K32t 1875 -jy> a', :?* * •> 6ttM..KKMPEU,i«.''p. ✓ , t. ■ - NATIONAL LIBRARY OF MEDICINE NLM Q05b2bT5 b SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W. D.S.G.O. NO.J..3JJJJ 8—513 NLM005626956 ► DISEASES OF WOMEN. A TREATISE ON THE f)igs}&gsj# O-tf wcrp};K, THEIR SYMPTOMS AND TREATMENT, OR PHYSIOLOGY OF THE FEMALE ORGANS OF GENERATION AND REPRODUCTION, BOTH ANIMAL AND VEGETABLE, WRITTEN WITH ESPECIAL REFERENCE TO THE MENSES AND THE MORBID CONDITIONS FOLLOWING THEM. BY JOHN KEMPER, M. D., GRADUATE OE THE DONG ISLAND MEDTCAL COLLEGE, NEW TOEK, AND LATE SURGEON OF 38th ILLINOIS INFANTRY VETERAN VOLUNTEERS, U. a ARMY. £' GALESBURG, ILL : \ COLVILLE & BRO., PUBLISHERS. 18T5- Entered according to act of Congress, in the year 1875, by JOHN KEMPER, M. D., In the Office of the Librarian of Congress, at Washington. PREFACE. In writing a work on the Diseases of Women for general use I do so in the knowledge that a great de- ficiency exists in our literature upon this very import- ant subject. I commenced this work merely to supply my own wants of information on this subject, but on an ex- amination of its merits thought it worthy of a general perusal. American practitioners have written so little on this subject of Woman's Diseases, that we have been obliged almost in every case to look to other works on the subject, such as General Practice and works on Obstetrics. Should it aid the inquiring mind or awaken the attention of those who have not hitherto thought upon this subject, and lead us to a more careful practice in alleviating the sufferings of woman, and help her to fulfil the all-important and indispensable functions of life for which she was undoubtedly intended by her Creator, my object will be accomplished. This department of science has made great advance- 6 PREFACE. ment in Europe, and even in this country, in the last few years; yet those cases have only been recorded in our special medical journals, and, consequently, out of the reach of the masses of the people by whom they should be thoroughly understood. It therefore appears to me that a book that would present this matter in a clear and at the same time simple form, could scarcely fail to do good to all, for we all know that there are women that do suffer near- ly death three or four days in every month for want of some simple, plain guide on this subject. I know that this work will fall into the hands of some persons well-informed in the science of Physi- ology, for we find in nearly every family a student of this science; I have therefore taken pains to use no words that would be objectionable to the most refined, and have written three chapters on Reproduction, which I consider one of the most important branches of the subject under consideration, and one that is, perhaps, the least of all understood by the masses of the people by whom it should be generally known and fully comprehended, as will readily appear from a careful investigation of the work. In the preparation of the work I have taken an in- dependent course, guided by a practical experience of many years successful practice after a thorough medical graduation at the best institutions the country affords, consequently I shall be limited or prescribed by no clique, faction or pathy, but shall endeavor to treat the subject in a plain, practical, common sense PREFACE. 7 manner, readily understood by those for whose bene- fit it is especially designed, and have recommended only such treatment as I have practically demonstrated, aided by the best lights that the science of the present day affords. THE AUTHOR. [COPY OF DIPLOMA.] The Regefits, Council and Professors of the Long Island College Hospital, Ota Each and All who may Head this Ddeloma, send GREETING: Be it known to you that John Kemper assiduously pursued Medical and Philosophical studies in this College, and after an examination has shown himself worthy of receiving the highest medical honors, wherefore it has pleased us, under the authorities granted by the laws of the State of New York, to admit him to the degree of Doctor of Medicine, and to grant and conifer the mo* ample power of teaching and practicing Medicine everywhere, and all other rights and immunities which here or elsewhere are wont to be conferred upon those who are exalted to the high position of Doctor. In further testimony whereof we have carefully appended to this Diploma the seal of oar College, and our signatures, given forth from the halls of the College, in the city of Brooklyn, on the 28th day of June, in the Slst year of our Independence, and in the year of our Lord 1867. REGENTS. John J. Van Nosxrand, Esq., Pres. J W«. J. Osborne, Eaq., Secretary. COUNCIL. T. L. Mason, Esq., Pres, Col. Dep., L. Mitchell, IE. P., Sec'y, Wh. H, Dudley, M. D., Registrar, Geo. Marvin, M. D. FACULTY OF THE COLLEGE. Austin Flint, M. IX, Prof, of the Prin. and Prac. of Med. Frank H. Hamilton, M. D., Prof, of Surgery, Fractures and Dislocations, and Mil. Surgery. Joseph C. Hutchison, M. D., Prof, of Op. Sur. De Witt C Enos, M. D., Prof of Gen. and Des. Anatomy. Samuel G, Armor, M. D_, Prof of Therapeutics, Materia Medica, and General Pathology. Edwin N. Chapman, M. D., Prof, of Obstetrics and Dis- eases of Women and Children, and Clinical Midwifery. Austin Flint, Jr., Prof. of Physiology and Microscopic Anatomy. Dakwin G. Eaton, M. D., Prof, of Chem- istry and Toxicology. ll'ic. Gillfillan, M. D,, Prof, of Surgical Anatomy. ^kble of Content^. CHAPTER I. Mode of Sexular Generation, Animal and Vegetable, 13-15. CHAPTER II. On the Female Organs of Generation and the Formation of the Egg, 16-22 CHAPTER III. Menstruation, 22-28. CHAPTER IV. General Remarks on Diseases of the Womb and Neighboring Organs, 29-37 CHAPTER V. Remarks on the Treatment of Diseases of the Wonib, 3S-43. X CONTENTS. CHAPTER VI. Flexions, or Bending of the Womb, 44-54. CHAPTER VIL Prolapsis, or Falling of the Womb, and Treatment, 55-64. CHAPTER VIII. Anteversion, or Falling Forward of the Womb, 65-68. CHAPTER IX. Retroversion, or Falling Backward of the Womb, 69-70. CHAPTER X. Chronic Inflammation of the Mucous Mem- brane of the Womb, or Chronic Catarrh, 71-79. CHAPTER XI. Polypi of the Mucous Membrane of the Womb, or Small Tumors that Grow from its Walls, 80-85. CHAPTER XII. Cancer of the Womb, 86-92. CHAPTER XIII. On the Changes of Menstruation. 93—97. CHAPTER XIV. Premature Menstruation, 98-100. CHAPTER XV. On Slow, or Tardy Menstruation, 101-105. CHAPTER XVI. On the Treatment of Changed Menstruation, 106-107. CHAPTER XVII. On Premature Cessation of the Menses, KhS-114. CHAPTER XVIII. Ameiiorrhcea, or an Obstruction of the Menses, and Treatment, 115-128. CHAPTER XIX. On Menorrhagia, or an Abundant Flow of the Menses^ 129-131. CHAPTER XX Dysmenorrhea, or Painful Menstruation, 132-139. CHAPTER XXI. On Congestive Dysmenorrhea, 140-146. CHAPTER XXII. Hysteria, and Treatment, 147-15S, Xll CONTENTS. CHAPTER XXIII. Prolapsis of the Vagina, 159-164. CHAPTER XXIV. Fistula of the Vagina, . 165-169. CHAPTER XXV. Inflammation of the Mucous Membrane of the Vagina, and Treatment, 170-174. CHAPTER XXVI. Inflammation of the Breast, Superficial and Deep, also, Abscesses and Treatment, 175-180. CHAPTER XXVII. St. Vitus' Dance, 181-183. CHAPTER XXVIII. Symptoms, Signs, and Diseases of Pregnan- cy and its Treatment, 184-190. CHAPTER XXIX. Abortion and Treatment, 191-206. CHAPTER XXX. Concluding Remarks, 207-208. Prescriptions, 209-212. CHAPTER I. MODE OF SEXULAR GENERATION. The generating functions are performed by two sets of organs capable of uniting with each other so as to produce a new individual, and are called male and female organs of generation. The female organs produce the germ or egg in a globular body which is capable of producing the body of the new animal or plant, the male the stimulating power; these arc the characters of the two organs taken together. In different organized beings these organs are very much modified. In plants that blossom and flower, which are the o-enerative .organs in this department of science, they have, first, the female organ, in the shape of a long stem, situated in the central part of the flower and on the highest point; around these organs are situated a number of xttunem. containing within their expanded ends the male organs of generation, called anthers; these parts are wholly surrounded by fine, delicate leaves or blossoms termed the corolla, with a number of green leaves outside of them called the calix, 14 DISEASES OF WOMEN. When the anther stamens ripen they give off a fine powder called the pollen ; this pollen is caught up by this high point of the female organs and finds its way down to the germ; the germ thus stimulated, the new plant is organized and its growth started. The old organs dry up and fall off as useless, while the new germ increases in size rapidly and changes in texture until it ripens and brings forth good seed or fruit, and will, if placed in good ground, grow and bring forth fruit in just the same way and manner as the parent. Now we have a great many plants where the male and female organs of generation are situated on the same flower, as in the case of the lily, violet, etc. We have other plants where the organs of generation, both male and female, are situated on different plants, as the willow and hemp. In the animal kingdom of all kinds the female or- gans are called ovaries, and in them we find the egg or new germ. In the tape worm each joint contains the organs of the male and female, connecting with each other by a central canal. In snails and some of the other lower animals we find both male and female organs of gen- eration in the same animal, but the organs do not ripen at the same time ; the female organ ripens first and performs its function, then the male organ ; so the same animal is not male and female at the same time, but first female and then male. But in all higher animals the two sets of organs are SEXULAR GENERATION. 15 situated in separate individuals, making two sexes in the species. We have, besides the two sets of organs, others which are secondary or accessory, which assist in the process of generation, such as the womb, mam- mary glands etc., of the female. The female has, as a matter of course, the protection and care of the young after birth, and the male the care for food and protection. There is a great difference in the structure of the body, which affects the whole structure of the two sexes, and even in a moral and mental point of view; in some cases this difference is so great that they would never be taken to belong to the same species unless they were found together. To prove this, and demonstrate this point clearly, we will point to the cock and hen, lion and lioness, buck and doe. In speaking of this subject more fully we shall take up the female organs of generation, together with their product and function. 16 DISEASES OF WOMEN. CHAPTER II. ON THE FEMALE ORGANS OF GENERATION. The globular body called the egg, which is produ- ced by every animal, varies considerably in size accord- ing to the species. Tn the human it is very small, not more than the one-hundred-aud-twentieth of an inch in diameter, while in the frog it is about one- twelfth of an inch in diameter; its composition is as follows: it has an external membranous sac called a vitelline membrane, and in this membrane the sub- stance of the egg, called vitellus, is contained. In birds and reptiles the vitelline membrane is very thin and cordy, or rough like fibrin, while in the higher animals, such as man, it is much thicker and smooth and at the same time very elastic. The egg may be flattened out under the microscope with a needle without being broken, and when the pressure is removed it will resume its original shape. Within the vitelline membrane is the vitellus, com- posed of both oily and fibrine matter, just in the same manner as the common lien's vgg, without tfie exter- FEMALE ORGANS OF GENERATION. 17 nal white; in the central part of this vitellus or yellow we find a clear transparent spot called the germinal spot or nucleus of the egg. We now come to speak of this vitellus, and find it to be the most important part of the egg, for it is out of this vitellus or yellow that the body of the new individual, bird or animal is to be formed, while the vitelline membrane or sac is only intended to protect the yellow during the stages of incubation. This egg that we have been 'leseribing is simply an external sac containing a yellow for the developement of the young body. Such an egg we find in the hu- man subject. In reptiles, aquatic birds, and most fishes and invertebrate animals, nearly all of those eggs where they are deposited in the water to be hatched out, as well as those that are retained in the body of the female to be developed, can absorb water from the floating current and food from the mucous membrane for their nutrition. But in reptiles, lizards and birds, where the egg is to be expelled from the body of the female at an early period to be incubated or hatched on land, we find no external source of nu- trition for the young animal to subsist on; in all of these cases the yolk is very large and bulky and the size of the egg very much increased by the addition of an external white which is a coat of pure albumen; yet this increased size in every part does not change the nature or general character of either sac (vitelline membrane) or yolk (vitellus), but it holds to the same law in this case to develope and bring forth a new an- IS DISEASES OF WOMEN. imal or bird that it did in the small egg of the frog. Now, with reference to these eggs, we say that they are produced in the body of certain organs called ovaries; these organs are composed of a number of departments like honey comb or sacs, and every sac or department contains an egg. Some physiologists teach us that the egg is secreted by the ovaries; we think that it is highly improper to call this egg a se- cretion, but we think that the egg is produced in the ovaries just in the same manner that the tooth is pro- duced in the jaw-bone, and forms one of the constitu- ents of the female body. Then we find, according to these conclusions, that the ovaries are the most im- portant part of the organs of generation of all females, because they produce the egg. Now we have other organs which are accessory or secondary to the ovaries, the most important of which are the two oviducts, symmetrical in form, which arc intended to receive the egg at the ovaries, and convey it to the womb. The mucous membrane along the pathway of these two ducts is calculated to furnish the egg with a coating and thicken its walls, and also to provide substance for its. nutrition and completion. In the frog we find the most simple form of these ducts, consisting of two tubes, one on the right and one on the left, slightly zig-zag in their appearance or course, and curving over themselves to encircle the ovaries, joining together near the outlet or lower part of the intestinal canal. If we examine a frog in the latter part of summer FEMALE ORGANS OF GENERATION. 19 We will find the ovaries presenting the appearance of small clusters of small, clear, round eggs. But early in the spring, when the first warm weather makes its appearance, we find the ovaries very much enlarged, perhaps to three or four times their natural size, and filled to their uttermost with transparent eggs; but in a short time incubation or hatching begins, when they change to a dark color. In all the lower animals, at the approach of the ac- tive season with them, the eggs, which have heretofore been in an inactive state, begin to increase in size and change their structure, the yellow or vitellus, which has been transparent, begins to granulate and increase in size and grow brown. But, in the human subject, the difference appears to be only in its color; that is, the egg will grow very fast and remain perfectly trans- parent. This enlargement gradually distends the little sac that contains it in the ovaries until it is fully ripened, when a rupture of the sac takes place and the egg is discharged into the oviduct to be conveyed to the womb or external world. In this way crop after crop is ripened, rupture takes place and the egg is discharged from the body or ovaries, and at the same time new crops of eggs are ripening for the next generative period, and, by dissection, we may- trace the young egg back three or four generative pe- riods to the same as we find in the hen. In the fish, reptiles and birds, this change occurs but once in a year, in some of the higher animals it may take place 20 DISK ASKS OF WOMEN. once a vcar, once a month or bi-monthly, but in every case it makes its appearance regularly. In the frog, when the egg leaves the ovaries in early spring, it consists of only the vitellus or yolk, but in its passage down the oviduct or canal it gath- ers albumen, or a thick, tenacious envelope or coating, and is finally discharged ; this albumen absorbs the water and gets very thick, and by its absorption lique- faction takes place and serves as nutrition for the new animal during the stages of incubation. In the common fowl the ovaries consist, as in the frog, of a large number of sacs or pouches containing the egg in different stages of developement; as it ap- proaches maturity it enlarges very much until a rup- ture takes place in the duct; as the egg is discharged from the ovaries of the fowl it is globular in form and only consists of the vitellus or yolk, and vitelline mem- brane, and a clear spot called the germinal spot. The egg now commences its course downwards through the common duct, and it is in this duct the eggs of all fowls gather the white or albumen. This substance, called the white of the egg, is a semi-solid, and is found in greater abundance in front of the advance egg than behind it, and in this maimer forms a point or cone to the advance egg, and is always in this way when coated with albumen or white, and pointed with the point downwards in all cases. In the third division of the oviduct the egg is nearly completed; it is here that it receives the thick mem- brane under the shell, and, finally, the egg is received FEMALE ORGANS OF GENERATION. 21 into the fourth division; here the mucous membrane exudes the earthy salts out of which the shell is form- ed. Soon after the expulsion of the egg from the fourth chamber it undergoes a process of evaporation of its wratery parts, which space is rapidly filled by air (this air that has filled this chamber is between the two coats of the fibrous membrane, and in all cases at the round end of the egg). After the expulsion of the egg the albumen liquefies, and the yolk being lighter, owing to the oil it contains, rises to the top with the germinal spot uppermost; this part presents itself im- mediately on breaking the egg; this position is very favorable for warmth and atmospheric air for the de- velopeinent of the egg or chicken. In the human subject the female organs of genera- tion present the following different parts: the ovaries consist of small sacs in a dense substance well supplied with bloodvessels, and around the whole mass a thick membrane called round or broad ligament; this is the substance that forms the oviduct to convey the egg from the ovaries to the womb in the same manner we have noticed above in the bird or common hen. These ducts then extend from the ovaries to the womb, but in the human subject the womb is so much developed at the expense of the duct that the latter hardly ap- pears to have an existence; but on opening the womb we find that it has a triangular shape running out to intersect the mouths of the ducts. The cavitv of the hodv of the womb terminates below in a constricted part called the os or neck. The womb has a thin, del- 22 DISEASES OF WOMEN. icate, rosy mucous membrane awd closely adheres to the subjacent muscular coat; it consists of small glands similar to those found in the stomach. The glands of the body of the womb have small openings on the mucous membrane; the secretion of these glands serves to produce nourishment for the new in- dividual during the early stages of womb develope- ment. The accessory female organs of generation, consisting of duct and tubes in the lower animals serve to hasten the egg to the external world. MENSTRUATION. 23 CHAPTER III. MENSTRUATION. By the term menstruation we mean the periodical return of the courses in the human female, which is of sufficient importance to justify a full description. During the early stages of the child-life the sexular organs, as we have found in a former chapter, are in a state of inacti vity. No excitement exists about the ovaries, no external phenomena show themselves; no egg is discharged, nothing to show that the stages of menstruation or courses are about to take place. In a short time, however, a very great and marked change takes place in nearly the whole organization of the bodv; the limbs are more round, the breasts are bet- ter developed, and, in fact, the whole body undergoes an entire change, showing that the state of maturity is fast approaching. At the same time a discharge of blood takes place from the generative passages, or from the mucous membrane of the womb, and at the same time she undergoes some considerable disturb- ance in her general health, and now the female is 24 DISEASES OF WOMEN. known to have arrived at the period of puberty, or a general completion of the ovaries or organs of gen- eration. The bloody discharge above referred to re- turns once every month, or once every twenty-eight days, and after this returns regularly it is then known by the name of menses or courses, and continues from the age of fourteen to forty-five, and during this time the female is capable of child-bearing, and liable to become pregnant at any time : but after arriving at that age, the menses become irregular, and in a short time cease altogether; this indicates that the organs have run their course, and the woman is no longer fertile, and, of course, pregnancy cannot take place. It is well known that derangements of the menstru- al discharge interfere with pregnancy, so that a woman who is regular in her menses is more apt to become pregnant than one who is irregular. When pregnancy takes place the menses or courses are sus- pended, and usually remain so duii.ig the period of nursing, and afterward recommence and continue in the same manner as before. The menstrual discharge consists of an excessive mucous discharge from the mucous membrane of the womb mingled with blood. When the menses are about to arrive, or the expected period comes around, the woman is affected with a certain amount of lassi- tude and some pain in the region of the hips and womb ; these symptoms are very slight in some, and again in others much more troublesome. An unusual discharge takes place from all the organs of genera- MENSTRUATION. 25 tion at this time, being at first of a mucous character, but by the second or third day it is nearly pure blood. The pains that are so common in the first stages now begin to subside, the flow begins to grow scanty and the color also changes from a pure blood to a brown, until it finally ceases altogether and the female is re- stored again to health. The menstrual period in the human is very much like the same period in the lower animals; their gen- eral resemblance does not require to be demonstrated. As in the human female, they are absent before the age of puberty, and also, like her, their periods du- ring the young-bearing period occur at regular times and are governed by the same laws as to pregnancy. In the human female the bloody discharge is more abundant than in the lower animals, but it is a phe- nomenon differing only in degree from that which shows itself in them. That the period of menstruation is the period of ovalation we have the most complete evidence, as has been found in a sufficient number of cases of birds and lower animals that have been demonstrated after death during the period of the courses. The sac containing the egg is ruptured at this time and is the cause of all the changes that take place in all the organs of generation, both direct and accessory. We do not know at what precise period of the menses the sac containing the vgg is ruptured and the egg discharged. It is the opinion of some that it takes place very early in the period, and of others that it 26 DISEASES OF WOMEN. occurs about the middle, and yet others in the last stages of the menses. I am inclined to think that it is ruptured very early in all healthy and natural cases; still, we may say the exact time cannot be given, it may be very early or it may be very late, because the menses are not regular themselves, sometimes coming two or three days earlier and at other times as much later, and I think we may say for. all practical pur- poses the same rule will hold good in the rupture of the sac and the discharge of the egg during the men- strual flow. We found that when the egg was discharged from the ovaries in frogs and birds, it found its way to-the womb or outlet by the central tubes or ducts called oviducts. Now, in the case of the human female we find the same thing takes place after the sac has been ruptured in the ovaries and the egg, being discharged, finds its way to the womb through the canals or ducts called Fallopian tubes. In the lower animals the egg is very much larger than in the human female, and does not run the same risk of being lost. In the human the egg being very small is liable to be lost, were there not some other provision made for its safety and protection. We find the tubes that convey the egg to the womb to be lined with a fine-pointed lining, with the points towards the womb, so that when the egg is received within those points it is driven on to the womb by the natural action and motions of the muscular coats of the tubes; yet it is subject to accidental causes that MENSTRUATION. 27 disturb this natural course, and it may be stopped along the way between the ovaries and the womb, and in this obstructed condition of the egg pregnancy may take place before the egg arrives at the womb. The egg may become impregnated at any time after it leaves the ovaries, but as a general rule pregnancy takes place before the egg arrives at the womb; and should it not take place, the egg is carried away with the womb secretion or the flow of the menses. Then as a matter of course, pregnancy is more likely to take place about the time of the menstrual flow than at any other time—either just before or soon after the courses. We cannot give the exact time during which impregnation may take place, sometimes soon- er, sometimes later. It is a fact that in some excep- tional cases pregnancy does take place when there has been no menstrual flow, that being only an external sign of the more important changes taking place within the organs of generation. The menses are very abundant in some, while scanty in others, depending very much on the circula- tion of the blood in the womb and other organs of generation, and, though the flow of blood is an index to the aptitude of this organ for impregnation, yet it is not always necessarily so, as all depends upon the expulsion of a healthy egg, whether menses follow or not. Then we draw our conclusion that the blood that is discharged during the menstrual flow is fur- nished by the mucous membrane of the womb. This has been demonstrated by examination of the womb 28 DISEASES OF WOMEN. after death of cases that have died in this condition. We find the mucous or internal coat of the womb filled with a thick, bloody discharge, and the blood has been seen to exude or flow out of the internal coat during falling of the womb, when the organ was turned wrong side out, called in scientific language procedentia, and takes place to very considerable extent, just as the blood is exuded from the lungs in consumption or spitting of blood; the blood, then, comes from the whole extent of the mucous membrane of the womb. DISEASES OF THE WOMB. 29 CHAPTER IV. SOME GENERAL REMARKS ON DISEASES OF THE WOMB AND OTHER SYMPTOMS. The most important organ in the generative system is the womb, and, of all the organs in the body, it is the most likely to become the seat of disease; in the human female it is the cause of more trouble and diseases than all the other organs together, and as a general thing it is as easy to give a plausible explana- tion of those symptoms as it is to explain the symp- toms and effects that this organ produces on the system in general or other organs of the body, while it is laboring under different diseases. It is sometimes very difficult to understand the influence that this organ exerts on the frame in general and other organs the most remote—without any connection whatever,—and notwithstanding our knowledge in anatomy and physiology we are com- pelled to look to those symptoms and thereby make up our conclusions from them. We will now proceed to examine some of the phe- 30 DISEASES OF WOMEN. nomena or symptoms produced on the remote organs during diseases of the womb, before passing to the diseases of the organ itself. We find this organ, whether pregnant or not, to present or represent a hollow muscle filled with a great many furrows and nerves and bloodvessels, having its internal part lined with a delicate, fine, soft, pinkish mucous membrane, and retaining its position between the bladder and rectum by means of special ligaments or bands for that purpose. Its superior portion extends up to the small intestine, or the upper portion of the womb extends to the intestine, while its lower portion extends down into the vagina. This anatomy of the different organs of generation is the cause of so many changes taking place in the sensibility or mobility of the organs. We have in those parts, both directly and indirectly, a great many nerves connecting with the ligaments of the womb, and connecting this organ with the ovaries and the tubes from the womb to the ovaries and ligaments. This may during disease of the organ produce a crowd of secondary symptoms, but as a general thing the womb is without sensation. In support of this statement we adduce the fact that neither diseases of this organ, contusion or cutting the womb produce any degree of pain, but by some changed condition of the mucous membrane it becomes enlarged or thick- ened, the nerves supplying those parts become very irritable and very painful, and this attains its highest DISEASES OF THE WOMB. 31 degree when the cavity is filled by something and the body is made tense. Again, when the womb is the seat of this thickening, the pain is limited to the region over the organ, still, we find it extending to the small of the back and downwards; the patient will then complain of weight, heat, and a burning sensation all over those parts. Now, if we find the tension is caused by too great an expansion of the walls of the womb, the pain is of short duration, lasting but a very little time,—not more than thirty or forty minutes. Women who have borne children say that these pains are just like the pains during confinement, and, in fact, we find them produced by the very same causes ; the cavity has become filled with something, and now the mus- cles of the parts are trying to throw it off, and it is this excessive action that produces the pains. Now these pains present one peculiar quality worth observ- ing, and that is this: the}7 are not increased by press- ure made on the womb through the uterine walls. These pains are called uterine colic, or colic of the womb. Now it is very evident from what we have learned about these that they are very formal; that is, they fur- nish us the key to disease that is making its appearance in the body of the womb of an inflammatory charac- ter ; yet we should be very cautious about classing all pains as of an inflammatory nature; We find pains of an expnlsatory character that are very much, like them, 32 DISEASES OF WOMEN. The inner surface of the womb is lined with a deli- cate mucous membrane, as we found above, and this internal coat is full of little glands, estimated at more than ten thousand. We can see that a very slight cause, stimulating all these little glands at one time, could increase the secretion very much indeed ; so much so that it would produce a continual mucous flow, called leucorrhaia, or whites; yet this is, as a general thing, always before and after the courses. After what we have said on this point, I think it may be taken for granted that this flow that takes place from the neck of the womb is, when in a normal or natural condition, as a general thing, confined to the menstrual period, or just before or after the courses. The mucous membrane of the neck of the womb has another peculiarity, which appears to be this; this flow taking place from its mucous membrane appears to act from a congestion of the body of the womb, and not from any congestion of its own parts. With ref- erence to the general character of this flow from the neck of the womb, we think that it is, beyond all ques- tion, alkaline in its nature ; yet we must be careful not to associate this secretion with those that take place in the organ or those below that point, for they are always acid in their character. On examining the discharge of the neck of the womb it is found to be of a thick, homogeneous mu- cus, holding in its solution round, globular bodies. These globules are found in part intact, and in part DISEASES OF THE WOMB. 33 undergoing decomposition ; and in the latter we find them very much enlarged by absorption of the watery material with which they come in contact. It remains for us to say, while on this part of our subject, that we have never found in the secretion or discharges from the neck of the womb any of those trichomonar or small growths like small animals or insects. We come now to speak of the discharges that take place from the internal coats of the womb. Thus far we have been speaking of the discharges from the neck of the womb. Now, aside from the mucus discharges from the internal parts of the womb, we have a bloody flow, which, however, in a normal or natural condition occurs periodically; this is the menstruul blood, and when the parts or organs are not diseased it takes place without any pain. The blood that flows from these parts is liquid and does not coagulate at all during the courses. . The dis- charges are very slight at first, but in a short time the quantity increases very fast, and in the course of two or three days it has reached its greatest amount. The exact amount of blood discharged at each time cannot be given; it may be six or seven ounces for the whole period of the menses. In temperate climates the courses make their ap- pearance between the thirteenth and sixteenth years, and with most women return every twenty-eight days after the arrest of the menstrual flow; yet any slight variation should not be taken as a symptom or sign of 34 DISEASES OF WOMEN. disease. Their duration, as a general thing, is four or five days, yet it is not uncommon to find them extend much longer, or, on the other hand, not lasting more than two days, and this among persons enjoying the best of health. The average time during which a woman has her courses is from twenty-five to thirty years ; they come on at about thirteen and disappear at about forty-five, unless something interferes to stop them. The changed condition that the courses or menses bring with them is felt all over the system, more par- ticularly in the organs in the region of the womb, and is accompanied by head-ache, slight enlargement of the breasts, vomiting, fear etc. However, those symp- toms do not last very long, and should not cause any alarm of trouble or disease; it all follows from an elevated condition of the temperature of the body. The phenomena of menstruation which we have been describing may, under the influence of different diseases of the womb, put on the most varied forms and modifications ; the quantity of blood that is given under those forms may be without limit, and in those cases we find it coagulate into clots when it conies in contact with the acid secretion of the vagina. On the other hand, it may be diminished to a few drops, and that is the only sign of menstruation. Diseases may also be the cause of too tardy or pre- mature appeaia'ice of the flow in the first place, or a too frequent return of it after it has made its appear- ance, or too long duration, or the Aqw of blood may DISEASES OF THE WOMB. 35 be too great,—all caused by latent diseases or those that have made their appearance. Now we can see that those symptoms are of the highest importance (from this exposition), looking towards diseases of some kind in the womb. We find another set of symptoms making their appearance as the result of those diseases, and they are the effects they produce on the rectum (those, of course, are all functional); all diseases of the womb characterized by an afflux of blood or congestion in the womb pro- duce the same effects on the rectum and the lower parts of the intestinal canal, and as a matter of course, a greater or less diarrhoea. On the other hand, if the flow from the womb be very scant it will produce just the opposite result, and an obstinate constipation fol- lows, of the very wrorst kind. The bladder may be affected in different ways, and we may find decompo- sition of the urine take place by a long retention, and a great many bad symptoms of the bladder iollow. We found above that the womb was directly con- nected with the ovaries by two canals; we can readi- ly see why disease of the womb would affect the ova- ries, but we find that, as a general thing, all of th< >se symptoms are secondary, and do not of themselves cause much trouble, yet they all point back to the womb and the neck of the womb as their starting-point. It is not uncommon to find disease of the womb accom- panied by disease of the ovaries, and we find it so in nearly all cases of inflammation. This is the reason why women that are suffering from those diseases 36 DISEASES OF WOMEN. have, nearly the whole time, sharp and fixed pain in the small of the back. These symptoms are, many of them, a true index to those diseases, namely, diseases of the ovaries. The vagina may be affected by the diseased womb; then, as soon as the augmentation of this organ takes place, the veins and bloodvessels of the vagina are affected and this chronic congestion gives rise to those changes in the secretion of the mucous membrane of this organ that so frequently accompany disease of the womb. The displacement of the womb may give rise to displacement of the vagina and its walls, and it cannot be denied that prolapsis of this organ often precedes prolapsis of the womb. What we mean by prolapsis, is a turning of the organ wrong side out, and, at the same time, a falling. Finally, we may say that certain diseases of the womb accompanied by corrosive discharges may bring on inflammation and ulceration of the vagina, which takes place in almost all bad cases, particularly in those of a cancerous nature, and now we find the sym- pathetic symptoms making their appearance in nearly every distant organ. It is true that the faculty possessed by disease of the womb of producing these effects on distant organs, has not been very well understood until lately, and we find it in the connection in the nervous svstem • yet it appears very mysterious; a detailed account of all the action by reflex action and other ways will hardly explain. DISEASES OF THE WOMB. 37 If we now direct our attention in the first place to the organs of digestion, we find the secondary affec- tion of the stomach accompanying nearly all diseases of the uterus, more or less, in a short time after they are manifest, and especially when the walls of the womb are actively engaged we find pains of some kind or other, called cardialgia, and obstinate vomit- ing following those pains or following the excessive action of the walls of the womb. We should not judge from this that the stomach is at fault, but only a symptom of disease in some other parts, and this vomiting is only sympathetic action of that organ. Now this difficulty is not at all times limited to the stomach, but may be transferred to the small intes- tines, causing tenderness in those parts, and even swelling and enlargement. From this, it is almost needless to say, these troubles of the digestive organs caused by some changed condition of the nervous system, would be transferred to the blood and the pro- cess of assimilation, rendering that fluid dull and poor. Thus we find women who have been laboring for a long time under disease of the womb present a dull, pale, worn-out look and appearance, and, in fact, in an exhausted condition. And of all the diseases that women are liable to, these uterine or womb diseases of all kinds are the hardest to endure and at the same time the most prostrating, working on the very vitals of the patient. 38 DISEASES OF WOMEN. CHAPTER V. REMARKS ON TREATMENT OF DISEASES OF THE WOMB. Within the last few years this department of medi- cine has made great advancement, and we have to some extent gone to another extreme with local treat- ment, or treatment applied directly to the pails them- selves, and have to some degree neglected the grand or constitutional plan of treatment. This omission, however, is not sufficient to drive us from the first, or local plan of treatment, for all know who have had any experience in the treatment of those diseases, that they can do more and better work with local applications, however simple, than they can do with medicine given through the stomach. But these remarks are general, since we will after a while take up individual disease of those organs, and treat them separately. The principal plan for- merly adopted in treating those inflammations and congestions of the womb was calomel and general bleeding, or the application of leeches to the thighs or DISEASES OF THE WOMB. 39 parts themselves; but in these days we direct our at- tention directly to the parts affected, local application of instruments, ointments, caustics and other medi- cines. This local treatment can here be done the best by scarification of the neck and internal parts of the womb. It is not the amount of blood taken (as the old writers thought) that produces the good results by any means, but it is the establishing in those ulcer- ated parts of a healthy action by inflammation, and causing those ulcers of long duration to heal and get well. Caustics are an important medicine in the treat- ment of diseases of the womb, provided, however, they are used with judgment, and for a special purpose. Caustics are applied to the womb, its neck or inter- nal portion, and to the internal parts of the vagina, according to the disease we are treating. For the neck of the womb the caustics mostly used are the nitrate of silver or even the solid stick, and they can be applied with a sponge with a proper holder, either to the womb or vagina. The neck is sometimes so tender that, with the utmost care, the caustic will produce bleeding, which is very injurious to the surface of those parts. In such cases it is best to use liquid caustic, such as a solution of nitrate of silver. This method of using caustic is designed for cases of superficial ulceration of the lips or neck of the womb, and should be used at all times with great care. The solid stick of nitrate of silver is to be used in 40 DISEASES OF WOMEN. common cases to burn off the recent growths. The pains that are produced by these operations are nothing or next to nothing, and you should not fear them. The womb and its neck are almost painless as far as an operation is concerned; you may cut or lacer- ate it with very little pain. However, the very idea of such an operation horrifies the patient, and it is well to be cautious and know beforehand that the treatment is perfectly safe and harmless and at the same time the only treatment that will effect a per- manent cure. We pass now to the application of various ointments to the womb in a diseased condition. In treating disease of the womb it will become necessary to use different kinds of ointment, and they are to be used in this manner; you can use the common speculum and then apply the ointment with a sponge on the end of something that will carry it to the parts. On the neck of the womb you may use a common probang straightened out, or the ointment may be applied without the speculum with the same probang, by taking a little pains. Be sure to carry the oint- ment to the neck of the womb. Another good way is to use the medicine, say belladonna, or any other medicine, with lard or wax made into small balls, wrhich may be carried to the neck of the womb with the index finger. The lard and wax should be of a consistency to be formed into small balls, the weight being not more than three or DISEASES OF THE WOMB. 41 four drachms, and not too hard nor on the other hand too soft, for they must be retained there for some time. The medicines that are applied to these parts in the shape of ointments are various. They are, as a general thing, narcotics, such as opium or belladonna, or astringents such as alum, sugar of lead, tannin and other medicines of a like nature; we very often use something to produce absorption, and for this purpose we use iodine and iodide of potassium. It must, how- ever, be remembered that when we wish prompt action it will not do to depend on those ointments, for their absorption from the walls of those parts, as a general thing, is very slow and uncertain, and we have also observed that this plan is not applicable in those cases where we wish to overcome very violent pain; this action is entirely too slow for those cases. We come now to speak of vaginal injections, and we find that they play an important part in the treat- ment of those diseases, and we may say that we can- not speak in too high praise of them, for several rea- sons. According to the effect that we wish to produce we use different kinds of injections. They may be applied with a common syringe, Davidson's is the best, or some one on the self-injecting plan. The liquid varies also, sometimes pure water or warm water, and at other times medicine is mixed with the water, but I am fully satisfied that warm water, gently and carefully used, is one of the very best solutions that we can use for general purposes; of course, if 42 DISEASES OF WOMEN. we have some special diseases to treat by injection, we must use some special medicine in the water. The instrument to be used in applying this solution or water is, as we have remarked above, a com- mon self-injecting syringe, yet we may use others; one on the plan of a syphon I think is very good. This apparatus costs but very little and renders the very best service, and, furthermore, the patient can use it without the help of an assistant and without fatigue. We shall not enumerate in this chapter all the dis- eases that require those injections, but will speak of them more fully when we come to treat of each disease individually; yet we think it proper to speak of some of them briefly at this time. As a general rule, the higher the temperature of the water or solution to be injected the greater the flux of blood to the parts of the genital organs, and when those applications have been used very abund- antly the parts get very warm and soft and at the same time increase or invite the blood to the surface. This bloody congestion that takes place in all of the organs of those parts is further evinced by an increas- ed menstrual discharge, and all promoted by the warm injection, or the injection of warm water into the vagina. Here, then, is a powerful stimulant to those parts to increase the courses, and we may always look for good results in nearly all cases of suppressed men- struation. The action of cold water has a contracting influence DISEASES OF THE WOMB. 43 or just the reverse of the warm, and its effects are not so general, but more local or to the parts the cold water comes in contact with. When we make an examination immediately after using cold water, we find the walls of the vagina contracted, and they will remain so for some time, and the secretion of the mu- cous membrane very much diminished; and if we have failing of the womb or of the walls of the vagina these cold injections have the very best effects by con- tracting the parts and giving strength to the muscular coats; in case of chronic enlargement the cold injec- tions have the happiest effects, by causing absorption of the excessive enlargement or thickened walls, and we find the womb gradually resuming its natural condition after the use of the cold injection. The force with which the material is injected modifies its action. As a general thing, the conges- tion excited by warm injection is very much increased when the liquid is thrown in with force and in an uninterrupted current; in the same manner the cold injection may produce results analogous to the warm stream. It is the mechanical irritation that produces the different results, and for this reason we should be very careful with both cold and warm fomentations to the parts for fear that we go too far with them, either in starting or checking the menses. If we use the warm water too long we are in great danger of subjecting our patient to dangerous flooding, and the same rule will hold good with the cold. 44 DI8EASE8 OF WOMEN. CHAPTER VI. FLEXIONS OB BENDING OF THE WOMB. We shall now speak of flexion of the womb; by this we mean the falling forward or backwards of the womb so that the neck forms an angle with the body, and the mouth of the womb either looks backwards or forward. On an inspection of this organ it shows that the top of the womb no longer occupies the su- perior portion of the organ, but has been flexed on itself and bent in the middle, so that now the superior portion has been thrown down and the middle portion is the highest up in the pelvis. The part displaced, if seized with the hand, can, as a general thing, be replaced in its natural position without much difficulty, but again, in a few minutes, will resume its flexed position. By looking more closely, and especially by an examination through the organ we can readily see that the womb is not only flexed on itself, but is also very much displaced, and in snch a manner that the anteflexion is complicated FLEXIONS OF THE WOMB. 45 with an antroversion, or partial turning of the organ. When this disease is of long duration we find that the attachment is very great, that is, the attachment of the womb to the near parts with which it is brought into contact. These adhesions are, as a general thing, the result of inflammatory action of the parts brought together, and become very dense and very variable in their character. We are informed by some medical writers that flexions are caused by inflammation of the lining membrane of the bowels, called peritoneum; we think that such conclusions are very much out of place, and calculated to lead the enquiring mind off from the true causes. We think that inflamma- tion of the lining membrane of those parts is some- times the cause of these flexions, but the idea that it is the sole cause is entirely out of place and unreasonable. The degree of the flexion of the womb upon itself is very important to know; it may be limited to a slight curve, presenting a very obtuse angle; in the other extreme the womb is completely folded double, and the angle very acute. We very rarely meet with those extremes of flexion except in women who have never borne children. The cause of this may be that in consequence of nu- merous pregnancies and labors the upper portion of the vagina loses its rigidity and elasticity ; and, in fact, the more the walls of the vagina possess the 46 DISEASES OF WTOMEN. power of resisting the better it places the neck of the womb in its normal or natural position. However, we can see from this that when the body of the womb is turned a little forward or backward the acute angle must be very great indeed; and, on the other hand, when the vaginal walls are relaxed and yield easily, the same cause which forces the top of the womb to bend forward will cause the neck, when not firmly fixed, to be borne backwards, and hence the falling forward of the organ will combine with an antrover- sion or turning of a greater or less extent, and the angle of the flexion will be much more open, and it will be the same in a falling backward of the organ or womb. Finally, in flexion of the womb the texture of the organ is very much changed ; very often we are struck with the appearance of the color, which is of a blood- red, or sometimes of a slate color, and by this we may always judge that a state of chronic inflammation exists in the walls of the womb. In such cases we find the upper part of the organ very much enlarged and its weight very much increased ; the vessels are very much dilated and full of blood, the muscles soft and relaxed; the cavity of the womb is also very much enlarged and as a general thing, full of mucus, watery or yellow and bloody. This abnormal secre- tion of the internal surface is caused by a chronic inflammation or catarrh, and partly from the contact of the front and back parts of the walls of the neck of FLEXIONS OF THE WOMB. 47 the womb preventing the natural escape of the secretion and confining it in the womb. When the flexions are very marked the mouth of the womb is a little opened and quite soft, and even in women who have never borne children. We think that the phenomenon is owing to the upper part of the womb being very heavy; when it falls backward it renders the parts of the neck and mouth very tense. It is for this reason that the organ is always gaping. We find that the organs situated in the neighbor- hood of the flexed womb are always changed;—such as the rectum, bladder, and in fact nearly all the parts in that locality. As a general thing it is among young adult females that we find flexions the most common, and it is between the ages of thirty and thirty-five that the organs of generation are the most in danger by repeat- ed pregnancies, causing them to become relaxed and to some extent worn-out or fail for want of rest. We know also that flexion has sometimes been found to exist in young girls who have not attained the age of puberty, and, on the other hand, it may be found in old persons; but in those extreme cases they are of very little importance, giving but little trouble. But we may say that we find the most cases among married women, for it is among this class that the most pregnancies and labors occur. Marriage at an undue time, as a general thing, has a great deal to do in producing these flexions ; for a multitude of labors before the organ has attained its proper shape and 4S DISEASES OF WOMEN. form is conducive to all these troubles. Women who in a short time have had a large number of labors are much more likely to suffer from flexion than those who have borne children less often than those who marry young and bring upon themselves this trouble of flexion and falling of the womb. They are also more liable to premature labor, and premature labor of any kind is very likely to produce flexion and falling, and, in fact, all kinds of diseases of the womb. We should not forget to mention as one of the very first causes of flexion and falling of the womb, the getting up too soon after parturition, when all of the parts are very much relaxed, and throwing all the weight of the bowels, and in fact, of all the organs in those parts, upon the neck of the womb, which will, as a matter of course, drive it out of its place. The process of parturition or delivery, when it takes place at the proper period or time, is always attended with more or less danger; and, as a general thing, one out of every six or seven cases is attended with either flexion or some other form of version or falling of the womb, and nearly every case where the forceps or instruments are used to assist in delivery of the woman. We think that a great many of these cases are pro- duced by the continued distention of the walls of the womb resulting from a multitude of pregnancies and deliveries, and in a great many of the recorded cases of flexion and womb displacements the women have FLEXIONS OF THE WOMB. 49 borne twins. This fact deserves the more attention because recorded cases have shown that accidents of every kind which are capable during confinement of delaying the return of the womb to its natural shape and size are often met with in women who subse- quently suffered with flexion of this organ. I would, in this connection, impress upon the mind the great danger of exercise too soon after delivery. As we have spoken of this subject before, we do so again, knowing the great danger attending those cases, in getting up before the tenth day after deliv- ery. Some recorded cases kept in Berlin show that in seventy-five cases of flexion thirty got up before the eighth day. Finally, in reviewing all the*causes of flexion and displacements that we have touched upon, we would say that an undue multitude of pregnancies and deliveries stand in this matter as the first great cause. We now come to speak of the symptoms of flexion and some of the changes produced on the womb by its displacement. We have, as the result of this flexion violent pain, leucorrhoea or whites,menorrhagia or an increase of the menses, flooding and difficulty in passing the water from the bladder. Now let us look at the causes of those symptoms. In the first place, it is, in a majority of cases, the disturbed menses or courses that give rise to the different symp- toms. The courses become very irregular and at the same time painful, and the flow much greater at some times than others. The period of the return is variable 50 DISEASES OF WOMEN. and marked by pain in the region of the womb which has never before been manifest. The pains resemble the pains of labor, with clots of blood; and also bladder troubles and nausea of the stomach, of a sympathetic character. In this state, if the patient be left to herself, she falls at last into a low, melancholy condition which dispenses with all social company, and is apt to be followed by the worst kind of internal diseases, such as pulmonary consumption. This is the progress made by diseases that are apt to follow flexion or other displacements of the womb—the termination of those cases of flexion. This class of cases, as we have intimated above, are among the worst that we are brought into contact with, and, to our humiliation, in spite of all we can do, we are persuaded that unless a natural condition is brought about by nature itself all our efforts will be in vain; hence scientific physicians never talk much about curing flexion, and this does not appear astonishing when we remember the cause of this dreadful disease. Preceded and favored by a relaxed condition of all the parts the flexion makes slow and steady advancement, and it is not until it has attained a very considerable degree that the symptoms are made manifest, and the disease is augmented by the different changes that take place. According as the flexion takes place the walls and coats of the womb get larger and softer. Then we would say by what means can we cause FLEXIONS OF THE WOMB. 51 the natural or normal condition to re-appear ? Still we would say in writing on this subject, that the patient is not to be given up, for, by a proper course of treatment she may be very much improved, and we would be chargeable should we refuse to treat and assist in those cases. It is clear that this condition will, sooner or later, exhaust the patient's strength and impoverish the blood, and soon difficulties in the form of nutrition and of the nervous 8}rstem make their appearance, and it is from those causes that the patient should have careful and special treatment. TREATMENT OF FLEXION. Within the last few years the treatment has gained considerable importance, and recently written works have thrown more light on the subject. Various procedures have been recommended and the maimer of treating this malady has been very various. The first great principle in the treatment of this tremendous disease, as we may say, is to get clear of the softening of the walls of the womb, and in the next place to strengthen the parts and restore the normal or natural condition by mechanical or other direct or indirect remedial means. We may say that the results as far as they have gone are not very favorable to the mechanical plan of treatment, and it is very hard for us to comprehend how it is possible by the introduction of a sound or other instrument 52 DISEASES OF WOMEN. into the womb to cause that organ to overcome its softening or gain its normal position and at the same time strengthen the muscular walls of the organ, a softening always existing at the place of the flexion. When the disease is not of long standing and is accompanied by pain, tumefaction and a loss of the natural walls, cold hip baths, vaginal injections; and ergot given two or three times per week will be found useful. We should not have recourse to caustics in those cases unless the whites or local discharge gets too great, and then we may use them to a good pur- pose; and, by their proper use, at the end of three or four weeks we shall succeed in relieving the uterine discharges and the great flooding or leucorrhcea or whites, and if this should not be successful we may with good results have recourse to local blood-letting. Every week or two we may use the knife on the mouth or neck of the womb. This will reduce the engorgements and very much assist in restoring the parts to their normal condition; but at home I cannot too highly recommend hip baths and injections into the vagina of warm water, soda and water or salt and water; but if the flow be too great you should use cold wTater, and should use it two or three times a day and—I must speak of the subject again before leaving it—we have nothing at our command that will pro- duce so much good as the proper and continued use of these injections into the vagina, either cold or warm, as the case may require, and I would recommend them in all cases at home, FLEXIONS OF THE WOMB. 53 The application of a solution of nitrate of silver to the cavity of the neck should be repeated frequently in cases of softening with pain and flooding. The ulcerated surfaces easily bleed. The nitrate of silver should be used freely, and if the bleeding is too great it will wash away the solution; then we may take a sponge on the end of a probe and apply a very strong solution, holding the sponge against the parts for some time until the bleeding has been overcome. It remains for us, while speaking of the treatment of these flexions and the diseases they bring,.to speak of uterine colic or colic of the womb,—spasmodic pains of this organ—which is nothing but symptoms of those flexions. Of all the medicines we have at our command I think opium is the most worthy of our confidence in the shape of a liniment. If there is no bleeding we may use warm hip baths, but opium, belladonna or chloroform are the great remedies in this dreadful disease. As for giving medicine internally, I think we can do but very little ; yet symptoms make their appearance that will call our attention, and it will be impossible to over- look them, and for this reason we must use some internal remedies to build up the worn-out blood. In those cases we are called on to use a tonic, such as columbo, gentian, cinchona and the different prepara- tions of iron, the best of which, I think, is the tincture of iron, twenty drops in a tablespoonful of water throe times a day after eating. 51 DISEASES OF WOMEN. The iron treatment should be contin ued for a long time, as it will require ten or twelve days for the system to get under the influence of the medicine. It should, therefore, be continued for three or four weeks, and, in fact, iron is the great treatment in nearly all diseases of the womb, for they are all suffering more or less from prostration, and a worn- out condition of the blood, and the tincture of iron is the best treatment. Let me then recommend its use without fear of any constitutional habits being con- tracted by its continued use. Finally, while speaking on the treatment of this disease, let me recommend a bandage around the hips and over the womb, with a pad immediately over the organ, so as to lift up the bowels and remove the pressure from the womb. We have seen the very best results from the use of the bandage. It should be made iu the shape of the letter T and placed firmly around the body. It fehould be made of strong muslin with the pad attached to keep it in place. FALLING OF THE WOMB. 55 CHAPTER VII. PROLAPSUS OR FALLING OF THE WOMB. In speaking of this disease I know that it is one that is commonly thought and talked of among those that are troubled with the disease and those that are not, and I propose now to make some general remarks. It is simply a settling down, the womb occupying a much lower position in its uterine cavity than its natu- ral one, and this may continue until the organ has made its appearance into the external world. This condition is called prolapsus. A prolapsus existing for a long time is always followed by a change in the womb and the accessory organs connected with it, and, in fact, all the parts that the womb is brought in contact with. In a case of complete prolapsus of the womb, we find, immediately under the falling portion a bluish- red tumor, more or less reducible, at the inferior part of which we recognize, under the form of a transverse fissure, the gaping orifice of the womb. But if, at the moment of inspection the womb does not pass through 56 DISEASES OF WOMEN. the external parts, the extraordinary space which sep- arates the two lips of the external parts, and the possibility of seeing the tumefied and livid walls, are evidences of displacement which exist during life, and in those cases by making pressure over the womb it is very often pressed out into the external world, and this is nearly always the case when pressure is made immediately over the top of the womb. In those cases it is wonderful to see the extent to which it will take everything along with it. We can ordinarily satisfy ourselves at the same time as to the extraordinary tension of the round ligament, and as a complete pro- lapsus always gives rise to trouble in the circulation of the womb or its appendages we may also prove the congestion of these parts by the veins being still dilated and gorged with blood, and often from the livid, color of some or all the organs of those parts. The great length to which the ligaments of the womb have stretched may be diminished by endeavor- ing to restore and replace the disordered organ to its normal or natural place in the cavity of the pelvis. By this word pelvis we mean the cavity formed by the two hip bones on each side and the lower por- tion of the backbone, behind which is the natural place or cavity for the womb, and when it descends out of that place or cavity we say that it is a case of falling of the womb, and the ligaments have under- gone such a stretching that in replacing the womb to its normal cavity we can readily crowd it up two or three inches beyond its natural place, and this FALLING OF THE WOMB. 57 condition will not disappear until the organ has been replaced and some time has been allowed for a slight inflammation to take place, and as a result of this inflammation, absorption of the excessive parts and a shortening of the ligaments before the womb can be retained in its original position. In those cases we are struck with the length and breadth of the womb, and the internal anatomy of the organ is also very much changed. When in a natural condition, the internal mucous membrane is full of small folds called rugm; in those cases of falling these folds have nearly all disappeared. Often after long duration of this disease there is a true version of the neck of the womb. The mouth at first dilates insensibly and its border forms a circle one inch in diameter, through which the neck is turned in such a manner as to throw the mucous membrane or internal surface on the outside. It is quite easy to reduce this turning of the neck by grasping the lower portion with one hand and keeping the organ in place with the other, and then to make gradual pressure until the organ is turned back to its original position. In those cases in the organs that have undergone displacements we find the obstructed circulation of the blood extends to them in just the same manner as to the womb. We wish to speak of some of the symptoms of fall- ing of the womb. This displacement is developed little bv little in consequence of an interior depression of this organ, or it may take place all at once, violentlyi 58 DISEASES OF WOMEN. from either external or internal causes. In the first case the patient complains for a long time, sometimes for months and even years, of a painful feeling about the small of the back and hips, extending all through the pelvis, and of a continual and sometimes of a lancinating character in the lower part of the abdo- men, as if a large mass was pressing them down in those parts of the pelvic region, and about to be pressed out into the external world. They are apt to be followed by pain and other trouble in the bladder, and very often with more or less disturbance of the bowels; costiveness of the very worst character is apt to follow all of these cases, and as the period of the menses approaches the womb gets very heavy and insupportable to the patient. In a majority of cases sympathetic symptoms make their appearance in the direction of the digestive organs; the food being insufficient, disorders in the functions of the nervous system make their appearance. This state of things will exist for an indefinite time, until all at once a tumor makes its appearance out of the genital organs into the external world. It is very painful and varies in size; at first it is not very large, but in a short time increases very fast and gets very dense in character. At this time the neck of the womb has passed out also, and is now with its mouth turned up instead of down, and if recourse is not had to proper treatment, or if the patient is forced to labor or work at anything requiring any considerable exercise, the uterus or womb and vagina FALLING OF THE WOMB. 59 progress outwards, and when the walls have enlarged they may form a tumor as large as the fist. This when growing presents a doughy appearance, and it is only by a strong pressure that we can tell that the womb is in the center of the tumor. Similar symp- toms render it extremely probable that the top of the womb and also the bladder undergo a displacement backward and downward in such a manner that the bladder is found in the pocket formed in front of the external parts. In such cases as this it is found to be impossible for the patient to pass her water without assistance. When the prolapsus of the organ is ver}r great it often drags the rectum down with it, and this gives rise to a dilation of the parts. Sometimes a prolapsus of the rectum accompanies that of the womb, especial- ly in old age. If the prolapsed womb remain long outside the body it is subjected to influences from the atmosphere and from the friction of the thighs and clothing, and in a special maimer to the urine that flows off the external parts. Hence we frequently find over the whole surface of the tumor, and particularly upon the inverted surface of the neck, ulceration and inflamma- tion which, if the proper treatment is not given, may very soon lead to something very dangerous, even to mortification and sloughing of all the parts exposed. In nearly all cases of prolapsus of the womb the mucous membrane of this organ is very sensitive and painful,—very much more so than it is in a natural 60 DISEASES OF WOMEN. condition, and the least exciting cause will subject the patient to the most excruciating pain. As a general thing, prolapsus is the cause of vari- ous changes in the menses; it may be defective or even amenorrhoea or absent, while, on the other hand, if the mucous membrane be very soft or relaxed the menstrual flow may be very abundant and more frequent than natural; again, it is not infrequent in the hastened case for the menses to be changed into flooding of a very dangerous character. Then we can readily understand that in consequence of the altered condition of those parts and the chronic catarrh that exists in the mucous membrane of the womb and accessory parts a woman affected in that way will not readily conceive. Sometimes the prolapsus takes place suddenly, as in lifting a heavy burden, or in a violent fit of coughing, etc. The sudden displacement of the womb causes intense pain about the region of the small of the back and, in fact, extending all over the genital parts. The falling of the womb is not necessarily a fatal disease, yet as a general thing it is incurable and very painful to the patient, and if proper treatment is not given it is constantly increasing in size and at last undermines her health. We propose now to speak of the causes of falling of the womb and find them to be the lengthening of the ligaments and other parts calculated to keep this organ in its place,' and also other unnatural changes which those organs undergo during pregnancy. DISEASES OF THE WOMB. 61 The lengthening of the ligaments and the dilation of the walls of the vagina which commence during pregnancy are such that it is almost impossible for them to resume their natural condition during confinement, and when the uterus or womb has contracted it does not find the same contraction in the ligaments and walls of the vagina that there was in a natural condition. If any cause pushes the Avon lb down this will push the yielding Avails of the vagina and it descends towards the external parts. It is not uncommon to find such a prolapsus after a single labor, but, as a matter of course, it is much oftener to be found after many and repeated labors, more especially Avlien they occur at intervals compara- tively short, and all these dangers are increased when the woman undertakes to perforin manual labor when all of the parts are more tender than when in an unimpregnated condition, and also by lacing tightly and thus crowding the bowels down on top of the heavy womb. We may conclude from Avhat has been said that the predisposing causes are many, producing falling of the womb little by little, yet Ave find other second- ary causes such as blows on the abdomen, falls, fits of coughing, laughter, lifting or carrying hea\v loads such as tubs of water and heaA-y kitchen utensils, while in a relaxed condition; and I may say that this last cause is more fruitful of trouble than all the rest together, and so long as a woman Avill continue such 62 DISEASES OF WOMEN. labor when in that condition we have but little hope of her recovery. This disease is of such a marked character that there would seem to be but little danger of its being confounded with any other, yet such mistakes do fre- quently take place A mistake may occur if the walls of the vagina are large and down, or if the neck is very much enlarged and at the same time very low, producing an external tumor, it may be taken for prolapsus. Noav, in order to distinguish prolapsus of the womb from Aversion of the same organ, it is necess- ary to remember that in prolapsus the mouth of the womb is always at the inferior or lower portion of the tumor and looks down, while in version the mouth of the womb is at the upper portion of the tumor and looks upward. Again, Ave may be misled hy a large polypus or tumor that sometimes makes its appearance and growth from the mucous membrane of the womb, and by its own weight finds its way through the exter- nal parts and may be taken for prolapsus. TREATMENT OF PROLAPSUS. It would take a large volume to describe all the treatment that has been prescribed for this disease by different authors. We shall, therefore, only attempt to state a few of the most important plans of treat- ment and what appears to us the most successful. In the first place, then, common sense Avould teach us that the object in view would be to replace the FALLING OF THE WOMIi. 63 prolapsed womb in its natural position and to retain it there. This reduction is generally not very hard to accomplish unless Ave have a tumor above pressing doAvn on the womb. When the body of the Avomb is not enlarged it does sometimes happen that the reduc- tion takes place spontaneously or without assistance. This, however, is when the prolapsus is not very extensive. To reduce this prolapsus artificially Ave separate the external parts with the left hand and Avith the other grasp the lower parts of the tumor and replace it gently and gradually in its proper position, and this can be done as well at home by the nurse as a physician can do it; all he can do is to take hold and return the Avomb to its natural place, and you can do the same if you take hold and use proper care and continue until it has been reduced. Place the patient on her back with the hips slightly elevated, and let her so remain during the operation. If the tumor has gained considerable size and is very tender and painful, Ave must use something to reduce the inflammation and pain. For this purpose warm fomentations, such as Avarm Avater, may be used and continued for some time, and will, as a general thing, answer every purpose. When ulcerations exist on the tumor they must be treated if they inter- fere Avith reducing the womb. This can be done with caustics; nitrate of silver, .twenty grains to the ounce of water, two or three times a day, applied with a camels' hair brush ; Ave will find in nearly every case 64 DISEASES OF WOMEN. that the use of this solution of lunar caustic is attended with the very best results. The womb, as soon as reduced, must be retained in its proper place or it will soon find its way back out- side the body, and for this purpose a great many pads or plugs called pessaries have been used without doing very much good. As a general thing, all pessaries are objectionable on account of their wTeight and the friction they produce. In cases where the prolapsus has not been too great and the body of the womb has not gained too much size and the external parts have not been relaxed too much, the womb may be put back and a cotton cloth or sponge dipped in oil carried up through the exter- nal parts and placed firmly and gently against the womb, and if the sponge is not inclined to stay in support of the womb a bandage may be placed around the parts in the shape of a T; the two horizontal parts may be placed around the waist and the inferior one passed between the limbs; in this Avay the womb may be retained in its natural place. To assist, this sponge may, after seven or eight days, be dipped in a solution of alum or white oak bark ooze. In connection with this treatment we should remember the general treat- ment, such as tonics. The alum should be kept clean and warm, and iron and tonic medicines given. ANTEVERSION OF THE WOMB. 65 CHAPTER VIII. ANTEVERSION OF THE WOMB. By the word anteversion we mean the falling of the womb forward to such a degree that we can observe that the organ has been displaced downwards and forward. Now in a natural condition the summit of the womb is slightly forward, the back part looking upward and the forepart downward. Its up-and-down axis is not perpendicular, so we see from this that the womb in a natural condition is thrown a little forward. This condition becomes a disease when it is by active predisposing causes very much thrown forward. When this is the case it gives rise to the most varied disorders in the function of the womb and the neigh- boring organs. We find this disease, as a general thing, among young women who have high hip bones and the cavity of the pelvis much thrown forward; for in this case, when the back part of the womb is looking up, it supports all the weight of the bowels resting on it. Again, this condition will be much increased if 66 DISEASES OF WOMEN. the womb has gained any considerable weight within its own walls. Then it is a very common thing for this displace- ment to result from pressure of other organs on and around the womb. Again, we may say that anteversion or a falling forward is only a symptom of depression or prolapsus of the womb; more particularly when the parts have been very much relaxed and a prolapsus of the vagina and bladder occupies a very low position, and an accumulation of urine takes place in the bladder, pushing backAvards the neck of the womb and thus bringing on an anteversion ; and this is all strength- ened by strong bands adhering to the parts to bind them down. We do not have much pain in those cases unless the patient is pregnant or the pain results from some mortal change or an affection of the bladder or some of the neighboring organs. The symptoms of anteversion of the womb are lim- ited to the tension about the rectum and bladder and a frequent necessity of urinating, and usually an obstinate constipation of the boAvels. All these symptoms increase as the period of menstruation ap- proaches. It is almost impossible to tell anything about this disease without an examination of the parts. We then find the mouth and neck of the womb very much thrown backward and in proportion to the amount that the top has gone forward, the mouth of the organ ANTEVERSION OF THE WOMB. 67 looking back. We also find the top of the womb thrown forward and lapping over the body and low down in the vagina, and at the same time the anterior part of the vagina is very much dilated and giving away to the weight of the top of the womb. We may say that this is a hard disease to cure, yet it is in our power to assist a great deal by wray of palliating forms of treatment. If the womb has been displaced by pregnancy we may expect that much may be done by treatment and returning it to its nat- ural position ; yet I would say that these forms of displacement, as a general thing, are the cause of sterility, in consequence of the unnatural location of the mouth and orifice of the Avomb. A great many mechanical means have been invented to hold the womb up to its normal or natural position, but they only do good as long as Avorn, bringing about only a momentary cure. Those instruments are objectionable because they bring about very severe pains, and are calculated to excite inflammation of the womb or peritonitis. In treating this disease we should in all cases look at the causes Avhich produce it; and Ave find in nearly all cases that it is produced by pressure from above crowding doAvn on the womb, and its attach- ments and ligaments give way and the organ is forced down into its neAV position. Then if this be the direct cause of the trouble Ave are taught that a bandage or girdle that would take off the pressure could scarcely fail to do good. I would recommend 68 DISEASES OF WOMEN. a girdle around the waist, letting the forepart come down in front so as to lift up the bowels and at the same time bear backward ; by this means you may do a great deal of good not only to the anteversion but also to the base of the bladder and rectum. REl'ROA'ERSION OF THE WOMB. 69 CHAPTER IX. RETROVERSION OR FALLING BACKWARDS OF THE WOMB. As we were saying in the last chapter, it must be remembered that in anteversion and retroversion the axis of the womb is always straight, and not bent up on itself as we have it in flexion, which we have had under consideration heretofore. We propose hoav to speak of retroversion, or a fall- ing backwards of the womb, in which the neck and mouth approach the anterior part of the vagina and as low down as the pubes. The retroversion of the womb is a secondary affection except in pregnancy. This disease is generally caused by adhesions to the top of the womb which are calculated to draw it backward, or some effusion between the womb and the posterior part of the bladder; and sometimes by tumors developing in the body of the uterine walls, or tumors or weight about the ovaries pressing upon the top of the organ. After what has been said it will be observed that this deviation of the womb is of secondary importance 70 DISEASES OF WOMEN. in comparison to the maladies that produce it by pres- sure upon the organ from some distant part. As the symptoms of retroversion are the same as in anteversion we will dispense with a detailed descrip- tion of them at this time. In this displacement the patient complains of painful pressure in the small of the back or sacral region, of painful menstruation and difficulty in passing the bowels, and finally the trouble is followed by sterility. Noav, as to the result of this disease the reader is referred to what we havre said in anteversion, and the treatment is also nearly the same. The first and great object is to replace the womb in its natural position and to keep it there, and to this end Ave should employ a spring pad or bandage, or anything that will bring about this result. Constitutional or local treatment that will unload the local congestion of the parts stands next in order after the womb has been replaced, and to this end wTe may by local blood- letting do a great deal of good to the parts themselves or to the neck of the womb. It may be done with a small knife on the end of a long probe, and, indeed, I think this the best plan of treatment in all cases depending on congestion. CHRONIC INFLAMMATION OF THE WOMB. 71 CHAPTER X. CHRONIC INFLAMMATION OF THE MUCOUS MEMBRANE OF THE WOMB, OR CHRONIC CATARRH. There is often an opportunity to study the anatom- ical character of this disease, owing to its frequency. We avi'11 not speak of the chronic catarrh that accompanies other diseases of the Avomb, considering only those in Avhich it constitutes a separate and independent disease. We will, in the first place, consider the changed condition of the mucous membrane in such cases. If we examine the cavity of the womb that is suffering from chronic catarrh we find the mucous membrane very much thickened and changed in color; in the first place it changes from a pale yellow to a slate grew The cavity is very much enlarged, both in its longitudinal and transverse diameters. In a great many cases of long duration the mucous membrane lias lost its inner coat and a change of epithelium takes place. We find in the Avomb of those cases a large lot of creamy or purulent mucus, to such an 72 DISEASES OF WOMEN. extent that it has filled the entire cavity. This mucus, if it be examined just before menstruation, Avill be found to carry globular or organized bodies, and also blood corpuscles or blood cells in great abundance. Now if Ave come to speak of the mucous membrane of the neck of the womb Ave find quite a difference between the two. Its color is, as a general thing, pale, and its surface more elevated in the shape of tumors in the neck of the Avomb; Ave have the differ- ence in the secretion that it is white, transparent, and fills the cavity of the neck entirely, resembling in its general appearance the white of an egg, or pure albumen. This altered condition of the mucous membrane of the womb that we have been describing extends down to the vagina, with excoriation and ulceration of the parts; more particularly is the ulceration confined to the mucous membrane of the neck. This chronic catarrh that we have been speaking of generally extends to the neighboring organs, such as the bladder and the neck of the bladder, the vagina and ovaries, with general enlargement of the parts and threatening enlargement of all the parts. In catarrh of the womb the most important symp- tom is the flow from the genital organs of a white, glairy mucus; this kind and character of mucus always indicates inflammation or ulceration of the neck; but if the secretion is purulent or creamy it will teach us that the discharge comes from the mu- cous membrane of the womb. And yet Ave may have CHRONIC INFLAMMATION OF THE WOMB. 73 lencorrhca or whites coming from the vagina, but as a rule, leucorrhcea or whites always indicates ulcera- tion of the neck of the womb. We have in some cases the symptoms of acute inflammation preceding leucorrhcea, but as a general thing the disease is developed little by little until all of the symptoms are manifest and they become painful to the patient. When the disease lasts for a long time and the mucus secretion is Aery abundant and in consequence of some obstruction becomes shut up in the body of the womb, the patient will complain of pains shooting in every direction from the Avomb, and as the period of men- struation approaches they get more and more intense. Then it is that the secondary symptoms make their appearance in distant neighboring organs, such as pain in the stomach, with vomiting and a general disturbance in the process of digestion and assimila- tion. Those secondary symptoms are continued upon the boAvels; constipation of an obstinate character being among the worst symptoms. All of these symptoms indicate trouble of the worst kind, and if left to themselves Avill at last sink the patient into a general state of anaemic hysteria and general loss of strength. Those symptoms are followed by a change in the menstrual IIoav, which becomes irregular, being too scanty at times and at others too profuse and at the same time very painful. In those cases if Ave have a large amount of mucus accumu- lated in the body of the womb, Ave can very often by 74 DISEASES OF \\OMENT. the presence of palpitation above the pubes recognize the enlarged womb. The vagina in those cases, on an examination, pre- sents a very high color, and sometimes even a livid red, and more particularly if the disease be of long standing. In the older cases and in those that have borne many children, the mouth of the womb is very uneven and tumefied; the anterior part of the mouth of the womb is very much the longest. From the mouth of the womb in those cases we can see pro- ceeding this white or pearly grey mucus. This is what is called leucorrhcea, or whites, and proceeds from the mouth and originates in the neck of the womb, and by the side of this we have the purulent discharge flowing at the same time. With regard to the result of those discharges, we may say that they may continue for years without endangering the pa- tient's life. This disease, as a general thing, is mis- understood by the patient herself in the first stages, Avhen the Aoav is not very great, or the odor not very bad, or not corrosive. Those symptoms, all taken together, make the pa- tient think she is getting well; but after the disease has continued for some time and become connected with distant organs by sympathetic action, and at- tained a degree insupportable, the patient seeks treat- ment, and not until then. In the early stages, when the disease might yield to a judicious plan of treatment, it is almost certain to be neglected, partly because parents and husbands CHRONIC INFLAMMATION OF THE WOMB. 75 pay so little attention to them and treat them with perfect indifference, as though matters of trifling im- portance, or nothing more than hysterics—while the poor Avoman knowing these facts would rather suffer death than make her condition known, Avhich is the principal reason why this class of diseases is so much neglected in its early stages, while in the reach of medical treatment, until, unfortunately for the pa- tient, the time for a radical cure has passed, before she has any attention whatever. After this leu cor rhcea or white of egg discharge has become very abundant it is almost impossible to effect a permanent cure, and we Avould say, from all the facts Ave have, that those long standing diseases become very dangerous. We will speak now of the history of chronic catarrh of the mucous membrane of the womb. This disease is as a general thing the result of acute inflammation of the organ. The process of parturition and the puerperal state add very much to producing this dis- ease. It sometimes happens that the lochia, or dis- charge after labor will pass into some unnatural secretion from the walls of the womb, and thus give rise to this disease ; and this will often happen Avhen the patient has not proper care and attention. Get- ting up too soon, or too much exercise after getting up, is very fruitful towards producing this disease. In cases of polypi or tumors from the mucous mem- brane, or cancerous infiltration, chronic catarrh is scarcely ever absent. It is also observed in conse- quence of diseases of the blood, or affection of dis- 76 DISEASES OF WOMEN. tant organs by sympathetic action, and producing congestion of all the organs of the pelvis. We find this disease as the result of heart, lung and liver dis- eases ; also voluntary trouble. The habits of life, poor clothing or food, Avet or damp houses, and neg- lecting washing and bathing the body, often produce this disease. TREATMENT. We have in this disease a great many plans of treatment—about as many as we have authors who have written on the subject—but I will give only such as can be used at home, and will do the most good in the shortest space of time. We have two plans of treatment—one an internal or constitutional plan, and the other a local plan of treatment. Now I think a union of those two will be the most profitable, and ac- cording to circumstances, either one of those plans. If the constitution of the patient is reasonably good, and the disease has not been of too long du- ration and is confined to the mucous membrane, we should use some local depletion; this may be carried on to the mucous membrane of the vagina with a small knife on the end of a probe. This should be continued two or three times a week ; and in a short time we may carry on local scarification up into the mouth and neck of the Avomb, and in fact I think that in those cases we can do more with this little knife on the internal mucous membrane of the neck of the womb than all the treatment we have at our com- CHRONIC INFLAMMATION OF THE WOMB. 77 mand, put together; yet judgment and great care should be exercised in using the knife. In the out- door department of the Medical College at Brooklyn, New York, nearly all cases of chronic catarrh of the womb are treated in this way, by scarifying the in- ternal parts of the mouth and neck of the womb, with the very best results. Some authors recommend leeches applied to the parts, but such treatmeut is out of the question in this part of the country. I think that the amount of blood taken does not cut any figure in those cases, or does any good. It is perfect non- sense to talk about a few drops of blood, taken either locally or generally, curing a catarrh of the womb, or leucorrhoea ; but in scarifying those ulcerated parts you will establish a healthy action, and those ulcerated surfaces will heal and get well, resume their normal mucous covering, and produce healthy action of the parts. With reference to a vaginal injection, 1 must say that they are very effective and powerful for good, either cold or warm, but we had better use them warm first, and if not objectionable they may gradually be used colder, and wTe may add an astringent, such as Avhite oak bark, perchloride of iron ; or Ave may use hip baths in those cases with the very best results, and continue them every day. Now in all cases where the cavity of the neck is the seat of the disease—and Ave can very easily tell by the character of the discharge, it being like the Avhite of an egg—Ave can produce the best results from the 7s DISEASES OF WOMEN. use of nitrate of silver. This may be used with a small sponge made fast to the end of a long probe and dipped in a solution of nitrate of silver, twenty or thirty grains to the ounce of water, and it may be used as strong as forty or even fifty grains to the ounce of water. Pure water should always be used This caustic should be used once in every five or six days. We should have no fears in the ute of this powerful medicine because of its strength, for it is the all-important medicine in those cases of chronic ulceration of the mucous membrane of the neck of the womb. When the inflammation has extended up into the internal surface of the womb and also to the body and substance of the organ, some authors recommend an injection of nitrate of silver up into the cavity of the Avomb, to Avash the internal surface entirely with the medicine, but I am inclined to think that a plan of treatment of that kind would be very heroic and cal- culated to do more harm than good, by exciting in- flammation in some of the neighboring organs, as it sometimes does with the peritoneum or lining mem- brane of the bowels. I would therefore say that when other treatment will do, do not use injections into the cavity, and I believe I will say that they never should be used, for they seldom ever do good, but are fruit- ful of harm, and this harm is of a dangerous charac- ter because it is extended to the lining membrane of the boAvels, called peritoneum. Then, from all these facts, I Avould recommend CHRONIC INFLAMMATION OF THE WOMB. 79 that the treatment should be confined to the mouth and neck of the womb. If the disease has not already advanced too far, wTe may do a great deal of good with something mild, continued for a long time—say six or eight weeks—such as local injections of warm Avater into the vagina, or salt and water, or sugar of lead and water, or tannic acid and Avarm water. All will do good if continued for a long time ; but if ul- ceration and granulation have made their appearance, this mild plan of treatment hardly reaches the case, and we must resort to a strong solution of nitrate of silver. Hygienic rules must form the basis of all treatment in those cases. Without proper care, with clean, good diet, and proper exercise, all our treat- ment in those cases will be in vain. so DISEASES OF WOMEN. CHAPTER XI. ON POLYPI OF THE MUCOUS MEMBRANE OF THE AVOMB, OR SMALL TUMORS FROM; THIS MEMBRANE. It is a common thing for large tumors to make their appearance from the body of the womb—that is, in- ternally. Those tumors are sometimes developed from the surface and at other times from the body of the organ or its walls, and do not, during the Avhole course of their developement, evince any tendency to detach themselves or to project into the cavity of the womb. At other times they are from the beginning more or less free in the cavity, and they gain consid- erable size, but as their treatment is purely surgical, I do not propose to notice them at this time, and this chapter shall be confined to treating of a small tumor making its appearance from the mucous membrane, not larger than a pea or the end of the finger—vet they may be a little larger. Those tumors are an en- largement or thickening of the mucous membrane, growing out in the shape of a tumor and starting from the papilla? of that membrane. Those little tumors POLYPI OF THE WOMB. 81 do not have any connection with the sub-cellular tissue, that is, the tissue below the mucous membrane; but have their attachments perfectly superficial. Each one of those little tumors have in their central part a cavitv full of secretion, and this cavity is formed by the glands of the mucous membrane. The vessels are found in a kind of netAvork on the out- side of the tumor, and furnish blood and nutrition to the little polyp, or tumor. We have in all of those cases a congestion of the mucous membrane, and it is in proportion to this con- gestion that we have the tumors enlarge and their cavities filled Avith a liquid secretion. Those polypi are of two or three kinds, according to the glands or papilla? that they start from. Some are elongated or club shaped at the outer extremity, and are consistent and most compact; others, again, are thinner and full of bloodvessels with large cavities full of secretion. Those little polypi that Ave have been speaking of are generally found in the cavity of the neck of the womb, and not in the upper part, or summit. Here again we meet that common disease of the womb that we spoke of in the last chapter—namely, chronic catarrh of the womb; for Ave find in all of those cases of uterine polypi that they have been preceded by chronic catarrh of the Avomb for some time—even for months. Those polypi, or tumors, may undergo many modi- fications or changes in their character when much inflamed, such as ulceration, or even mortification. We find Avhere those tumors are very long and small S2 DISEASES OF WOMEN. at their attachments, or uterine attachments, that they may become detached by reason of their own weight and moATements, or twisted off from the surface of the Avomb. Now of course tumors of that kind and size would be calculated to have their influence on the Avomb, and present some strange symptoms; and those changed actions will be in proportion to the size of the tumor; and we find also that the locality of the tumor has a great deal to do with the symptoms. If the tumor is situated in the body of the organ the neck will not be changed by dilation, butAvill remain perfectly normal; but if, on the other hand, Ave find the tumor in the cavity of the body and it is of con- siderable size, it is then that the neck wTould remain in a normal condition and all the bad symptoms we Avould look to come from the body of the womb ; we would find the womb very much enlarged, and in some cases Avhere the tumor is very large they will bring on expulsive pains, resembling very much labor pains; and in some cases the tumor has been throAvn off by such pains and labor. To distinguish -this disease from other diseases of the womb, Ave have some trouble when the tumor is very small and situated near the summit of the organ and out of our reach, but Avhen it has made its appear- ance at the mouth of the womb Ave may Avith the ex- ploring finger readily distinguish the character of the tumor or disease; but we find most of these little tu- mors situated in the side of the neck of the Avomb, and it juts out at the mouth—so in this form we can very POLYPI OF THE AVOMB. S3 easily distinguish its nature and character. The in- sertion of those little tumors is important, for by this Ave can distinguish the kind that have their origin from the mucous membrane from those larger kinds that are developed and grow in the Avails and body of the organ ; and then, again, those large tumors that are developed in the Avails of the womb are scarcely ever formed in the neck or about the mouth. Where a polyp makes its appearance at the mouth of the womb it is easily recognized by its color, that of the mouth being very pale, Avhile the tumor is quite red. If Ave take a long probe and pass it in at the mouth of the womb and around the tumor, it will most always discover the insertion. It is quite easy to distinguish uterine polypi from any other tumor of the AAromb, if Ave pay attention to the signs and symptoms. First—in the mucous polypi we have a long slender tumor, club shaped at its outer extremity, with a small attachment to the surface, and can be readily tAvisted off from the mucous mem- brane Avith a pair of forceps, and resembles very much a leech Avith its mouth attached to the mucous mem- brane of the womb; while in the other form of tumors they make their appearance in the walls or body of the Avomb, and are round and more solid in their character to the finger. When the tumor is situated very high up in the cavity of the womb, it is more troublesome, but we must remember that those small mucous polypi are as a general thing situated in the cavity of the neck. S4 DISEASES OF WOMEN. TREATMENT OF POLYPI. There is, according to the symptoms, (me first or general rule to be adopted in the treatment of this disease, and that is to remove the tumor when it can be done, and Ave may say that it is the only plan of treatment that will stop the periodical pains. Some recommend us to use the caustic—and in doing so we should use the solid stick—but I think that kind of treatment will do no particular good ; besides it will make the pains in a great many cases worse, and at the same time not remove the cause. If the attachments to the mucous membrane be small we should get hold of the body of the tumor and tAvist it off from the sides of the womb. This can be done by introducing two fingers gently into the vagina Avith a pair of strong forceps, with which the tumor is to be seized and tAvisted off from its attach- ments to the mucous membrane of the neck or body of the womb. Sometimes when the tumor is very soft it is crushed Avith the forceps. In those cases it is best to take aAvay all that can be removed with the forceps and then apply the solid nitrate of sihrer to the point or attachment, and, by so doing, we may effect a perfect cure. We think that the tumor should be removed, al- though its removal may not be so simple as the above description would seem to indicate. If the attach- ments are very large, or high up in the womb, then our task is more difficult, and requires great care. POLYPI OF THE WOMB. 85 We find, then, that we cannot twist such a tumor from its hold, and Ave should bring to our assistance some kind of instruments, and we think the best instrument is a pair of scissors. We draw the tumor down as low as possible with the fingers, or with a hook, and cautiously carry the scissors near the surface and clip the attachments. Or, again, we may use the same treatment on those tumors that we use on tumors of the rectum, or piles; and we can, with perfect safety tie a ligature around the pedicle and allow the string to cut the tumor off. The ligature should be placed around the pedicle as near the surface of the womb as possible. 86 DISEASES OF WOMEN. CHAPTER XII. CANCER OF THE WOMB.--GENERAL REMARKS. By the term cancer, we mean a morbid or unnatu- ral formation taking place in any part of the body. The natural, or normal cell of the parts is sub- stituted by the noted cancer cell. The growth in those cases is very rapid; so much so that, in a short time, the natural parts are removed by the new growth. When a patient is suffering from cancer of the womb, it is the vaginal portion of the womb that is affected first; and the disease gradually extends up the body and walls of the organ. After the disease has extended nearly all over the organ, the softening and ulceration extends from inwards out in such a manner that the circumference, or outer portion of the Avomb, is in an almost leathery condition, while the internal portions are nearly all swept away by this dreadful disease. And after the disease has extended thus far it is very common for it to extend to other CANCER OF THE WOMB. 87 neighboring organs, such as the rectum, bladder, and, in fact, to all the regions of the pelvis. We may say that the disease will extend to every part of the organs of generation, and even to all the body ; for, in a short time, it will become constitutional, and every gland in the body will feel the effects of this pain. We very often find, as the result of this disease, catarrh and dysentery of the bowels, and also the worst kind of derangement of the stomach and other organs of digestion. We have a number of different kinds of cancer making their appearance in the body, but the kind that we find in the womb, as a general thing, is the encephalic, or brain-like cancer. This kind is char- acterized by its abundant discharges and number of vessels, and a remarkable tendency to decomposition, and its ragged surface and ugly appearance. This form of cancer has a particular tendency to spread to neighboring organs, such as the bladder and rectum, and even penetrating the abdominal Avails. We wnll now Speak of the cause of cancer of the womb, and would say that the cause of this disease is but little known. We find the womb, as a general thing, attacked by this disease at a certain age, but as for the predisposing cause we know but little. The most common time of this disease is about the age of forty or forty-five, or about the change of life. Wo- men that have not borne children are more liable to those diseases, both of the womb and breast, than 88 DISEASES OF AVOMEN. those that have ; and then it Avould appear from all the facts in the case that Avomen that have been con- fined unnaturally frequently are more liable to this disease than others. It is impossible to give in all cases the cause, so we say that dark hair and dark complexions are more lia- ble ; then other writers say that fair complexions, with red or light hair, are more prone to the disease. It is some stimulating cause that has its starting point in the cellular substances of the womb, because of the natural action of the organ being set aside. This disease is much more common in large cities than in the country, and among the poorer classes who neglect their food and houses. Among the most prominent causes are emotions of different kinds. We find this disease to be fearfully great among this class of women. The first symptoms of this disease, as a general thing, will make their appearance shortly after such pernicious causes as immoderate action of a sexular character, which is a very fruitful cause of this dis- ease, and in a great many cases is the cause of the trouble by exciting some unnatural action or growth in those parts. In some cases leueorrhcea of long standing has been the exciting cause; changing the menstrual flow, and exciting the disease to action. Inflammation of the womb is set down as one of the first causes, exciting, in the first place, chronic enlarge- ment of the womb, sometimes with, and sometimes without ulceration; but in a short time other synip- CANCER OF THE WOMB. 89 toms of a cancerous nature Avill make their appear- ance. We may say that chronic enlargement of the womb may be in a very short time converted into a disease of a cancerous nature or character. SYMPTOMS OF CANCER OF THE WOMB. The symptoms that mostly accompany cancer of the womb are pain in the region of the organ of a lancinating character, bleeding from the parts, and a purulent discharge. These symptoms are found in some other diseases, such as we have been describing, as we find them in advanced flexion, but not in the same marked character. Cancer of the womb does sometimes exist without producing those exciting symptoms, and it is found in some cases that this disease will run its course in the first stages of the disease without exciting any consid- erable alarm; but in the last stages of the disease, and also in cases of cancer in old persons, the symptoms are very painful and marked. Now in young women the symptoms are very different from the very start. The first thing that will attract our attention is a change in the menses in different Avays. We may have dysmenorrhoea, or painful menstruation, and then the menses will be sometimes longer, and some- times shorter, with derangement of the digestive or- gans; the courses do not return at regular periods, but come too soon, and in some cases too late, and the 90 DISEASES OF WOMEN. flow may be too copious at some times, and at others too scant. The constitution, as a general thing, will not give way until the loss of blood, or the abundant secretions from the parts are of a puriform character from the giving way of the nervous system. In some of those cases the courses will return after being ab- sent for many years, and the flow of blood be so great as to endanger the patient's life; and this flow °f blood will be in proportion to the age of the pa- tient. We have in most all of these cases of cancer of the womb a very disagreeable odor proceeding from the secretion of the parts, which is one of the most marked symptoms of cancer of the womb; and lastly, we would say that the cancer pains are the most characteristic of all the symptoms. How to distinguish this disease from others. We find in the last stages of this disease but very little trouble in making up our conclusions; but in the first stages, when the patient's health is good, and she has not suffered from any pains, or excessive loss of blood, we have some difficulty in coming to a true knowledge of the disease. We would naturally think that in a disease so dangerous as this we should have some signs or symptoms that would not lead us astray, but we find that all cases are not alike. We may have two cases in the early stages of the disease, and find one very different from the other. Now if we take the different swellings, and the hardness and complete absence of sensibility, and the appearance of the dis- CANCER OF THE WOMB. 91 ease on the turn of life, we may say that they are strong characteristic signs of this fearful disease. The termi- nation of this disease is always unfavorable, notwith- standing the many cases that have been recorded by different persons at different times. The duration of this disease is very variable; it de- pends in a great measure on the patient's age. If she has passed the change of life before the disease has made its appearance, then it is more likely to con- tinue for some time; but if the disease is developed in young women who are menstruating, the periodical congestion hastens the cancerous infiltration and soft- ening; and on the other hand gives rise to the loss of a great amount of blood, which soon exerts an injuri- ous influence on the whole constitution. TREATMENT. As for the treatment but little can be said. The disease is incurable, and it is so thought by all sensi- ble men. Ignorant and superstitious people tell us of Faith Doctors, Indian Doctors, and long-eared doc- tors of different kinds that haA^e cured it, but that is both ignorant and Avicked; and yet, in spite of science and education, we find in every part of the country persons that are always ready to run after such things. If Ave have the good of our patient at heart, Ave should tell her in plain language her true condition, and not trv to take advantage of a dying woman for the sake of a little money. 92 DISEASES OF WOMEN. Now we have two or three kinds of cancer making this appearance in the body and neck of the womb. In the first place we have scirrhus, or hard cancer, which is not so destructive to the parts as the kind we have been describing, and which yields more readily to treatment than the soft cancer ; but unfortunately for our treatment, we never see the disease until it has extended into the body of the womb, and then an operation to remove the disease from the neck would do no good. If the disease is limited to the vaginal portions of the womb, or neck of the womb, it might be possible to remove the neck, or diseased portions and hope for some good. But I must say, in conclud- ing my remarks on this dreadful disease, that it must be remembered that all treatment that we can use is of a palliative nature, and can only be directed against the local symptoms without any hope of curing the disease. CHANGES OF MENSTRUATION. 93 CHAPTER XIII. ON THE CHANGES OF MENSTRUATION. We speak in one of our first chapters of the physi- ology of natural menstruation. We propose now to Bpeak of changed, or disturbed menstruation. In the phenomena of the female organism, we have a series of changes taking place which have for their object the periodical ovalation, or the periodical menses or courses. By the term ovalation, we mean the changes that take place in the ovarieB once in every twenty- eight days, and the bringing forth of the little ripened egg which ruptures the sac that contains it in the ovaries, and through the agency of the two central ducts, or canals, find its way into the Avomb. The exact phenomena of this yet mysterious change are to a very considerable degree closed from our science, be- cause those changes that take place in the ovaries and canals from the ovaries to the womb are unapproacha- ble during life. And when Ave come to speak of the morbid or diseased action of those organs in connection with the diseased action of the breasts, and at the same 94 DISEASES OF AVOMEN. time remember that all the bloodvessels and veins in those parts havTe undergone similar changes, we find ourselves with our present knowledge of this action almost lost; or wre can say with justice to ourselves, and justice to others, that a great part of those changed and natural phenomena is concealed from our ob- servation. But before we commence to speak of the diseases that are apt to follow from the obstructed courses, we will speak of some of the anatomical changes that are so apt to folloAV a function so important as this. We find that a congestion of all the genital organs takes place periodically as well as of the ovaries; that is, the congestion is not only in the ovaries, where the egg is found and brought forth, but extends to all the genital organs of the womb and its appendages, and this is now generally acknowledged by all of our first-class books on physiology and diseases of women. But it must be remembered that the periodical congestion has its starting point in the little sac containing the ripe egg in the body of the ovaries. If the sac con- taining the egg is superficial, the congestion is not so great; but if,the egg is situated deeper in the body of the ovaries, the congestion will be more extensive. This is verified in a single case. We find that in the same case the woman is not always the same ; for in some months she Avill be better than in others; she will have more pain and longer, and the flow will be much greater at some times than at others. After the egg has been discharged from the little CHANGES OF MENSTRUATION. 95 sac that contained it, the walls of the cavity soften and grow thicker; the external layer of this sac con- tracts and assists in filling the cavity ; and we find after healing has begun, that the cavity is full of blood. But the walls of the sac soon glue themselves together, and the liquefied clots of blood are allowed to escape, and the healing process continues until the cavity is only marked by the appearance of a scar in the shape of a star. Those we have remaining and marking every one of those ruptures in the ovaries, small bodies called corpus luteum. Then we find from this description, that after very many menstrual periods, and every one leaving one of those yellow bodies to mark their rupture, or the discharge of the egg, that the ovaries would appear very rough and un- even. This roughness is very much marked in old women who have menstruated a great many times, and whose ovaries have undergone absorption, and are reduced very much from their natural size, or whose ovaries are atrophied. But it must be remembered that the womb undergoes congestion, or participatos in the menstrual phenomena of which the ovaries are the cause. In the congestion of this organ its vessels are en- gorged and full of blood, and at the same time the mucous membrane is very red and congested, and at the same time the glands of the neck and body of the organ have undergone quite a change, and have be- come very sensitiATe and tender, and, at the same time, very painful. in those cases the mucous membrane 96 DISEASES OF WOMEN. undergoes a periodical catarrh; after this condition remains in the organ for a short time the bloodvessels of the mucous membrane become very much relaxed, and, as a result of this condition of the mucous membrane, the bloodvessels become ruptured and a bloody discharge takes place from the genital organs. This is the menstruation or monthly courses. Now, we find after this state of things has continued for some time in a natural way, that the mucous mem- brane of the Avomb, or the lining to the mucous mem- brane, called epithelium, becomes detached and falls off. But in other portions of the genital organs the changes are limited to softening, congestion, and in- creased sensitiveness. And Avhile the genital organs are undergoing such marked changes, the breasts take on sympathetic action and become tumefied and begin to swell, and are very painful. It is not uncommon for the nipple to become very red. At such periods we find that changes that the sexular organs undergo provoke in other parts of the body sympathetic ac- tion of an abnormal character, which proves to us the powerful influence that the sexular organs have on the whole body. The nervous system is very much changed during the menstrual period, and this changed condition of the nervous system may be preceded and accompa- nied by some mental and moral disturbances of a melancholy nature. During the menstrual period the functions of digestion are very varied and changed; sometimes the appetite is very good, and at others CHANGES OF MENSTRUATION. 97 a perfect abhorrence for all kinds of food is felt; and this condition is felt on the bowels, causing diarrhoea, or constipation, and even colic, by the accumulation of different kinds of gases. 98 DISEASES OF AVOMEN. CHAPTER XIV. ON PREMATURE MENSTRUATION. Phenomena of some kind manifest themselves in the female economy about the age of thirteen or four- teen, either in the discharge of blood or by some other changes in the body and genital parts, that teach us that the state of puberty is about to arrive, and that the organs of generation have been fully developed and the egg ripened. The generative organs have gained their majority, and the manifestation or pres- ence of the courses is direct evidence of that fact. Before the ovaries have had time to properly develop, it is eAadent that menstruation can not take place, nor have a regular course. We would draw our con- clusions from this—that none but women that have arrived at the age of puberty could menstruate; but we find the facts in the case very different—for girls not more than three or four years of age have been known to menstruate regularly, and everything would teach us in those cases that it was the appearance of the natural courses. The breasts would be enlarged and the menstrual discharge would be perfectly PREMATURE MENSTRUATION. 99 natural; "yet Ave may have local discharges taking place from those parts in girls that have no appear- ance of the menstrual discharges. This local dis- charge takes place sometimes in newly born children in consequence of a change in the circulation of the blood about the time of birth, and at other times it is present Avith older children who are suffering from some skin disease, such as small-pox or measles. These discharges can be distinguished from the men- strual IIoav by their cause, and frequency, and traced to some blood disease, or Avhat is knoAvn as blood dis- ease ; and then, again, they appear only once or do not appear regularly, as do the courses in women. And all the facts in those cases go to prove that the discharge is produced by some local, and not by any premature development in the girl's generative or- gans, and can not be considered as the regular courses of the ovaries and womb. The female organism does not always suffer from premature menstruation, for cases have been obseiwed where the hemorrhage from the generative organs was very great, Avithout any bad effects on the woman's general health ; and then, again, other facts on the same subject go to prove that the great loss of blood may be followed by antenna, or prostration, and general debility of the whole system. Those great losses of blood may, by debilitating the system, be followed by the very worst kind of symptoms and diseases, after the general strength has been reduced below the natural con- dition. It may be followed by fatal disease, such as 100 DISEASES OF AVOMEN. consumption, dropsy, or other affections that would be calculated to prostrate and wear out the patient's strength. Then, in a case of changed menstruation, the greatest care should be taken in all cases that Ave come to proper conclusions at once, as Ave know that more can be done in the first stages of the disease than can be done after the disease has made permanent and lasting impression on distant organs or brought a change in their own parts, and all the more where we know that after this morbid condition has been es- tablished that nearly all efforts to bring about a per- manent cure will be in vain ; for I think that in those bad cases of obstructed menstruation of long standing all our efforts to bring about a cure will be powerless. Exercise in the open air, baths, cold water appli- cations, and proper hygienic regimen should consti- tute our treatment in those cases, together with good diet and a proper use of tonic medicines, such as whisky, brandy, and the simple tonic barks, Colombo, gentian and cinchona ; but I think we can do more good in those cases of changed menstruation of long standing, with extreme debility and prostration of the system, with iron. Take the tincture of iron, twenty drops three times a day, in a tablespoonful of cold water, after meals, and let this treatment be continued for six Aveeks or tAvo months, not forgetting the hip baths every night at bed time. SLOW MENSTRUATION. 101 CHAPTER XV. SLOW MENSTRUATION. Now if we call menstruation premature that occurs before the proper time, it Avill not be very difficult to say that if the courses appear before the thirteenth year it will be premature menstruation; but the case is different and not quite so simple when we come to speak of tardy menstruation. We may take the four- teenth year as the middle epoch for the menses to make their appearance, and for two or three years after that Avould be considered a delay ; but this de- lay is so frequent and common that we can hardly call it a disease or a pathological condition. Then Ave find that it is common for the menses to delay their appearance at the proper time, and it is not proper to call those cases diseases of the genital organs ; but if this delay in the courses continue too long, that de- lay will produce disease. The cause of tardy menstruation Ave may say is poor blood and general debility. This disease, as Ave know, makes its appearance about puberty, and if the 102 DISEASES OF AVOMEN. patient has proper treatment for the purpose of build- ing up the general health and improving the blood, rather than special medicine for the changed or ab- sent menstruation, it is not uncommon for the patient to go two or three years without menstruation. We find some young women that do go that length of time without menstruating, after the proper time has arriAred ; and yet this does not prove that the phenom- ena of internal menstruation are completely absent, for in some of those cases we find the patient suffering from dysmenorrhea, or painful menstruation, or an acute sensation about the mucous membrane of the womb; and those changes will be periodical, and re- turn at regular times. All of those facts go to prove in those cases, al- though they do not present any external signs of men- struation, that the work of nature has made its ap- pearance on the internal organs of generation ; and then, again, it can be proven that pregnancy has ta- ken place in some of those cases when the courses have never made their appearance externally. Now we may say in this connection that if the egg is properly developed and ripened in the ovaries, and rupture of the sac takes place and the egg is dis- charged into the oviduct and womb, that pregnancy can and may take place without any external signs of the menses, or courses. Now it is not uncommon for the body to be well developed and the organs of gen- eration retarded and not developed in proportion to the body. We haATe such girls in every town and SLOW MENSTRUATION. 103 neighborhood, where the size of the body would indi- cate de\relopment of the whole structure, and yet as far as the organs of generation are concerned, are nothing but children. Then we find that it is among this class of cases that we find young women Avell de- veloped and in robust health, with blooming appear- ance, remain for some time without the appearance of the menstrual discharge. The cause of such delays must be sought for in the organs of generation them- selves, and cases are rare where we cannot find some morbid conditions existing in the organs themselves; and in those cases where there are no marked changes taking place in the organs that would lead us to think that they Avere at fault, then we must look to the ner- vous system for defective innervation, as we haAre found that certain nervous alterations may prevent the congestion of the organs of generation, and there- by prevent the courses. Cases have been recorded where a woman menstruated regularly for years, and after paralysis of the lower extremities they never made their appearance again. Then we may say just- ly, I think, that a changed condition of the neiwous system is one of the most powerful causes of tardy or delayed menstruation. Sometimes we find the cause to be a change in the Avails of the womb and the ac- cessory organs, such as the ovaries, and this change mav take place by chronic inflammation of those organs. Sometimes the congestion that takes place in the ovaries for the purpose of rupturing the sac and discharging the egg has the opposite effect, and a 104 DISEASES OF AVOMEN. plastic exudation takes place between the mucous membrane and the walls of the womb, and an organi- zation of this plasma soon takes place where they will exert a continual pressure on the vessels, in such a maimer as to prevent a congestion again taking place; and in this manner the vessels of the mucous membrane prevent a pressure of blood, and Ave can see from this that a hemorrhage could not take place from the genital organs, or a menstrual discharge could not take place under those circumstances. Then we may say in this connection that chronic enlargement is one of the first causes of tardy or slow menstrua- tion. We may say that the influence of this disease is very variable. Sometimes we see women who have attained the age of tAventy-five or thirty years Avithout ever having menstruated, without any particular change in their health ; and then again, on the other hand, we find cases—and their number is not very small—who meet with a greater amount of trouble as a result of this condition—namely, a want of the menses at the proper time. And again, we should remember in this connection the increased sensitive- ness of the mucous membrane of the genital organs and what Ave so often observe in those cases, after it has lasted so long, and is subjected to certain changes ; and are due to this, that the menstrual congestion is not sufficient to rupture the capillaries and excite the secre- tion of the mucous membrane of the womb. And wre find that it is in those cases that Ave find chronic catarrh and leucorrlnea, which ever after the courses SLOW MENSTRUATION. 105 haA-e been established obstinately resist all treatment and medicine. Our experience teaches us that the delay in the courses, either by an abnormal condition of the genital organs or by some change that takes place in the organs of digestion and assimilation, are the consequences of change in the whole nervous system, and so give rise to the whole train of symptoms called hysterical. In making up our conclusion on this disease we should not fail to remember the cause of this abnor- mal condition. We wTould not expect a very favor- able conclusion if we knew the disease was depending on some development in the ovaries or other organs of generation. If we find that this disease, after a careful examination of all the symptoms and condi- tions, is depending on some organic changes in the parts themselves, then Ave would form an unfavorable opinion. We Avould have more hope if we found the case simply difficulties of innervation. 106 DISEASES OF WOMEN. CHAPTER XVI. TREATMENT OF SLOW MENSTRUATION. In speaking of the treatment of this disease, the causes will guide our choice of medicines, either in- ternally or locally, or whether they be in the form of regimen, or a general plan of constitutional treatment. Our first plan will be in a mild way to excite the menstrual hemorrhage, or local discharge from the genital organs, when its appearance is delayed too long. Now we found, when speaking of the cause of this disease, that it was depending on a want of congestion in the parts, and, in treating this disease, we should keep those causes in view, and use some plan of treatment that would be calculated to bring , about that condition ; and I think we can do more with warm water, in the shape of warm hip baths, warm fomentation over the region of the womb and ovaries, than we can Avith any other simple form of treatment ; but it is not uncommon to find cases that hot water is not sufficient to bring on the local con- gestion. In thos« cases we should use some stimu- TREATMENT OF SLOW MENSTRUATION. 107 lating or irritating medicine, but always in a careful manner, such as the flour of mustard, common salt, or even ashes in the warm water, and this solution should be throAvn into the vagina two or three times a day with a womb syringe, or a self-injecting syringe. We will find in those cases where it is possible to use the speculum to scarify the mouth and neck of the womb, it will be followed by the very best of conse- quences. And again, we may with propriety recom- mend in those cases of absent or tardy menstruation the use of a solution of nitrate of silver applied to the neck and mouth of the womb with a sponge made fast to the end of a long probe. And again, we may use other stimulating applications to the parts, such as the tincture of iodine or collodion. We should remember while using these and other treatment on those cases, that they are more powerful in their ef- fects just before the menstrual period than they are at any other time. 108 DISEASES OF AVOMEN. CHAPTER XVII. ON THE CESSATION OF THE MENSES PREMATURELY. We found, when speaking of menstruation, that it made its appearance about the age of thirteen, and disappeared about forty-five. We propose, in this chapter, to notice its disappearance before the natural time, or before the age of forty-five. We will say then that, as a general thing, a woman ceases to menstruate at that age, and that natural condition has been called the change or life. The ripening of the eggs terminates at this time, and pregnancy is impossi- ble. But we find cases very different from this gen- eral rule; the courses some times lasting much longer than that, and their cessation occurs at other times very much earlier. But we may say that women arrive at the change of life earlier who oegan men- struating before the natural time. If a woman be- gins to menstruate at ten or twelve years of age, she will arrive at the change of life much earlier than a woman who began at fourteen or fifieen. PREMATURE CESSATION OF THE MENSES. 109 Another cause of this disease is continual pains and frequent labors occurring at short inteiwals; and we find it again in consequence of abnndant losses of blood, difficulties in the digestive organs, and differ- ent organic diseases that find their way into the sys- tem at this particular time, any of which may be the cause of this undue cessation of the courses, and it is not uncommon to find in those cases an undue atro- phy of the ovaries, and other accessory organs of gen- eration, as the cause of this undue cessation of the courses; and then, again, it may be a family com- plaint, or hereditary predisposition. All the female members of the same family may be sometimes af- fected in this Avay. It was formerly thought by the old Avriters that the menstrual flow Avas the evacuation of some injurious substance from the blood, without which a Avoman could not maintain good health ; and then, from this course of reasoning, premature cessation of the courses wras thought to have the most dreadful effects on the general constitution, or on some of the organs of gen- eration. But Ave find that the menstrual flux is the result of Avell knoAvn changes taking place in the OA-a- ries and other organs of generation. Hence those opinions have been considerably modified, for Ave hoav consider the menstrual flow not a disease, or the result of a disease, but the result of natural changes going on in the ovaries, and the discharge from the genital organs is only the sign of that natural condition. We do not deny, however, that a sudden suppression 110 DISEASES OF WOMEN. of the menses will bring on the Avorst consequences, locally and generally; but we must remember that no harm results from a case of early cessation of the menses when haAring made their appearance two or three years before their natural time. Now Ave find, by exploration of the genital organs, that a great many changes that we find in their struc- ture that were considered or attributed to the cessation of the menses, should not be so attributed to their ef- fect, but to their cause. Now, if we were making up our conclusions on this point, it would be very import- ant to know Avhether in spite of the cessation of the courses, the ovaries did, or did not, go ahead and produce and ripen the egg; for the courses would only be suppressed when it Avas impossible for the en- gorged bloodA^essels to discharge their blood. We cannot fail to see that such engorgements of the mu- cous membrane of the womb, without a discharge, could not fail to do harm; but the most of those dan- gers will disappear when the cessation of the courses is caused by the absence of congestion in the parts. In making up our conclusions in reference to the appearance or non-appearance of the courses, or whether they be too fast or too slow, Ave must remem- ber that the external discharge from the genital or- gans is the only evidence that we have of their ap- pearance, and I think that it might be possible, and, in fact, we found it so above, that the ovaries might perform their functions, and pregnancy take place. PREMATURE CESSATION OF THE MENSES. Ill without any menstrual discharge from the genera- tive passages. Hence when those evidences of men- struation or the action of the ovaries fail, it becon e- almost impossible for us to know whether this func- tion is performed regularly. This will teach us, when making up our conclusions, that we should be very careful, for a proper knowledge is very important at this particular time; yet we need be rarely deceived if we do not attach too much importance to the exter- nal signs, for we do find cases where the cessation of the menses, or the external evidences of menstruation, have been set aside without any dangerous symptoms making their appearance. Now, in prescribing treat- ment for those cases, it Avill be better to use mild and tonic remedies, and give the patient time to gain her general health than to use much strong medicine for the purpose of stimulating the parts to action; and to beware of the useless preparations that have been proposed or recommended for suppressed menstrua- tion, for we find in some of these medicines, if they act at all, they could scarcely fail to do a great deal of harm by exciting congestion in the parts at an im- proper time, and bringing on the patient unnatural and dangerous symptoms. But if we are satisfied that there is a natural congestion taking place in the mucous membrane^of theAvomb, and it is at the prop- er period, then stimulating medicines may with care be used to a very good advantage. But Avhen Ave find that this premature cessation of the menses or courses has been caused by some organic condition about the 112 DISEASES OF AVOMEN. change of life of the organs of menstruation, the case is quite different, for all experience teaches us that organic changes of the womb and other organs of gen- eration, that take place about the change of life, make Arery rapid progress. I iioav propose to speak of menstruation when the cessation has been delayed too long, and the courses remain for years after the time comes for them to disappear. We may often find women of fifty years of age who are menstruating regularly; but after that age we do not often see Avomen have any menstrual hem- orrhage from the genital parts periodically. We find in some of those cases, however, when no regular dis- charge takes place; but this seldom ever comes from the womb by a sanguineous discharge from the vagi- na. We think that after the age of fifty it is impos- sible for the ovaries to produce and ripen the egg. We know that some very good writers claim that the menstruation, in a regular way, may take place, and from the egg produced pregnancy take place. We do not wish to say that such a thing could not take place, but we think it is going too far to claim that it actually does take place. We think that in all of those cases that have been recorded, that the action has been stimulated by some local cause, and the dis- charge has been locally, without any natural menstru- ation. We find in some of those cases when the men- ses remained too long, that the Avomb was very soft and enlarged, and the mucous membrane was con- PREMATURE CESSATION OF THE MENSES. 113 gested, and the cavity of the womb contained some blood. Those facts teach us that we should be very careful in making up our conclusions in those cases, and if a bloody discharge takes place from the genital parts, to be sure that it comes from the mucous mem- brane of the womb in a natural Avav, or whether it comes as the result of some local cause, such as polypi or chronic catarrh, or some other local disease. We do not consider such a hemorrhage as a menstrual flow, without it occurs at the proper time, and when it comes and goes at regular times, and Avhen the quantity of blood is neither too abundant nor too scanty, and when the bloody discharge is accompanied by a more or less complete series of changes, or phe- nomena, which characterize the ovarian changes, and when these changes are not brought on by some dis- ease in the organs of generation. We may say, in speaking of those cases, that, as a general thing, those pathological conditions, when the courses are prolonged two or three years beyond their natural time, do not produce any injurious influ- ences on the general health of the patient; yet we wish to remember that in those cases of prolonged menstruation, flooding of a dangerous character is ninch more liable to occur than at other times. We know that flooding is more liable to come on at an advanced age than at any other time, and we think that this cause is to be found in the changed condition of the uterine Avails and body and vessels, or blood- vessels of those parts. In this changed condition of 114 DISEASES OF WOMEN. the parts in old age, the parts lose the power to re- sist the pressure made upon them by the blood, and they become relaxed and give way under the press- ure and thus forming the rupture of the mucous mem- brane of the walls of the womb, or the rupture of the bloodvessels supplying the mucous membrane, and an extravasion takes place, or a loss of blood from those parts. As for the treatment, we should be governed by general principles. We found that this disease was depending on some cause, such as debility. To this end Ave should employ good diet and tonic medicines, such as the bark of cinchona and tincture of iron, recommended above, Avith hip baths, either warm or cold. AMENORRHEA. 115 CHAPTER XVIII. AMENORRHCEA, OR COMPLETE ABSENCE OF THE MENSES OR COURSES. We come now to the most important part of our book, and would ask special attention to the next three or four chapters. We propose also to speak in this chapter of vicarious menstruation, or Avhere the men- ses are substituted for something else, such as men- strual or blood discharges from some of the other organs of generation. We found in a former chapter that the menstrual discharge was only one of the symptoms of the process of ovalation, and that ovala- tion, or the production of the egg, might take place at regular periods, and pregnancy take place without the recurrence or returns of the menstrual Aoav. It is the absence of the menstrual Aoav from the external organs of generation that Ave mean by the term amen- orrhoea. The old writers on this subject considered ameiiorrhcea as a special disease, but Ave consider it a changed condition in the sexular apparatus, and in some cases the blood is at fault. We then consider 116 DISEASES OF AVOME1. ameiiorrhcea as a symptom only of some changed con- dition of the parts themselves, and not a special dis- ease, as it was thought to be many years ago. In speaking of the cause of this delayed condition in es- tablishing the coursps, Ave should not forget to men- tion the morbid state of the blo-ed as one of the first causes, and also the distant organs unconnected with the process of menstruation as one of the unfavorable causes. And Ave Avould say that a great many of those cases are suffering from the effect of chlorosis, scrofu- la, and tubeicuhn cci sumption. Those all have their effect on the nervous system to produce this disease If, then, it is a fact that ameiiorrhcea is only depend- ing on a changed condition of other organs and parts of the body, we should not enlarge very much on the cause of this disease, specially. It is true that a large number of cases belonging to this class have their menses suppressed by cold or other external causes; but we would answer that ever, in those cases that are suffering from this changed condition in the Aoav of the menstrual discharge, it is only secondary, for we ahvays find in those cases a changed condition in the womb or its appendages. We find that cold has very injurious effects on a Avoman who is menstruating where it occasions the suppression of the courses ; and then we are apt to find something following the sup- pression of a dangerous character, such as general or local inflammation of the parts. We have as a result of this suppression, in a great many eases, acute in- flammation of the Avails of the womb, followed by AMENORRHEA. 117 engorgements of the parts, producing premature ainenorrhcea, or suppressed condition of the menstru- al floAv. Now we find that the sexular apparatus un- dergoes certain modifications as the result of lively emotion, which prevents the congestion of the organs of generation, which is essential to the periodical ovalation, or maturation of ovaries, in a great many cases this condition of amenorrhcea or a stop in the menses is found to exist after a general bleeding. We must look for the cause in the blood. This blood has been so much reduced by the bleeding that its watery parts have gained the ascendancy, and now wTe have a state of general debility existing as the result of this loss of blood or this great drain on the system, and a case of ainenorrhcea existing as a result of this worn- out condition. We are informed by some authors that ameiiorrhcea exists in most cases as the result of improper food, high life, without proper exercise, and a neglect of a proper course of hygienic treatment. We should seek for the cause in such cases in a too great irritation of the nerves of the digestive organs, which occasions in them a considerable flow of blood to the parts and diminishes the congestion in the or- gans of generation; and in this way it will interrupt very materially the menstrual discharges. Now where this condition of the digestion continues for a long time and makes some lasting impression on the blood, we find that it will in this way bring on ameiiorrhcea, or suppressed menstruation, as the results of this con- dition of general debility, or anaemia. Then avc find 118 DISEASES OF AVOMEN. that a poor condition of the blood or a worn-out state of the activity of the system is one of the first causes of amenorrhoea or suppressed menstruation, and that this disease, whether acute or chronic, is only the re- sult of something that has gone before as a predis- posing cause, and by a continued influence on the blood has brought on this disease called amenorrhoea. We will find, however, that the influence of this change in menstruation is not so injurious on the system as we would think for without some consider- able thought on the subject, or even as we judge from the writings of some authors ; for it was taught by the old writers that menstruation was an excretion of all the impurities of the blood, and Avhen the menses were suppressed from any cause those unhealthy ex- cretions were retained in the blood. Some people are so foolish as to have the same theory about the liver, and in cases of torpor of that organ liver pills in the shape of calomel, or taraxacum, or some other of the so-called anti-bilious medicines, are given to force the liver to throAv off this oppressive bilious matter. Such a doctrine is preposterous, and will not stand the investigation of exact science for one moment. We think that the same rule will hold good in the case of suppressed menstruation, for the menstrual blood does not differ in any way from blood from other parts, and its exit from the vessels should not be considered as a purifying process for the whole system, but it comes and goes as a result of a periodical congestion AMENORRHEA. 119 which has its starting point in the ovaries, and the menstrual flow is the result of the congestion. If we are satisfied with our conclusion that we have just arrived at, we can see that it is evident that a suppressed menstrual flow could do the patient no harm, except when the periodical congestion of the organs of the pelvis takes place regularly, notwith- standing the amenorrhoea, for the menstrual flow could not take place without the local congestion of the mucous membrane was sufficient to induce the capillaries of the bloodvessels to rupture and pour out their blood. Noav it may appear to some that the dangers of amenorrhoea are much greater than we have made them appear in this chapter; and we think when we remember that they are local and only affecting the sexular apparatus, that we will make up our conclu- sion accordingly, as we find that the dangers formerly attached were very much exaggerated. We now propose to speak of vicarious menstrua- tion, or a substitution for the courses or menstrual discharge from other mucous membranes, in the place of the mucous membrane of the womb. We find in those cases of suppressed menses, or courses, that a local discharge takes place from other organs at regular periods, and resembling the character of the menses both in time and quantity of the flow- AVe must say that Ave have some of the very best authors who doubt this condition, or who doubt that this condition is a true menstrual flcnv. We cannot 120 DISEASES OF WOMEN. but think that such a condition does at some times exist, but whether or not it is a true menstrual con- dition I am not prepared to say; yet I am inclined to think when a hemorrhage or flow of blood takes place from other organs aside from the genital organs that this bloody secretion is depending on some local cause in the parts themselves. This may be brought on by an excessive amount of blood or bloodvessels, called vascularity, and at the same time the walls of the mucous membrane of those organs may be very thin ; for we know that periodical ripening of the egg in the ovaries of most women excites to a very great degree the vascular congestion of nearly all the or- gans in the body, and in a majority of cases we have local as well as general phenomena making their ap- pearance. Now if at such periodical epochs the circulation of the blood be increased and those organs are full of blood, and the wall of the bloodvessels being unnatu- rally thin, the energy of the increased circulation will force the blood through the mucous membrane and we will have an external hemorrhage. We will have the very same results follow the copious bleeding during menstruation. If the bleeding be very abund- ant, so as to cause the local congestion in the womb, we will have no menstrual flow from the parts ; but if, on the other hand, the local congestion in those distant organs be high and the bleeding from those organs very scanty, local congestion in the mucous membrane may be sufficient to cause the blood to AMENORRHEA. 121 break through and produce a menstrual discharge from that membrane or from the womb. We find, then, that a congestion in distant organs when that congestion is sufficient to produce a local discharge from the external parts, is sufficient to produce amenorrhoea, or suppressed menstruation from the mucous membrane of the womb. Those local bloody discharges which take place from distant organs, such as the lungs, stomach, and the mucous membrane of the boAvels, are Avhat have been called vicarious men- struation. We should remember, in making up our conclusions on this disease, that this supplementary menstrual discharge takes place from some mucous membrane whose great vascularity predisposes it to this hemorrhage or loss of blood, as in the case that we haA-e cited above—lungs, stomach, and mucous membrane of the intestinal canal. We find, howTeArer, that supplementary menstrual hemorrhage has no great importance and no serious results are observed, unless in those cases where the loss of blood is very great, as sometimes occurs in cases of spitting of blood from the lungs, called haemoptysis; or in spitting of blood from the stomach, called gastorrhagia : or to functional disturbance of some of the important or- gans. Now we find by close attention to this subject that in a majority of those cases the disease has dis- appeared in a longer or shorter time, of itself, or by the use of a judicious plan of treatment. This disease does not interfere with conception, but Ave have ob- 122 DISEASES OF WOMEN. served that after pregnancy has taken place the vicarious menstruation from distant organs dis- appears. We wish now to speak of another peculiar change that takes place in those cases, besides a local hem- orrhage from distant organs, and that is a local secre- tion, or a very much increased secretion in the organs of generation, such as the mucous membrane of the vagina and womb, and this is periodically, at the same time as the menses, accompanied by amenorrhoea; but we must remember that a majority of those cases are suffering from a peculiar condition of the blood called chlorosis. We know that in this disease the watery properties of the blood are very much in- creased, and this unequal distribution through the vascular system is said to be the cause of this exces- sive secretion in those parts, or is the cause of the disease that we call chlorosis; and in those cases of chlorosis, or general debility, we find suppressed menses or amenorrhoea. TREATMENT OF AMENORRHEA. We found in treating of the symptoms and causes of amenorrhoea that it was the result of general or local diseases affecting the genital parts. Now it is evident that we could not expect any good results from the use of medicine, without treating directly against the primary affection, which we found to be the exciting cause of the disease. Doubtless the treat- ment directly against the cause of amenorrhoea is sec- TREATMENT OF AMENORRHEA. 123 onded by the application of medicine which is calcu- lated to combat this grave symptom. We will now speak of those medicines called em- men agogues, or medicines that are calculated to stimulate the mucous membrane of the womb to pro- duce the menstrual discharge. They all occasion a flow of blood to the parts, and assist the local conges- tion. They nearly all have the same effect. This local congestion caused by those medicines unites with the menstrual engorgements of the bloodvessels of the mucous membrane of the womb in such a manner as to rupture the capillaries, and a hemorrhage takes place, or the menstrual flow takes place. We find that the effect of all those stimulating medicines called emmenagogues have a different ac- tion. Some of them have a special or local action, while others have a constitutional or general action. We find, also, that heat has a powerful action on the bloodvessels of the mucous membrane of the uterus or womb, and one of our very best treatments in this disease is Avarm water, in the shape of warm hip- baths, or applied locally by means of a womb syringe or a self-injecting syringe, and in obstinate or bad cases this application of warm water should be con- tinued for some hours. We say that this is one of the very best plans of treatment, and the Avater should be thrown up into the vagina Avith some considerable force. We will find that the power this stream has from the syringe has a great deal to do with the effect that the warm water litis on the mucous membrane of L24 DISEASES OF WOMEN. the womb for good. The stimulating powers of this warm Avater on the Avomb can be very much increased by the addition of some irritating medicine, such as the flour of mustard, liquor of ammonia, or even warm milk ; and you will do Avell to retain the liquid in the vagina by means of a sponge. We find that some Avriters on amenorrhoea recom- mend the injection of Avarm stimulating medicines in a liquid form into the cavity of the Avomb, but I am of the opinion that such a plan of treatment would be very dangerous, and likely to produce uterine colic and inflammation of the lining membrane of the bowels, called peritoneum. We think, therefore, that we should be very cautious about using such heroic treatment. We may continue our warm injection, with stimulating medicines in the warm water, to the rectum; and in those cases we may use a solution of aloes or mucilage in the warm water to be injected, with the very best results. I think that in all those cases of suppressed menses we should use mild treatment and give the patient a fair opportunity to gain her general health and get well. I think that too much dependence is put in strong stimulating medicine, and not enough paid to the causes of the disease. Leave off everything that is calculated to assist the trouble, go to bed at the proper time, bathe the body regularly in warm water, and be constant and regular in your habits. In cases of chronic congestion of the womb we may obtain the very best result from scarifying the TREATMENT OF AMENORRHEA. 125 neck and mouth of the womb with a small knife made fast to a long probe ; but this should be used with great care, for after the use of the warm water we find the engorgements very great, and then a free use of the knife may produce some very dangerous symptoms in the way of flooding. And let me say here—once for all—that we should use great care in treating any or all of those diseases of the womb. There has been too much recklessness manifested in the treatment of those diseases. If we wish to use a local stimulus for the purpose of bringing on the menses, we will find one of the best in the shape of a suction apparatus ap- plied to the nipple. The local congestion that this little irritating machine will produce is sympathetic action, and will be extended to the genital organs. Some use mustard or other irritating application to the breasts in those cases with very good results, but the principle is the same as that of transferred sym- pathetic action from the breast to the womb. It is possible for us to do a great deal of good with consti- tutional treatment, having also a local action. We may employ such medicines for this purpose as myrrh, ergot;, nitrate of potassi, and iron, making our selection according to the symptoms and condition of the patient's health. If the patient is suffering from great debility, and the watery properties of the blood are in excess, then Ave should use some preparation of iron, and I think the tincture is much the best, being in a liquid form; 126 DISEASES OF AVOMEN. and if taken after meals, it will be taken up with the food and assist very much in enriching the worn out blood. Tincture of iodine, continued for a long time, assists the process of digestion, and thereby the com- position of the blood, and at the same time, perhaps, has an absorbent effect on certain organic diseases of the womb. Again, we may say that aloes is one of the very best medicines that we can use in those cases, for the pur- pose of assisting the local congestion, and thereby bringing on the courses; but this medicine should be used with great care, as its effects on the organs of generation are very great, and it wrould be well to use it with some other medicines, such as myrrh. But we may say that the use of those medicines alone will never cure a case without the use of local and hy- gienic means on the part of the patient herself. We will speak a few words about the treatment of supplementary, or vicarions menstruation, although wre can do but very little in the wa}Tof treatment; and in fact we are in favor of the opinion that nothing should be done without the general health of the wo- man demands it. We have some cases Avhere the blood flows from a wound or an ulcer; but when the wound or ulcer is cured the changes in the men- strual flow generally disappear. Now if Ave take one of these ulcers, or fistulas of lnog standing, which has been the cause of vicarious menstruation, we will find that it is very hard to dispose of, because of the TREATMENT OF AMENORRHEA 127 periodical congestion of the parts, and then it is very hard to control the menses, or courses, because of the diseased parts having such an influence on them. us DISEASES OF WOMEN. CHAPTER XIX. OF MENORRHAGIA, OR AN ABUNDANT MENSTRUAL DIS- CHARGE OF BLO>>D, OR FLOODING. Flooding is not exactly proper in speaking of this disease, but we find that in some of those cases the flooding is nearly as great as it is in abortion, or after labor. We will speak of the causes of this disease, and we find that the change in the blood, Avhich predisposes in general to too abundant local congestion in those parts is one of the first causes; and then some cases are so peculiarly or morbidly constituted in their organism as to determine an excessive menstrual congestion of all the organs of the pelvis, or organs of generation, at the time of the menses, or courses. It is in those two changed conditions during the course of which there is a great excitement in the circulatory system, coexisting with a changed condition of the blood, which predisposes it to flowing or flooding. And Ave find also that this condition of the blood is found in other conditions or diseases, such as measles, scarlet MENORRHAGIA. 129 fever, and some other skin diseases, during the exist- ence of which a great local discharge takes place from the genital organs. Now Ave find during the course of some long continued diseases or fevers, that as a general thing the courses are suppressed ; yet they may be changed the other way, and flooding take place in a very dangerous way, so much so as to exhaust the patient's feeble force, and hasten a fatal termination. We find in nearly all those cases of a very copious menstrual flow during the progress of these fevers or diseases, that it is depending on some morbid change in the blood; and in those conditions, if local dis- charges take place from the skin, nose, rectum, or oth- er parts, they are very unfavorable symptoms. Nearly all chronic diseases of the blood, such as scorbutus, which have been produced by an improper diet, and a want of vegetable, as Avell as animal food, may be folloAved by an increase in the menstrual flow. The same thing holds good in all cases of anaemia, or general debility, and even in scorbutic patients, when the thinness of the blood favors the extravasation, or increase of the menstrual discharge, or flow. We find the cause of menorrhagia, or too abundant menstrual flow, to be depending on the circulation of the blood, or the venous part of the blood, as it is re- turning to the heart, meets with opposition, as in case of valvular disease of the heart, producing congestion in the parts, or in the Avails of the Avomb. The blood vessels of the mucous membrane of the womb gorged 130 DISEASES OF AVOMEN. Avith blood must then be ruptured and give rise to the menorrhagia, or flooding. And we may have certain local affections producing menorrhagia of the womb, such as inflammation of the organ; yet it is not uncom- mon for inflammation of the womb to produce sup- pressed menses; however, we do have cases of acute inflammation followed by the worst kind of menorr- hagia, or even flooding, when the acute congestion of the womb often returns, or when from continued dif- ficulties it passes into a chronic congestion, or infiltra- tion of the body or substance of the womb takes place, and sometimes is followed by flexion, prolapsis, tu- mors, or other abnormal position and condition of its parts. All of those cases are predisposed to rupture of the bloodvessels lining the womb. Thus it plays an important part in producing menorrhagia, or abun- dant menstrual flow. We will mention here that those uterine diseases which cause more or less loss of the substance of the the womb are a cause of menorrhagia, or too abundant menstrual flow. Those excessive discharges of blood are apt to follow granular degeneration of the body of the womb, and also cancer and ulcer of the organ ; and we find that in cancerous ulcers of the womb this symptom of flooding at times is scarcely ever ab- sent; and we will mention while on this subject, the growth of plastic bodies situated in the walls of the womb, fibrous bodies, fibrous and mucous polypi, all of these produce a local congestion of the organs and are almost always the cause of ruptures in the mucous MENORRHAGIA. 131 membrane, and consequently the cause of the men- orrhagia. We find from what we have learned about this dis- ease that in nearly every case menorrhagia is only a symptom, and cannot be considered as a special mor- bid condition of itself, and without forgetting its im- portant relation to the entire body, or economy, we should study carefully the primary causes thar pro- duce it. And, in fact, this rule will hold good in menorrhagia that Ave found to be true Avhen speaking of other diseases of the genital organs, that in nearly every case they had been brought on the patient and supported in the system by some exciting cause suffi- cient to bring about a changed condition in the parts, and those diseases, such as menorrhagia, amenorrhoea, and in fact all of those troubles, were only symptoms of those changed conditions, or the common action of those changed organs or parts. 132 DISEASES OF AVOMEN. CHAPTER XX. DYSMENORRHEA, OR PAINFUL MENSTRUATION. By this term we mean a changed condition of the effects produced by menstruation from its natural or normal state to one of an abnormal or painful condi- tion. Now, we found, while speaking of the physiology of menstruation, that while in a state of perfect health, it was the cause of no notable difficulty, but it may be accompanied at the start, and continued through- out its course, with painful symptoms of a very fear- ful and disagreeable character. This is what we call dysmenorrhoea We have spoken of a great many ute- rine diseases which would giA-e rise to dysmenorrhoea, and will speak of this condition as we have of others as a symptom of some other general or local trouble, depending on some cause, such as flexion, fibrous po- lypi, cancer, and inflammation. Now, when we find a case of this kind, we call it organic dysmenorrhea, for we must make a distinction in this disease, for we find some cases that are purely nervous, or functional, DYSMENORRHEA. 133 and in speaking of this disease we shall speak of those tAvo kinds. Nervous dysmenorrhea we find in women who man- ifest an excessive irritation of the entire nervous sys- tem, or different portions of it. Those women are nearly all hysterical, and, by close examination, it is not difficult to observe in them some of those symp- toms. But we should not judge from this that those cases tiro confined to the delicate, nervous, anaemic patient, for Ave find this form of dysmenorrhoea in strong, robust, plethoric women of good constitution. The symptoms of nervous dysmenorrhoea generally make their appearance two or three days before the menses make their appearance. The woman will evince a bad humor, be sad and downcast in her ap- pearance, avoiding company, and seeking solitude, complaining of a general disturbance, Avhich appears to run all over her, and which she cannot explain or define. They are very often affected with a very disagreeable disturbance of the digestive organs, and it is not uncommon for the patient to be seized with violent vomiting. Constipation follows those cases, and in fact the entire intestinal canal evinces consid- erable disturbance, and the process of digestion is nearly set tiside, and after this state of things has been continued for some considerable time, this mor- bid action of the bowels brings on a nervous headache sometimes in one side and sometimes in the other, and sometimes in both at the same time. This head- ache may bo followed by changes in the sight of the 134 DISEASES OF WOMEN. eyes, and at times may be partially dim with an excess- ive secretion of the lachrymal glands, or an abundant flow of the tears, and then by degrees a dragging, painful sensation in the organs of the pelvis. Those pains are of a floating character, and are limited to the region of the womb, radiating towards the small of the back, and also to the breasts. The external parts are rigid and constricted, and at the same time convulsed; the urine is changed to a straw color and is alkaline in its reaction, and contains a great many organized bodies resembling vegetable growths, and as the menstrual epoch makes its appearance, these symptoms gain their maximum intensity, but when the courses have been well established, they gradually subside, and we find cases of those who suffer intense- ly just before the commencement of the courses, that are perfectly well some hours after, and get up and at- tend to their every day Avork. With each period those attacks are more or less painful and severe, and it is not uncommon for them to suddenly disappear with- out returning again, and we are not able to discover the cause of this condition. In this form of dysmenorrhoea, an examination will not reveal any anatomical alteration, either in the womb or the appendages to the womb ; yet it should be remembered that in dysmenorrhoea of an organic nature the menstrual epoch is preceded by symptoms analogous to those just described. The cause of dysmenorrhoea is not very well under- stood, more particularly the nervous kind. It is pos- DYSMENORRHEA. 135 sible that the abnormal irritation originates in the ovaries. At this particular time the nerArous irrita- tion of the womb exists at its highest, and both taken together may prevent the flow of the menstrual dis- charge. This engorgement, Avithout the menstrual flow, may produce pressure of the nerve filaments, and in this way cause painful menstruation, or dys- menorrhoea. Again, we may say that the abnormal irritation of the nerves of the organs of generation may cause re- flex action on the neck of the womb, causing that organ to contract aud shut up in the body the al- ready secreted blood, and thus cause painful men- struation, or dysmenorrhoea. And Ave find this is just what takes place. After a strong pain lasting for several hours the patient suddenly expels a large quan- tity of blood, which is sometimes coagulated, and at other times liquid, followed by almost instant relief. In making up our conclusions, we may say that a fatal termination need neA7er be feared in this disease ; yet it Avill produce some of the worst kind of symptoms, such as hysteria and other abnormal nervous troubles. We have said that it constitutes one of the symptoms of hysteria, yet this disease may be produced by other causes, especially if a predisposition exists in the pa- tient to it, or to this disease. Those troubles of a hysterical nature may he direct and immediate, or indeed the digestive organs may be affected by it in a sympathetic way, all caused by an increased action of the nerves of those parts. 136 DISEASES OF WOMEN. This course of things may continue until the process o*/ ■*- of assimilation is set aside in part or entirely. The ner- vous system in those cases would suffer for Avrrnt of nutrition, and in the course of which the irritability would be considerably augmented. Those symptoms all taken together are what Ave call hysteria, which is always a nervous disease and real. I know that a great many think that this trouble is all a notion,or supposition; but hysteria is a disease of a nervous character, resulting from an excessive action of the nerves supplying the organs of genera- tion. It is said by some very good Avriters that ner- vous dysmenorrhoea is the cause of anatomical chan- ges in the structure of the body of the womb, but we are inclined to think that organic changes are the cause of dysmenorrhoea, and that those organic chan- ges have existed for some time in a latent stage, and have escaped exploration and notice of the patient. We may often find just such cases after some organic changes have been noticed. TREATMENT OF DYSMENORRHEA. In treating this disease, wre should at all times re- member its cause and origin; and as Ave found while treating of its history that it was produced by some excessive action in the neiwous system, we should conclude that narcotics, such as opium or belladonna, Avould play the most important part in the treatment of this dreadful disease. For local application avc DYSMENORRHEA 1 9" may use chloroform and aconite in the shape of liniment over the region of the womb. Take one ounce of chloroform to three ounces of tincture of aconite and make a liniment and use as di- rected. We should be very careful with this liniment as it is very poisonous. Wash the hands and parts after its use. Medicated balls may be used and introduced into the vagina. Take some kind of wax and lard mix with belladonna or opium, and make into small round balls, and press them up against the womb, and let them remain two or three hours. We gain some of the very best results from their use. Sometimes we can use these same medicines in the shape of injections. Take twenty drops of tincture of opium in a tea cup of warm water, and use as an injection into the vagina. The injection should be retained there for some time. Finally Ave think more can be done with warm wa- ter injection in those cases of constricted and painful menstruation, when the pains are the result of the ob- struction of the flow in the neck of the womb, (and we think that this is, as a general thing, the cause of the pains,) than can be done Avith any other form of treatment. We should have the patient sit doAvn on a large vessel of warm Avater, and use a self-injecting syringe. This treatment should be continued for twenty or thirty minutes, and then repeated in a short time. L38 DISEASES OF WOMEN. This plan of treatment may be very much assisted by the use of warm hip baths. This last treatment should not be neglected. In all of those cases it should be continued every day. With or without the pains, after the courses have left the patient, and dur- ing the interval, we should do everything in our pow- er to build up the general health, by good care, good diet, and, in fact, a good regimen in every particular. The patient should be put on a treatment of iron, and the best preparation is the tincture. It should be given in twenty drop doses three times a day, in a tablespoonful of Avater, after eating. We are to ex- pect the good effects of this medicine by its contin- ued use for weeks, or even for months. The object of the continued use of the medicine is to restore to the blood some material that it is deficient in, and that is its coloring properties. We can do more in restor- ing to the blood its color with iron thau Ave can with any other medicine. I would recommend to be used during the interval of paroxysms the tincture or fluid of black snake-root. The fluid extract may be given in twenty drop doses, in one ounce of water, three or four times a day, and this should be contin- ued two or three months. We find that some of the very worst cases yield to this treatment, after every thing else has failed. And, lastly, in this nervous form of dysmenorrhoea, of a hysterical character, we may use what is called anti-hysterical medicines, such as castor, assafcetida, DYSMENORRHEA. 139 musk, and amber; but it must be remembered that all of our efforts will be in vain without good care on the part of the patient. 140 DISEASES OF AVOMEN. CHAPTER XXI. We will now speak of dysmenorrhoea of a conges- tive character, for we find quite a difference betAveen the nervous form of the disease just described and the congestive form. In this form of dysmenorrhoea we find all the symptoms to be of a congestive nature. All or nearly all of the organs of the pelvis, or the organs of generation^ undergo a decided congestion two or three days before the time for the menses to make their appearance; the patient feels a sensation of fullness, weight, and heat, in the region of the womb, pain about the small of the back, a frequent desire to go to stool, the bladder becomes irritated and painful, with a desire to uriijate frequently : and this as a general thing is followed by symptoms of a febrile character, first in the organs of the pelvis and then extending to the Avhole system. The face is red and full, the pulse strong, and the signs of cerebral or brain congestion make their appearance very fast, and this is followed by a distressing headache ; and it is not uncommon for this abnormal condition of the vascular system to give rise to palpitation of the heart DYSMENORRHEA. 141 —and sometimes Avith delirium, convulsions, or coma. Noav if Ave turn our attention to the organs of genera- tion wre find the temperature of the vagina very much increased, the womb is very much enlarged, tumefied and painful. This tumefaction as a general thing disappears in a short time after the courses make their appearance, and is strongly marked when the dys- menorrhoea is complicated with a chronic engorge- ment of all the organs of generation. This engorge- ment and tumefied condition of the Avomb can be recognized by the patient herself, and we may say that the tumor has been enlarging for two or three days before the courses make their appearance. In the early stages of the congestive dysmenorrhoea on the first day the flow is very scanty, being some- times limited to a very few drops; but after two or three days the pains diminish in intensity and at the same time the discharge becomes more and more abundant, and the flow may become so excessive as to be pure blood and last five or six days. In those cases the floAv becomes coagulated and passes in clots; and in some of those worst cases the mucous membrane of the Avomb is thrown off, or a part of it, at any rate. We find it at times thrown off in small pieces, and at other times it will be one or two inches square ; it is ahvays in fragments. Those membranes are not found at every menstruation ; they will be present at one time and absent at others. This will depend very much on the pains, their duration, and their expul- sive power. If we have a very painful and long con- 142 DISEASES OF WOMEN. tinned case of dysmenorrhoea, with strong expulsive pains, we may then look for the membranes ; but if we havTe a very mild, with little pain or expulsive con- traction of the walls of the womb, the membranes will be absent. The patient as a general thing can tell a week or ten days before the menses return, by the symptoms in the region of the womb, that she will or will not pass those mucous membranes. Those mem- branes are formed on the internal side of the womb in a great measure in the same manner as the decidua, which is formed after conception by often and re- peated congestion of that membrane, and this of course would produce an excessive development. After the membrane has been enlarged to such an extent, its detachment takes place either by an accumulation of liquid between the membrane and the walls of the womb, or by mechanical force, caused by the pains and contraction of the organs, which precede the menstrual flow. Some tell us that this form of dysmenorrhoea is caused by a plethoric constitution, but we find this disease making its appearance in some patients who are at the time suffering from general debility; and we may go further, and say that nearly all of those cases are suffering from some form of anaemia, or a low and worn-out condition of the blood, wdiich char- acterizes the disease. It is a fact, however, that the debility does not make its appearance until after the dysmenorrhoea ; but we must remember that quite as often it makes its appearance before, and that the DYSMENORRHEA. 143 ansemia or general debility must be cured before we can do anything in the way of treating or curing the dysmenorrhoea, which is only a symptom of some- thing which has preceded it. In speaking of the cause of this disease we should not overlook the very many organic changes of the different organs of generation as stimulating and causing this form of dysmenorrhoea. In treating on the cause of this disease it should be borne in mind that the egg situated in the ovaries may be deeper and require more congestion and a longer time to effect the rupture of its sac than those that are superficially situated, and thus the menstrual discharge is kept up for a longer time, and as the egg is deeper in the substance of the ovaries it will take more action of all the muscles of the parts, and thus produce the pains of dysmenorrhoea. We may then with just propriety give this as one of the reasonable causes of this disease. We may say again that any change of the organs of the neighborhood that would obstruct the return of venous blood would cause congestion of the womb and be a cause of dysmen- orrhoea. In making up our conclusion about this disease, we may say that when congestive dysmenorrhoea exists without any organic changes in the parts themselves, it is more favorable than the nervous form, and is not as a general thing thought to be Aery dangerous, and wrill yield to treatment much more readily. The dis- ease is cured spontaneously much more frequently 144 DISK ASKS OF WOMEN. than the nervous form. We may at any rate count on relieving our patient to some extent if proper treatment is used. If the patient be left to herself in this form of the disease, and waits for a spontaneous cure, she will be veyv much disappointed; and the congestion will continue in the form of an exudation in the neighboring parts, as the body of the womb and ovaries. We will consider those cases less favorable when the mucous membrane of the womb is thrown off at every menstrual discharge, as described above, and when the disease is due to the formation of those membranes. We come now to speak of the treatment of this dis- ease, and would say that everything should be done in the interval of the periods to diminish the local congestion. This may be done in the first place with mild cathartics, such as saline waters or seidlitz pow- ders ; but we should never give strong cathartic med- icine, such as pills, calomel, or medicine of the same kind. We will find the very best results follow local bleeding, or scarification. This may be done with a small knife on the end of a long probe, and by the assistance of the speculum. This treatment should be on the mouth and neck of the womb, and continued for some time. Notwithstanding our patient is suf- fering from anaemia, or general debility, the treat- ment will unload the engorged bloodvessels of the mouth and neck, and even body, of the womb, with- out producing a too considerable loss of blood, which the patient could not stand at this time. DYSMENORRHEA. 145 We would very favorably recommend in this dis- ease the continued use of iron, notwithstanding some very good Avriters claim that a continued use of this medicine is always followed by local congestion of the organs of the pelvis. We think that by a continued use of this medicine for months a great many of those diseases caused by anaemia, or general debility, may be cured. We would further recommend as an assistant to the local bleeding, or scarification, internal vaginal injec- tions of warm Avater, more particularly Avhen there exists beforehand a local chronic engorgement. Those vaginal injections should be continued for three or four days, or even longer if the nature of the case de- mands it; and they may be very much assisted by warm hip-baths or bathing the body, partially or entirely. The pains generally disappear after the ap- plication of the knife to the month of the womb or after the patient has been bathed in warm water, or even after a dose of opium. Some writers recommend in those cases of expul- sion of the mucous membrane that the internal sur- face of the womb should be cauterized with a stick of nitrate of silver, but I cannot see how this could fail to do harm. It surely must be admitted to be a very heroic plan of treatment, and I think avc can do more good Avith a milder form or plan, and hence Ave would limit all of our treatment to the external local parts, and if they do no good, will certainly do no harm. 146 DISEASES OF WOMEN. It must be remembered in this disease, as in others, that all of our efforts for good will fail if proper care and attention is not given to the care of our patient. Everything should be done to improve her general health—good diet, good care, and regular habits. HYSTERIA. 147 CHAPTER XXII. HYSTERIA. This disease belongs to females, yet we often find this pathological condition among males. This name embraces a great many morbid conditions, all of the nervous system. The mind is very susceptible to the morbid condition, and will enter, as a morbid element, into a large number of those affections, and appears powerless to resist the impressions made upon it by this disease, and will yield to nearly every impression or emotion Avhen those symptoms make their appear- ance, with Aveeping or laughing, without a cause, and are irrepressible, sometimes laughing and weeping, and at other times weeping and laughing, alternately changing abruptly from one to the other. We say the patient has hysterics, and we may say that this disease is a real pathological condition, and is just as much a disease as intermittent fever. They are all changes of the nervous system. The word has gone abroad that hysteria is hypo- thetical, made up by the free will of the patient, and 148 DISEASES OF AVOMEN. could be thrown off at any time; and this notion of the disease has become popular, and it will not do for medical-men to talk very much about hysterics to their patients, think what they may; but should keep their mouth shut, and act accordingly. Hysterics is a disease, and must be treated as such and will yield to proper treatment just as readily as intermittent fever. If we talk to patients during the paroxysms of this affection they will try to enlarge on their symptoms, and to exaggerate all of their feel- ings, and make you think something awful is going to happen to them very soon. We should always make due alloAvance for them, remembering that the mind is at fault. They will sometimes try to make you think that they are labor- ing under some tremendous organic disease of the heart or lungs, and that their disease is incurable; and that it has been sent upon them as a punishment for something they have done. The patients who suffer from this disease wTill expe- rience considerable pain about, and in the region of the stomach, with a fullness in the throat as though some foreign body had lodged there, and that in spite of all their efforts it could not be removed. This last symptom is one of the very best signs of hys- terics. When we have a patient Avith these last symptoms Avell marked, and she is all the time trying to swal- low something, we may take it for granted that she has the hysterics. To the above symptoms may be HYSTERIA. 149, added a number of morbid phenomena, such as head- ache, irregular chills, yawning and stretching, twitch- ing of the muscles, and eA DISEASES OF AVOMEN. of soda water, or seidlitz poAvders. Medicines of any kind, used during pregnancy, should be very mild. All heroic treatment should be avoided, and the patient kept quiet on a good, nutritious diet, and her clothing should not be binding. ABORTION. 191 CHAPTER XXIX. ABORTION. We come now to speak of abortion, and by this we mean the premature expulsion ,of the fcetus, com- monly called miscarriage. This is brought on by some accidental cause, such as falls, blows, or by heavy lifting, or any unnatural exertion. Again, it may be brought on by a predisposition. Some women will abort about the same time in their pregnancy in spite of eA'erything that can be done. This appears to be a habit. Abortion may be classed in two divisions; namely J that of abortion and premature labor. If by any means the Avomb is caused to lose its contents before the sixth month of pregnancy, it is called abortion ; after that, until the full time arrives, it is called prem- ature labor. Some cases of abortion are attended with no danger, and others again are the most dan- gerous of all the cases that Ave have to treat. Doctors, as a general thing, would rather attend any other kind of a case than one of those dangerous ones. I 192 DISEASES OF WOMEN. never had a case of any other kind of disease that was so perplexing and hard to manage as one of those abortion cases that came on during the first month of pregnancy, as they are much harder to handle than those that occur later. The mouth of the womb will not dilate, and the continual pains and flooding will wear out the patient. The same treatment as in the early cases will not do in miscarriage. Women that have good health, and who take gentle and reasonable exercise, with proper care of themselves, are not apt to abort; yet all wo- men are liable to, and some much more so than others. As for laboring women being more liable to this acci- dent than those that belong to the so-called high life, we do not find it to be the case. - Labor, or common work, will not hurt a pregnant woman, provided she takes good and proper care of herself. It is true she is more liable to accidents than the other class, but she has better blood and better health ; and good blood is what the foetal development is depending on. No woman can go through with her pregnancy, and be delivered iu the natural Avay Avith safety to herself and child, without good health; and if any difference is made between these two classes, it must be in favor of the woman that gives herself proper care in her work and regimen of health. If a woman excludes herself from everything of this kind, simply because she belongs to the so-called high class, and gives her condition all of her thought and neglects the proper care that I have spoken of, ABORTL >N. 193 it is very likely that she will not go to her full time. Abortion is something that is almost entirely unknown among the Indians or uncivilized part of humanity. It appears to be a disease of the so-called refined life; but this remark does injustice to our women. A wo- man can be refined and educated and accomplished in everything that she should be, and not bring on abortion. It is the mock refinement that produces these effects, and not true woman's character. Everything like tight lacing, or corsets, and enter- taining fashionable company late at night, and in fact anything that the Avoman herself knows to be wrong, should be left off, for the sake of her condition. We have stated above that abortion, Avith hemorr- hage or flowing, is not dangerous. The first change that takes place is the detachment of the ovum from the womb, and it is this that causes the flooding or bleeding, and it is this that causes the danger. After all the bloodvessels have been ruptured and torn from the Avomb, and that organ does not contract, the wo- man is liable to bleed to death. The second action is the expulsion of the ovum after it has been detached ; this is done by the contraction of the walls of the womb, and in this contraction to expel the ovum every bloodvessel is stopped from bleeding. It is not necessary the vitality of the ovum be destroyed to produce abortion, for it takes place sometimes vrithout loss of vitality or life. When this unfortunate condition comes on in or during the first month of pregnancy, the ovum and 194 DISEASES OF AVOMEN. after-birth will, as a general thing, come away together, and this is as it should be. When the placenta, or after-birth, is retained, it constitutes one of the most dangerous diseases that Ave are called upon to treat. Abortion may be accompa- nied by fearful bleeding, and put the patient's life in great danger; and those are the cases that Ave are called on to treat—those that are very light Ave, as a general thing, have nothing to do with. We may say that a case of miscarriage may last but a feAv hours, or it may be continued for weeks. I once had a case where the after-birth Avas retained for several weeks. No definite time can be given—we must content our- selves with attending to our patient when avc are called on, let it be long or short. As a general thing it takes more time than we Avant to give. We have stated above that the cause of abortion was of two different kinds ; first, accidental, which may be called an exciting cause ; and then, again, a predisposition, or habit formed, and hence some avo- men will abort in the same month or week that they did before. We propose now to notice the cause of this acci- dent a little farther. If we take a woman in good health, and while at work she receives a fall, or bloAv on the abdomen, or over the region of the womb, it will, as a general thing, be followed by abortion. We may say that anything that will produce the contraction of the muscular wTalls of the Avomb sufficiently strong to ex- ABORTION. 195 pel the contents, Avill be the cause of this disease. It may sometimes be mental impressions of a strange nature, grief or fear. I have known women that Avere suffering all the time, after finding out that they Avcre pregnant, for fear something would go wrong before or during their delivery. Such women are not apt to do well. AVe may state here that one of the most powerful predisposing causes is general debility, or anaemia. poor health, poor blood, etc. Some women are not physically strong enough to go through with their conception ; they become pregnant while in this state and the development and growth of the new being dies for want of poAver and strength, and the mother's condition is not sufficient to supply this deficiency, or want of life. Noav some will tell us that abortion is brought on by the death of the foetus, but our experience teaches us differently. We do not deny but Avhat this will bring on abortion ; but we kncnv that it will take place without it, and that life is demonstrated after the expulsion of the ovum. We have stated above that anything that would cause the contraction of the Avails of the Avomb would produce abortion ; but avc must look a little farther back for a cause that produces this contraction, and avc may state that the condition of the ovum, or egg, has a great deal to do in this matter of preserving its own life. The ovum, undoubtedly, after it has been impregnated, begins to take on new life and action ; 196 DISEASES OF AVOMEN. the changes in the first feAv hours are very great, and if the ovum is not in a healthy condition it will not develope and grow. The membranes that surround it, called amnion and chorion, are not formed in the natural way, or normal condition, but are thrown up in rugae or folds. This change in its formation, is of itself enough to produce abortion, and we are safe in saying that the improper formation, and the rup- ture of the membranes are the starting cause of abor- tion. If by any means the amnion and chorion (the mem- branes surrounding the foetus) become ruptured, abortion is sure to follow. It may'not the same clay, nor for a few days, but this rupture Avill cause a flow of the liquid surrounding the foetus which will be followed by its expulsion. A knowledge of those facts has induced parties to undertake to bring on ab- ortion : but avc should remember that this is always done at the risk of the woman's life. This cannot be done with instruments without immediate danger of death, and 1 have been shocked by persons who ap- peared to have sense who would come and desire abortion produced on some one. They say that they have a friend that wants you to come and Avork in this way, and they are the friend every time. They want you to go and produce death on some poor girl or Avoman, to save themselves the trouble of being the neighborhood talk, or to save their good name; and they will speak with confidence in the matter, as though it was the duty cf the physician. But let me ABORTION. 197 here say that whoever assists, directly, or indirectly, in producing abortion, is a murderer at heart, and should be condemned as such. Abortion cannot be produced Avithout great danger of death. In making up our conclusion in reference to dan- ger, and the opportunity of treating our patient suc- cessfully, we must look to the general health. If the health is good, and the patient has not aborted before, and she has not lost much blood, the chances are good. A\re should at ad times be very careful about the amount of blood lost; for on this the success of our treatment depends. Every case of abortion with pro- fuse bleeding is extremely dangerous. Now, if the contraction of the womb is spasmodic, or irregular, and lasting only a feAV moments, it is not likely to produce abortion ; but if the pains resemble labor pains, by being long and regular, and produce com- plete contraction of the Avomb. then we may look for miscarriage. The symptoms of this disease are many, but the most marked are the contraction of, and the flooding from the Avomb. Then, again, a woman may judge that she is about to miscarry if the above symptoms are present, and then the sympathetic feelings are all gone that generally attend pregnancy, such as morn- inw sickness. When this happens we may drtiAV our conclusions that our patient is about to abort. The character of the pains has a great deal to do with making up the symptoms. At first they may be \e\y light and only momentary, and in the first stage-of 19* DISEASES OF WOMEN. this disease, Ave may expect to do the most good Avith our treatment; but after a while, if they are not stopped, they will gain more strength and power, and the flow from the womb is in proportion to the force and character of the pains. In treating this disease it should be in accordance with the facts in each particular case. If our pa- tient is known to have aborted before at a particular time, then everything should be done to prevent it by- certain rules and regulations. If lifting, walking, or washing has been the cause before, this all should be avoided, and the patient kept quiet; and this can only be done by the greatest care, for it will come on Avhen we are not thinking about it. But if Ave can carry our patient (avIio has been in the habit of aborting) past the sixth month, it is quite likely she will go to her full time. It is not absolutely necessary for a woman of this kind to remain in bed at all times, yet it is best for her to stay in her room and remain as much as possi- ble in a lying position, for if she does not take this particular care of herself, it is not likely that she will go to her full time. Her running about from house to house, and from room to room, will expose her to some of those causes without her knowledge. AVe Avould say that after the womb has begun to contract, and Ave are satisfied that they are true pains, then we should use our best means, or treatment, to quiet them, and, if possible, to restore the natural condition to the parts. We should make ourselves fa- ABORTION. 199 miliar with all the facts connected with each case, and the cause, Avhether accidental in the way of falls or bloAvs, or if a case of habitual abortion, and notice very particularly the character of the discharge and pains. This should all be done; yet there is nothing, as a general thing, more unsatisfactory than to stop a case of abortion after U has once commenced. It is almost sure to continue mtil the contents of the womb has been expelled, and this Avill be the case every time if the membrane has been ruptured and much blood be lost. Now it should be remembered that we have a great many pains in the small of the back and region of the womb that haAre nothing to do Avith abortion. The pains that we haA7e been speaking about are those in the muscular Avails of the womb; they have their ori- gin there, and they remain there, but those spoken of lastly have nothing to do Avith the womb, yet if not attended to in their early stages, will be transferred or communicated to ihe Avomb, and bring on pains pe- culiar to abortion. It is in those last cases that Ave are to expect our good effects from properly directed treatment. TREATMENT. In this we may say that a great many forms >r plans have been given by different authors, and the same rules will hold good in this disease as in others. AVhere avc have a disease so grave as this, we have also 2UU DISEASES OF WOMEN. a great many kinds of treatment. But something more is now required than the horizontal position and being kept quiet; yet this should never be forgotten in any case after once commenced. If the case con- tinues we are required to go to work in earnest and not be satisfied with merely treating symptoms—our patient is noAv flooding to death. After she has been placed in bed in a cool room, and made quiet, we should use opium in one grain doses every forty or fifty minutes until ,the pains havTe been overcome, or until the woman is completely under the influence of the medicine. The patient should have two or three pilloAvs under her head if she has lost much blood.; and if she sIioavs signs of fainting, give brandy in large doses. Nothing is safer in this trouble, par- ticularly in those dangerous cases, than opium and brandy, provided enough is given; yet we should not be careless or reckless, but should wtitch Avith care all the symptoms, and give those medicines accordingly. It is said that brandy will overcome the vertigo of the head, or overcome the fainting. In those cases where alarming flooding begins with the pains, we should give up at once the treatment to save the ovum, and turn all our attention to the safety of the mother, for all our exertion, after flooding has been established, to save the conception will be of no use, and Avill at last prove in vain ; therefore Ave should go to Avork at once for the mother's safety. Everything that is used, in the Avav of Avashes, drinks, or baths, should be cold. Warm applications of all ABORTION. 201 kinds should lie avoided. Give opium and brandy as directed above, and require your patient to remain in bed, Avithout moving either hand or foot, until you have the flood arrested, and the patient safe from danger. Any or all force or violence to bring away the ovum must be aA-oided, and in fact it must not be done. If Ave resort to such means as that to accom- plish the extraction, we will find when it is too late that it Avill be followed by the death of our patient. Let her alone, keep her quiet, and give the opium and brandy, and trust to the effort of nature. If she has not flooded too much before you began the treatment, it. is reasonable to suppose that she will get well. 1 am inclined to think that in a great many of those dangerous cases more harm than good is done by get- ting too eager. AVe become frightened and do too much. Mechanical means that are calculated to ex- tract the ovum from its uterine attachments, will do harm; and this word seems too mild to use with ref- erence to such treatment—it Avill put the life of our patient in danger at once, and should never be clone. Some very good Avriters recommend the use of ergot of rye. When the case appears to be tedious, and where the flooding is not too great, this medicine is given to hasten and compel the expulsion of the ovum ; but I am inclined to think that kind of treat nient, as Avell as mechanical, is calculated to do a o-reat deal of harm, and Ave had better be content with mild forms of treatment, and give plenty of time for nature to bring about those changes ; and then 202 DISEASES OF AVOMEN. if the case does not terminate as favorably as Ave would Avish it to do, Ave feel as if we had done no harm, and that all we can do in those cases is to assist the changes that nature is trying to bring about. Now in those cases of dangerous flooding, after eA7erytbing has been employed without any good effect and the flooding is becoming fearfully dangerous, we have but one treatment left, and that is plugging the vagina with anything that will stop the bleeding. One of the best and most effectual plugs is made out of a sponge, well soaked or saturated with alum wa- ter. This may be carried up to the mouth of the womb and retained there in such a way as to stop the bleeding. Other material may be used—cotton cloth or anything. We may dip them in oli\Te or sweet oil. This is equally as good or better than the alum. This tampoon, or plug, may be permitted to remain (if it does not cause increased action of the muscular walls of the womb, or cause pain to the patient, which it sometimes does) for hours, not more than twenty- four or thirty. If it should prove to be more than the patient can bear, then it should be gently removed with great care, and after its removal should the flood- ing begin, it must be put back at once, for it is the only thing that will save the woman's life in those cases, and so continue with this plug until your pa- tient gets better. This tampoon. or plug, i9 not always safe. AVe find some cases that it will not reach, although it is probably the best thing that can be done. But it ABORTION. 203 must be remembered that in abortion, after the sixth month, or miscarriage, the womb has attained to such a size that it Avould hold enough blood to put the wo- man's life in great danger, and the tampoon can do no good to the blood that is shut up in the organ. It is after that organ has been filled and the blood be- gins to flow out into the vagina that we expect the good effects from the use of the plug. Now we will find cases of exhaustion of the system to such a degree as to require stimulants such as brandy or whisky, according to symptoms. Give it for same effect, much or little, and it may be given with milk or eggs. In those cases that last for a Aveek or more, if something of this kind is not done for the purpose of supporting the system, the vital forces will give way and the patient dies from exhaustion. I always recommend good diet, not only in this dis- ease but in all others, and 1 am not so easily fright- ened with stimulants and a supporting plan of treat- ment as some are, for I think on general principles I can do more with good diet, good care, and good nursing, than I can with all the medicine in the world. I think that the great fault or lack of success of the practice of the present day is that we want to do too much, and use too much strong medicine, without giv- ing plenty of time, Avith care, for the patient to get well. '' Our success," says a certain author, " will depend on the way Ave abandon heroic treatment," and I be- 204 DISEASES OF WOMEN. lieve it. People haA-e got in the habit of taking too much medicine. AVe are often called to attend cases of abortion after the pains have been at Avork for hours, or days, and the woman has lost a great deal of blood. AVe do not know whether or not the membranes have been rup- tured and the ovum lost. In those cases Ave should be very careful to examine any clot of blood that has been passed from the vagina, and we should take some pains with this examination, for it is this knowledge that Mall direct our treatment, for if we are satisfied that the ovum has been expelled, then we should di- rect all our attention to the safety of the mother. We have stated above that no force should be made with instruments, or otherwise, for the purpose of ex- tracting the ovum from the uterine attachments, and Ave should be particular also with reference to the membranes. They should not be burst or other- wise injured. If they are kept whole the ovum and after-birth will come away together and the womb will then contract and all our troubles are over ; but the danger is in the bursting of the membranes con- taining the ovum, and its immediate expulsion. The after-birth will in all those cases be retained, and is the cause of all the trouble, or as a general thing they Avill be retained. Then again the membranes may be ruptured and the ovum be expelled, with part of the placenta, or after-birth, and the other part retained. This is a very unfortunate result, for as long as anv part of the placenta remains, the flooding will con- ABORTION. 205 tinne and the woman's life is in clanger. We should use all our best efforts to have it all come aAvay to- gether, and this may be done, if we give ourselves plenty of time in the treatment of the case. Give something to quiet the pains and let the natural con- traction of the womb do the work, and if the worst comes to the worst use the tampoon or plug. Some very good writers recommend an instrument in the shape of a hook introduced into the womb, and by its use the detached portions be removed; but I am inclined to think that those instructions were never intended to go any farther than the book they were written in. I do not think they intended that the hooks should be used ; it is a recommendation that should never leave the paper that it is written on. We have a great many of those paper recommendations, such as Avashing out the womb with a syringe, using astringents, such as nitrate of silver in warm or cold water ; and I am persuaded that the patient would be better if such recommendations were left in the books. The idea of introducing the hand or an in- strument in the Avomb in cases of abortion before the sixth month is, I think, out of the question. 1 wTould say one thing about the after-birth that is retained for so long in the womb after the ovum has been expelled. It must have, or as a general thing it has some attachment to the womb, and its life is kept up, for it will not undergo decomposition to any con- siderable degree. Every one knoAvs, who has had much experience, that those after-births may be re- 200 DISEASES OF AVoMET. tained for weeks and then be expelled with as much life as when in the first clays of the rupture. In concluding my remarks on this chapter I would beg to repeat what I have said about brandy and opium, and also the use of instruments in forcing the after-birth away from its uterine attachments. This must not be done; the great danger is in such treat- ment. Place the woman in bed in a cold room, and if the attachments remain, use opium ; it will keep blood in the brain, and the brandy will stimulate and support the powers of life. CONCLUDING REMARKS. 207 CHAPTER XXX. CONCLUDING REMARKS. I have endeavored in writing this work to make everything plain and simple, and at the same time clear and distinct; and to make an impression on the minds of my readers, to make them familiar with this important and much neglected subject My aim has been to give, first a general history of all diseases 1 have treated, then the causes, conclusions, and treat- ment; then to give some general rules for the gov-- eminent of all patients during the different stages of those troubles, without which all our efforts for good would be in vain, for all the medicine in the world will neArer cure a disease without proper care and at- tention on the part of the patients themselves. This theory is gaining ground every day among scientific practitioners, and also Avith the more intelligent masses of the people. It is in proportion to our im formation or ignorance that we have confidence in preparations or compounds called medicines. I think if we Avould have less confidence in such medicines, 20 S DISEASES OF AVOMEN. and more in good care and attention to our habits of life, Ave would get along much better. AVe are apt to reverence things that are dark and mysterious, and abhor everything that is made simple and plain. AVe forget our education, and run after signs in the moon and quack preparations, more particularly if they have some superstitions name, such as Indian pills, Wizard oil, or rattlesnake grease, thinking that they convey some charm or unwritten knowledge. 1 think the time has come for us to use our judgment and reason and be consistent in all things. Throw aAvay and give up those old sayings—they will do us no good ; they belong to the dark ages of the world. In writing this work I have been just as plain and simple as it was possible for me to be. I have, how- ever, used some medical Words Avhich may appear strange, but that could not very w^ell be avoided. All that is required is for the reader to refer to Webster's Dictionary. PRESCRIPTIONS. 209 PRESCRIPTIONS. Eor General Debility, accompanying nearly all Womb Diseases. No. 1. R. Tincture of iron, 20 drops in a table- spoonful of Avater, three times a day, after eating. This may be given in any disease. No. 2. R. Tinct. columbo , a a. oz. i. gentian Avhisky oz. vi. Mix. S. Teaspoonful every three hours. N.>. 3. R. Tinct. cinnamon, ( a a. oz. i. •inchona, y whisky oz. vi. Mix. S. Teaspoonful every 1 hours. No. 4. R. Aromatic sulphuric acid, oz. i. S. 20 drops in a Avineglassful of Avater, three times a day. Good for night SAveats and all debility. No. 5. R. Tincture cinchona, ) ' > a a. oz. i. ginger, ) whisky, oz. vi. Mix. S. Teaspoonful every 4 hours. For Ainenorrhcea use tonic treatment prescriptions Nos. 1, 2, 3, or 5. Menorrhagia, abundant Menstruation long continued. No. 6. R. Tincture cinchona, } " opii, camph., > a a. oz. i. (or paregoric), ) sherry Avine oz vi. Mix. S. Teaspoonful every 4 hours. 210 DISEASES OF AVOMEN. Dysmenorrhoea, or painful Menstruation. No. 7. " R. Tinct. opii camph, ) a & qz { Mix k' cinchona, > S. Teaspoonful every 3 hours. No. 8. R. Fluid extract black snake-root, oz. i. S. 20 drops three times a day in table- spoonful Avater. This is one of the best prescriptions for this fear- ful disease. AVhite Liniment, for Sprains, Bruises, and Ulcers. No. 9. R. Olive oil, ) acpia ammonia, > a a. oz. i. Mist. tinct. camphor, ) S. Rub the parts 3 or 4 times a day. Liniment for Neuralgia, Rheumatism, and all pains in the back or sides. No. 10. R. Tinct. aconite, oz. ii. Chloroform, oz. i. Mist. Rub 3 or 4 times a day with a feather. Use with great care—poison. Common Diarrhoea. No. 11. R. Tinct. opii camph, > QZ ; Migt " cinchona, ) S. Teaspoonful every 3 or 4 hours. Chronic Diarrhoea. No. 12. R. Tinct. iron, oz. i. ) ,f. . . > Mist. pure water, oz. vi. ) S. Teaspoouful every 4 hours. No. 13. R. Nitric acid, dr. ii. ) A/r. , . > Mist. pure Avater, oz. vi. ) S. Half teaspoonful, in tablespoonful Avater, 4 times a day. One of the best prescriptions for chronic diarrhoea. PRESCRIPTIONS. 211 No. 14. R. Aromatic sulphuric acid, oz. i. pure water, oz. at. Mist. S. Teaspoonful every 4 hours. For Cramp Colic, Avith Diarrhoea. No. 15. R. Compound spirits ether, oz. i. Tinct. opii, camph, oz. iii. Mist. Teaspoonful every 2 hours, in water. Bronchitis, Phthisic, and Inflammation of the Mucous Membrane of the Lungs. No. 16. R. Iodide potassium, dr. iv. pure Avater, oz. vi. Mist. S. Teaspoonful 3 times a day. This is one of the best prescriptions for those dis- eases, and should be used in asthma for a long time, as it will help nearly every case. No. 17. R. Bromide potassium, oz. i., tinct. cinchona, oz. i., pure Avater, oz. vi. Mist. S. Teaspoonful 3 times a day. For all female diseases or weakness, Avith pain in the small of the back, side, or head, with Avant of sleep, accompanied with or without the whites. This prescription should be used for three or four Aveeks. Summer Complaint in Children. No. 18. R. Greta preparata, dr. ii., Tinct. opii, camph. oz. i. Mist. S 20 drops every 4 hours. Lung Balsam—for all Coughs and Lung Diseases; one of the best in use. No. 19. R. Syrup tolu. ") *" scillae, :■■ a a. oz. i. Mist. tinct. opii, camph, S 8. Teaspoonful every three houis. 212 DISEASES OF WOMEN. Kidney Diseases. No. 20. R. Nitrate potassi, oz, Ty tinct. cinchona, 03. i., aqua pura, oz. vi. Mist. S. Tablespoonful every 4 hours. No. 21. R. Tinct. opii, camph. ) spts. ether compound, ) a a. oz. 1., tinct. cinnamon, oz. ii. Mist. S. 20 drops every 4 hours. An excellent soothing syrup for children. No. 22. R. Tinct. camphor, ^ " rhei, . - . > Mist. " opii., a a, oz. i. V From 20 to 60 drops every two hours, until the dis- ease is arrested, increasing the dose according to symptoms. Excellent for cholera morbus, cramp colic, or first stages of Asiatic cholera. Tasteless Worm Destroyer. No. 23. R. Santonin, dr. iv., simple syrup, oz. iv. Mist. S. Half teaspoonful twice a day. A pleasant, safe, and sure cure for Avorms in chil- dren. This is one of the best worm medicines that has ever been prepared. Nearly all of the patent worm medicines are some form of this prescription. Use it in every case of worms, without fear. Ague Cure. No. 24. R. Quinea sulphas, gr. xi, Aromatic sulphuric acid, dr. i., Avhisky, oz, i. Mist. S. Teaspoonful every 3 hours. / ^ / NLM005626956