it is always possible with anaesthesia to dilate the vagina more perfectly by means of the specula; others, however, operate without chlo- roform. The fistula having been rendered thoroughly accessible, we should proceed to freshen the edges. In doing this, care must be taken to remove all of the callous and but slightly vascular por- tions, and the freshened edges should be smooth and tolerably wide, and should consist of normal tissue. To this end a pointed URO-GENITAL FISTUL.E. 525 knife is entered about a fifth of an inch or more from the margin of the fistula, in such a manner that its point emerges just at the edge of the vesical mucous membrane; or, as advised by Simon, even within the mucous membrane of the bladder. If now the edges of the fistula are pared in this way all the way around, the fistula will be converted into a large funnel-shaped wound, with its narrowest part towards the bladder. In order to make the incision at the same distance from the margin of the fistula all around, it is well, beforehand, to mark out with the knife the line which it is to follow in the mucous membrane. Simon removes a good portion of the vesical mucous membrane in paring the edges, but this is hardly necessary, and is liable to give rise to troublesome hemorrhage from the bladder after- wards. If the sides of the funnel-shaped wound are not too steep, but the incision is made rather flat, in accordance with the American method, in Avhich a large area of the vaginal mucous membrane is cut away, the edges of the fresh wound will be very broad, and, unless there is great tension, may be brought into perfect coaptation. In case the surfaces of the wound are not left quite smooth, or little islands of mucous membrane are found remaining here and there, these can be trimmed off afterwards with the knife or with curved scissors. The bleeding is stanched by means of cold water; spurting arteries are either twisted or ligated; but, if possible, all the ligatures are removed before the wound is finally closed. The edges of the fistula having been freshened, the next thing is to close the wound. Unless tliere be some especial objection to it, the upper and lower edges should be united together, so that the resulting cicatrix may run transversely. The silver-wire suture possesses no advantages whatever over good, smooth, silk thread. The sutures are introduced by means of short, sharply curved needles, which are grasped by means of the needle- holder. The mucous membrane of the bladder is either not included at all in the suture, or only to a very slight extent. All of the sutures having been inserted (and they should be placed tolerably near to each other) we proceed cautiously to tie them. If the edges of the Avound do not everyAvhere come 526 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. into good coaptation, superficial sutures are applied in the inter- vening spaces between the others. Stitches or incisions for the purpose of relieving tension are unnecessary. After the operation the patient must lie quietly in bed for eight days, during Avhich time no interference is necessary ; not even the catheter should be passed, unless the patient is unable to urinate of her own accord. From the fifth to the sixth day the sutures are cautiously removed. The above method of procedure may easily be modified. For example, it may be necessary, previous to the operation, to divide adhesions or cicatricial strictures in the vagina. It is exceedingly rare that the prolapsed mucous membrane of the bladder becomes adherent to the posterior Avail of the vagina, so that they have to be separated with the knife. When the defect is very large, it is often necessary to join the edges in complicated T- or Y-shaped figures. It is particularly disagreeable to be obliged, before operating, to overcome a stricture or atresia of the vagina. Great care should be taken not to include the ureters in the sutures, for they occasionally lie just to one side of the fistula. Seeing bloody urine escape from the ureters, per saltern, it might be possible for the operator to mistake them for spurting arte- ries. As soon as they are discovered they should be avoided as carefully as possible while paring the edges of the fistula, and especially when applying the stitches, for should they be included in the latter, acute hydronephrosis would be the result. The operation is not ordinarily dangerous to life, since only very exceptionally (in deep, vesico-utero-vaginal fistulae) does the peritoneum come within reach of the knife, and pyaemia is an exceedingly rare sequel. A very unfortunate accident, which may complicate the opera- tion, is hemorrhage from the bladder. It may be so copious that the bladder reaches to the navel, and symptoms of a high grade of anaemia are induced. But little can be done for it thera- peutically ; applications of cold to the abdomen or within the vagina do but little good, and injections of ice-water or styptic solutions into the bladder itself may do direct injury, since they tend to augment the contents of the bladder and increase the URO-GENITAL FISTULA. 527 vesical spasms. The operation usually proves a failure under these circumstances, for the contractions of the bladder con- tinue until the coagula are forced out through the wound. Very often a little fistula is left, after the operation, in one corner or in the centre, which then demands a separate opera- tion, unless an effort be made to close it by cauterization. If the fistula is situated high up in the vicinity of the anterior lip of the os, or in case it is a superficial vesico-uterine fistula, the anterior lip itself must be pared and united with the anterior edge of the wound. Cases, however, occur in which an operation upon the fistula is impossible. This may be so because the fistulous opening is too large, though the operation has succeeded in some very large fistulae; or one edge of the fistula may be draAvn over so far towards the pelvic wall, in consequence of cicatricial contrac- tion, that it is impossible to freshen it or to bring it forward so as to fill up the defect. Moreover, uterine fistulae, which are generally inaccessible, cannot, as a rule, be operated upon. In this event, in order to obviate the involuntary discharge of urine, the transverse obliteration of the vagina, according to the method of Simon, may be performed. This consists in freshening the anterior and posterior walls of the vagina at cor- responding points as high up as possi- ble, though, of course, below the fistula, and then uniting them together. By this means an enclosed space is created above the point of occlusion, which com- municates through the fistula with the bladder, and the contents of which (con- sisting of mucus and menstrual blood), together with the urine, can escape only by way of the urethra. Through this procedure the principal evil consequence of the fistula, viz., the involuntary discharge of the urine, is prevented. Hence, in those cases Avhere any other method of relief is impracticable, this oper- ation decidedly merits a trial. It Avas performed by me in the case mentioned above. I first operated upon the fistula at the Fig. 131. Large vesico-utero-vaginal fistula, with transverse obliteration of the vagina. v, vagina ; b, bladder, the two com municating by means of the fistula ; s, blind lower extremity of the vagina ; o, point of the obliteration. 528 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. bottom of the stenosed vagina, and then converted the stenosis into a complete occlusion. To be sure, if we regard the results accomplished, the trans- verse obliteration of the vagina is a very different matter from the cure of the fistula itself, since, in consequence of the oblit- eration, the capacity for conception is always sacrificed, and the ability to have connection is, to say the least, considerably dimin- ished. Nevertheless, the operation may become indispensable, for the condition of the patient while suffering from the fistula is simply intolerable; of course, in old Avomen it may be resorted to without hesitation. The theoretical danger of disorders ensuing in consequence of the stagnation of the urine behind the occluded spot, and from the passage of menstrual blood through the bladder and urethra, is found by experience practically not to exist. In the case of an inaccessible uterine fistula the external os may be closed, instead of the vagina, by freshening the anterior and posterior lips and then sewing them together. Furthermore, in the fistulae of the ureter, the transverse oblit- eration of the vagina offers the only possible means thus far known of effecting a cure. If the vesical end of the ureter is closed, it is necessary first to create an artificial vesico-uterine fistula, and then to occlude the vagina below this point. In deeply situated vesico-utero-vaginal fistulae, with a large defect in the anterior lip, we may have to unite the posterior lip with the anterior wall of the vagina. The vagina then remains open for purposes of coition, though conception is impossible, and the menses have to pass off by the urethra. But should even transverse obliteration be impracticable, the patient is in an extremely unfortunate condition; no artificial apparatus has yet been devised that perfectly fulfils the object of collecting the urine. VAGINO-INTESTINAL FISTULA. Simon, Prager Vierteljahrschrift, 1867, B. 4, p. 1.—Simon, Mon. f. Geb., B. 14, p. 439.—Heine, Archiv fur klin. Chir., XL, 1870, p. 485. Etiology. An abnormal communication between the rectum and vagina, VAGINO-INTESTINAL FISTULA. 529 hence a recto-vaginal fistula, occurs most commonly, too, in con- sequence of parturition, though not in the same manner (through mortification due to pressure) as the vesico-vaginal fistulae, but most usually under circumstances where large perineal ruptures have extended into the septum recto-vaginale, and only the thicker portion of the perineum has afterwards healed, leaving the thin vagino-rectal wall still open. I have seen a double perforation into the rectum occur in childbed, from deep-seated diphtheritis of the posterior vaginal wall. Exceptionally the recto-vaginal wall may also be torn through by instruments used during delivery or by clyster syringes. It is very seldom that other injuries, such as falling upon some sharp-pointed object, are the cause of the fistula. Perforation by means of a neglected pessary is a rare accident; the same is true of a fistula resulting from an abscess in the vaginal wall, which per- forates both ways. We pass over here the perforation betAveen the rectum and the vagina, which is occasioned by cancerous disintegration. Fistula, of the small intestine may occur in consequence of a laceration of the posterior arch of the vagina during parturi- tion, giving rise to a protrusion of a knuckle of intestine through the opening, followed by strangulation, gangrene, and sloughing of the prolapsed bowel; or, a coil of intestine, lying in Douglas's cul-de-sac, may be seriously compressed, and a previous adhe- sion between it and the posterior arch of the vagina having occurred, a perforation may take place through the latter. In the former case, an anus praeternaturalis is developed in the pos- terior vaginal arch; in the latter, a fistula. Pathological Anatomy. The recto-vaginal fistulae vary greatly in size ; sometimes they are exceedingly small, and merely the intestinal gas escapes, whde in other cases almost the entire vaginal wall is destroyed. Symptoms. Their characteristic symptom is the escape of contents of the bowel through the vagina. In the case of rectal fistulae, vol. x.—34 530 SCHROEDER.—DISEASES OF FEAIALE SEXUAL ORGANS. according to their size, either the whole amount of the faeces are passed involuntarily through the vagina, or simply the fluid por- tions ; sometimes only flatus escapes. In fistulae of the small intestine it is the thin, bright yellow pultaceous matter, consist- ing of the digested food, which is evacuated. The effects of the involuntary fecal discharges naturally cause great annoyance and distress. Diagnosis. The examination is performed in the same manner as in the case of the vesico-vaginal fistulae, and by this means there is scarcely ever any difficulty in discovering rectal fistulae. The fistulae of the small intestine are distinguished from those of the rectum by ascertaining chat the rectum is intact, as we may infer when, by means of the sound and rectal injections, we fail to discover any communication between the rectum and vagina. Furthermore, the escape of the digested remains of the food is characteristic, occurring one or two hours after each meal. Prognosis. Recent recto-vaginal fistulae, unless too large, may heal spon- taneously by granulation. It is no easier, at least, to cure them by operative treatment than it is the vesico-vaginal fistulae. Treatment. Cauterization with the nitrate of silver, or with the hot iron, is advisable only in the case of quite small fistulae. If the fistula is at all large, then it must be exposed to view, the edges pared and the stitches applied in the same way as in vesico- vaginal fistulae. Simon has recently advised, in the more diffi- cult cases, uniting the edges by sutures introduced within the rectum. The fistulae of the small intestine are operated upon in pre- cisely the same manner as any other fistulae, by cauterization or by freshening the edges and applying sutures. It is far more VAGINISMUS. 531 difficult, however, to remedy a false anus in the posterior vaginal cul-de-sac. In the first place, we must endeavor to convert the anus praeternaturalis into a fistula. To this end one blade of a pair of intestine-shears may be pressed into the rectum, and the other into the small intestine, and the attempt made thus to establish a direct communication between the two. A better way, however, is to connect the two extremities of the small intestine with each other by means of the shears, according to the method of C. O. Weber and Heine. If this is successful, the remaining fistula is closed by freshening the edges and applying stitches. Heine has, by this method, achieved a perfect recovery. If the attempt is unsuccessful, we may compel the evacuations to take place through the rectum, by making a large vagino- rectal fistula, and then below this point effecting a transverse obliteration of the vagina. In a case (not very clearly reported) which was observed by Wilms,1 several coils of the small intestine became gangrenous and were cast off. Besides a vesico- vaginal fistula, an anus praeternaturalis was developed, into which both small intes- tine and rectum opened. The aperture could not be closed either by cauterization or by sutures. VAGINISMUS. Simpson, Edinburgh Med. J., Dec, 1861, p. 594.—Debout and Michon, Bulletin de thgrapeutique, 1861, Nos. 3, 4, 7.— Charrier, Contr. spasmod. du sphincter vag. These. Paris, 1862.—/. Marion Sims, London Obst. Tr., Vol. III., 1862, p. 356, and Clin. Notes on Uterine Surgery, New York, 1871, p. 318.—Scan- zoni, Lehrbuch, II., 4. Aufl., p. 263, and Wiener med. Woch., 1867, Nos. 15- 18.—Hoist, Scanzoni's Beitr. z. Geb. u. Gyn., B. V.. 1869, H. 2.—Scharlan, Berl. Beitr. z. Gob. u. Gyn., B. I., p. 64.—Hildebrandt, Archiv f. Gyn., B. III., p. 221. —Martin, Berl. klin. Woch., 1871, No. 14.—Stadfeldt, Ugeskrift for Laeger, 1872, Nos. 23, 24.—Breisky, Schweiz. Correspondenz-Blatt., 1873, 5. Definition and Etiology. By vaginismus we understand an excessive sensitiveness of the orifice of the vagina, combined Avith spasmodic contraction of the constrictor cunni and the muscles of the floor of the pelvis. With regard to the immediate cause of the affection, we must » Bartels, Arch. f. Gyn., B. 3, p. 502. 532 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. entirely concur, so far as the majority of cases is concerned, in the views expressed by Scanzoni. The cause is traumatic, and is due to irrational and frequently repeated attempts at cohabita- tion; hence it is most commonly observed in newly married women. Impotence of the husband is by no means a necessary condition to its production, and, in fact, is not often present under these circumstances. There may be an unusual narrow- ness of the vagina, or too great rigidity of the hymen ; but they also are not necessarily present. The commonest source of vagi- nismus is a small vaginal orifice. If the husband happens to be wholly inexperienced in ama- tory matters his efforts at connection will very likely be clumsy and ineffectual. The penis will not always hit the right direc- tion, but impinges upon the anterior or posterior commissure. In this respect very much depends upon the position of the vulva, which presents marked variations in different individuals. In fact cases occur where the vulva lies partly upon the sym- physis, so that the lower margin of the latter is found below the orificium urethrae. Under such circumstances the penis is directed too far back, and instead of penetrating the orifice of the vagina it is forced into the fossa navicularis. By this means, where the attempts are frequently repeated, a gradually increasing sensibility of the parts is developed, combined with excoriation. Now the wife, beginning to dread cohabitation on account of the pain it causes her, shrinks away from her hus- band, so that his efforts are defeated ; while, on the other hand, the constantly renewed desire leads to frequent repetitions of the attempt, in the hope that, coition once consummated, concep- tion may happily occur, and with it a return to health. Thus the traumatic influence operates more and more frequently, the redness and excoriation in the fossa navicularis or in the region of the urethra are continually increasing, until the sensitiveness of the parts becomes so great that the patient screams out at the least touch. Now reflex spasms become associated with the dis- order, and all the pronounced features of vaginismus are present. Hence vaginismus is most common among wholly inexperi- enced married couples. I have met with a case where after three years of wedlock, during which the hymen remained VAGINISMUS. 533 intact, the husband fully supposed that everything was quite as it should be, Avhile the wife only had a vague suspicion that perhaps she was not formed exactly like other women. In all these cases there is merely increased sensitiveness at first, while the spasms are not developed until later. Thus in the case of a woman who had only been married three months, and who suffered from excessive sensitiveness of the posterior commissure, I found that the introduction of the finger occa- sioned the most intense pain, together with hysterical convul- sions, but gave rise to no contraction of the constrictor cunni. Beside this class of cases, which decidedly predominates, there is another, in which the spasms form the most promi- nent feature. They depend unquestionably upon psychical causes (sometimes upon the extreme apprehension caused by the thought of an examination). Thus, in a virgo intacta of twenty years, with a protruding hymen (such as we find in new-born infants), I have seen exceedingly severe spasms of all the muscles of the pelvis take place, which commenced as soon as the finger was brought near the parts. There was evi- dently some tenderness when touched with the sound, but it was not very great. She complained also of spontaneous pains in the vulva and about the anus, and of a desire to micturate. In another case I met with vaginismus in a young woman who had been married for six months. The ordinary etiology did not here apply, for I ascertained positively that husband and wife lived together simply on a footing of pure friendship, as the husband expressed it. Here also the sensitiveness was not at all excessive, but violent spasms of the pelvic muscles occurred on passing the hymen. Neftel' has called attention to still another etiology. He is of the opinion that vaginismus may occur also as a symptom of lead poisoning (in one case in connection with paralysis of the extensors, in another, with lead colic, in consequence of using cosmetics which contained lead). Martin regards vaginismus as a hyperaesthesia of the vaginal 1 L'Union medicale, 1869, No. 19, and Brit, and Foreign Med. -Chir. Review, Octo- ber, 1873, p. 516. 534 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. orifice, induced in consequence of gonorrhoeal infection. In none of my own cases was it possible to attribute the affection to gonorrhoea. Pathological Anatomy. The anatomical changes found in the orifice of the vagina are usually unimportant, yet in recent cases there is generally redness of the affected parts, erosion, swelling of the follicles, and increased secretion of the mucous membrane ; in many cases also we find quite characteristic papillary excrescences, closely aggregated together in the fossa navicularis. Later, even these appearances may disappear, so that the orifice of the vagina looks perfectly healthy. The complications which are referred to by many authors are either accidental, as, for instance, the uterine displacements, or secondary to other troubles, such as the inflammations of the womb. Symptoms. The properly characteristic symptoms have already been mentioned. They consist in violent paroxj^smal pains, which are developed on merely touching the sensitive spots, and in spas- modic contractions of the constrictor cunni, or, in the worse cases, of the entire muscular system of the floor of the pelvis. The spasms are sometimes lacking, notwithstanding the sensi- tiveness is extreme; in other cases the sensitiveness is insignifi- cant, whHe the mere touch with the finger or the sound gives rise to spasmodic contractions. The consequence of this is, that the introduction of the penis is rendered impossible, or at least extremely difficult, so that conception takes place only exceptionally. Packard' reports an instance where, although the introduction of the penis had never occurred, nevertheless conception took place, but it terminated in six months in an abortion. In the further course of the affection, in consequence of the severe and frequently repeated irritation, disorders supervene in 1 Amer. Jour, of Obst., Vol. II., p. 348. VAGINISMUS. 535 the other genital organs (though of course such may have existed previous to the vaginismus). General disturbances of nutrition may ensue, and furthermore, hysterical symptoms, emotional disorders, and physical depression are apt to be present. Arndt' especially insists that vaginismus plays an important part in the etiology of the psychoses. Prognosis. Recovery takes place spontaneously only when the irrational attempts at cohabitation are abandoned, that is, when coition is either not indulged in at all or is performed in a proper manner and considerately. If pregnancy take place, the vaginismus may occur again after delivery. If the proper treatment is pursued, recovery invariably fol- lows. The very fact that so many different methods of treat- ment are recommended, all of which insure a recovery, proves that vaginismus is easHy cured ; moreover, an obvious deduction from this is, that all severe operations are unnecessary. Treatment. I have employed the method of treatment advocated by Scan- zoni with satisfactory results. This consists in requiring the husband to abstain entirely from coition, in bathing the external genitals cautiously with lead water, and afterwards, when the redness has subsided, in pencilling the sensitive parts with a solution of the nitrate of silver (one hundred and sixty grains to the fluid ounce). I have also found a solution of carbolic acid (one part to fifty) very efficacious. Vaginal suppositories of cacao-butter, with narco- tics, are unnecessary. If the redness has disappeared, and the vaginal orifice is but slightly sensitive when the finger is introduced, cylindrical spec- ula of gradually increasing size should be passed in daily and allowed to remain for from half an hour to an hour. Though the introduction of the speculum is painful at first, it is well > Berl. klin. Wochenschr., 1870, No. 28. 536 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. borne after it has remained there for a little while. If the vaginal orifice has been considerably dHated, and scarcely any tender- ness remains, the husband and the wife having been properly instructed, coition may be permitted again, and everything goes well. I have been so successful with this plan that I have never been obliged to resort to any other method of treatment. Hoist' recommends ice ; Burns and Simpson divided the nervus puden- dus subcutaneously. A peculiar plan of operation is proposed by Sims. It con- sists in excising the hymen, as well as other sensitive spots, and in making afterwards a deep lateral incision in the sphinc- ter, after which a dilator is worn. Whether or not this bloody operation may be necessary in very rebellious cases we are unpre- pared to say ; but, as a rule, it certainly may be dispensed with. A less severe method than that of Sims is the forcible do- tation, as proposed by different authors—Charrier,2 Horwitz, Courty, and Sutugin.3 Under profound anaesthesia both fore- fingers or both thumbs are introduced into the vaginal orifice, which is then forcibly dilated until the muscle tears. In America "ethereal cohabitation" has been introduced as a means of cure for vaginismus, that is, the wife is anaesthe- tized, and while she remains in a state of narcosis the husband performs coitus, with a view of inducing conception, in order that recovery may be brought about by parturition. In those cases of vaginismus in which the spasms are especially prominent, a very good effect may be derived from hip-baths with a temperature of from 95° to 100° F. Other Spasms of the Vagina. Besides true vaginismus, other spasmodic contractions of the vagina occur, which are sometimes accompanied with pain and are sometimes painless. Thus Hildebrandt4 calls attention to a 1 Scanzoni's Beitr., B. V., Heft 2. 2 Gaz. des hop., 1868. 3 Petersburger med. Zeitschr., 1872, Heft 4 and 5, p. 469. 1 Arch. f. Gyn., B. III., p. 221. MALFORMATIONS OF THE VULVA. 537 spasm of the levator ani, in which the penis is firmly grasped during coitus, and for a few minutes is held imprisoned (penis captivus). Ferber' reports a case in which a sudden sensation of painful constriction of the vagina occurred during sleep. Spasmodic contractions of the vagina may be the cause of sterility, by expelling the semen as soon as deposited in the vagina, through the contraction of muscles in the floor of the pelvis. This reflux of the semen has been referred to by Sims2 and Storer.3 We would expressly state that it is our firm con- viction that the reflux of the semen is a not infrequent cause of sterility, and that it may occur in healthy women without the existence of any painful sensation. Neither the insertion of a ring within the vagina, nor allowing the penis to remain in the vagina for some time after copulation, wiU be of any avail in preventing it. DISEASES OF THE VULVA. Malformations. It is very necessary to a perfect comprehension of the defects of development in the vulva to premise a few words relative to the normal development of this part. The vulva is formed in the following manner: At first a depression takes place in the external skin (see Fig. 132, a), and this gradually deepens until a communication is established from without with the allantois, which is not yet separated from the bowel (see Fig. 133). At the point where the allantois emerges from the bowel, the perineum protrudes forward, sepa- rating the original cloaca into two parts, the sinus urogenitalis in front, and the anus behind (see Fig. 134). Into the sinus urogenitalis open the most dependent portion of the allantois, which becomes narrowed down to form the ure- thra, and the inferior extremities of the two canals of Miiller, which unite to form the vagina. 1 Berl. klin. Wochenschr., 1871, No. 15. aL. c, p. 264. 3 Boston Gyn. Jour., Vol. III., p. 73. 538 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. The relation of these parts to each other varies decidedly with the degree of development of the different parts. Pig. 132. all, allantois, afterwards the bladder; r, rectum; m, Miiller's canal, afterward the vagina; a, external depression of the skin, which becomes the anal orifice. Fig. 1&3. The external depression of the skin is perforated and forms the cloaca (cl). Fig. 134. The perineum has formed, separating the anus from the sinus urogenitalis (su). u, ure- thra ; v, vagina. In the beginning, the sinus urogenitalis is comparatively long, and its direct continuation is formed by the lowest portion of the allantois, which becomes the urethra (see Fig. 135). Later it ceases to increase in length, and forms merely the short vestibule of the vagina ; and since the urethra, meantime, has remained a narrow canal, while the vagina has become relatively enlarged, the latter then appears to form the direct continuation of the sinus urogenitalis (i.e., of the vaginal vestibule). (See Fig. 136.) Fig. 135. The urethra (u) still forms the continuation of the sinus urogenitalis («'«)»into which the vagina {v) also opens. Fig. 136. The genitals complete. The sinus urogenitalis has become the flattened vestibule into which the urethra and vagina (the latter bein^ separated bj the hymen) open. Fig. 137. Complete atresia. Rectum (r), bladder (6), and genital canal (g) communicate. The above normal course of development is liable to a whole series of deviations, which result in the following malformations: Complete atresia occurs when the depression in the external integument, which by perforating into the allantois should form the cloaca, does not take place. Then the bowel and the allan- tois (which goes to form the bladder) may either communicate, as in the beginning (see Fig. 137), or be separate (see Fig. 138). Not infrequently atresia occurs in connection with other defects of development; for example, it may be associated with a uterus MALFORMATIONS OF THE VULVA. 539 didelphys, and the bladder and genital canal opening into it then become distended to a shapeless tumor by the urine collecting in them. Under these circumstances the invariable result is a non- viable monster. In other cases, where the depression of the external integu- ment is not lacking, the cloaca may yet be preserved, by reason of the fact that the perineum, which descends from above and divides the sinus urogenitalis from the intestinal canal, does not develop. We have then what is incorrectly termed atresia ani vaginalis; it is, however, more properly an opening of the rec- tum into the sinus urogenitalis (see Fig. 139). Fig. 138. Complete atresia. The allantois has become separated from the rectum (r). Bladder (6) and genital canal (gr) distended with urine. Fig. 139. Atresia ani vaginalis. The perineum (d) has not yet developed so that the cloaca (see Fig. 133) is preserved, and bladder (6), vagina (»), and rectum (r) open into the cloaca in common. The real character of the preserved cloaca is almost invariably misapprehended, in that its upper portion, by reason of the considerable length which the cloaca often has, is taken for the vagina, and accordingly a communication of the rectum with the vagina is spoken of. Heppner,1 also, erroneously terms it vaginal cloaca, supposing that the rectum empties into the vagina. In the exceedingly interesting case described by him the two vaginae are wholly separate, and the part designated by him as the simple vagina belongs still to the sinus urogenitalis, that is, it belongs, embryologically, not to the canals of Miiller, but to the allantois. In his " Fig. 3 " b is not the sinus urogenitalis, as he supposes, but b, e and/form together the cloaca, that is, the sinus urogenitalis, into which not only the urethra and both vaginae open, but, inasmuch as no perineum has yet developed, the rectum also. But even where the perineum is developed normally, the sinus urogenitalis, as it exists in the foetus, may be preserved, so that the vaginal vestibule remains uncommonly long and narrow (like a urethra), and the common canal divides into the urethra and vagina, comparatively high up. This defect has been designated —not very happily to be sure—as the high orifice of the urethra ; it is often associated with hypertrophy of the clitoris, and is then 1 Petersb. med. Zeitschr., 1870, I., p. 204. 540 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. designated as the lowest grade of female hypospadia (see Fig. 140). ^ ^# Fig. 140. Fig. 141. Persistence of the sinus urogenitalis (s). Into Female hypospadia. The entire allantois has It open the urethra (zi) and the vagina (»). The been transformed into the bladder (6), so that clitoris (c) is hypertrophic. Is easily mistaken the latter, without any urethra, opens directly for male hypospadia. into the sinus urogenitalis (s), the vaginal vesti- bule. True hypospadia is understood to embrace those cases in which the sinus urogenitalis has undergone retrograde develop- ment in the normal way, while the lowest portion of the allan- tois, which generally becomes transformed into the urethra, is merged in the developing bladder, and hence the vagina and the bladder open into the vaginal vestibule without any urethra.l The manner in which epispadia (which, by the way, is much rarer in the female than in the male) occurs, is not fully established, and it is yet a question whether there is always a primary defect in the abdominal wall. This defect might give rise to a rupture of the anterior wall of the allantois, though the rupture of the allantois might also be the occasion of the defect in the abdomen. Epispadia may arise in connection with the development of a cloaca. With regard to the treatment of these defects of develop- ment, we observe that for the atresia no operative procedure will afford any relief, except in very rare instances; for, almost invariably, the condition is very complicated, and such that pro- longed life is an impossibility. Moreover, in the cases where a cloaca has been formed, the condition can only be remedied through operations of an ex- tremely complex nature. In true hypospadia there is involuntary micturition. But even here no plastic operation will avail to provide a urethra capable of performing its function. We must endeavor to close the opening in the bladder by means of a compress which presses the posterior wall against the anterior. Absence of the vulva is met with in rare instances, even when 1 Heppner, Monatsschr. f. Geb., B. 26, p. 401. MALFORMATIONS OF THE A'ULVA. 541 the internal genitals are normally developed. The sinus uro- genitalis then opens in the region of the vulva as a simple aper- ture. In other cases particular parts of the vulva, as the labia majora and minora, the clitoris, or the perineum, show a rudi- mentary development. Moreover, the vulva may preserve its infantile form. Among the female malformations belongs also female herma- phroditism, that is, that form of defective development in which the malformed female genitals simulate the external genitals of the male. Such cases, that is, misshapen male or female geni- tals which show a resemblance to those of the opposite sex, were formerly designated by the term hermaphroditismus trans- versus. Those cases only can be regarded as true instances of hermaphroditism in which well-marked ovaries and testicles are both present in the same individual. It may take the form of hermaphroditismus lateralis, in which an ovary is developed on one side, and a testicle on the other, or of hermaphroditismus androgynus bisexualis, in which both ovary and testicle occur on each side. Nearly all the cases which have been described as instances of true hermaphroditism rest upon insufficient observa- tion. The case reported by Meyer,1 however, which was thoroughly investigated by Klebs,2 is doubtless to be regarded as an instance of real hermaphroditismus later- alis, though the ovary of the right side was very poorly developed. The only well- established case of hermaphroditismus bilateralis has been recently described by Heppner.3 He examined the genitals of a two months' child whose external genital organs, as is often the case, might have been taken for those either of a male or of a female; of the internal genitals, the female were the best developed, and of the male genitals, the prostate and both testicles (as demonstrated by the microscope) were present. The latter lay close by a parovarium, which at the same time repre- sented a rudimentary epididymis. Notwithstanding both male and female sexual glandular organs were present in this case, still it cannot be looked upon as a perfect androgyna, that is, as an individual capable of functionating both as a male and as a female, for in all such cases the external genitals are greatly deformed. Katharina Hohmann,4 who has of late years exhibited herself for money in most places in Germany, is a male, though there is probably an ovary on the left side. ] Virchow's Arch., XL, p. 420. 2 Handb. der path. Anat., IV., Lief. 1, p. 728. ' » Arch. f. Anat., Physiol., etc., 1870, No. 6, p. 679. 4 Von Franque, Scanzoni's Beitr., B. V., p. 57. B. Schultze, Virchow's Archiv, B. 43, p. 332. Friedreich, Virchow's Archiv, B. 45, p. 4. Virehow, Berl. klin. Woch. 1872, No. 49. 542 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. In the pseudo-hermaphroditism of the woman there is an hypertrophy of the clitoris, so that the latter looks like a penis. Moreover, since the external labia have the form of a scrotum, and are attached to one another below, and since beneath the penis-like clitoris there is usually a very narrow opening into the sinus urogenitalis, the external genitals acquire a striking resem- blance to those of a male hypospadias. The urethra and vagina then open into the sinus urogenitalis. The internal female geni- tals may exhibit all forms of rudimentary development, though they may also be formed normally. The breasts are sometimes feminine, and sometimes but slightly developed, and the entire aspect may be either more feminine or more masculine, as the case may be. In some cases the resemblance of the external genitals to the male organs is increased by the fact that the ovaries are situated in the labia, in consequence of inguinal hernia?, so that it may seem on examination as though one were feeling testicles in a scrotum. Atresia of the labia minora is a deformity that may be acquired. Sometimes in little girls adhesions of the labia mi- nora are met with, extending from below as far as the region of the urethra, and in rare cases beyond, so as to interfere with the evacuation of the urine. The adhesion may generally be remedied by tearing the labia apart; in the worst cases a division is effected with a bistoury and grooved probe.1 The large labia may also be adherent posteriorly, so that the perineum has the appearance of extending very far forward. HYPERTROPHY OF THE VULVA. Hypertrophy of the nymphm occurs amongst certain tribes (Hottentots, Bushmen) as a peculiarity of the race, and is com- monly known as the Hottentot apron (this, however, should be distinguished from the peculiar deposit of fat in the nates, which also occurs in the Hottentot women). But hypertrophy of one or both labia is not an uncommon thing with us too ; and it occurs of the same magnitude as seen 1 Bokai, Jahrb. f. Kinderheilk., 1872, V. 2, p. 163. MALFORMATIONS OF THE VULVA. 543 in Luschka's' illustrations of Hottentots. Occasionally, though not always, the enlargement is due to onanism; the nymphse hang down and show a brownish pigmentation, but, as a rule, no further changes appear. Moreover, they generaUy occasion no special symptoms, though, exceptionally, they may act as a bar to pleasurable sensations during coition. In a case reported by Breslau 2 there was incontinence of urine, which disappeared after the opera- tion. Amputation of the nymphse is a simple and perfectly safe operation. Hypertrophy of the clitoris may occur as a congenital mal- formation, of which we have spoken above, and it may also be acquired and become so great that the clitoris may be larger than the male penis. In Germany such an hypertrophy appears to be extremely rare—at least it is observed in women who masturbate only very exceptionally, for in women who have long been addicted to the habit the clitoris usually remains quite normal. But where the clitoris is greatly enlarged, and other morbid symptoms exist which must necessarily be ascribed to it, clitori- dectomy becomes indicated. The removal by the knife is doubt- less preferable either to the operation with the ligature or to that with the ecraseur (with which Mason3 removed a clitoris four inches long). If the hemorrhage is profuse, and the deep application of sutures does not suffice to still it, a tampon satu- rated with a solution of perchloride of iron may be employed. But while clitoridectomy, when performed under these con- ditions, is a perfectly justifiable operation, the indiscriminate extirpation of the normal clitoris, as practised by Baker Brown, and for which he was expelled from the London Obstetrical Society, is to be decidedly condemned. Neither in hysteria, nor in epilepsy, nor in onanism, nor in the psychoses that are connected with sexual processes, can anything be accomplished by the removal of the normal clitoris. 1 Monatsschr f. Geb., B. 32, p. 343. 2 Scanzoni's Beitr. zur Geburtsk. B. 3. 3 New York Med. Record, Vol. III., p. 104. 544 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. ACUTE CATARRH OF THE VULVA. Huguier, Acad, de Med., Sept. 8, 1846, and Journal des Connais. med.-chir., 1852, Nos. 6-8.—Oldham, Lond. Med. Gaz., May, 1846. — Von Barensprung, Charitg- annalen, VL, 1, p. 20.—Martin et Leger, Arch. gen. Janvier et Fevrier, 1862. —Zeissl, Allg. Wiener med. Z., 1865, Nos. 45,4Q.—Kuhn, Zeitschr. f. Med., Chir. und Geb., 1866, V., p. 114. Etiology. An acute inflammation of the vulva may be produced by want of cleanliness, by discharges from the internal genital organs or from urinary or faecal fistulae, by injuries, violence (rape), mas- turbation, or violent cohabitation, but most commonly by infec- tion with gonorrhoeal poison. Erythema of the labia majora may be produced by friction against the inner surfaces of the thighs, particularly in fat persons, during the hot season of the year, and after protracted walking. In children inflammation of the external genitals may arise from the oxyuris creeping into the vulva from the anus. Pathological Anatomy. The acute catarrh is marked by swelling, relaxation, and injection of the mucous membrane. The nymphse are especially swoUen, and discharge a profuse muco-purulent secretion. The small sebaceous glands are also swollen by the retained secre- tion, and may thus form acne tubercles, or even pustules. In the latter case the adjacent connective tissue may also become inflamed with the development of a furuncular abscess which discharges offensive pus. In the virulent form of catarrh, acuminate condylomata are very apt to develop on the labia minora, the carunculse myr- tiformes, and in the vicinity of the orifice of the urethra. Furthermore, in gonorrhoea, though also exceptionally in benign catarrhs, inflammation of the glands of Bartholini is liable to occur either on one side or on both. Sometimes suppuration is confined to the excretory duct. ACUTE CATARRH OF THE VULVA. 545 Symptoms. In severe cases the inflammation of the mucous membrane occasions very intense pain, which is particularly severe when the two sides chafe against each other in walking. There is also a discharge, which is sometimes mucous, in other cases wholly purulent. In case a gland of Bartholini suppurates, a tumor is developed in one labium, but rarely becomes larger than a pigeon's egg. The pus is discharged either through the normal excretory duct, or through a perforation on the inner surface of the small labium. The consequence of the abscess may be com- plete obliteration of the gland. Diagnosis. The affection is easily recognized, inasmuch as the affected parts may be exposed directly to view. The swelling of the gland of Bartholini is discovered by its situation and by the tenderness of the roundish tumor. Treatment. By observing absolute rest and the proper degree of clean- liness the catarrh soon disappears. It is particularly important to thoroughly remove the secretion from the diseased mucous membrane in the gonorrhoeal form, which sometimes lasts for a considerable time; but it is difficult to do this, on account of the crypts in the mucous membrane in which the secretion adheres. If the secretion continues abundant for a long time, astringents are required. The abscess of Bartholini's gland may sometimes at an early stage be evacuated through the duct by pressure ; when this is impossible it must be incised. Chronic catarrh may be the sequel of the acute, but it is very commonly observed in all those cases where various discharges from the internal genitals are present. If the cause which produced it is withdrawn, it recedes of itself ; but, again, it may be extremely obstinate, causing a long- continued irritation and hypertrophy of the vulva. VOL. X.-35 546 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Phlegmonous processes in the vulva, sometimes leading to considerable swelling of the labia, are liable to occur, second- arily, in consequence of infected wounds of the vaginal orifice ; hence, more particularly in connection with puerperal ulcers. Gangrene of the vulva, besides occurring in chHdbed, may happen in small-pox, measles, scarlet fever, typhus, cholera, etc., and also in consequence of diphtheria. In children, it occurs spontaneously in the form of noma. Erysipelas and herpes in this region differ in no respect from these affections when they occur in other situations. HERNIAE OF THE VULVA. An inguinal hernia descending into the labium majus of the corresponding side is known as hernia labii majoris anterior. By the term hernia labii majoris posterior is designated a hernia which causes the lateral peritoneal pouch, in front of the ligamentum latum, to protrude downwards, and to emerge in the labium. Hernia perinealis is formed by a protrusion of the perito- neum behind the ligamentum latum, and emerges at the peri- neum. The diagnosis of these hernise is not unimportant, since by mistaking them for other tumors serious consequences may arise. They may be recognized from the fact that it is possible to trace them upwards into the abdominal ring, as can most easily be done in the inguinal hernise ; furthermore, from the fact that an impulse and a forcible protrusion downwards is produced in coughing, from the possibility of reducing them, and from the tympanitic intestinal resonance. NEOPLASMS OF THE VULVA. Aubenas, Des tumeurs de la vulve. Th&se. Strasbourg, 1860. Elephantiasis. Herzog, Ueber die hypertrophic der ausseren weiblichen Genitalien. Erlangen, 18^2.—Rogers, London Obst. Tr., Vol. XI., p. 84.—Jayakar, Med. Times, 1871, Vol. I., p. 37.—L. Mayer, Berl. Beitr. z. Geb. u. Gyn., L, p. 363. NEOPLASMS OF THE VULVA. 547 Etiology. The erysipelatous attacks which precede the elephantiasis cruris are, as a rule, wanting in hypertrophy of the vulva, which comes on insidiously. In the East, elephantiasis of the vulva is very much more common than here. Where a predisposition to it exists, it occurs at the height of sexual development—most generally between the ages of twenty and thirty—and is usually owing to inflammatory irritation acting upon the vulva. Of importance in this connection are, first, syphilitic infection, then masturba- tion and sexual excesses generally. Moreover, the development of an elephantiasis may occasionally be provoked by a blow or a contusion. The diseased labia are often greatly swollen just before or just after menstruation, and sometimes they increase in size very rapidly during pregnane}^; Louis Mayer, however, observed improvement take place under the latter condition. Pathological Anatomy. It is rare that the vulva is hypertrophied uniformly ; gener- ally only certain portions are the seat of the tumefaction, and most commonly the labia majora, next the clitoris, and most rarely of all the nymphse. The affection consists in a hypertrophy of the structure form- ing the external integument. According to Virehow1 there is, in the first place, probably a disease of the lymphatic glands, which interferes with the backward flow of the lymph. In con- sequence of this the skin becomes saturated with lymph, and the connective tissue becomes hypertrophied. The epidermis, in ele- phantiasis of the vulva, is generally about normal, though occa- sionally thickened. The papillary body is sometimes greatly hypertrophied, so that the tumor consists almost wholly of papillaiy growths. These are so like enormously developed condylomata acuminata that it is impossible to discriminate between the two conditions. 1 Geschwiilste, I., p. 320. 548 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. In the interior of the tumor the hyperplasia of the connective tissue advances iiTegularly, so that uneven nodulated tumors are produced, which give the surface an irregular appearance, and the tumors are sometimes pedunculated. Louis Mayer1 describes a case which was of an ulcerative form, the ulceration being the most marked feature. Symptoms. The tumor may be extremely annoying, since it sometimes becomes so large as to reach below the knee, weighing as much as thirty pounds. It then becomes a serious mechanical impedi- ment and a very burden- some weight. It may be very painful too, and discharge a copious se- cretion. Conception may take place notwithstanding, even in the most aggra- vated cases (as shown by a case of Jayakar's). Even very large tumors do not impede delivery, for the vagina remains intact. Treatment. Since the elephantia- sis does not get weU of Elephantiasis of the vulva, after L. Mayer. The hypertrophied itself, and antiphlogistic left labium (a) is seen behind the enlarged clitoris. X o treatment is only of ser- vice at the commencement of the disease, it is necessary to remove the tumor by an operation. This may be done with the knife, with the scissors, or else with the galvano-caustic wire loop. Notwithstanding the great size of the tumor the oper- 1 L. c, Taf. XIIL, Fitf. 4. NEOPLASMS OF THE VULVA. 549 ation for removing it is tolerably simple, since, particularly where the tumor consists of the hypertrophied labia, the dis- eased portions may be simply cut away. Relapses are very rare. Lupus of the Vulva. Martin and Lorent, Mon. f. Geb., B. 18, pp. 348 and 350. Lupus very rarely affects the vulva, but it sometimes de- velops in this situation, and may occur in any of its forms and in any part of the vulva, even to the perineum. The diagnosis must depend upon the microscopic appear- ances and the various other characteristic marks of the disease. The prognosis is far more favorable than that of carcinoma, for a spontaneous cure may result after considerable cicatrization. A cure may also be effected by destroying the new growth by means of the strongest caustics. Papillary Growths. Condylomata. Thibierge, Archives generates, Mai, 1856.— Klob, Path. anat. d. weibl. Sex., p. 459. We pass by here the syphilitic hyperplasia of the papdlary body, with superficial ulceration (the flat condylomata). Extensive papillar}r growths, known as condylomata acumi- nata, develop in consequence of the irritation of the gonorrhoeal poison, but according to Thibierge the}' may also occur in preg- nancy independently of gonorrhoea. The acuminate condylo- mata may become very large, and form such enormous tumors (Gasco}^en' saw one as large as a child's head) as to resemble the papillary form of elephantiasis. Most of these condylomata are undoubtedly gonorrhoeal in their origin ; after delivery they disappear. The so-called caruncles—small, flat, or pedunculated poly- pus-like growths—develop most usually around the orifice of the urethra, in the form of circumscribed hyperplasia? of the mucous membrane, with implication of the follicles. The sebaceous follicles may become plugged up, producing 1 Med. Times, Jan. 21, 1872. 550 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. acne of the labia, but these must not be confounded with the little elevations of the skin like goose flesh, which, according to Klob, consist of growths analogous to tubercular formations, and, in the form of prurigo senilis, occasion violent itching. Cysts of the Vulva. Boys de Loury, Revue m6d. de Paris, Dec, 1840, T. IV.—Huguier, Mem. de l'acad. demed., T. XV., and Gaz. mgd. de Paris, 1826, 14, 37. —Von Bdrensprung, Chariteannalen, VL, I., p. 41.— Lotze, Ueber Cystendegeneration der Cowper'- schen Driisen der Frau. Diss, inaug. Gottingen, 1869. The cysts of the glands of Bartholini are the most common of the cysts of the vulva. They may spring either from the excretory duct or from the gland itself. In the former case they are oblong at first, and become afterwards round, while those of the gland itself grow to a larger size and exhibit occa- sionally a lobulated form. They are situated in the labium majus, in the region of the gland or of its excretory duct, though exceptionally, and as shown in a case observed by Hoe- ning,: they may extend up along the side of the vagina into the true pelvis, and even beyond the vaginal cul-de-sac. The contents of the cysts are usually clear, mucilaginous, and stringy, but occasionally they are colored, even to a dark brown sometimes. They cause no disturbance other than mechanical, and hence only produce discomfort; still, at the menstrual periods, they may swell -up and become painful. The elastic consistence and painlessness of the cyst suffice for its diagnosis, and the characteristic seat indicates the variety. It is not sufficient simply to evacuate the cyst, for it fills up again, but it must either be injected with iodine or else extir- pated. Other cysts, however, occur upon both the labia majora and the labia minora ; they remain for the most part small, though exceptionally they may grow to be as large as a child's head. Their etiology is obscure. It is possible that they develop in consequence of contusions of the connective tissue, and prob- 1 Monatsschr. f. Geb., B. 34, p. 130. NEOPLASMS OF THE VULVA. .5.51 ably also in connection with hemorrhages. The cyst wall is firm and distinct, and the contents may be either serous or mucous in character, and have a variable color. Dermoid cysts also occur in the vulva. Lipomata. Lipomata occur in the labia majora and on the mons veneris, and may attain an enormous size. Thus Stiegele ' removed one weighing ten pounds, and Koch2 extirpated one entire which hung down to the knees and the lower half of which had already been cut off by the patient herself with her husband's razor. Fibromata. Storer, Bost. Gyn. Jour., Vol. IV., pp. 271, 325, and 336.— Morton, Glasgow Med. Jour., 1871, p. 146.—Grime, ibidem, p. 265. These growths usuaHy consist of true fibro-myomata, which spring from the labia majora, and can be enucleated from their surroundings. When they attain a considerable size they drag down the skin by their weight, like polypi, and hang between the thighs ; indeed the traction may be so great as to develop ulceration in the skin. Fibro- mata, like the uterine fibroids, may become cedematous (parti- cularly during the menstrual periods and pregnancy), and may even develop cysts. The extirpation is not at all difficult, for when the tumor has drawn down the skin into a long pedicle it may be simply cut off, and in the other case they are enucleated from the labia. Fibroid of the labium majus, after Storer. ' Zeitschr. fur Chir. u. Geb., 1856, B. IX., p. 243. 2 Grafe und Walther's Journ., 1856, p. 24, p. 308. 552 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. Carcinoma of the Vulva. Louis Mayer, Virchow's Archiv, B. 35, p. 538, and Mon. f. Geb., B. 32, p. 244.— Belirend, Diss, inaug. Jena, 1869. The cancerous degeneration may proceed from the labia majora or minora, or from the clitoris, and occurs in the most various forms, sometimes having more the nature of a cancroid neoplasm and sometimes occurring in the form of cancerous ulceration. The pain is not very severe usually, and at first only a certain inconvenience is experienced, owing to the pres- ence of a tumor in the vulva ; after ulceration has taken place, however, the tumor becomes extremely annoying. The diagnosis is simple, and with regard to treatment, where there is any prospect of success, the growth should be removed by an operation. Pig. 144. Carcinoma of the vulva. The tamor of the left labium ulcerated, likewise that of the mons veneris. In the case represented in Fig. 144, the left labium minus was undoubtedly affected originally ; a large secondary tumor developed on the mons veneris at the point where the labia meet, and a little to one side. Moreover, the inguinal glands were markedly infiltrated. Owing to the fact that besides the extensive local affection, a small retro-uterine tumor of a suspicious character was discovered, no operation was undertaken. N'KOPLASMS OF THE VULVA. 553 The chances for an operation were better in the case represented in Fig. 145, in which the external genitals showed a complete senile atrophy. The clitoris was indicated merely by a diminutive tubercle without praeputium or frenulum ; the left labium minus was quite obliterated, the labia majora somewhat atrophic. The inner Fw. 145. Carcinoma of the vulva. surface of the right labium majus was occupied by a carcinomatous tumor, almost as large as a hen's egg, which, commencing at the right side of the clitoris, extended as far as the frenulum, and probably sprang originally from the right labium minus. It had been twice operated upon by the physician in charge of the case, so that the existing tumor was the second relapse in the same place. The tumor was excised with the production of considerable hemorrhage, and the incisions were so made that the edges of the wound were situated in perfectly sound tissue. The wound healed, so far as it had been stitched, per primam intentionem; in the region of the clitoris, where the chloride of iron had been applied, it healed with copious suppuration. Under the microscope the tumor appeared evidently cancer- ous ; flat and cylindrical epithelial cells lay in alveoli of connective tissue. Four- teen months after the operation there was not the least sign of a relapse. Sarcoma of the Vulva. Louis Mayer, Monatsschr. f. Geb., B. 32, p. 250. In Mayer's two cases there were warty sarcomatous growths in the vulva. Neuromata. Simpson found neuromata beneath the mucous membrane in the vicinity of the meatus. 554 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. THROMBUS OR HEMATOMA OF THE VULVA. The bloody tumors of the vulva, excepting those associated with parturition, are almost exclusively traumatic. Yon Franque1 saw a thrombus develop in the labium majus of a woman who had never borne children, in consequence of violent straining at stool. RUPTURE OF THE PERINEUM. Verhaeghe, M6m. sur un nouveau procfide, etc. Bruxelles, 1857.—Biefel, Mon. f. Geb. B. 15, p. 401.—J". Baker Brown, Surg. Diseases of Women, 3d ed. London, 1866, p. l.—Lane, Lancet, 1866, I., No. 5.— Simon, Prager Viertelj., 1867, B. 3, p. 80.—Hirschberg, Die Operation des veralteten complicirten Dammrisses.— Heppner, Langenbeck's Archiv, B. X., p. 655, and B. XV., p. 424.—Freund, Tageblatt d. Wiesbadener Naturforscherversammlung, 1873, p. 175. Leaving the etiology of rupture of the perineum, as well as its prophylactic treatment, and also the treatment of the recent rupture, to the treatises on obstetrics, we shall confine ourselves here to the consideration of old ruptures of the perineum which have cicatrized. The symptoms produced by old ruptures of the perineum may be of an injurious character, and, under certain circum- stances, are most distressing and unfortunate. We have already referred to the facility with which prolapse of the posterior wall of the vagina and of the uterus occurs when the floor of the pelvis is lacking. But apart from this, where, in aggravated cases, the sphincter has been torn through, inability to retain the intestinal evacua- tions may exist, not to such an extent that the entire fecal con- tents of the bowel escape, but to such a degree that perhaps only flatus escapes involuntarily, or, while the patient has the power of retaining hardened faeces, so soon as diarrhoea occurs, defecation becomes involuntary. The treatment of old perineal ruptures must, of course, be operative, and this involves (since the. vulva and anus lie in close proximity to each other) the formation, artificially, of a new perineum. 1 Memorabilien, 1867, I., p. 6. RUPTURE OF THE PERINEUM. 555 -gffe The operation of perineoplasty, as described by von Langen- beck, is performed in the following manner: That portion of the surface which is covered with skin, and which extends from the vagina as far as or into the sphincter, is dissected up in such a way that a vaginal flap is formed. The edges of the wound are then stitched together laterally, so as to form a new perineum, which towards the vagina is covered with the vaginal flap. If the rupture is deeper, the mucous membrane is also separated from the rectum, and the anterior surface of the rectum is covered over and united by sutures with the newly formed perineum. This complicated and difficult operation is not apt to be very successful, since by taking flaps from the mucous membrane there is a great liabHity of a recto-vaginal fistula being left behind. Far better results are obtained with the per- ineoplasty proposed by Simon. In this method, unless the rupture extends into the sphincter, the region of the perineal cica- trix is freshened in the shape of a triangle, the apex of which extends into the vagina, while the anal orifice lies at the middle of its base. Then the two limbs of the triangle which extend into the vagina are united, and afterwards the two halves of the base are joined by perineal su- tures to form the new per- ineum. If the rupture extends quite through the sphincter, the middle an°de of the freshened part is directed inwards into the Pig. 146. Perineoraphy according to Simon. v, posterior vaginal wall; a, b, c, d. e, f. g, h, the fresh- ened part, the sides a 6 and d e uniting to form the perineum, 6 c and c d, the anterior rectal wall, and a, h, g, and e, f, g, the posterior vaginal wall. 556 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. vagina; and, in addition to this, the freshening is extended on either side in the form of butterfly wings, as illustrated in Fig. 146. Then, vaginal stitches are taken in the portion freshened in the vagina, and the stitches are tied so as to present an appearance as represented in Fig. 147. Next, sutures are intro- duced in the vagina and rectum (deep sutures in the latter case) alternately, and are immediately tied, so that the knots lie both in the vagina and in the rectum, and the vagino-rectal wall is artificially elongated. Finally, the perineal stitches are put in, rather superficially, because they have not much to hold, the tension being borne chiefly by the rectal stitches. Fig. 147. i„fA£angement °f *he|a*?f in Simon's perineoraphy. The stitches which close the angle projecting into the vagina are already tied; vv, vagmal stitches; rr, rectal stitches ; dd, perineal stitches projecnng The after-treatment is mainly passive. Care should be taken to prevent diarrhoea, and eventually the sphincter ani may have to be divided posteriorly. The perineal sutures are removed after three days, since they otherwise will cut through; the vaginal and rectal stitches are taken out gradually from the fifth to the sixth day, the latter not all being removed before PRURITUS VULVAE. 557 the twelfth. The rectal stitches must be sought for with the speculum. PRURITUS VULVAE. C. Mayer, Verh. d. Berl. Geb. Ges., VI., p. 137. Etiology. Pruritus, or an itching sensation in the vulva and its vicin- ity, is frequently owing to long-continued external irritations, such as arise from acrid discharges, in blennorrhcea particularly, though also in carcinoma of the uterus. Here also probably belong those cases in which pruritus occurs during the men- strual flow, as well as those that occur in connection with dia- betes, where the vulva is bathed in the saccharine urine (accord- ing to Friedreich,1 the pruritus is then owing to the develop- ment of fungous organisms). Pruritus occurs also in connection with inflammation of the uterus and vagina, without any irritating discharge ; moreover, it also occurs in diseases of the urethra, bladder, and kidneys. In other cases, onanism may be the cause, as well as the effect of pruritus, an intolerable itching occurring secondarily, in con- sequence of the continued irritation; though onanism by no means invariably leads to pruritus. But cases also occur in which the above causes are entirely lacking. They are generally met with in women somewhat advanced in life, who are either approaching or have reached the climacteric. Pathological Anatomy. Changes in the vulva, properly characteristic of pruritus, are either wanting entirely or at least are very slight; very excep- tionally a true papular dermatitis with the above-mentioned little prurigo tubercles is met with. The secondary effects of pruritus are more apparent. We fre- quently find excoriations, with scabs upon them, due to the scratching, together with swelling and infiltration of the vulva, 1 Virchow's Archiv, B. 30, p. 476. 558 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. which is often very apparent to the eye, and is owing to the pro- longed irritation. Moreover the brown, or slate-graj' pigmented skin presents a peculiar rigid appearance, and, on account of the abundant desquamation, yields a thick, whitish secretion. Symptoms. Pruritus, especially in its lighter forms, is pretty common ; it consists in a violent itching of the orifice of the vagina, as well as of the lower portion of the vagina, of the labia majora, of the perineum, of the mons veneris, and of the adjacent surfaces of the thighs. The itching, which is occasionally accompanied with sexual excitement and erection of the clitoris, occurs most commonly in bed at night; it is also especially marked during any considerable excitation of the genitals, after physical exer- tions (in a warm temperature), as well as after excitements of the circulatory system. The itching also occurs in paroxysms often, so that ordina- rily the patient feels perfectly well, or is merely conscious of slight abnormal sensations in the genitals, whHe from time to time, every few days, every day, or several times in a day, an attack of intense itching comes on, which, beginning at some particular spot in the vaginal orifice or in the anus, thence radi- ates to the adjacent surfaces of the thighs and extends into the vagina. The pruritus is sometimes extremely intense, so that intelli- gent women declare that it wHl drive them to suicide, and women who possess great self-control are unable to resist scratching the affected parts. By this means the above-mentioned conse- quences are produced, including in many cases, onanism. Fur- thermore, disorders of nutrition ensue, together with an inclina- tion to solitude, insomnia, and profound melancholic" depression. Treatment. First of all, attention must be directed to the removal of any evil to which the affection may be owing, more particularly dis- charges of various descriptions. In this connection great benefit COCCYGODYNIA. 559 may be derived from the regular employment of hip-baths, the temperature of which will depend upon the condition and age of the individual, and they should be repeated at least twice daily. The addition of potash to the bath will prove very serviceable. Of actually curative agents we can only speak with confidence of the carbolic acid. I use it in a solution of one part to sixty, but most frequently from one to fifty to one to twenty, and indeed in the worst cases as strong as one to ten. Although it is only recently that I have commenced to employ this remedy, having thus far used it in only six cases, and being therefore unable to assert that relapses may not follow, yet the healing effect has been so obvious that I am sure no one who has once tried the carbolic acid will ever return to any of the other reme- dies that have been recommended. Among the latter, it has been proposed to smear the affected parts with a chloroform liniment (one part of chloroform to ten of almond oil according to Scanzoni), and Scanzoni and Veit have advised applying alum within the vagina either in solution or mixed with sugar, on cotton tampons ; in the worst cases, pure powdered alum, according to Scanzoni, may be introduced into the vagina. Weston and Martin' recommend tar, either in an alcoholic solution (four parts to thirty) or mixed with glycerine. In very obstinate cases cauterization with potassa fusa has been employed, but with no very good effect. Dawson2 saw a relapse occur in a case of follicular vulvitis, notwithstanding the fact that the entire mucous membrane had been cut away by Thomas. COCCYGODYNIA. Simpson, Diseases of Women. Edinburgh, 1872, p. 202.—Scanzoni, Wiirzb. med. Z., n., p. 4, and Krankh. d. weibl. Sexualorg., II., p. 325—Horschelmann, Petersb. med. Z., 1862, H. 16.—Nott, Amer. Jour, of Obstet., Vol. I., 243. Occurrence and Etiology. There sometimes occurs, not exclusively, though by far most 1 Boston Gyn. Jour., Vol. IV., p. 79. 2 Amer. Jour, of Obstet., Vol. II., p. 113. 560 SCHROEDER.—DISEASES OF FEMALE SEXUAL ORGANS. commonly, in women, and especially in such as have borne children, a violent pain in the region of the coccyx. Its origin is generally traumatic, and it is most commonly associated with parturition, especially in deliveries with the for- ceps. The pain may, however, be produced by other traumatic influences; thus Scanzoni attributed it, in two instances, to riding. According to Simpson, coccygodynia may also arise from exposure to cold (the case occurred in a washerwoman). Pathological Anatomy. Since the pain is localized in the coccyx, and is developed on motion of this part, its seat is doubtless either in the periosteum or in the articulations of the coccyx. Scanzoni found the coccj^x very long in several cases, as well as unusually movable, and frequently it was deflected to one side; he has also found decided inflammation, and even suppuration, in the vicinity of the bone. Symptoms. The sole symptom is the pain, which is called forth especially when the muscles inserted in the coccyx—the gluteus maximus, coccygeus, and levator ani—are contracted. The pain is most sure to be excited in sitting down and get- ting up ; in many cases it continues while the patient sits, and, in fact, some women can only sit on one buttock, while they sup- port themselves perhaps with one hand. Moreover, the pain is sometimes produced by walking. Defecation is apt to be espe- cially painful. Occasionally the pain occurs only in connection with certain particular (not always the same in different individuals) actions of the muscles. Thus in a case that came under Scanzoni's observation, the pain always became very severe during coition. The degree of the pain is very variable; sometimes the patient is conscious merely of a dull, heavy sensation in the region of the coccyx, while in other cases the pain is of the same character and intensity as a toothache. COCCYGODYNIA. 561 The coccyx is tender on pressure; occasionally, however, only over the posterior surface, while from the rectum it may be touched without causing any discomfort; passive motion of the coccyx is always extremely painful. Coccygodynia is a tedious disease, and is often very rebel- lious to treatment, and shows a decided tendency to relapses. Treatment. Scanzoni recommends in those cases which manifest hyperse- mic or inflammatory symptoms, local antiphlogistics, in addition to the maintenance of continued rest in the horizontal posture, and attention to keeping the bowels freely open. He has also seen subcutaneous injections of morphine followed even by per- manent relief. Simpson, on the other hand, who denies the efficacy of these means, cures the affection by an operative procedure. He either divides the tendons, which are attached to the coccyx, subcu- taneously, or, in the most obstinate cases, extirpates the entire coccyx, as had been previously recommended and several times performed by Nott. vol. x.—36 INDEX. Abscess of the nteras, following acute metritis, 98. Abulcasem, 4. Ackermann, 151. Age, influence of, in cancer of the uterus, 273; in carcinoma of the body of the nterus, 298; in fibroids of the uterus, 223; upon menstruation, 319; in the origin of ovarian cysts. 359 ; in sar- coma of the mucous membrane of the uterus, 303; in sarcoma of the parenchyma of the uterus, 306. Aitken, 25. Alcott, 36C. Amputation of the cervix uteri, for hypertrophy, 90, 145; for metritis, chronic, 123 ; in prolapse of the uterus, 206 ; of the uterus in inversion, 221 ; in prolapse. 214. Amussat, 57, 228, 252. Anesthesia in gynecological examination, 8. Andreef, 200. Aran, 129, 445. Arndt, 535. Arnott, 227, 283, 286. Ashford, 99. Ashurst, 251. Ashwell, 242. Atlee, W. L., 22, 258, 371, 378, 379, 388, 395, 405. Aubinais, 198. Auscultation in gynecological examination, 9. Aveling, 201, 206. Bailet, 390. Baker, 329. Balard, 244. Ballard, 377. Bamberg, 434. Bantock, 22, 423. Barker, Fordycc, 276, 286, 290, 296. Barnes, 69, 85,138, 219, 236, 371, 468. Bartels, 531. Barth, 243. Bartholini,99. Basch, 22. Baudelocque, 4. Baum, 3S6. Bauingartner, 7. Baumler, 410. Bayle, 223. Beatty, 388. Becquerel, 101, 135. Beebe, 423. B6hier, 242. Beigel, 179, 317. Bengelsdorf, 251. Benham, 316. Bennet, Henry, 69. Benporath. 229. Berard, 55, 346. Bernutz, 244, 445, 446, 448. Beronius, 59. Beta, 507. Billroth, 40, 49, 405. Binz, 234. Bird, Frederic, 99. Bischoff, 21. Blackbee, 32. Blasius, 370, 377. Blau. 274, 282, 283, 286, 298. Blick, 435. Bohata, 328. Buhm, 228. Boinet. 229, 242, 255, 268, 400. Boivin, 237, 377, 443. Bokai, 542. Boulton, 290. Boyer, 56. Bozeman, 516. Braun, C, 59, 123, 137. 195. 207. 20S, 404. Braun, G., 69, 176, 242, 258, 403, 4S6. Braus, 59, 60. Breisky, 47, 59, 60, 214. Bresgen, 7. Breslau, 59, 124, 204, 543. Bristowe, 377. Brown, 32. 253, 264. Brown, Baker, 57, 211, 244, 254, 258, 376, 401, 405, 422, 543. Bruch, 440. Brunton, 242. Bryck, 55. Budd, Charles A., 20. Biihring, 405. Bumham, 255, 425. 564 INDEX. Burns 46. 401, 536. Byrne, 32, 266, 290. Cahen, 377. Calvi, Marchal de, 243. Canals of Miiller, 32. Capuron, 129. Carr, 360. Cazeaux, 56, 242. Chamberlain, 135. Chambers, lfcO. Chambon, 4, 22, 51. Chan-ier, 46, 536. Charriere, 27. Chiari, 95, 204, 223, 236, 244, 273, 275. Chipendale, 208. Chisolm, 273. Chopart, 198, 222. Choppin, 214. Chrobak, 169, 363, 376, 401. Churchill, 59. Chrysmar, 405. Clamps for securing the pedicle in ovariotomy, 414. Clarke, John, 150, 242, 269. Clay, Charles, 255. Clay, John, 405, 408, 421, 429. Clemens. 442. Climate, influence of, upon menstruation, 319. Cloquet, 222. Coghill, 70. Cohnstein, 138, 321. Colles. 208. Corazza, 40. Corliss, 403. Cortis, 322. Courty, 1U1, 135, 183, 227, 229, 242, 536. de Coze, 227. Craig, 425. Crede, 59, 475. Crevet, 88. Cruveilhier, 81, 222, 234, 244 Curtis, 421. disco, 27. Cutter, 178. Dance, 4. Dancel, 330. Davis, Hall, 507. Dawson. 559. Deces, 59. Degen, 235. Demarquay, 244, 255, 268, 296. Deneux, 357. Denman, 377. Depaul, 212, 244. Desormaux, 4. vou Dessauer, 345. Detschy, 179. Diagnosis, Fallopian Tubes, constriction and closure, 343 ; inflammation, 346. Menstruation, dysmenorrhoea, 333 ; dysmenorrhcea membranacea, 336. Ovaries, carcinoma, 440; cysts, blood, 350; cysts, dermoid, 436; fibroids, 4'8; hernia, 356; inflam- mation, oophoritis, 353 ; prolapse, 358 ; sarcoma, 442; tumors. 378. Uterine Ligaments, hematocele, retro-uterine, 481; parametritis, 466 ; perimetritis, 458. Uterus, atresia, 53 ; cancer of the cervix, 287; car- cinoma of the body of the uterus, 311; catarrh of the cervix. 143; descent and prolapse of the uterus, 198; displacements, 169; ectropion of the cervix, 143 ; endometritis, acute. 128: endometri- tis cervicis, 143; endometritis, general, chronic, 133; fibroids. 245; interstitial fibroids. 246; sub- mucous fibroids, 248; subserous fibroids. 245 ; fol- licles, enlarged, of the cervix, 143 : haematometra, 53; haematometra, unilateral, 02: hernia. 222; hydrometra, 55; hypertrophy of the infravaginal portion of the cervix, 78; hypertrophy of the me- dian portion of the cervix. 90; hypertrophy of the .supravaginal portion of the cervix, 84 ; hyper- trophy, follicular, of the lips of the uterus, 152; hypertrophy, general, of the uterus, 75; inversion, 217; metritis, acute, 99; metritis, chronic. 110 ; mobility, excessive, of the uterus, 187 ; ovula Na- bothi. 143 ; papillary tumors of the uterus, 271; polypi, fibrous, 202; polypi, mucous, 147: sarco ma of the mncous membrane of the uterus, 305 ; sarcoma of the parenchyma of the uterus, 309; stenosis, 08 ; tuberculosis, 310. Vagina, cy>ts, 507 ; fistulse. uro genital, 521; fistulae, vagino-intestinal, 530; inflammation, croupous and diphtheritic, 495; prolapse, 505. Vulva, carcinoma, 552 ; catarrh, acute, 545; cysts, 550 ; hernia, 546 ; lupus, 549. Dieffenbach, 208, 405, 513. Dittrich, 274, 310. Dohrn, 490. Dolbeau, 474. Domm' s, 211. Duges, 237, 443. Dull, 235. Dumesnil, 236, 244. Dumreicher, 385. Duncan, Matthews, 20,191, 227,239, 253, 258, 305, 451, 460. Dupuytren, 56, 224, 460. von During, 179. Eberth, 442. Edis, 353. Edwards, 176, 198. IXDEX. 565 Eggel, 55. Ekhwald, 368, 435. Ellinger, 22, 69. Elmer, 198. Elytroraphy in prolapse of the uterus, 208. Emmet, T. Addis, 31, 210, 218, 219, 220, 253, 516. Engelmann, 315, 323, 234. Engli-eh, 355, 357. Eppinger, 51, 273, 282, 298, 349. Erich, 32. Etiology, Fallopian Tubes, constriction and closure, 339; displacements 346. Menstruation and its Derangements, amenor rheea, 327 ; dysmenorrhcea, 331; dysmenorrhcea membranacea, 334. Ovaries, carcinoma, 439; cysts, 359 ; cysts, dermoid, 432; hernia, 354; oophoritis, 351 ; prolapse, 35S. Deformities of the Mouths of the Tubes, 3CS; bibliography, 338 ; general description, 338. Constriction and Closure of the Tubes, with their Results : Hydrops Tcbarum. Hydro- salpinx, 339; bibliography, 339; etiology, £39; pathological anatomy, 341; hydrosalpinx. 342; its contents, 342; natural mode of evacuation, 342; symptomatology, 343 ; diagnosis, 343; prog- nosis, 344; treatment, 344. Hemorrhage of the Tube, 314. Inflammation of the Tubes, Salpingitis, 344; bibliography, 344 ; pathological anatomy, 345; symptomatology and diagnosis, 346. Displacements of the Tubes, 340 ; etiology, 346. Neoplasms of the Tubes, 346; fibroids, 346; car- cinoma, 347; lipomata, 347; tuberculosis, a47. Fehling, 6S. 504. Ferber. 474, 537. Fergusson, 28. Fieber, 404. Field, 220. Finn, 105. Fleming, 244. Flesch, 435. Fock, 398. Foltz, 20. Forster, 156, 345. Forster, Cooper, 390. Fourcade, 244. Foveaux, 31. Fox, George, 322. Frank, P., 158. von Franque, 196, 198, 206, 541, 554. Fredet, 244. Freund, 59, 138, 195, 196, 201, 220, 236, 244, 408, 463. Fricke, 211. Friedlander, 140, 433. Friedreich, 410, 541, 557. Fritz, 390. Froriep, 195. Furst, 137, 403. Fiirth, 237. Gardien, 129. Gascoyen. 549. Gassmann, 242. Gentian root for the dilatation of the cervix uteri, 23. Germann, 3SS. Gervis, 47. Giles, 446. Girardin. 208. Glatter, 274. 275. Godefroy, 47. Goldschmidt, 131. Gooch, 133. Goodell, 242, 251. Uterine Ligaments, haematocele, 470; haematocele, ante-uterine, 485 ; parametritis, 402 ; perimetri- tis. 445. Uterus, atrophy, 93; cancer, 273; carcinoma of the body of the uterus, 297 ; catarrh of the cervix, 139; descent and prolapse, 1S9; dis placements, laLeral, 185; ectropion of the os uteri, 139; elevation of the uterus, 214; endo- metritis, acute, 126; endometritis cervicis, 139; endometritis, chronic, general, 130; fibroids, 223; flexions and versions of the uterus, 158 ; follicles, enlarged, of the cervix, 139; haematometra, unilateral. 58; hernia, 222; hypertrophy of the infravaginal portion of the cervix, 76; hyper- trophy of the median portion of the cervix, 67 ; hypertrophy of the supravaginal portion of the cervix, 81 ; hypertrophy, follicular, of the lips of the uterus, 149; hypertrophy, general, of the uterus, 72; hysteralgia, 312; inversion, 215; metritis, acute, 96 ; metritis, chronic, 103; mobil- ity, excessive, of the uterus, 186 ; ovula Nabothi, 139: papillary tumors of the uterus, 269; polypi, fibrous, 259; polypi, mucous, 145; sarcoma of the mucous membrane of the uterus, 303 ; of the parenchyma of the uterus, 306 ; stenosis 65. Vagina, catarrh, chronic. 496; cysts, 506; fistulae, uro-genital, 514; fistulae, vagi no-intestinal, 528; inflammation, acute, 491 ; inflammation, crou pous and diphtheritic, 494 ; prolapse, 500 ; vagin ismus, 531. Vulva, catarrh, acute, 544; coccygodynia, 559; con dylomataof f he vulva, 549; cysts, 55(1: elephan tia>i> 547 ; pri ritus, 557 ; thrombus, 554. Euryphon, 188. Eustache, 506. Full.>pian Tabes, Diseases of, 338. A_nomauks of Formation, 338. 066 INDEX. Goodrich, 360. von Gorup, 395, 409. Gosselin, 49, 56, 194. Gotthardt, 506, 512. Goupil, 194, 445. Graf, 52. Granville, 405. Greenhalgh, 23, 70, 179, 436. Grenser, 388. Grohe, 349. von Grunewaldt, 25, 132. Gueniot, 242, 249. Guersant, 357. Gusserow, 275, 286, 304, 305, 442. Guy, 51. Guyon, 244. Gynecological Examination, 3; history, 3; the vaginal speculum, 4 ; the uterine sound, 4; posi- tion of the patient, 5; the couch or chair, 6; manual examination, 7; external examination, 7; the use of anaesthesia, 8; percussion, 8; aus- cultation, 9; internal examination, 9 ; per vagi- nam, 9: per rectum, 10 ; the conjoined method, 10; bibliographyr 10 ; examination per rectum, 13; examination with the uterine sound, 15; bibliography, 15 ; the instrument, 15 ; indications for its use, 16; measurement of the length of the uterine canal, 16; the coufse of the cavity, 17; question of contents, 17; permeability of the canal, 17"; facilitating palpation of the uterus, 18; testing its mobility, 18; sensitiveness of its internal surface, 18 ; difficulties encountered in the use of the sound, 18; dangers attending its use, 19; dilatation of the cervix for diagnostic purposes, 21; bibliography, 21; instruments, 22; sponge-tents, 22; laminaria bougies, 22; gentian root, 23 ; decalcified ivory, 23; mode of introduc- tion of the sponge tent, 24 ; length of time for its remaining in situ, and mode of removal, 25; its dangers, 25; examination by inspection. 26 ; bibliography, 27; specula, 27; method of their introduction, 29; Sims's speculum, 30; Simon's speculum, 31; other varieties, 31; apparatus for artificial illumination, 32. Hall, Marshall, 208. Hardie, 239, 244. Hardy, 371. Harris, Robert P., 322. Harvey, 198. von Haselberg, 138, 139. Hauff, 36. Hausmann, 126, 336. Heath, 255. Hecker, 244, 390. Hegar, 59, 60, 64, 80, 86, 93,123, 212, 213, 253, 266, 288. Heine. 531. Heller, 386. Henckel, 402. Henle, 501. Henneberg, 291. Hennig, 47, 137, 326, 370. Henoque, 227. Htnsen, 4.2. Heppner, 38, 57, 539, 541. Herpin, 242. Hertzfelder, 59. Hervez de Chegoin, 99. Heschl, 348. 435. Hewitt, Graily, 87, 177, 229, 311 Hicks, Braxton, 219, 267. HildebranQt, 20, 139, 163, 169, 242, 250, 492, 500, 536. Hilger, 395. Hippocrates, 188, 227. His, 432. Hodge, 176. Hofmann, 59, 62. Holmes, 357, 408. Hoist, 4, 59, 536. Honing, 20, 63, 550. Horwitz, 322, 536. Hough, 273. Howitz, 390. Huffel, 86, 93, 123, 213. Huguier, 5, S7, 188, 194, 244. Hunter, 31. Huss, 376. Husson, 51. Hymen, atresia of, 44. Ivory, decalcified, for dilatation of the cervix uteri, 23. Jacquet, 59. Jago, 390. James, 512. Jarjavay, 244. Jenks, 438. Johnson, 385. Jones, Robert, 59. Jorg, 4. Joulin, 153. Kaltenbach, 506. Keating, 251. Kehrer, 68. Keith, 407, 431. Kennedy, 208. Kern, 138. Ketchum, 322. Kidd, 242, 258, 387. Kilian. 264. Kirkland, B., 405. INDEX. 567 Kirschner, 158. Kirsten, 3<-5. Kisch, 321, :-;ai, 330, 331. Kiwisch, 4. 5. 98, 99, 158, 179, 234, 268, 273, 283, 342, 357, 402, 438. Klebs, 60, 349, 370. 385, 541. Klcinwachter, 438. Klemm, 137. Klob, 21, 72, 94, 101, 147, 166, 107, 223, 229, 342, 371, 438. 442, 451, 510, 550. Kn ght, 424. Kf.berle, 183, 406, 421, 422, 429. Koch, 551. Kolporaphia, anterior, 209, 210. Koster, 352, 364. Krause, 386. Kreis, 435. Krieger, 319, 320, 325, 327. Kristeller. 68, 244. Kroker. 370. Kiichenmeister, 244. Kumar, 388. Kundrat, 315, 318, 323. 334 Kunert, 304. Kussmaul, 59, 322, 348. Kuster, 232. Kuthe, 408. Labbe, 370. Lados, 98. Lagemart, 244. Lair. 4. Lallcment, 222. Laminaria, bougies for dilatation of the cervix uteri, 23. . Landi, 388. Langenbeck, 124, 208, 214. 290, 305, 405, 555. Larcher, 244. Larrey. 436. Lassus, 357. Laugier, 208. Laumonier, 405. Lazarewitsch. 178. 205. Lebert, 273. 276, 283, 286, 298. Lee, C. C, 388. Lee, Robert. 244. Lee, Thomas, Safford, 244, 273, 359, 438. Le Dran, 404. Le Fort, 38. Lehmann. 21, 49. Lehmns. 20. Leopold, 226, 437. Leroy, 59. Lever, 266, 273, 276. Levret, 4. Leyden, 169. Liebmann, 229. Lisfranc, 137, 153, 244. Lizars, 405. Loeper, 355, 357. Loewy, 327. Logan, 424. Loir, 236, 244. Lott, 67, 140. Louis, 227. Lowenhardt, 179, 316. Liiwenthal, 183. Lucke, 385. Lumpe, 244. Luschka, 338. Macdonald, 446. Macnamara, 322. Madge. 242. Magron, 472. Maisonneuve, 244 Malgaigne, 224. Marconnet, 496. Marcuse, 320. Maret, 222. Martin, 20, 70, 85, 124, 136, 175. 179, 189, 193, 207, 263, 290, 385, 392, 405, 435, 472, 5:33, 559. Maslieurat, 244. Maslowsky, 422, 423. Mason. Erskine, 543. Mathiou, 70. Mauke, 7. Mayer. C, 115,123, 179, 185, 204, 207, 290. Mayer, Louis, 169, 319, 320, 322, 327, 517, 553. McClintock, 224, 242. McCluer, 357. McDowell, Ephraim, 405, 421 McGuire, 388. McMillan, 376. Meadows, 32, 125, 357, 384. Mears, 433. Meissner, 377, 389. Mende, 22. menstruation and its Derangements, 313. Normal Menstruation, 313; bibliography, 313; definition, 314; ovulation and menstruation, 314; different views, 315; age of commencement of menstruation, 319; influence of climate, 319 ; mode of life, 320; early marriage, 320 ; other in- fluences, 320 ; continuation of menstruation, 321 ; the menopause, 321 ; precocious menstruation and conception. 322: prolonged menstruation, 322; anatomical changes during menstruation, 323; the Graafian follicle. 323; the Fallopian tubes. 323; the uterine mucous membrane, 323; the uterine parenchyma, 324; the mucous lhein- 3EX. 568 ini brane of the vagina, 324; secretion eliminated during menstruation, ?24; the type of menstrua- tion, 325; duration of the periods, 325 ; amount of menstrual blood, 320 ; effects of menstruation upon the system at large, 326. Amenorrhea, 327 ; the persistent form, 327 ; tem- porary form, 327 ; psychical influences, 328; vica- rious menstruation. 32S; treatment, 329. Menorrhagia, 330; definition, 330; treatment, 330. Dysmenorrhcea, 331; bibliography, 331; symptoma tology, 331; diagnosis, 333 ; treatment, 333. Dysmenorrhea Membranacea. — Decidua Men- btrualis, 334; bibliography, 334; etiology, 334 ; pathological anatomy, 335; symptomatology, 336; course and results, 336; diagnosis, 336; progno- sis, 337; treatment, 337. Menzcl, 370. Merkel, W., 349. Mettaucr, 290. Meyer, 541. Michels, 256. Mikschik, 290. Miller, 116, 136. Min'r 424. Minkiewitsch, 496. Mohun Sircar, 333. Montet, 3S7. Mosler, 353. Miiller, 46, 236 Munde, Pan! F., 207, 294 Murray, 237. Mursick, 425, 430. Neboux, 357. Neftel, 533. Nelaton, 46, 406, 468. Neugebauer, 59, 422. Neuschler, 230. Noeggerath. Emil, 20, HI, 135, 219, 400, 446. Nonat, 445, 454. Nott, J. C, 31, 139, 561. Nussbaum, 405, 415, 430. Ollivier, 38. Olshausen, 49, 59, 69, 469. Oppel, 69. Osiander, 22. Ott, 481. Otto, 59. 60. Ovaries, Diseases of the, 348. Complete Absence. 348; bibliography, 348. Rudimentary Formation, 348. Supernumerary Ovaries, 349. Hyper.emia and Hemorrhage, 349; blood-cysts, 350 ; diagnosis, 350 ; results, 350. Inflammation of the Ovary, oophoritis, 351; bibliography, 351 ; etiology and mode of occur- rence, 351; pathological anatomy, 351; symptom- atology and results, 352 ; diagnosis, 353 ; treat- ment, 354. Displacements of the Ovary, 354; Ovarian hernia, 354 ; etiology and anatomy, 354; symptomatol- ogy, 355 ; diagnosis, 356; treatment. 356 ; herni- otomy, 356; removal of the ovary, 357; prolapse of the ovary, 357; bibliography, 357; etiology, 358; symptomatology, 358; diagnosis, 358; treat- ment, 358. » Cysts and Cystomata, 358; bibliography, 359; etiol- ogy and mode of occurrence, 359; influence of age, 359; frequency of double ovarian disease, 360; pathological analomy, 361; follicular dropsy, 362; its origin, 362 ; formation from a corpus luteum, 363; ovarian cystomata, 363; their origin, 363; merging of several cysts into one, 365 ; continued development of the cyst wall, 366; the cystoma proliferum glandulare, 366 ; the cystoma prolife- rum papillare, 366; their combination, 367 ; mi- croscopical features, 367 ; size of the tumors, K67; the pedicle, 367; contents of the cysts, 368 ; adhe- Bions of the tumors, 369; hemorrhage into the cyst, 369; inflammation of the cyst, 370; its rup- ture, 370 ; fatty degeneration, 371 ; atrophy, 371; twisting of the cyst on its own axis, 371 ; mixed tumors, 372 ; symptomatology, 372; menstrual disturbances, 372 ; symptoms owing to pressure on the rectum and bladder, 373; constitutional symptoms, 374; progress of the disease, 375; spontaneous arrest of growth. 375 ; rupture of the cyst, 376; escape of its contents, 376; into the abdominal cavity. 376; into the intestines, 377 ; into the vagina, 377 ; into the bladder, 377 ; ex- ternally through the abdominal wall, 378; diag- nosis, 378; the smaller tumors, 378; their diag- nosis from cysts of the broad ligament, 379; from tumors of the Fallopian tube, 379; from fibroids of the uterus, 379 ; from paran etritic exudations, 3S0 : from intraperitoneal exudation, 380 ; cysts complicated with perimetritis, 381: intraperito- neal exudation encysted in Douglas's cul-de sac, 381; retro-uterine haematocele, 381 ; incarcerated uterine fibroids, 382; retroflexion of the gravid uterus, 382; the larger tumors, 382; their diag- nosis from pseudo-abdominal tumors, 382: from encysted peritoneal fluid, 384; from distended bladder, 385; from hydronephrosis, 385; from soft interstitial fibroids, 387; from a distended uterus, 388; from extra-uterine pregnancy, 389 ; from tumors of the liver, 389 ; from tumors of the spleen, 389; from a movable kidney, 390; from tumors of the mesentery or peritoneum, 390; cases with complications, 391; ovarian cystoma and ascites, 391; ovarian cystoma and pregnancy, INDEX. 569 891; diagnosis of disease of right or left ovary, 391; question of double disease, 392; unilocular or compound cyst, 392 : diagnosis by puncture of the tumor, 393 ; characteristics of the fluid, 394; exploratory incision for diagnosis, 395 ; prognosis, 396; treatment, 396; general measures, 397: puncture of the cyst, 398 ; through the abdominal wall, 398 ; per vaginam, 399 ; per rectum, 399; puncture with subsequent drainage, 399 ; ovario- centesis vaginalis, 400 ; formation of a permanent opening between the cyst and the abdominal cavity, 400 ; Le Dran's operation, 404; electro- lysis, 404. Ovariotomy, 404; bibliography, 404; history, 404; indications for the operation, 406; diagnosis of adhesions, 411; the operative procedure, 412; general preliminary treatment, 412 ; instruments, 413; details of the operation, 415 ; difficulties encountered, 418 ; separation of adhesions, 419 ; adhesion of the omentum. 420 ; methods of treat- ing the pedicle, 421 ; the extra-peritoneal method, 421; the serrenoeud, 422; the intra-peritoneal method, 422 ; the actual cautery, 422; the liga- ture, 423 : other means, 423 ; relative advantages of the two plans, 42'); ovariotomy by enucleation, 424 ; cases in which the second ovary is diseased, 425 ; treatment of the peritoneum, 426 ; applica- tion of the sutures, 427 : the after treatment, 427 ; hemorrhage, 428 ; peritonitis, 42S ; septic infec- tion, 428; removal of intra peritoneal exudation, 429 ; incarceration and perforation of the bowel, 431 ; prognosis, 4'il; vaginal ovariotomy, 431. Dermoid Cysts, 432; bibliography, 432; etiology, 432: pathological anatomy, 433; symptoma- tology and course, 435; diagnosis, 436; treat- ment, 436. Fibroids of the Ovary, 436; bibliography, 436; their characteristics, 436 ; symptonuttology. 43S; diagnosis, 438; prognosis, 439 ; treatment, 439. Carcinoma of the Ovary, 439; bibliography, 439: etiology, 431: pathological anatomy, 439 ; symp- tomatology, 440 ; diagnosis, 440: treatment, 441. Sarcoma of the Ovary, 441; bibliography, 441; course of the disease, 442; prognosis, diagnosis, and treatment, 442. Papilloma of the Ovary, 442; bibliography, 442; general description, 442. Tuberculosis of the Ovary, 442; its rarity,442. Packard, 3S8, 534. Paget, 434. Fallen, 31. Palm, 377. Pare, Ambroise, 4. Parker, Willard, 516. Parry, 370, 371. Parvin, 328. Passauer, 59. Pathology, Fallopian Tubes, constriction and closure, 341; inflammation, 345. Menstruation, dysmenorrhoea membranacea, 335. Ovaries, carcinoma, 439; cysts, 361 ; cysts, de moid, 433; oophoritis, 351; papilloma, 442; sarcoma, 441. Uterine Ligaments, haematocele, 469; parametritis, 462: perimetritis, 448. Uterus, atrophy, 93; cancer of the cervix. 270 : car- cinoma of the body of the uterus. 298; catarrh of the cervix, 140; descent and prolapse of the uterus, 191; displacements, 164 ; ectropion of the cervix uteri, 140; elevation, 214; endometritis, acute, 126; endometritis cervicis, 110; endo- metritis, general, chronic, 130; fibroids, 224; follicles, enlarged, of the cervix, 140; haema- tometra, unilateral, 60 ; hypertrophy of the infravaginal portion of the cervix, 76: hyper- trophy of the median portion of the cervix, 88; hypertrophy of the supravaginal portion of the cervix, 82: hypertrophy, follicular, of the lips of the uterus 150 ; hypertrophy, general, of the uterus, 74; hysteralgia, 312; inversion, 216 ; metritis, chronic, 105; ovula Nabothi, 140; pa- pillary tumors, 270; polypi, fibrous, 259; polypi, mucous, 146; sarcoma of the mucous membrane of the uterus, 304; sarcoma of the parenchyma of the uterus, 306 : stenosis, 65. Vagina, carcinoma, 509; catarrh, chronic, 497; cysts, 506; fistulae, uro-genital, 516; fistula?, vagino- intestinal. 529; inflammation, acute, 492; in- flammation, croupous and diphtheritic, 494; pro- lapse, 503; vaginismus, 534. Vulva, catarrh, acute, 544 ; coccygodynia, 560; ele- phantiasis, 547; pruritus, 557. Paul of ^Egina, 4. Pean, 229, 242. 255, 268, 387. 406. Peaslee. 22. 342, 300, 371, 379, 393. 405. 429. 511. Percussion in gynecological examination, 8. Perineoplasty, 555. Pessaries, various kinds, 175. Peter, 169. Peters, 507. Petrequin, 20. Pfliiger, 314, 315. Philipart, 377. Phillips, 36, 195, 208. Picard, 46. Pinault, 243. Pinkham, 116. 'Pirogoff, 462. Pistor. 55. Playfair, 136, 242. Ploss, 32. 570 INDEX. Polytomes, 266. Pommier, 435. Pooley, J. H., 360. Pott, 357. Prieger, 256. Priessnitz, compresses of, 122. Priestley, 22. Prognosis, Fallopian Tubes, constriction and closure, 344. Menstruation, dysmenorrhoea membranacea, 337. Ovaries, fibroids, 439; after ovariotomy, 431; ova- rian tumors, 396; sarcoma, 442. Uterine Ligaments, hsematocele, retro-uterine, 483 ; parametritis, 467 ; perimetritis, 460, Uterus, cancer of the cervix, 288; catarrh of the cervix uteri, 143; descent and prolapse of the uterus, 199; displacements, 170 ; ectropion of the cervix, 143; endometritis, acute. 128; endome- tritis cervicis, 143 ; endometritis, general, chronic, 133 ; fibroids, 248; hasmatometra, unilateral, 64 follicles, enlarged, of the cervix, 143; hypertrophy of the infravaginal portion of the cervix, 78; hypertrophy of the supravaginal portion of the cervix, 85; inversion of the uterus, 218; metritis, acute, 100; metritis chronic, 111; ovula Nabothi, 143; papillary tumors of the uterus, 272 ; polypi, fibrous, 263 ; polypi, mucous, 148; sarcoma of the mucous membrane of the uterus, 305 ; sarcoma of the parenchyma of the uterus, 309; stenosis, 69. Vagina, fistulse, uro-genital, 522; fistulae, vagino-in- testinal, 530; vaginismus, 535. Puech, 51, 52, 55. Puzos, 4. Quittenbaum, 405. Rabl-Ruckhardt, 29. Rabuteau, 326. Raciborski, 328. Rasch, 173. Rayer, 385. Rocamier, 4, 293. Reinmann, 99. Reynolds, J. B., 20. Richard, 370. Richelot. 183. Ricord, 27. Rigby, 242. Rindfleisch, 271, Ritchie, 362. Robert, 153. Roberts, 388. Rockwell, 329. Rodier, 135. Rokitansky, 59,156, 231, 232, 260, 811, 362, 363, 371, 438. Rollett, 390. Roloff, 244. Rose, Cooper, 377, 385. Roser, 140, 205. Routh, 49,133, 224, 242, 258, 292, 385. Rouyer, 131. Rowlet, 322. Rneff, 4. Ruysch, 46, 194. Salins, 227. Santesson, 49. Savage, 258. SSxinger, 73, 96, 98, 227, 244. Saxtorph, 158. Scanzoni, 48, 85, 96, 98, 101, 112, 114, 122, 153, 189, 205, 206, 207, 242, 262, 263, 273, 275, 276, 323, 342, 347, 359, 360, 422, 469, 500, 532, 535, 543, 559,560, 561. Scharlau, 290. Schatz, 218. Schetelig, 183, 386, 395, 488. Schilling, 204. Schmitt, W. J., 4, 158. Schnabel, 434. Schneider, 158, 244. Schnetter, 403. Schott, 196. Schroeder, 59. Schultz, 46. Schultze, 4, 161, 163, 177, 179, 234, 350, 541. Schwabe, 402. Schweighauser, 158. Scultetus, 4. Sedgwick, 32, 242, 244. Sedillot, 293. S&galas, 27. Seyfert, 73, 101, 201, 206, 273, 275, 282, 469. Sibley, 276. Silver, 333. Simon, 13, 31, 59, 80, 123, 152, 208, 212, 265, 294, 386, 388, 514, 515, 518, 524, 527, 555. Simpson, Alexander R„ 294. Simpson, James Y., 20, 70, 102, 158, 229, 231. 242, 266, 273, 286, 290, 291, 294, 300. 303, 343, 344, 346, 377, 389, 401, 423, 436, 445, 451, 516, 518, 536, 553, 560, 561. Sims, J. Marion, 30, 68, 80, 124, 183, 209, 258, 326, 405, 429, 514, 536, 537. Skene. Alex. J. C, 102, 291. Slavjansky, 131, 305, 351, 353, 364. Sloan, 23. Smith, Albert, 32. Smith, Nathan, 405, 421. Smith, Porter, 264. Smith, Tyler, 140, 218, 405, 423. IXD Soranus, 3, 188. Souchon, 31. Soulie. 472. Sound, uterine, history of, 4. Southam. 401. Speculum, vaginal, early history of, 4 Speculum, vaginal, varieties of, 27. Spiegelberg, 72. 80, 81, 123, 125, 136, 139, 176, 212, 218, 252, 258, 2S7, 295, 304, 305, 370, 3S7, 393, 405, 415, 418, 422, 423, 436, 440, 412: 487, 510. Sponge-tents, mode of preparation of, for dilatation of cervix uteri, 22. Squarey, 35. Steiner, 46, 49. Stiegele, 551. Stilling, 388, 405, 421. Stocks, 374. Stockton-Hough. 32. Storer, 25, 116,136, 405, 421, 537. Sullivan, 390. Sutugin, 536. Swiderski 250. Symptomatology, Fallopian Tubes, con- striction and closure, 343 ; inflammation. 346. Menstruation, dysmenorrhoea, 331; dysmenorrhoea membranacea, 336. Ovaries, carcinoma, 440; cysts, dermoid, 435; fibroids, 438; hernia, 355; oophoritis, 352; pro- lapse, 35S; tumors, 372. Uterine Ligaments, haematocele, retro-uterine, 475; parametritis, 463 ; perimetritis, 452. Uterus, atresia, 51; cancer of the cervix. 283; car- cinoma of the body of the uterus, 299; catarrh of the cervix, 142 ; descent and prolapse of the uterus, 196; deviations, lateral, of the u erus, 186; displacements of the uterus, 167; ectro pion of the os uteri, 142 ; endometritis, acute, 127; endometritis cervicis, 142; endometritis, general, chronic, 131; fibrocystic tumors, 239; fibroids, 237; interstitial fibroids, 210 ; submucous fibroids, 239 ; subserous fibroids, 238; follicles, enlarged, of the os uteri, 142; haematometra, unilateral. 61 ; hypertrophy, follicular, of the lips of the uterus, 152 ; hypertrophy, general, of the uterus, 74 : hypertrophy of the median por- tion of the cervix, 89; hypertrophy of the infra- vaginal portion of the cervix, 77 ; hypertrophy of supravaginal portion of the cervix, 83; hyster- algia, 312 ; inversion of the uterus, 217 ; metritis, acute, 97: metritis, chronic. 106: mobility, exces- sive, of the uterus, 1«7 ; ovula Nabothi, 142; papillary tumors of the uterus, 271 ; polypi, fibrous, 261 ; polypi, mucous, 147; sarcoma of the mucous membrane of the uterus, 304; sar- coma of the parenchyma of the uterus, 307; stenosis, 66; tuberculosis, 310. I ex. 571 Vagina, carcinoma, 509; catarrh, chronic, 496; cy.-.ts, 507; fistulae, urogenital, 520; fistulae, vagino-intestinal, 529; inflammation, acute, 593 ; inflammation, croupous and diphtheritic, 495; prolapse, 505 ; sarcoma, 510; vaginismus, 534. Vulva, catarrh, acute, 545; coccygodynia, 560; elephantiasis of the vulva, 548 ; pruritus vulvae, 558. Szukits, 298. Tait, Lawson, 21, 26, 43, 371, 516. Tanchon, 273. Tanner, 273, 275, 276. Tappehorn, 388. Taylor, Isaac E., 90, 207. Teale, Pridgin, 408. Telford, 401. Thibierge, 549. Thoman. 401. Thomas, T. G., 20. 26, 30, 31, 46, 102, 122, 144, 177, 220, 253, 393, 431, 559. Thompson, 26, 46, 55, 398. Thungel, 59. Tibbits, 408. Tillaux, 403. Tilt, 320, 377. Times, 232. Tobold, 32. Tracy, 408. Treatment, Fallopian Tubes, constriction and closure, 344. Menstruation, amenorrhoea, 329; dysmenorrhcea, 333; dysmenorrhcea membranacea, 337; menor- rhagia, 330. Ovaries, carcinoma, 441; cysts and cystomata, 396; cysts, dermoid, 436; fibroids, 439; hernia, 356; oophoritis, 354; prolapse, 358; sarcoma, 442. Uterine Lioamrnts, hematocele, 484; parametritis, 467; perimetritis, 460. Uterus, cancer of the cervix, 289; carcinoma of the body of the uterus, 302; catarrh of the cervix, 143 ; descent and prolapse, 200 ; deviations, lateral, 186; displacements of the uterus, 171; general measures, 171; replacement of the uterus, 172; by manual means, 172; by instrumental means, 173 ; retaining the uterus in position, 175 : operations, 183; palliative treatment, 184 ; ectropion of theoa uteri, 143; endometritis, acute, 143; endometritis cervicis, 143 ; fibroids, 249: general internal treat- ment, 249 ; hypodermic nse of ergotir.e, 250 ; elec- tricity, 251 : operation, 251; symptomatic treat- ment, 255; follicles, enlarged, of the cervix, 143; haematometra, 57; haematometra, unilateral, 64; hernia, 222; hydrometra, 58 ; hypertrophy, follicu- lar, of the lips of the uterus, 152; hypertrophy, general, of the uterus, 75 ; hypertrophy of the in- 572 INDEX fravaginal portion of the cervix, 79; hypertrophy of the median portion of the cervix, 90 ; hypertro- phy of the supravaginal portion of the cervix, 85 ; hysteralgia, 312 ; inversion, 218; metritis, acute, 100 ; metritis, chronic, 112; mobility, excessive, 187; ovula Nabothi, 143; papillary tumors, 272; polypi, fibrous, 263 ; polypi, mucous, 149; sarco ma, 309 ; stenosis, 69. Vagina,- carcinoma, 510; catarrh, chronic, 498; cysts, 508; fibroids, 508; fistulae, uro-genital, 523; fistulae, vagino-intestinal, 530; inflamma- tion, acute, 493; inflammation, croupous and diphtheritic, 496; polypi, 509; prolapse, 506; sarcoma, 510 ; smallness, congenital, 490; vagi- nismus, 535. Vulva, carcinoma, 552; catarrh, acute, 545; coccygo- dynia, 501; elephantiasis, 548 ; fibromata, 551; lupus, 549; pruritus vulvae, 558; rupture of the perineum, 554. Turner, 231. Uterine Ligaments and tiie adjacent Portions of tiie Peritoneum, Dis- eases of the, 443. Diseases of the Ligamenta Rotunda, 443; bibli- ography, 443. Hydrocele of the Round Ligament, 443; bibli- ography, 4-13 ; its characteristics, 444. Peuimetiutis, or Pelveo-Peritonitis, and Para- metritis, 444; bibliography, 444; their relations, 445. Perimetritis, Pelveo-Peritonitis, 445; etiology, 445 ; pathological anatomy, 448; symptomatology and course. 452; the chronic form, 452 ; the acute form, 553; adhesions, 454; their results, 456; diagnosis, 458; prognosis, 460 ; treatment, 460. Parametritis, 462 ; etiology, 462; pathological ana- tomy, 462; symptomatology and course, 463; diagnosis, 466 ; prognosis, 467 ; treatment, 467. Retrouterine Hematocele, 467; bibliography, 467; definition and mode of occurrence, 468; pathological anatomy, 469 ; etiology, 470; sources of the hemorrhage, 472 ; from the Fallopian tubes, 473 : from the ovaries, 474; from the broad liga- ments, 474; from the pelvic peritoneum, 474; hemorrhagic diathesis, 475 ; symptomatology, 475; partial peritonitis, 476; internal hemor- rhage, 477; pelvic tumor. 477; course of the disease, 480; the ultimate result, 480 ; perfora- tions, 4S0 ; diagnosis, 481; the differential diag- nosis, 482 ; from perimetritis, 482 ; from retro- flexion of the gravid uterus, 482; from ovarian cysts or uterine fibroids, 482 ; from extra-uterine pregnancy, 482; from retrouterine carcinomata, 483; prognosis, 483; treatment, 4S4; artificial evacuation, 484. I Ante-Uterine Hematocele, 485 ; definition, 485 ; etiology, 485. Thrombus or Hematoma of the Connective Tissue (Hematocele Extra-Peritonealis), 486; general characteristics, 486. Cysts, 487; bibliography, 487; general description, 487. Myoma, Fibroma, and Fibro-myoma, 4S8; their origin, 48S. Carcinoma and Tuberculosis, 488; their charac- teristics, 488. Uterine sound, history of, 4. Uterus, Diseases of tiie, 32. Malformations, 32; bibliography, 32; entire ab- sence and rudimentary development of the ute- rus, uterus bipartitus, 33; bibliography, 33; uterus unicornis, with or without a rudimentary horn of the oppostie side, 36; uterus duplex, 38; uterus bicornis, 38; uterus septus. 39; uterus fcetalis and infantilis, 40: bibliography, 40; congenital atrophy of the uterus, 42 ; biblio- graphy, 42; atresia of the uterus, vagina, or vulva, haematometra, hydrometra, 43; biblio- graphy, 43; congenital malformations, 44 ; atre- sia of the hymen, 44; atresia of the vagina, 44; atresia of the uterus, 45 ; acquired atresia, 46 ; various effects, 47; the Fallopian tubes, 48; symptomatology 51; results, 51; diagnosis, 53; prognosis, 56; treatment, 57. Unilateral Haematometra. with Duplication of the Genital Canal, 58; bibliography, 58; eti- ology, 58; pathological anatomy, 60 ; different varieties of the malformation, 60; symptoma- tology, 61; terminations, 62; diagnosis,"^ ; p; og- nosis, 64 ; treatment, 64. Stenosis of the Uterus, 65; etiology and patho- logical anatomy. 65 ; symptomatology, 66 ; dys- menorrhcea, 66; metritis and perimetritis, 67: sterility, 67; diagnosis, 68; prognosis, 69 ; treat- ment, 69; by dilatation, 69; by operation, 69. Hypertrophy of the Uterus, 72 ; general hyper- trophy 72; bibliography, 72; etiology, 72; patho- logical anatomy, 74 ; symptomatology, 74 ; diag- nosis, 75; treatment, 75. Hypertrophy of the Cervix, 75; bibliography, 75; hypertrophy of the infravaginal portion, 76; bibliography, 76 ; etiology, 76 ; pathological anatomy, 76; symptomatology, 77; diagnosis, 78; prognosis. 78 ; treatment, 79 ; hypertrophy of the supravaginal portion of the cervix, 80; bibliography, 80 ; etiology. 81 ; pathological ana- tomy, 82; symptomatology, 83; diagnosis, 84; prog?u>sis, 85; treatment, 85; hypertrophy of the median portion of the cervix, 87; etiology, 87; pathological anatomy, 88; symptomatology, 89; diagnosis, 90; treatment, 90. INDEX. 573 Atrophy of the Uterus, 93; bibliography, 93; etiology arul pathological anatomy, 93; senile atrophy, 93 ; puerperal atrophy, 94 ; atrophy from other causes, 95. Inflammation of the Parenchyma of the Ute- rus, Metritis, 96; acute metritis, 96 ; biblio- graphy, 96: etiology, 96 ; pathological anatomy, 96; symptomatology, 97 ; the formation of ab- scess, 98; diagnosis, 99; prognosis, 100 ; treat ment. 100 ; chronic metritis, infarction of the uterus, 101; bibliography, 101; question of name, 101; etiology, 103; pathological anatomy, 105; symptomatology, 106; subjective symptoms, 106; objective symptoms, 108 ; terminations, 109; diagnosis, 110; prognosis. Ill ; treatment, 112; general measures, 112; local depletion, bloodletting. 113; application of cold. 116; regu- lar evacuations of the bladder and rectum, 117 ; resort to various mineral springs, 118; compara- tive values of mineral waters and local treatment, 121 ; internal administration of iodine, 121 ; the douche, 121; sitz baths, 122; Priessnitz' com- presses, 122; local application of iodine, 122; amputation of the cervix, 123 ; various methods, 123. Inflammation of thk Mucous Membrane, 126 ; acute endometritis, 12 i; bibliography, 126; eti- ology, 126; pathology, 126 ; symptomatology, 127 ; prognosis, 128; diagnosis, 12J; treatment, 128; chronic endometritis, catarrh of the uterus, 129; bibliography, 129; general considerations, 129.— Catarrh of the whole mucous membrane, 130 ; etiology, 130 ; pathological anatomy, 130 ; symp- tomatology, 131 ; diagnosis, 133; prognosis, 133; treatment, 133; bibliography, 133; prophylaxis, 134: general regimen, 134; baths, 134; the ques- tion of local treatment, 134; various methods, 135; intrauterine injections of fluids, 137; ob- jections to their use, 137; selection of cases, 138; different drugs, 139; the use of the galvano-cau- tery, 139.—Endometritis cervicis, catarrh of the cervix, ectropion of the os uteri, enlarged fol- licles, ovula Xabothi, 139; bibliography, 139; etiology, 139; pathological anatomy, 140; symp- tomatology, 143: diagnosis, 143; prognosis, 143: treatment, 143 ; caustics, 143; evacuation of con- tents of the follicles, 144; actual cautery, 145; amputation of the cervix, 145. Mucous Polypi, 145; bibliography, 145; etiology, 145; pathological anatomy, 140; symptomatology, 147; diagnosis, 14S; prognosis, 148; treatment, 149. Follicular Hypertrophy of thk Lips of the Uterus, 149; bibliography, 149; etiology. 150; pathological anatomy, 150: symptomatology, 152; diagnosis, 152 ; treatment, 152. Erosions and Ulcers of the Vaginal Portion of the Uterus, 153; bibliography, 153; the simple erosion, 153 ; the papillary erosion, 153; fc'.'.icu- lar ulcer, 155; pluigedenic or corroding u.cer of the uterus, 150; c/tancre of the vaginal portion, 156. Displacement of the Uterus, 157 ; Versions and flexions, 157 ; bibliography, 157 ; history, 157 : de- finition and etiology, 158; pathologi- al anatomy, 164; sequehe, 167 ^symptomatology «/imteHcxion, 167; of retroflexion, 168; of anteversion, 16-1; of retroversion, 169; diagnosis, 16.); prognosis, 170 ; treatment, 171; general measures, 171; mechani- cal means, 172; replacement of the womb, 172 , by manual means. 172; by instrumental means, 173; methods of retaining the uterus in position, 175; vaginal pessaries, 175: intrauterine pessaries. 178; selection of cases for the use of intra uterine pes- saries, 182; operations, 183; palliative treatment, 184; lateral deviations of the uterus, 1S5; biblio- graphy, 185 ; etiology, 185 ; symptomatology, 186; treatment, 1S6: excessive mobility of the uterus, 186 ; etiology, 186 ; symptomatology, 187; diagno- sis, 1N7; treatment, 1S7 ; descent and prolapse of the uterus, 188; bibliography, 188 ; history. 188; etiology. 189; pathological anatomy. 191: differ- ent grades of prolapse 191; changes in the vagina, 192; changes in the uterus, 193; changes in the cervix uteri, 193; changes in relations of other pelvic viscera, 194; symptomatology, 196; pain and dragging in the back. 197; urinary disorders, 197; mechanical injuries to the tumor, 197 ; men- struation and sterility, 198; diagnosis, 198; dif- ferential diagnosis, 199; prognosis, 199; sponta- neous cure, 19J; treatment, 200 ; general meas- ures, 200 ; reduction of the uterus, 201; means of retention, 202; pessaries, 202: the Roser and Scanzoni hysterophor, 2i!5: bandages, 205 : radical cure, 206 ; amputation of the cervix, 206; cauter- ization, 208; elytroraiihy, 208; kolporaphia. an- terior (Sims), 209; episioraphy, 210; episio-elytro- raphy, 212; kolporaphia anterior (Simon), 212; perineauxesis, 213; amputation of the entire uterus, 214 ; elevation of the uterus, 214 ; etiology, 214; pathological anatomy. 214. Inversion of the Uterus, 215 ; bibliography. 215 ; etiology, 215 ; pathological anatomy, 216 ; differ- ent degrees of inversion, 216: symptomatology, 217; diagnosis, 217; prognosis, 218; treatment, 218: reduction of the tumor, 218; by instru- mental means, 219; by manipulation, 219: the use of ergot, 22 I; gastrotomy, 220 : amputation, 221 : different methods of operation, 221. Hernia of the Uterus. 222: bibliography, 222; etiology, 222: diagnosis, 222; treatment, 222. Fibroids of the Uterus (Myoma, Flbromyoma, 574 INDEX. Leiomyoma), 222; bibliography, 222; etiology, 223; pathological anatomy, 224 ; softening, 226; induration, 220; calcification, 227; suppuration, 228; the mixed tumors, 228 ; degeneration into carcinoma, 229; into sarcoma. 229 ; fibroid of the body of the uterus, 230 ; the subserous fibroid, 230 ; the submucous fibroid, 232; the interstitial, intra- parietal, or intramural fibroids, 233; fibroid of the cervix, 236 ; symptomatology, 237; the subserous fibroids, 238 ; the fibrocystic tumors, 239; the sub mucous fibroids, 239 ; the interstitial fibroids, 210 ; the cervical fibroids, 241; termination of fibroids, 241; arrest of growth, 241; disappearance of the tumor, 241; expulsion of the tumor, 243; perfora- tion into other organs, 244 ; diagnosis, 245; the subserous fibroids, 245; the interstitial fibroids, 246; the submucous fibroids, 248; prognosis, 248; treatment, 219, internal general treatment, 249 ; hypodermic use of ergotine, 250 ; electricity, 251 ; removal of fibroids through the vagina, 251; bibliography, 251; the operation, 252; its dan- gers, 253; removal of fibroids by laparotomy, 254; bibliography. 254: the operation, 254; symp- tomali, treatment, 255. Fibrous Polypi, 259 ; bibliography, 259 ; pathologi- cal anatomu, 259; symptomatology, 261 ; diagno- sis. 262; prognosis, 263 ; treatment, 263; ligation, 264; excision, 264; symptomatic treatment, 267. Uterine Cysts, 268 ; papillary tumors of the titer us, 268 ; bibliography, 268; etiology, 269 ; pathologi- cal anatomy, 270 ; symptomatology, 271; diagno- sis, 271; prognosis, 272 : treatment, 272. Cancer of the Cervix Uteri, 272; bibliography, 272; etiology, 273 ; influence of race, 273 ; of age, 273; of sexual indulgence, 275; hereditary de- scent, 275 ; depression of mind, 216 ; pathological anatomy, 276 ; symptomatology, 283 ; duration of the disease, 286 ; diagnosis, 287 ; prognosis, 288; treatment, 289. Carcinoma of the Body of the Uterus, 297; bib- liography, 297; etiology, 297; influence of age, 298 ; of child-bearing, 298 ; pathological anatomy, 298; symptomatology, 299; diagnosis, 301; treat- ment, 302. Sarcoma of the Uterus, 302; bibliography, 302; sarcoma of the mucous membrane, 303 ; etiology, 303 : influence of age, 303 : pathological anatomy, 304 ; symptomatology, 304 ; diagnosis, 305; prog- nosis. 305; sarcoma of the parenchyma, 306; etio- togg, 306; influence of age, 306; pathological anatomy, 306; symptomatology, 307 ; diagnosis, 309; prognosis, 309; treatment, 309. Tuberculosis of the Uterus, 309; bibliography, 309; symptomatology. 310 : diagnosis, 310. Echinococci of thk Uterus, 310; bibliography, 310; history, 311. Hysteralgia, 311; bibliography, 311; etiology, 312; pathology, 312 ; symptomatology, 312 ; treatment, 312. Vagina., Diseases of the, 488. Complete Non development and Rudimentary Formation, 488; bibliography, 4S8; their char- acteristics, 489. Vagina Unilateralis, 489. Vagina Septa, 490. Congenital Smallness of the Vagina, 490; treat- ment, 490. Atresia of the Vagina, 491. Inflammation of the Vagina—Vaginitis, Col- pitis, Elythritis, 491; bibliography, 491. Acute Catarrhal Inflammation, 491 ; etiology, 491; pathological anatomy, 492; symptomatology, 493; treatment, 493. Croupous and Diphtheritic Inflammation. 494; etiology, 494; pathological anatomy. 494 : symp- tomatology, 495; diagnosis, 495; treatment, 496. Perivaginitis Phlegmonosa Dissecans, 496; bibliography, 496. Chronic Catarrh, Fluor Albus, Leucobrhcea, 496; etiology, 496; pathological anatomy, 497; symptomatology, 498 ; treatment, 498. Prolapse, 500 ; bibliography, 500 ; etiology, 500; pathological anatomy, 503 ; cystocele, 503 ; recto- cele. 503; enterocele and ovariocele, 504; symp- tomatology, 505 ; diagnosis, 505 ; prognosis, 505 ; treatment, 506. Cysts, 506; bibliography, 506 ; etiology, 506; path- ological anatomy, 506 ; symptomatology, 507 ; diagnosis, 507; treatment, 508. Fibroids, 508 ; bibliography, 508; general character- istics, 508; treatment, 508. Polypi, 508; bibliography, 508; their characteristics, 508; treatment, 509. Carcinoma, 509; bibliography, 509; pathological anatomy, 509 ; symptomatology, 509; treatment, 510. Sarcoma, 510 ; bibliography, 510 ; symptomatology, 510; treatment, 510. Tuberculosis, 510; bibliography, 510; its rarity, 510. Foreign Bodies, 511; bibliography, 511; general considerations, 511. Entophyta and Entozoa, 511; bibliography, 511; general remarks, 512. Injuries, 512. Uro Gfnital Fistule, 513; bibliography, 513; his- tory, 513 ; etiology, 514 ; pathological anatomy, 516 ; symptomatology, 520 ; diagnosis, 521; prog- nosis, 522; treat?nent, 523 ; operative procedures, 524. Vagino-Intestinal Fistulae, 528; bibliography, INDEX. 570 528; pathological anatomy, 529; symptomatol- ogy, 529; diagnosis, 530 ; prognosis, 530; treat- ment, 530 ; operative procedures, 530. Vaginismus, 531 ; bibliography, 531; definition and etiology, 531; pathological anatomy, 534 ; symp- lomutology, 534 ; prognosis, 535 ; treatment, 535; oMer spasms of the vagina, 536. Vaginal speculum, its early history, 4. Van Buren, 371. Veit, 4, 7, 20, 48. 55, 57, 59, 106, 212, 405, 407, 431, 506, 509, 559. Velpeau, 208, 227, 242, 252. Viardin, 244. Vidal de Cassis, 137. Vigarous, 4. Virehow, 83, 142, 151, 195, 225, 229, 231, 232, 237, 438, 474, 488, 510, 541, 547. Voisin, 51. Volker, 296. Volkmann, 293. "Vulva, Diseases of tiie, 537. Malformations, 537; complete atresia, 538; hypo- spadia, 540; epispadia, 540; absence of the vulva, 540; hermaphroditism, 541; atresia of the labia minora, 542. Hypertrophy, 542; the nymphae, 542; the clitoris, 543. Acute Catarrh, 544; bibliography, 544; etiology, 544 ; pathological anatomy, 544; symptomatol- ogy, 545; diagnosis, 545; treatment, 545. Hernie, 546; diagnosis, 546. Elephantiasis. 546; bibliography, 546; etiology, 547; pathological anatomy, 547; symptomatol- ogy, 54s: treatment, 548. Lupus, 519; bibliography, 549; diagnosis, 549; prognosis, 549; treatment, 549. Papillary Growths, Condylomata, 549; bibli- ography, 549, etiology, 549; general character- istics, 549. Cysts, 550; bibliography, 550; etiology, 550; diag- nosis. 550 ; general characteristics, 550. Lipomata. 551; their size, 551. Fibromata, 551; bibliography, 551; their character- istics, 551; treatment, 551. Carcinoma, 552 ; bibliography, 552; diagnosis, 552; treatment, 552. Sarcoma, 553. Neuromata, 553. Thrombus or Hematoma, 554; etiology, 554; gen- eral characteristics, 554. Rupture of Perineum, 554; bibliography, 554; treatment, 554; perineoplasty, 555; the after- treatment, 556. Pruritus, 557; bibliography, 557; etiology, 557; pathological anatomy, 557; symptomatology, 55M : treatment, 558. Coccygodynia, 559, bibliography, 559; etiology, 559 ; pathological anatomy, 560; symptomatology, 560 ; treatment, 561. Wagener, 268. Wagner, 281, 283, 345, 371, 440. Waldeyer, 338, 339, 362, £63, S66, 272, 393, 394, 422, 423, 432, 438, 487. Walker, 393. Walter, 234, 266. YValther, 46. Weatherby, 290. Webb, 362. Weber, C. H., 444. Weber, C. O., 531. Wegner, 475. Wegscheider, 360. Weinberg, 124, 189. Wells, Spencer, 32, 360, 370, 371, 386, 387, 390. 391, 401, 405, 407, 408, 410, 412, 419, 423, 425, 426, 431, 433. Wenzel, 237. Wernich, 6S, 250. West, 73, 129, 223, 231, 275, 276, 286, 353, £59, 373, 376, 387, 390. Weston, 559. Wheeler, 386. Whitall, Samuel, 27a White, 219. Whiteford, 244. Willard, 322. Willaume, 244. Williams, Wynn, 292. Willich, 158. Willigk, 273, 298. Wilms, 531. Wiltshire, 571, 410. Wmge, 435. Winkel, 23, 178, 179. Winkler, 389. Wrany, 59, 273, 283. Wright, 179. Wutzer, 513. Wylie, W. G., 345. Ziemssen, 244, 290. Zini, 21. 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