Rººt r trºº - ºz ºr º ********A*.*.* sº. B 477039 Pººl (AL GYNAECOLOGY SOU'L'HWICK ºf 3 ºf ſº & 36%. ... * * .* ºr * +i - Pºirº. É!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!！!!!!!!!!!!!!!!!!!!!!!!!！!!!!!!!!!!!!!!!!!！!!!!!!! №rrrrrrrrrrrrrrrrrrREWSTERwrs • , ！|--S§·ºffſ -. . . . --！， ） → 2 №.| ae ĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪſ | ſ- ķŠ -，§ ·ſ.º. ●•* ſ; * √∞ ſraeſtron ÄN.§.}} №. ºſſiſſae ſº tº: } }} jſºſſſſſſſſſſſſſſſ IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII iſiſſiliiſiſſiiiiiiiliſiſſiſſiſſilſſſſſſſſſſſſſſſſſ !!!!!!！!!!!!!！!!!!!!!!!!!!!!!!!!!!!!!!！!!!！!!!！!!!!!! • • • • • • • • • • • • • • • • • •■ ■ ■ ■ ■ ■ ■ ■ §§§ ¿NY minimummiminimuml tiºn * = cºlº ------------ºr sº º º Timirºmulºn. Q.------------------ Fºllº A \ PRACTICAL MANUAL *::::::=rrºr: " Pfc." GYNECOLOGY BY G. R. SOUTHWICK, M.D. ASSISTANT PROFESSOR OF OBSTETRICS IN THE BOSTON UNIVERSITY SCHOOL OF MEDICINE ; L. M. ROTUNDA HOSPITALS, DUBLIN BOSTON OTIS C L A P P AND SON 1891 Copyright, 1890, By OTIs CLAPP AND SON. PR E F A C E. YNECOLOGY is a child of the present generation. Its growth has been rapid and vigorous. Yet progress in this specialty has been in the direction of sur- gery rather than of medicine; partly because we lack a thorough knowledge of the effects of drugs on the female organism, and partly because a surgical opera- tion appears to be a more rapid and definite method of treatment. The author believes that many uterine diseases are largely due to faults either of nutrition or of vascular or nervous supply, and, like other diseases, can be effectually and permanently cured by internal medication. In his practice and experience in teaching he has felt the need of a practical manual of gynecology, in which the general practitioner and student could readily find all the details of minor surgical gynecology, diagnosis, local treatment, and therapeutics of uterine diseases. This book has been de- signed, therefore, as a safe and practical guide for these classes, rather than for the specialist. Hence the history, anatomy, details of pathology, and major operations, ex- cepting reference to careful descriptions of them, have been omitted; not that they are unimportant, but because they are easily found in other works, and do not have the direct and practical importance of the subjects presented. iv PREAEA CE. The indications for remedies, the recommendations for methods of treatment, and operations to be performed, are based upon the author's observations in many European and American hospitals, upon the study of all carefully recorded cases, so far as he can find them, in a thorough search through medical works and journals by German, French, English, and American writers covering nearly half a century; upon the communications from his pro- fessional colleagues; and also upon his own experience in private, hospital, and dispensary practice. Many clini- cal cases are quoted to illustrate the action of remedies. The writer has endeavored to give others credit for their contributions to gynecology, either in the list of books, of journals, of authors, or among the foot-notes. He also desires to acknowledge the courtesy of Drs. Con- rad Wesselhoeft, T. F. Allen, James B. Bell, and others, in allowing him the use of their libraries, from which much valuable aid, otherwise unattainable, was obtained. Conscious that a work of this kind must be necessarily incomplete, suggestions from members of the profession, statements of careful verifications of symptoms, and re- ports of cases cured by the use of remedies employed singly, will be gratefully received. G. R. SouTHWICK. BosTON, 136 BOYLSTON STREET, January 1, 1888. PR E FA C E To THE SECOND EDITION. - HE present edition has been carefully revised, nearly every page showing Some alteration or . addition. The practical character of the book for the general practitioner and student has been adhered to, and hence the omission of some rare diseases, as well as the discussion of various theories current in gyne- cology. The most noticeable changes will be found in the chap- ters on Laceration of the Perineum, in which is described Tait's operation, Displacements of the Sexual Organs, Endometritis, Erosion and Laceration of the Cervix Uteri, Benign Growths of the Uterus, Malignant Disease of the Sexual Organs, Pelvic Haematocele, and Diseases of the Fallopian Tubes. Two new chapters are added, on Mas- sage in Gynecology and Electricity in Gynecology. The number of the illustrations is more than doubled, some of which have been prepared for me by Dr. Maurice Worcester Turner. Acknowledgments are also due to Professors Conrad Wesselhoeft, J. Heber Smith, L. L. Danforth, and B. F. Betts, who have kindly furnished annotations, which are credited in each instance in the foot-notes. - vi AREPA CE 7"O THE SECOAVD Aº DZZYOAV. The favorable reception of the first edition by the pro- fession, and the kind criticism of its reviewers, lead the author to hope that the present issue may meet with equal favor. G. R. SOUTHWICK. Boston, 386 Boylston STREET, November 1, 1890. C O N T E N T S. CHAPTER I. THE CAUSES OF GYNECOLOGICAL DISEASES Introduction. — Relation of Education, Fashion, Bodily Posture, and Society to Uterine Diseases. – Hygiene for Young Women and Girls. – Influence of Marriage and its Associations. – Influence of Celibacy. — Question of Marriage with existing Uterine Disease, as Dysmenorrhoea, Inflammatory Disorders, Amenorrhoea, Myomas (Fibroid Tumors); or Hereditary Disease, as Cancer, Tuberculosis, or Insanity. — Marriage of near Relatives. CHAPTER II. MINOR SURGICAL GYNECOLOGY, AND THE PRINCIPLES OF LO- CAL TREATMENT Hygiene in Gynecology. – Question of Examination.—How to examine. — The Bi-manual Examination. — The Use of the Sound; Speculum (Cylindrical, Bivalve, Sims's). — Cleansing the Cervix. — The Use of Tampons; Material, and how to make them. — Applica- tions to the Cervix and Uterine Canal ; Liquids, Powders, Ointments; Gelatine or Cocoa-Butter Pencils. – Indications for the Use of Alum, Belladonna, Boracic Acid, Boroglyceride, Bromide of Potash, Calen- dula, Carbolic Acid, Chloral Hydrate, Chromic Acid, Elaterium, Eu- calyptus globulus, Glycerine, Hamamelis, Hydrastis, Iodine, Iodized Phenol, Iodoform, Iron, Jequirity, Nitrate of Silver, Opium, Pinus Canadensis, Plantago and Boracic Acid Cerate, Red Powder, Sangui- naria, Tannin, Zinc Oleate, severe Caustics, the Hot-water Vaginal Douche. — The Spinal Ice-Bag. — The Spinal Hot-water Bag. — Pes- saries, how to select and fit them, with Rules for the same. — Varieties of Tents, and how to use them, with rules for the same. — Dilata- tion of the Cervix by Tents, by Goodell's Method. — The Use of the Curette. PAGE IO viii CO/WTE/WTS. CHAPTER III. 1FAGE DISEASES OF THE URETHRA . . . . . 73 Vascular or Neuromatoid Growths. – Prolapse of the Mucous Membrane. — Fissures at the Neck of the Bladder. — Urethritis. – Gonorrhoea. — Therapeutics. . CHAPTER IV. CYSTITIS . . . . . . . . . . . . . . . 83 Etiology. — Symptoms. – Prognosis. – Local Treatment. – Irriga- tion of the Bladder. — Medicated Fluids. – Therapeutics. CHAPTER V. PRURITUS VULVAE . . . . . . . • - - - - - 93 Etiology. — Diet. — Local Treatment. — Parasites of the Vulva. — Clinical Cases. – Therapeutics. CHAPTER VI. LACERATION OF THE PERINEUM . . . . . . . . . IO 2 Rule for deciding on an Operation. — Support given by the Peri- neum and Fascia to the Uterus. – Injuries to the Fascia. — Time to per- form the Primary and Secondary Operations. – Forms of Laceration of the Perineum, and their Effects. – Perineorrhaphy without a Recto- cele; with a Rectocele. — Emmet's Operation. — Preparation of Cat- gut. — The Coil Suture. — Tait's Perineal Operation. CHAPTER VII. ABSCESS OF THE LABIA, AND PHLEGMONOUS INFLAMMATION OF THE VULVA . . . . . . . . . . . . . . . I32 Etiology.— Local Treatment. —Therapeutics. – Digest of Remedies. CHAPTER VIII. VULVITIS. —VAGINITIS . . . . . . . . . . . . Vulvitis, Simple. – Gonorrhoeal. — Gangrenous. – Diphtheretic. — Follicular, in Children. — Eruptive Local Treatment. Vaginitis, Simple, Specific, Granular, Adhesive, or Senile. — Local Treatment. — Therapeutics for Vulvitis and Vaginitis. – Clinical Cases. . I36 COAVTEAVTS. ix CHAPTER IX. PAGE VAGINISMUS. — ATRESIA. — FISTULAF. . . . . . . . . . I48 Etiology and Treatment of Vaginismus. – Therapeutics. – Etiology of Artesia. — Treatment.—Imperforate Hymen. — Etiology of Fistu- lae. — Treatment. CHAPTER X. PUBERTY AND THE CLIMACTERIC PERIOD . . . . . . . I58 Peculiarities of each, and their Hygiene. — Menstruation. — Albu- minuria preceding Puberty. — Remedies for it. — Chlorosis. – Thera- peutics. – Chorea.— Hysteria. – Epilepsy. — Trance and Catalepsy. — Management. — Therapeutics. – Nymphomania. — Remedies. – Pollu- tions. – Menstrual Headaches. – Therapeutics. – Menstrual Tooth- ache. — Remedies. – Anomalies of the Climacteric Period. — Clinical Cases. – Therapeutics. . . CHAPTER XI. AMENORRHCEA . . . . . . . . . . . . . . . I87 Etiology. — Prognosis. – General Treatment. — Therapeutics. – Di- gest of Remedies. CHAPTER XII. MENORRHAGIA AND METRORRHAGIA. . . . . . . . . 202 Etiology. — Diet. — Local Treatment. — Curetting. — Therapeu- tics. – Clinical Cases. – Digest of Remedies. CHAPTER XIII. VICARIOUS MENSTRUATION . . . . . . . . . . . . 218 Etiology. – Clinical Cases.—Therapeutics. CHAPTER XIV. DySMENORRHCEA, OR PAINFUL MENSTRUATION . . . . . 22 I Neuralgic, Ovarian, Congestive, Obstructive, Membranous. – Dif- ferential Diagnosis. – Treatment of each Form. — Therapeutics.- Clinical Cases.— Digest of Remedies. X COMTEMTS. CHAPTFR XV. PAGE DISPLACEMENTS OF THE SEXUAL ORGANS . . . . . . . 243 Classification.— Normal Position of the Uterus. – Cystocele.— Rec- tocele.— Retroversion.— Retroflexion.— Anteversion.— Anteflexion.— Lateroflexion. — Prolapsus Uteri. — Inversion of the Uterus. – Dis- placement of the Ovaries. – Treatment with and without Adhesion and Fixation of the Uterus. – Local Treatment.— Mechanical Treatment.— Therapeutics. – Clinical Cases. – Digest of Remedies. CHAPTER XVI. ENDOMETRITIS . . . . . . . . . . . . . . . . 291 Acute, Chronic, Cervical, and Corporeal. — Etiology of Leucor- rhoea. — Local Treatment. — Gonorrhoea. — Therapeutics. – Clinical Cases.—Digest of Remedies. CHAPTER XVII. EROSION AND LACERATION OF THE CERVIx UTERI . . . . 313 Effects of Laceration of the Cervix. — Diagnosis. – Operation for its Repair, i. e. Trachelorrhaphy. — Effect of Operation in causing Sterility.—Details of Operation and After Treatment. CHAPTER XVIII. ACUTE METRITIS . . . . . . . . . . . . . . . 336 Etiology. – Symptoms. – Local Treatment. — Therapeutics. * CHAPTER XIX. CHRONIC METRITIS . . . . . . . . . . . . . . .338 Synonyms.— Etiology.—Sub-involution.—Super-involution.— Symp- toms. – Prognosis. – Treatment. — Care during the Puerperal Period. — Local Treatment. — Therapeutics. – Clinical Cases. \ CHAPTER XX. BENIGN GROWTHS OF THE UTERUS. . . . . . . . . 348 Myomas (Fibroid Tumors). — Leiomyomas. – Fibrocystic Tu- mors. — Fibrous Polypi. — Fungoid Endometritis. – Glandular Polypi. COAVTEAVT.S. xi PAGE — Cellular Polypi (Adenomas). — Soft or CEdematous Myomas. – . Changes in the Endometrium. – Relation of Uterine Myomas to Mar- riage and Child-bearing. —Symptoms. – The Physical Examination. — Diagnosis. – Differential Diagnosis. – Prognosis. – Diet. —Local Treatment. — General Considerations for Surgical Treatment. — Oper- ations. – Fibrocystic Tumors. — Therapeutics. CHAPTER XXI. MALIGNANT DISEASE OF THE SEXUAL ORGANs . . . . . 381 Forms of. - Sarcoma. — Corroding Ulcer. — Cancer. — Etiology. — Symptoms. – Diagnosis. – Differential Diagnosis. – Treatment, Palliative and Radical. —Question and Choice of Operations.—Contra- indications.—Statistics. – Prognosis. – Therapeutics. –Clinical Cases. CHAPTER XXII. PELVIC CELLULITIS (PARAMETRITIS), PELVIC PERITONITIS (PERI- METRITIS), AND PELVIC ABSCESS . . . . . . . . 4oo Chronic Atrophic Parametritis. – Frequency of Pelvic Peritonitis, often called Cellulitis. – Pelvic Cellulitis. – Pelvic Congestion. — Clinical History. — Diagnosis. – Prognosis. – Pelvic Peritonitis. – Etiology. – Surgical Operations.—Clinical History. — Diagnosis. – Differential Diagnosis of Pelvic Peritonitis. – Pelvic Cellulitis. – Pelvic Abscess. – Myoma, or Ovarian Tumor. — Haematocele. — Prognosis. — Pelvic Abscess. – Etiology. – Symptoms. – Diagnosis. – Progno- sis, – Treatment. — Treatment of Pelvic Peritonitis and Cellulitis. – Therapeutics of Pelvic Cellulitis, Pelvic Peritonitis, and Pelvic Ab- scess. – Clinical Cases. CHAPTER XXIII. PELVIC HAEMATOCFLE . . . . . . . . . . . . . 425 Etiology. – Extra-uterine Pregnancy. —Intra-peritoneal Haemato- cele. —Clinical History. — Extra-peritoneal Haemotecele.—Symptoms. —Treatment. — Therapeutics. CHAPTER XXIV. DISEASES OF THE FALLOPLAN TUBES . . . . . . . . 434 Diseases not admitting of Diagnosis without an Operation. — Sal- pingitis. – Forms of. — Diagnosis. – Treatment. xii CO/VTEAVZ.S. CHAPTER XXV. PAGE OVARIAN NEURALGIA . . . . . . . . . . . . . .440 Etiology. – Symptoms. – Diagnosis. – Prognosis. – General Treat- ment. — Therapeutics. – Clinical Cases. CHAPTER XXVI. DISEASEs of THE OVARIES . . . . . . . . . . . 444 Palpation of the Ovaries. – Normal Position of the Ovaries. – Ab- sence or Imperfect Development. — Displacement. — Haematoma. — Ovaritis, Acute and Chronic. — Symptoms. – Diagnosis. – Prog- nosis. – General and Local Treatment. — Therapeutics. – Digest of Remedies. – Clinical Cases. CHAPTER XXVII. TUMORS OF THE OVARIES AND BROAD LIGAMENTS . . . . 458 Etiology of Ovarian Tumors in Relation to Marriage.— Classification of Tumors. — Malignant Tumors, Cancer, Sarcoma. — Benign Tumors. —Dermoid Cysts. – Ovarian Cysts. – Parovarian Cysts. —Symptoms. — Examination. — Diagnosis. – Differential Diagnosis. – Clinical His- tory. — Ovariotomy. — Reports of Cases of Ovarian Tumors cured by Remedies. CHAPTER XXVIII. MASSAGE OF THE PELVIC ORGANS . . . . . . . . . 481 Theory of Massage. — Contra-indications. – Indications.— Neces- sary Knowledge. — Exudations. – Frequency of Treatment. — Dress and Position of Patient. — Details of Manipulation.— Percussion of Spine. — Movements to strengthen Dorsal and Abdominal Muscles, to strengthen Levator Ani and the Pelvic Floor. — Treatment of Prolap- sus Uteri. CHAPTER XXIX. ELECTRICITY IN GYNECOLOGY . . . . . . . . . . 493 Forms of Electricity.—The Faradic Current. — The Galvanic Cur- rent. – Effects of Negative and Positive Poles. – Effects of the Size of Wire in the Faradic Coil. – Apparatus. – Electrodes. – Active and COMTEAWTS. xiii . PAGE dispersing Electrodes. – Failure of Batteries to generate Electricity.— Formulae for Solutions. —Contra-indications.—Application of Electri- city to Acute Inflammations.—Adhesions.--Amenorrhoea.— Cellulitis and Pelvic Peritonitis. – Pelvic Abscess. – Displacements of the Ute- rus. – Dysmenorrhoea. —Endocervicitis and Endometritis: — Exuda- tions.— Fibro-cystic Tumors. — Fibroid Tumors of the Uterus. – Hemorrhages. – Leucorrhoea. — Menorrhagia and Metrorrhagia. – Metritis. – Myomas of the Uterus. – Galvano-puncture. — Non-devel- opment. — Ovaritis. – Ovarian Irritation. — Pelvic Pain. — Salpingi- tis.--Stenosis.-Sub-involution. —Super-involution.—Vaginismus. INDEx . . . . . . . . . . . . . . . . . 525 · », , .---****· · · * * w? ILLUSTRATIONS. FIGURE I. i IO. II. I2. I3. I4. I 5. I6. I7. I8. I9. 2O. 2I. 22. 23. 24. 25. 26. 27. 28. 29. Marks Chair The Harvard Chair . The Bi-manual Examination . Simpson's Graduated Uterine Sound Simpson's Graduated Telescoping Uterine Sound . Delicate Coin Silver Probe o tº º First Stage of Passing the Sound . . . . . Second Stage of Passing the Sound, when retroverted & e e s e º e o s Second Stage of Passing the Sound, when the toward the Front Use of Short Sound in making a Bi-manual Examination . 22 Sound properly turned Sound improperly turned . . . . . . . . Replacing the Uterus with the Sound . . . . Ferguson's Speculum © Nott's Speculum . . . . . . . . . . . Graves's Speculum . . . . . . . Hunter's Modification of Sims's Speculum . Cusco's Improved Speculum . Bozeman's Uterine Dressing Forceps Uterine Syringe Sims's Speculum . • * tº e º 'º e e Cleveland's Speculum . . . . . . . . . Cleveland's Speculum tº e Emmet's Uterine Applicator . . . . . . . Southwick's Cervix Syringe . . . . . . . Gehrung's Blower . . . . . . . . . . Powder-blower tº a tº e C Southwick’s Ointment Injector . . . . . Gelatine Pencil . . . . . . . . . . . PAGE I4. I4 . I5 I8 I8 I8 . . . . I9 Uterus is * . . . * 20 Uterus is 2I 23 • . . . 23 • . . . 24 • 24 25 25 26 27 28 29 3O 3I 3I • • - 32 o 32 • - 33 • - 34 34 36 xvi ILLOWSTRA TYO/VS. FIGURE - - º PAGE 30. Gelatine Pencil . . . . . . . . . . . . . . . 36 3I. Pencil Insertor . . . . . . . . . . . . . . . 36 32. Rectal Ointment Injector . . . . . . . . . . . . 36 33. Southwick's Gynecological Case . . . . . . . . . . 37 34. Southwick's Modification of Baker's Pan . . . . . . . 47 35. Reynolds's Siphon Bed-Pan . . . . . . . . . . . 47 36. Reservoir for Vaginal Douche . . . . . . . . . . 47 37. Davidson's Syringe . . . . . . . . . . . . . . 48 38. Bow-Curved Pessary . . . . . . . . . . . . . 51 39. Harding's Pessary . . . . . . . . . . . . . . 51 40. Hodge's Pessary . . . . . . . . . . . . . . . 51 41. Smith's Pessary . . . . . . . . . . . . . 5 I 42. Thomas's Modification of Smith's Pessary . . . . . . 51 43. Gehrung's Pessary . . . . . . . . . . . . . . 51 44. Taliafero's Pessary . . . . . . . . . . . . . . 51 45. Hofmann's Pessary . . . . . . . . . . . . . . 46. Retroversion Pessary supporting the Uterus . . . . . . 53 47. Open Cup Pessary for Anteversion . . . . . . . . . 56 48. Thomas's Anteversion Pessary . . . . . . . . . . 49. Thomas's Anteflexion Pessary, Closed and Open . . . . 56 50. Thomas's Anteflexion Pessary, with Stem . . . . . . 56 51. Grailly Hewitt's Anteversion Pessary . . . . . . . . 56 52. Cutter's Ring Pessary e e º 'º e e s e e s e 53. Thomas's Open Cup Pessary supporting the Uterus . . . 55 54. Cutter's Pessaries . . . . - . . . . . . . 58 55. Donaldson's Pessary . . . . . . . . . . . . . 58 56. H. Sims's Pessary . . . . . . . . . . . . . . 59 57. Ordinary Stem Pessary . . . . . . . . . . . . . 59 58. Rubber Ring for Procidentia . . . . . . . . . . . 60 59. Emmet's Sponge Tent Carrier . . . . . . . . . . 65 60. Galvanic Stem Pessary . . . . . . . . . . . . . 61. Goodell's Modification of Ellinger's Dilator . . . . . . 68 62. Wylie's Modification of Sims's Dilator . . . . . . . 68 63. Thomas's Blunt Curette . . . . . . . . . . . . . 71 64. Sims's Sharp Curette . . . . . . . . . . . . . 71 65. Skene's Endoscope . . . . . . . . . . . . . . 74 66. Southwick's Cervix Syringe . . . . . . . . . . . 78 67. Instrument for washing out the Bladder . . . . . . . 85 68. Crutch for the Knees . . . . . . . . . . . . . Io'7 69. McBride-Packard Yoke . . . . . . . . . . . . IoS 70. Irrigator Attachment . . . . . . . . . . . . . Io9 71. Russian Needle Forceps . . . . . . . . . . . . Io9 FIGURE 72. 73. 74. 75. 76. 77. 79. 8o. 8I. 82. 83. 84. 85. 86. 87. 88. 89. 90. 9I. 92. 93. 94. 95. 96. 97. 98. 99. IOO. IOI. IO2. IO3. IO4. IO5. Ioé. Io'7. Io8. io9. II O. b ILLUSTRA TVOAVS. xvii TAGE Emmet's Twisting Forceps. Io9 Sims's Shield © e & Io9 Péan's Artery Forceps . . . . . . . I O Emmet's Scissors curved for Right Hand . I IO Emmet's Tenaculum . I IO Sims's Tenaculum . I IO Sims's Sponge-Holder . I to Scissors curved on the Flat II 2 Counter-pressure Hook . II 2 Solid Tenaculum • * * * * * * * * * II 2 Diagram of Freshened Surface with Sutures inserted . II3 Diagram of Section in Median Line after the Sutures are tied • . . . . . . . . . . . . . . I I4 Diagram of “Butterfly Freshening” with Sutures inserted 114 Diagram of Freshened Surface for Perineorrhaphy with a Rectocele . . . . . . . . . . . . . I IQ Diagram of Section of Perineum through the Median Line 120 Diagram of Perineum when drawn together by Sutures I2 I’ Diagram of Y-shaped Laceration of the Perineum . . I22 Diagram of Effect of Y-shaped Laceration of the Perineum as in Fig. 87 . . . . . . . . . . . 123 Diagram of Perineal Laceration with a Rectocele . . I24. Diagram of Sutures in Perineorrhaphy (Emmet's Method) 125 Eureka Bed Pan . . . . . . . . . . . . . . I26 The Coil Suture . . . . . . . . . . . . I27 Angular Scissors for Splitting the Septum . . . . . I28 Splitting the Recto-vaginal Septum for Tait's Operation I29 Flaps separated in Tait's Operation . . . . . . . I29 Interrupted Sutures in Tait's Perineal Operation . I 30 Continuous Catgut Suture in Tait's Perineal Operation 13o Sims's Glass Vaginal Plug . 149 Roux Curette e G 2O4 Buttle's Syringe . . . . . . . . 2O5 Normal Position of the Uterus . . . . . . . . . . 2:44 Relation of the Pelvic Organs to the Surface of the Body. 245 Retroversion of the Uterus . © . . . . . 248 Retroflexion of the Uterus . • . . . . . . . 249. Diagnosis of Retroflexion by Bi-manual Examination . . .25o First Stage of the Introduction of the Sound . 25 I Second Stage of the Introduction of the Sound . . . . 252 Method of Replacing Retroverted Uterus with the Sound 253 Nott's Uterine Elevator and Depressor . . . . . 254 xviii AZ/L (WS7RA 7TWO/VS. FIGURE PAGE III. The Knee-Chest Position sº s e º º 254 I 12. Retroversion Pessary supporting the Uterus . . . 255 I 13. Retroflexion of the Uterus with Adhesions and Prolapse of the Ovary © e > e tº e º e 258 I 14. Anteflexion of the Uterus ſº tº 265 115. Fibroid Tumor simulating Anteflexion . 266 I 16. Anteversion Pessary in Position * * * e e 267 117. Normal Position of Uterus and Degrees of Prolapsus . 269 I 18. Martin's Curette modified from Roux 297 II9. Southwick’s Cervical Syringe . 297 120. Southwick’s Ointment Injector 298 121. Gehrung's Blower . . . . . . . . . . . . 299 122. Diagram of Uterus with line of Cervical Laceration 3I4 123. Diagram of Effect of Laceration of the Cervix • 314 124. Diagram of Uterus with Line of Laceration in the Cervix. 31.5 125. Diagram of Uterus showing Effect of Laceration of Cervix 3 15 126. Bilateral Laceration of the Cervix as seen in the Speculum 317 127. Sims's Speculum 325 128. Emmet's Tenaculum . 325 129. Sims's Tenaculum . 325 130. Solid Steel Tenaculum 325 131. Dawson's Scissors 326 132. Emmet's Cervix Scissors 326 133. Counter-pressure Hook . 326 134. Emmet's Wire-Twister . 327 135. Sims's Shield 327 136. Uterine Sound . e 327 137. Sponge-holder . . . . . . . . . . . . . . . 327 138. Diagram of Cervical Laceration, showing Sutures inserted and Area of Freshening . . . . . . . . . . . 328 139. Diagram of Cervix after Trachelorrhaphy, with the Sutures in Place . . . . . . . . . . . . . . 329 14o. TEpithelioma as seen in the Speculum . . . . . . 383 141. Scirrhous Cancer of the Cervix as seen in the Speculum . 384 142. Epithelioma of the Cervix Uteri 385 143. Hofmann's Pessary © e º 418 144. Pyosalpinx Sacs, distended . . . 435 145. Pyosalpinx Sacs, collapsed . e s e e º e 436 -146. Movement to strengthen the Abdominal Muscles . . 484 147. Bi-manual Massage . . . . . . . . . . . . . 485 148. Percussion of the Back . . . . . . . . . . 486 149. Movement to strengthen Abdominal and Dorsal Muscles . 487 ILLUSTRATIONS. xix FIGURE PAGE 150. Movement to Strengthen Pelvic Floor . 488 151. Elevating the Uterus for Prolapsus Uteri (First Position) 490 152. Elevating the Uterus for Prolapsus Uteri (Second Position) 491 I53. Cabinet Battery . . . . . . . . . . . . . . 497 154. Thirty Cell Galvanic Battery . . . . . . . . . . 498 155. Faradic Battery with Englemann Coils . . . . . . . 499 156. Chloride of Silver Faradic Battery . . . . . . . . 5oo 157. Chloride of Silver Galvanic Battery . . . . . . . . 501 158. McIntosh Chloride of Silver Battery . . . . . . . 502 I59. Wire Gauze Electrode . . . . . . . . . . . . 503 I60. Clay Electrode . . . . . . . . . . . . . . . 503 I61. Fry's Combination Electrode . . . . . . . . . . 504 I62. Vaginal Electrode . . . . . . . . . . . . . . 504 I63. Mundé Combination Electrode . . . . . . . . . 504 164. Intra-uterine Electrode . . . . . . . . . . . . 505 165. Intra-uterine Electrodes of Hydrogenized Steel . . . . 505 I66. Bi-polar Vaginal Electrode . . . . . . . . . . . 506 I67. Bi-polar Intra-uterine Vaginal Electrode . . . . . . 506 I68. Myoma Spear . . . . . . . . . . . . . . . 506 I69. Myoma Trocar . . . . . . . . . . . . . . . 507 170. Case of Electrodes . . . . . . . . . . . . . 507 BOOKS AND PERIODICALs CONSULTED AND REFERRED TO IN THE PREPARATION OF THIS MANUAL, Abdominal Surgery Acute and Chronic Diseases * - & American Cyclopaedia of Gynecology and Obstetrics . BOOKS. Amerikanische Artzneiprüfungen . . . . Annual of the British Homoeopathic Society. Annals of the Universal Medical Sciences Behandlung Prolapsus Uteri Chronic Diseases of the Organs of Respira- tion . © a Clinical Medicine . Clinical Memoirs on the Dise Clinical Therapeutics ases of Women Comprehensive System of Materia Medica and Therapeutics Contributions to the Surgical Treatment of Tumors of the Abdomen Cyclopaedia . . . . Cyclopaedia of Obstetries and Gynecology Diagnosis of Pathological Anatomy . Die Krankhaften Geschwälste Die Neubildungen des Uterus Die Operative Gynākologie Diseases of Females . Diseases of Females . Greig Smith. AHartmann. Mazzzz. C. Hering. Sajous. Profamter. Meyhoffer. Jousset. Bermutz und Gaupil. T. Hoyne. Hempel. 7%omas Keith. Von Ziemassen. Grandin. Orth. VZrchow. Gaesserozy. Hegar und Kaltenbach. . Jahr. Diseases of Females and Children Diseases of the Female Mammary Glands Diseases of the Ovaries . Diseases of the Ovaries . Peters. Williamson. Ballroth. Olshausen. Tait. AOOKS AAWD PER/OD/CA/C.S. Diseases of the Ovaries . Diseases of Women Diseases of Women Diseases of Women Edited by Diseases of Women Diseases of Women Diseases of Women Diseases of Women . . Diseases of Women Diseases of Women . . . . . Diseases of Women, and Abdominal Surgery Diseases of Women and Children Diseases of Women and Children Domestic Physician tº e o e º e Du Traitement Électrique des Tumeurs de I'Utérus . . . . . . . . . . Electricity in Diseases of Women . . Electro-Therapeutics . . . . Eléments de Médecin Pratique Gynecological Electro-Therapeutics . Gynecological Operations Gynäkologische Klinik º Gynäkologische Operationen . . . . . Homoeopathy the Science of Therapeutics . Jähresbericht tiber Geburtshilfe und Gynā- kologie • e e º e º e º e Jähresbericht tiber Pathologie . © tº Krankheiten der aussere Genitalien und die Damrisse . e e s e º e º 'º e Rrankheiten der Weiblichen Geschlechts- organen tº e s 6 tº gº tº e s Klinische Erfahrungen © Lectures on Clinical Medicine . Lectures on Materia Medica Lehrbuch der Homöopathie e - Lehrbuch der homóopatische Therapie . Lessons in Gynecology Manual of Gynecology Manual of Pharmacodynamics Manual of Therapeutics . Massage in der Gynäkologie Massage in der Gynākologie xxi Spencer Wells. R. Barnes. Eaton. Grailly Hewitt. Dr. A/. Marion. Sims. . Leadame. Ludlam. Matheson. May. Thomas. WZacáel. Mawson Zazt. Guernsey. Mintom. C. Hering. Apostol. Massey. Aïng. Jousset. Bigelow. Dorazz. W. A. Frezzºad. Aofmeier. Dunham. Aºromzmel. - Virchow und Hirst. Zweifel. Schroeder. Aºûcherſ. Jousset. C. Dunham. Von Grauvogel. Schwabe. Goodell. A/arf and Barbour. R. Hughes. R. Hughes. Profamter. Alfred Resch. xxii AOOKS A/VD PAER/OD/CA/C.S. Massachusetts Bureau of Statistics of Labor, Report XVI. Materia Medica Materia Medica Materia Medica Pura . Matière Medicale Exper. et de Thérap. . . Jousset. Positiv. . . . . . . . . . Minor Surgical Gynecology . . . Neuralgia, and the Diseases that produce it New Remedies . tº Notes on Uterine Surgery Obstetrics © e º e º e º On Some of the Diseases of Women Operative Gynākologie Ovarian Tumors . . . Pathologie und Therapie d. Frauenkrank- heiten • e s e o e Pathology and Therapeutic Hints Pathological Anatomy Pharmacodynamics Practical Medicine Practical Medicine º tº gº Practical Application of Electricity Practice of Medicine . e e Practice of Medicine . e Principles of Biology . . . . Principles and Practice of Gynecology . Records of Homoeopathic Literature Reference Handbook of the Medical Sci- enCeS Rest for Women During Menstruation . Science of Therapeutics Sex in Education System of Medicine System of Medicine System of Medicine . . . . . . System of Surgery e tº e º Text-book of Gynecology . . . . Text-book of Medicine and Surgery. Text-book of Medicine . . . . . . Text-book of Midwifery . . . . The Building of a Brain © The Marriage of Near Kin. Cowperthwaite. Hering. S. Hahnemann. P. Muzzdé. Azzszze. Aſale. Marion Sims. Cazeaux und Tarnier. Matheson. Hegar und Kaltenbach. W. Atlee. A. Martime. Aºaze. Ziegler. Płughes. Loomis. AWiemeyer. Liebig and Rohé. A/zzzz. Small. H. Spencer. A memef. Aºazze. Bzzcá. Jacobi. Baehr. Clarke. Armedt. Pepper. A’eynolds. A/e/muth. Cowperthwaite. Aºudalocá. Striimpell. Galabin. Clarke. Alfred H. Huth. BOOKS AAWD PERVOD/CAL.S. Theory and Practice of Medicine . Therapeutics . . . . . . . . Traitement Électrique des Tumeurs fibreu- ses de l’Utérus . . . . . . . . . Transactions American Institute of Homoe- opathy. - Transactions American Medical Association. Transactions American Gynecological So- ciety. Transactions International Homoeopathic Congress, London, 1881. Transactions Massachusetts Homoeopathic Medical Society. Transactions Michigan State Medical So- ciety. w - Transactions New York State Homoeopathic Society. - Transactions 9th International Congress, Washington, 1887. Transactions Philadelphia Obstetrical So- ciety, 1878. Transactions World's Homoeopathic Con- vention, 1876. Treatise on Ovarian Tumors Tumors of the Breast Uterine Surgery Uterine Therapeutics, Verdaungskrankheiten Vesico-vaginal Fistulae Virchow's Archives. Vorlesungen über Allgemeine Pathologie PERIODICALS. xxiii Marcy. E. M. Hale. L. Carlet. Peaslee. Gross. J. Marion Sims. MŽn foot. A’zwald. Emmet. Cohnheime. Allgemeine Homöopathisch Zei- tung. American Homoeopathic Journal of Gynecology and Obstetrics. American Homoeopathic Review. American Journal of the Medical Sciences. American Journal of Homoeo- pathic Materia Medica. American Journal of Obstetrics and Gynecology. American Observer. American Practitioner. Anatomische Anzeiger. xxiv. AOOKS AAWD PE/P/OD/CA/.S. Annales de Gynécologie. Annals of Gynecology. Archiv für Gynākologie und Ge- burtshūlfe. Berlin Beitr. z. Geburtshilfe und Gynākologie. Berlin Klin. Wochenschrift. Boston Gynecological Journal. Boston Journal of Homoeopathy. Boston Medical Journal. Boston Medical and Surgical Journal. British Gynecological Journal. British Medical Journal. Bull. de la Soc. Méd. Hom. de France. Bulletin Général de Thérapeu- tique. . Centralblatt für Gynakologie. Deutsche Med. Zeitung. Dublin Medical Journal. Edinburgh Medical Journal. Fortschritten des Medicin. Gazette de Gynécologie. Hahnemannian Monthly. Homoeopathic Recorder. Homoeopathic Journal of Obstet- rics. Homöopatische Vierteljahrschrift. Homoeopathic World. International Journal of Surgery. Journal of the American Medical Association. Journal of Homoeopathic Clinics. Journal de Médecine. Journal of Psychological Medi- CII) e. - Le Mouvement Medical. London Lancet. London Medical Record. Medical Advance. Medical and Surgical Reporter. Medical Current. Medical News. Medical Record. Medicinische Wander-Vorträge. Monthly Homoeopathic Review. New England Medical Gazette. New York Medical Journal. New York Medical Record. New York Medical Times. North American Journal of Ho- moeopathy. Observer. Popular Science Monthly. Practitioner. & . Prager Med. Wochenschrift. Samlung Klinische Vorträge- Volkman. The Clinique. Therapeutische Monatshefte. United States Investigator. United States Medical and Sur- gical Journal. Wiener Klinik. Wiener Med. Wochenschrift. Zeitschrift für Geburtshūlfe und Gynākologie. Zeitschrift für Hom. Klinik. Zeitschrift für Klinische Medicin. LIST OF AUTHORS MENTIONED IN THIS MANUAL. Allen, Nathan Andouit Anstie Apostoli, G. Arndt, J. L. Ash Atlee, W. L. Aveling Baehr, Bernard Baertl, J. Bailey Baker, H. A. Baldy, J. M. Bantock, G. Barbour Barnes, Robert Battey, Robert Bayes Bennett, Henry Betts, B. F. Bernutz Bigelow, H. R. Billroth, Th. Black, Francis Blake, Edward Bönninghausen, C. Boxall, R. Bozeman, Nathan Braithwaite Brant, Thure Brodie, Sir Benjamin Bröse Brown, Baker Brown, D. Dyce Brown-Séquard Brownson, Mary Bryne, John Bunge |Burnett, J. C. Burt Butler, C. W. Canfield, Corvesta T. Carfrae Carlet, L. Champlin, H. W. Chapman, M. Cholmogoroff, C. Clarke, Ed. H. Cohn Cohnheim Cooper, Isaac Cooper, Robert T. Cowperthwaite, A. E. Coxe, J. R. Craig Crampton, Henry Cushing, C. Cutler Da Costa, J. A. Danforth, L. L. Defries, W. P. Dewees Dewey, John Donaldson, S. J. Doran, Albert Doughty, F. E. Drysdale, A. Dudgeon - Duncan, Mathews Dunham, C. Dunn Duvernoz Eaton Eggert Elb Emmet, T. A. Englemann, G. Evetzky, E. | Ewald Falk Farrington, E. A. Fay, Edward A. Fellner Flint, Austin t Fornias, E. Foulis Fritsch - Frost, J. H. P. Freeman - Freund, W. A. Friedreich Galabin, A. L. Garrigues Gärtner Gehrung Gilchrist Goelet Goodell, William Goubeyre, Imbert Goullon Goullon, H. Goupil Gram Grandin, E. H. Grauvogel, Von xxvi A.I.S.T OF A UTHORS. Gray, J. F. Gross, S. W. Guerin Guernsey, H. M. Gusserow Hadra, B. Hahnemann, S. Hale Hall, Lucy M. Hammond, Wm. A. Hansen, Oscar Hart Hartmann Hausmann Hawkes Hegar, Alfred Hempel, Charles J. Hennig Henriques Hering, C. Hering, J. R. Coxe Hewitt, Grailly Hilberger Hildebrandt Hirsch His Hodge Hofmeier, W. H. Holcombe Homans, John Hood, Peter Houghton, H. C. Hoyne, T. S. Hoyt, W. H. Hughes, Richard Hunter, T. C. Huth, Alfred H. Jacksch, Von Jackson, R. Jacobi, Mary Putnam Jahr, G. H. G. Jermans Johnson, F. W. Johnstone, Arthur Jones, S. A. Jordan Jousset, P. Kallenbach Kaltenbach Kafka, Th. Kapper - Keith, Thomas Kellogg, J. H. Kelly, Howard Kent, J. T. King, J. C. Kippax Kirk, J. C. Klein, Gustav Kleinwaechter Küster Küstner Landry Leadam Ledetsch Le Fort Leopold Levinstein Liebig Lobeth Loewenthal Loomis, L. L. Ludlam, R. Madden, T. M. Marcy, E. E. Martin, A. Martin, F. H. Martineau Massey, G. B. Matheson McClintock McGeorge Meadows, Alfred Meyhoffer Mikulicz, J. Miller Mitchell, Wier Moffat Moore Moore, John Müller, Clotar Mundé, Paul F. Neggerath Neisser Neugebauer Niemeyer Norström Nothnagel Nuñez Nunn Olshausen, K. Orth, J. Oser - Packard, Horace Pallen Palmer, A. P. Parrot Patten, M. A. Planat, M. Felix Polk Pope, A. C. Porter, Philip Post, Sarah E. Prall Preston, H. C. Preuschen, Von Price Prochownik Profanter Ramos Raue Reed, H. H. Reibmayr, Albert Resch, Alfred Ring, H. Rockwell Roesger Rohe Routh Roux Royal, George Rückert Ruddock Russell Rydygier Salisbury Sånger Scanzoni Schatz Schauta Scholtz Schultze, B. S. Schroeder, Karl Schücking Schwabe Schwartz Senn, N. Sentin Shaw Shuldham, Simon, Gustav Simpson, Sir James Sims, H. Marion Sims, J. Marion Skene, Alexander Skutsh Small, A. E. Smith, A. L. Smith, Greig Smith, J. Hamar Smith, J. Heber Spencer, Herbert Spiegelberg Stens J.I.S.T OF A UTHORS. Stevenson Sumner, Charles Tait, Lawson Talbot, I. T. Tannen Terry, M. O. Teste Theobald Thomas, T. G. - Thompson, Sir Henry Thornton, J. Knowsley Thirear Tilt Tompkins, A. H. Trinks Tritschler Ussher Utley, J. Vedeler Velloso, J. A. Virchow Wahle Waldeyer Waller Watteville, De xxvii Wegner Wells, B. H. Wells, Spencer Wesselhoeft, C. Wesselhoeft, W. West Weston Whiting Whittier, D. B. Wiedow Wiener Wilcox Williams, C. D. Wiltshire Winckel, F. Winterburn Winter Withington Wood, J. C. Woodbury, J. H. Worcester, S. Wyder Wylie, W. G. Zeisel, Von Zweifel ARRANGEMENT. THE remedies recommended are divided into four classes. The most important are marked with a double bar (II); the next impor- tant have a single bar (I); the ordinary remedies without a bar; the least important, and those remedies seldom used, are placed at the close of the therapeutics, as an additional list for consultation, the more important remedies of which are printed in Italics. The characteristic symptoms are generally printed in Italics, and the remedies in parenthesis among the symptoms refer to those reme- dies having similar symptoms. t The digests are given to facilitate more accurate prescribing, and to serve as suggesting rather than absolutely indicating the remedy. Indeed, the same holds true of those remedies where indications are given, as it is the totality of the symptoms of the case which is our real guide. The indications mentioned, therefore, are those more peculiar to the genital organs, and might be termed the beacon lights to guide us to the remedy. The study of Hughes's Pharmacodynam- ics, Cowperthwaite's, Hering's, and Farrington's Materia Medicas, with these symptoms, will be of material help in deciding on the best remedy. PRACTICAL MANUAL OF GYNECOLOGY. CHAPTER I. THE CAUSES OF GYNECOLOGICAL DISEASES. HY are American women SO prone to diseases peculiar to their sex? It may be considered an open question, if they are more affected than women of other nations. They have that reputation however; and it seems to be true, that those diseases characterized by various disturbances of the nervous system are not only more frequently met with in the United States than in other countries, but are also increasing. A young woman has completed her education, perhaps with honor; as a girl she was healthy and robust, but for some occult reason a peculiar train of nervous phenomena, called hysteria, is developed. Like the fly-wheel of an engine without the steadying influence of the governor, there seems to be a lack of correlation of the nervous forces. The nicely adjusted balance between volition and impulse is lost, and the har- monious action of the vital forces destroyed. The fault may be detected in a piece of machinery, but the human organism is so complex in its structure, that neither physi- ology nor pathology will always enable us to determine where the trouble lies. On further inquiry in the class of cases referred to, we are liable to find an unnatural con- dition of the monthly periods. They may be irregular or I 2 CA O.S.A.S OF G VAWAECOZOG/CA/C D/SAEASE,S. profuse, and accompanied with a varying amount of ova- rian pain. The patient may be subject to severe head- aches, and in her later womanhood wonder why she is not as well as some of her friends. Like the hot-house plant she can endure but little, and is easily affected by her surroundings. Both have been forced to bloom prema- turely. At the time of puberty, the nervous forces are directed from their proper channels, and physical vigor is sacrificed to intellectual development.” Instead of the Outdoor sports and games of boys, rowing, skating, etc., she is taught that such things are hoidenish. While the boys are strengthening their muscles with plenty of out- door air and exercise, she is practising her music or read- ing the latest novel. When the menses appear, she is seldom warned and advised concerning them. Instead of taking perfect physical and mental rest at these times, she goes about as usual. Imprudence during the menstrual periods, from ignorance of the consequences, is a fruitful cause of disease. No mother does her whole duty to her daughter who fails to point out and impress upon her the importance of this one thing. At this time, too, the girl just entering into womanhood is undergoing the cram- ming processes of school life and various accomplishments. The generative organs, which are rapidly developed at this period, may suffer from mal-nutrition in consequence of the perversion of nerve force. One of our most prominent gynecologists believes this is a fruitful source of imperfect development of the sexual organs, with the consequences of various “weaknesses” and sterility, either absolute or relative.” * Dr. William A. Hammond has an interesting article on “Brain-forcing in Childhood,” in the Popular Science Monthly for April, 1887. He believes that much injury is done by sending children to school too young, and with too great a variety of studies. - * Dr. Matthews Duncan attributes to it, not only sterility, but also “destruc- tion of sensuality of a proper, commendable kind, and its consequent personal and social evils.” The writer is quite sceptical concerning this statement, as A. DOCA TYO/V AAVAD AEASA/NOAV. - 3 The demands of education are not the only ones made upon her. Fashion decrees that she must wear longer and heavier skirts and dresses, too often suspended from the waist instead of the shoulders. Tight-fitting corsets must be added to make the latter fit well, and still further impede the free circulation of the blood. Habits of luxury and ease also play a part. Sitting on stuffed easy-chairs compresses the sides of the pelvis and the blood-vessels, instead of allowing the pressure to come upon the ischial tuberosities, where nature intended. Bodily posture is not without its influence: too often, in sitting down, the pelvis is tilted upward and the body forward, the erect position is lost, and the weight of the intestines allowed to come directly upon the contents of the true pelvis." A similar condition is produced by wearing high-heeled shoes. All these tend not only to cause, but also to maintain, a chronic congestion of the pelvic organs from the very beginning of her sexual life. - - One of the best ways to study the social life of a nation is to observe the caricatures in its literature. Among the most common we see are those of young misses discuss- ing their parties, calls, beaux, fashions, theatres, etc. As if patients of practically no education whatever in the lower classes complain of this fully as much as the better classes. He would also ask, Why should higher education under the same conditions affect the ovaries of a woman any more than the testicles of a man 2 Emmet, Principles and Practice of Gynecology, pp. 17–25. See Address of Dr. Moore on the Higher Education of Women, before the British Medical Association, British Medical Journal, Aug. 14, 1886, p. 295. Though a good summary of the opinions of various persons, he does not found his opinion on a personal investigation of statistics bearing on this question. It is commended, however, by an editorial in the Journal of the American Medical Association, Sept. 4, 1886, p. 267. A very interesting reply, by Dr. Lucy M. Hall of Vassar College, to Dr. Moore's Address, will be found in the Popular Science Monthly for March, 1887. See also Health and Sex in Higher Education, by John Dewey, Ph. D., Popular Science Monthly, p. 606, March, 1886. Compare Herbert Spencer’s Principles of Biology. * Bodily Posture in Gynecology, by Dr. S. J. Donaldson. 4 CA USA.S OF G PAVECOZOG/CAA D/SAEASAE.S. the evils of education and fashion were not enough, soci- ety itself must conspire against them, and demand their entrance into it two or three years before that of the oppo- site sex, the boys, who meantime have enjoyed far better opportunities for physical culture." Girls should certainly be allowed as much time as the boys for higher education. The demands of Society at an early age are a great and serious mistake, only adding to the high pressure and the nervous strain to which they are already subjected. Let not these remarks be misconstrued. I thoroughly believe in the higher education of women in whatever direction they may manifest peculiar talent and ability, and I also believe in giving the girls a fair chance.” Dr. Wier Mitchell believes a girl should not undertake hard study till after eighteen years of age. This is practically the opinion of Dr. Conrad Wesselhoeft, who expresses his opinion that a girl should not begin severe study till after sexual maturity; after that, she may work her mind hard. It is not so much study as a lack of physical exercise, late hours, improper food and dress, which generally injure a girl's health. The remedy for these things is simple; plenty of out- door air and physical exercise, rest in a recumbent posi- tion during each menstrual period until regularity in time and quantity are established.” After this, she need not lie down, but ought to have both physical and mental rest. Teach her proper care of herself, and the danger of Sup- 1 Education of Girls connected with Growth and Physical Development. By Dr. Nathan Allen. In Journal of Psychological Medicine, Vol. V. Part 2, London, 1879. - 2 Dr. Edward H. Clarke, Sex in Education ; or, a Fair Chance for the Girls. Also, The Building of a Brain. 8 Dr. Mary P. Jacobi, in her essay on “The Question of Rest for Women during Menstruation” (p. 231), expresses her opinion that “mental work ex- acted in excess of the capacity of the individual may seriously derange the nutrition ” in young persons; but she thinks there is no need of rest for healthy women during menstruation. INFLUEvcE OF MARRIAGE. 5. pressing the flow by wetting the feet, or sitting on the ground or on cold stones. Keep her a girl and out of society till at least the age of eighteen. From fourteen to seventeen avoid hard study and the reading of light lit- erature. Moderate study with outdoor air and exercise, going to bed early and sleeping long, is not likely to injure any one. There will still be time enough for her to ac- quire a collegiate education if she wishes, and, if possible, develop into a strong healthy woman." f * After marriage there are three great causes of uterine disease: prevention of conception, the induction of abor- tion, and lack of proper care during and after parturition. It is impossible to condemn too strongly the cold water, acid, or astringent injections used to destroy the vitality of the semen, or the various mechanical measures to pre- vent the entrance of the spermatozoa into the uterine canal. The injurious effects of such repeated injections, when the generative organs are excited and congested, must be apparent to every practitioner. Very many seek to rob Nature of her due by withdrawal before completing the sexual act. This tends to produce a nervous erethism and chronic congestion.” It thus becomes a fertile cause of diesase, and is practised in ignorance of the consequences. Nature's laws may be infringed, but sooner or later she demands a heavy penalty. ; The induction of abortion, the murder of a child by its parent, is unquestionably the source of many of the dis- eases which come to the gynecologist for treatment. Its * The health statistics of female college graduates, in the Sixteenth Annual Report of the Massachusetts Bureau of Statistics of Labor, show that the health of such graduates bears a favorable comparison with that of non- graduates. It is noticeable that only about one third of the number had married, and one third of these had not given birth to a child. The report unfortunately only comprises 54.65 per cent of college graduates, as the remainder did not answer the circulars addressed to them. The statistics, therefore, can only be considered approximately accurate. * Goodell, Lessons in Gynecology, p. 560, 1890. 6 CA O.S.ES OF G VAWECO/LOG/CA/C D/SAEASA.S. pernicious effects are so plainly evident to every physician, it needs no further comment. Lack of care during and after parturition is more often the fault of the doctor than of his patient. Meddlesome midwifery is practised, a rup- tured perineum is not sewed up, he neglects to inquire after the various functions, and ascertain for himself that they are properly performed after delivery. The patient may move about too Soon, and over-exert herself in vari- ous ways. She may be subjected to coitus early, which never should take place during the three months after de- livery. Excessive venery and too frequent child-bearing are also causes of much subsequent trouble. It may not be out of place to mention here what is, to say the least, a great mistake, and a positive wrong to our patients. Many a physician has professed to understand and treat cases of uterine disease, of which in reality he knew nothing. Two reasons seem to account for this: first, a desire to make money out of the case; secondly, the fear lest his patient should not think him skilful if he sent her to some one better informed on the subject. In consultations some doctors seek to consult with one who is sure to agree with them, no matter what the treatment has been, rather than one who might advise differently, and aid them in the treatment of the case. This may seem harsh judgment on the profession, but such instances are not infrequently observed. The practice of medicine should be for the good of the patients, and above such mercenary, selfish motives. * Marriage, and especially child-bearing, apparently con- fer a certain amount of protection against some disorders of the climacteric, particularly the growth of fibrous tu- mors and mucous polypi if we accept the views of Dr. Emmet," whose observations and statistics differ widely from those of most Continental authorities, though sin- 1 Principles and Practice of Gynecology, p. 548, 1884. f **. A/VFL UAE/VCAE OF AZAARAE/AGAE. 7 gularly in accord with the theory of Cohnheim." On the other hand, epithelioma of the cervix is seldom seen in the sterile, and with few exceptions is associated with lacer- ation of the cervix uteri. Cancer of the breast is much more common in married than single women,” and more frequent among those who have than those who have not nursed their children.” Nature seems to have ordained that the cycles of ovulation and menstruation should be occasionally interrupted and held in abeyance, and that the progressive and regressive changes in the uterus dur- ing its growth and involution should be essential to the health of women. The question of marriage with existing uterine disease not infrequently demands our consideration. There seems to be a feeling among the laity, that “she will be all right when she gets married.” In the great majority of cases this is quite the reverse, and the patient's complaints are increased instead of relieved. There are, however, some few conditions which are improved or cured by pregnancy and child-bearing, such as the so called obstructive dys- menorrhoea, and various displacements of the uterus. In the latter class of cases, it is very often the best remedy. ' Where the menses are a little irregular in time and quan- tity, the marital relations will sometimes regulate them. The various forms of hysteria, and all inflammations of any of the pelvic organs, are likely to be increased. Girls who have reached the age of twenty without any sign of the menstrual flow should be examined to ascertain the cause. It may depend on defective development, and conception will not be possible. If the marriage takes place under such a condition, both parties ought to know there will be no offspring. Only a short time ago I was consulted in a case of this kind, where the young woman 1 Vorlesungen über Allgemeine Pathologie, Berlin, 1877. * Gross, Tumors of the Breast, p. 280, Am. Cyclop, Gyn., Vol. II. * Billroth, Diseases of the Female Mammary Glands, p. 132. 8 CAUSES OF GENEcoLog/CAA DISEASEs. had married, hoping it might bring on the menses, and conception result; but all to no purpose. Fibroid tumors, which are rare in young women, some- times raise the question of marriage. Unless the growth be very small, marriage should be distinctly forbidden till after the tumor is removed. The increased irritation and . congestion consequent upon the new relations would tend to favor its growth. Should pregnancy ensue, delivery might be attended with serious complications from dys- tocia, or post partum hemorrhage. Fibroid tumors have but little vitality, and the pressure to which they are subjected in labor is liable to cause their death, disorgan- ization, Sloughing, and as a consequence puerperal sep- ticaemia. I have in mind, while writing, the death of a young woman from this cause. Young women in whose family there is very distinct and decided hereditary disease, such as cancer, tubercu- losis, or insanity, for two or three generations back, should not marry. Not only will they bestow a fearful legacy on their offspring, but pregnancy and child-bearing very de- cidedly favor the development of these diseases, particu- larly the two first mentioned. - - The physician is sometimes asked regarding the mar- riage of relatives." There has been à false alarm among the people and many of the profession concering it. Idi- ocy, deformity, albinoism, sterility, and especially deaf- mutism, have been attributed to it. All the evidence which has been accumulated by the most painstaking care is to the contrary. The offspring of such marriages are subject to the laws of heredity as seen in other marriages. Pecu- liarities of either parent are often transmitted to the child, and should both the parents possess the same peculiarities 1 Those interested in the subject will find it ably presented, with full bibliography, in “The Marriage of Near Kin,” by Alfred Henry Huth, 1881, and more concisely by C. F. Withington, Reference Handbook of the Medical Sciences, Vol. II. p. 272, 1886. MARRIAGE OF RELATIVES. 9 the child is doubly liable to receive their impress. Ten- dencies for either good or evil thus become intensified in the child, and if scrofula, for instance, exists in both par- ents it is twice as likely to appear in some form in the child than if only one parent were affected. Consangui- neous marriage is not in itself a true cause of deaf-mutism, but the numerous instances in which deaf-mutism follows such marriages are to be considered as cases of heredity." 1 Edward Allen Fay, Reference Handbook of the Medical Sciences, Vol. II. p. 367, 1886. IO MLVOR SURGICAL GPMECOLOGY. CHAPTER II. MINOR SURGICAL GYNECOLOGY, AND THE PRINCIPLES OF LOCAL TREATMENT. EATNESS, both in person and methods of treatment, is always noticed and appreciated by ladies who have occasion to consult a physician for any peculiar difficulty requiring an examination. Neat, fresh linen is a matter of no little importance. The finger-nails should be kept short and clean, to avoid giving unnecessary pain or infecting the patient. It is needless to remark, that the utmost delicacy should be observed in any exam- ination, and all undue exposure carefully avoided. This is of so much practical importance to the physician, that the ordinary manipulations will be described in some detail. - A thorough practical knowledge of general practice is essential to any specialist. The various organs of the body are so intimately connected that one influences another, and the suffering may be due to disturbance quite remote from the seat of the disease. In no branch of medicine is this more true than in gynecology. Not infrequently the trouble is due to imperfect portal cir- culation, or the disease may be merely the expression of general debility. On the other hand, there are some diseases, more especially those of a neuralgic type, which depend on some form of uterine trouble, though the local symptoms of the latter may be quite insignificant. A golden rule for every practitioner to follow in treating the diseases of women is to consider carefully every func- tion of the body, and in every case the totality of the GAZAVAEACA/C ZTA’AºA 7TMAE/WZT. I F. symptoms. Such advice may seem commonplace and threadbare, from the constant repetition of this idea, but the fact is it will not do to focus investigation on one organ and ignore the rest of the body. Many a woman has suffered more from unnecessary and harsh local treat- ment than the disease itself would have caused, if a little common sense and hygiene had only been employed, and all because her physician concentrated his entire attention on that much abused organ, the uterus. • Cleanliness, rest, and good nourishing diet to build up the general health of the patient, will be of great advan- tage. I do not mean to say that local treatment is un- necessary, - not by any means; but I believe it is very much abused, and the general treatment of the patient too often neglected. Carefully selected remedies should be relied on, rather than local applications, for the per- manent cure of the disease. Why is it necessary to apply remedies locally so much more to the mucous membrane of the genital tract than to the mucous membrane of the nose or throat, in treating affections very similar to each other? - - - - A careful record should be kept of every case; the history and symptoms, as well as the remedy and the results. It requires not nearly as much time as it would seem at first thought; the symptoms once noted do not have to be repeated, and only a few words are necessary to record the results at each subsequent visit. The more important cases can be indexed, and in a few years valu- able experience is collected in a ready form for reference. The arrangement of the author's case-book" is given on the succeeding pages in reduced (%+) size. Indexes are provided for the diseases and the patient's address, After the record is once made, much time is saved in the sub- Sequent visits of the patients. The question when to examine a patient depends very 1 For sale by De Wolfe, Fisk, & Co., Boston. I2. MINOR SURGICAL GPMEcoLogº. MAME, SiRNGLE. SENT BY * MARRIED, ADDRESS, WIDOW. AGE. CHILDREN. MISCARRAGES. OCCUPATION. NATIONALTV- . FAMILY HISTORY, AND HIsroRY FROM 10 ro 20. * PREvious diseases. FIRST APPEARANCE EXTERNAL GENITALS JR. KIDNEY L KEREY REGULARITY PERINEUM} BLADDER -z DURATION: VAGINA URETHRA 9 - º: AMOUNT . VAG|NAL VAULT COLOR OF LIRINE AND SEDIMENT # 2 CHARACTER DOUGLAS’S POUCH QUANTITY § - -: PAIN-BEFORE SHAPE, ANALYS18. DURING APPEARANCE × AFTER : EXTERNAL OS g SACRUM INTERNAL OS; R. OVARY L. OVARY POSITION ABDOMEN - SIZE GROWNS EXTREMTIES gº MOBILITY - > : | HEAD -> DEPTH THORAX SENSITIVENESS INTERCOURSE OVARIES MICTURITION *TUBES ExERçISE SROAD LIGAMENT8 - B t AMOUNT ABDOMEN : 5 CHARACTER. . RECTUM tºo > : DURATION ANUS \ #EGULARITY pHEGNANCY —º § 4:ONSISTENCY LABOR lº - D DURATION PUERPERIUM. DRaw Aromauss of Cass is Diagnaws or Aaboum (A), Palvis (B), Cravn (C), and Mabtan Plaus or rus?sivis(p). largely upon the circumstances of the case. There is a great difference in persons. Some will not consent to it, though it may be very necessary; others feel that they consult the physician for special troubles, and he fails in his duty if he neglects an examination and a certain amount of local treatment, though the latter may be nothing more than a dry pledget of cotton. The doctor should exercise a certain amount of judgment and tact in each individual. SOUTHWICK’S CASE-BOOK. I3 biaGNosts case. In patients suffering from considerable pelvic pain, Severe back-ache, much bearing down, and profuse leu- corrhoea, or much loss of blood, he should urge upon them its necessity; while in girls, it should be the last resort, and carefully avoided as far as possible. Unless patients decidedly object to an examination, it is well to make a thorough one at the beginning, enter the diagnosis in the record, and also re-examine occasionally, even if there be no local treatment. The record of the case is thus much more accurate and valuable for future refer- €11Ce. 14 J///VOA’ SUA’C/CA/L G. PAVE.CO/LOG P. It is exceedingly difficult to explore thoroughly the pelvis, with the patient lying on a low lounge or couch. Ladies naturally dislike to climb on to a table for the purpose, though some gynecologists prefer it. For such I would recommend Turner's table, on account of the tilting top. There are various kinds of chairs for the physician's use, good, bad, and indifferent. The writer Fig. 1. No. 4 MARKs CHAIR. Showing straight stirrups, made without the back legs, or adjustment for elevating front of seat. has used Marks's chair for some time with much satis- faction. The great objection to it is the expense, and it requires some strength to raise a heavy person. By having an extra cushion made, the ordinary Marks library chair answers every purpose for the general practitioner. The Har- vard chair admits of a greater variety of positions, but is more difficult to move about the room, and has a more repulsive appear- ance to the patient. A small cabinet near the chair, to hold the instruments and various medicaments for local Fig. 2. The Harvard Chair. 7TH/AE AEXAM/AWA 7TWOAV. I5 use, is very convenient. If good sunlight cannot be had, an ordinary candle with a good reflector attached to the candlestick affords an excellent and cheap substitute. If cheapness is a secondary consideration, there are vari- ous small electric lights which are very serviceable. With the patient in the dorsal position, which is the only one allowing a thorough examination, and covered with a sheet to protect her person, the physician is ready to commence the examination. Having washed his hands immediately before, he anoints the forefinger of the left hand if he wishes to examine the left side of the pelvis more particularly, or the forefinger of the right hand if the right side of the pelvis. Only one finger need be Sºs sº Cº., } ſº - &/º * §2. º - • Wºź º FIG. 3. THE BI-MANUAL ExAMINATION. (Hart and Barbour.) used, for as much can be felt with one finger as with two, by pressing firmly backward and upward on the perineum. Unless there is some reason to suspect the presence of venereal disease, pediculi, or some affection of the vulva, the patient should not be exposed before or while intro- I6 M/AWOR SURG/CAL GPAVECOLOGY. ducing the finger. The knuckle can be passed up in the cleft of the buttocks, over the perineum, and the tip of the finger at once glides into the vagina. The condition of the perineal body should be noticed by compressing it between the tip of the finger in the vagina and the thumb against the anterior margin of the anus. The vaginal walls, whether relaxed or not, dry, moist, or hot, next deserve attention. The cervix is finally reached. Here important information may be obtained from its shape, feeling, and direction. The condition of the cervical canal, as well as any bulging into the vaginal vault anteriorly or posteriorly, should be carefully noted. The fingers of the other hand are now placed nearly flat on the abdomen just above the pubes and corresponding to a portion of the pelvic brim. Any tenderness or localized hardness in the pelvis is then ascertained by seeking to bring the tip of the internal finger and the external fingers together, the pressure of the latter being exerted downward and forward. This is called a bi-manual examination, and is absolutely essential to obtain a correct knowledge of the case. In girls and unmarried women, enough information as to pelvic inflammation or uterine displacement can often be gained by a rectal examination instead of the vaginal. If the latter be necessary, the application of cocaine in a six per cent solution, or cerate, will diminish the sensi- tiveness of the hymen, which will gradually stretch with scarcely any laceration by gentle but continuous pres- sure till the finger enters the vagina. I have also used the cocaine successfully when the vagina was excessively sensitive. Outlining the uterus, which is indispensable in arriving at a diagnosis, is so often very difficult for the beginner, that a description will be given in some detail. The diffi- culty is frequently increased by the almost involuntary contraction of the abdominal muscles. This is best over- come by instructing the patient to keep herself perfectly THA. BZ-MAAVOA Z EXA MAAVA 7TWOAV. 17 relaxed, to breathe out, and keep the mouth open. If this is not sufficient, endeavor to engage her in conversa- tion: she cannot talk and keep the abdominal muscles contracted at the same time. Then crowd the internal finger well up into the anterior vaginal fornix at the junc- tion of the vagina and cervix, by steadying the corre- sponding elbow against the hip, at the same time pushing back on the perineum and up in the pelvis, while the outside fingers about two or three inches above the pubis press downward and a little forward into the pelvic brim in the median line; next, try to bring the fingers of both hands together, first on either side and then in the median line, where the uterine body will usually be felt. If this manoeuvre fails, place the tip of the internal finger on the posterior lip of the cervix, and raise the organ well up and a little forward in the pelvis, at the same time press- ing down from the outside as before. If this does not succeed, examine both sides of the pelvis for any lateral displacement. If the uterus be retroverted, the upper por- tion of the pelvis will be empty, the fundus bulge against the posterior cul-de-sac, and the cervix point upward and forward. Unless there is a flexure of the cervix upon the uterine body, the direction of the former will indicate to a certain extent the position of the latter. Besides the position of the uterus, the examiner will ascertain in a sim. ilar manner whether there is any undue tenderness of the ovaries, or displacement, the existence of inflammation, exudation, or the presence of any foreign growth. Having obtained all the information possible by a digi- tal examination, the physician is ready to use either sound or speculum. The, former is a safe instrument in careful hands, but is liable to provoke some irritation, and should never be used without a distinct indication; moreover, all unnecessary manipulation should be avoided. Most physicians have the ordinary Simpson's sound, with the little knob two and a half inches from the tip, 2 I8 M/ZVO/º SOVA’G/CA/ G PAVE.CO/COG P. the average depth of the normal uterus. In addition to this, a much smaller sound, or Sims probe, will be of great service, where, as in sub-mucous fibroids, it is neces- sary to ascertain the depth and direction of the uterine canal with the least possible irritation. The Simpson i : N g g & & º sound should be passed into the uterus without a specu- lum, with the tip of the forefinger on the OS uteri as a guide; the probe must be used with a speculum, prefera- bly Sims's. Either is absolutely contra-indicated by any inflammation of the pelvic organs, even if it be of a sub- acute character, endometritis and sub-involution excepted, - 7THE USE OF THE SOUAVD. I9 and also if there be any suspicion of pregnancy. For this reason, and also for the important information it gives as to the position of the uterus and probable direction of the uterine cavity, digital examination should invariably pre- cede the use of either sound or speculum. The sound is most often employed to detect the pres- ence of an intra-uterine growth, such as a fibroid; to p *... s ºf *.*.*, * w ******* * fºr */ %& % º % % % % % ź -----º 23 º FIG. 7. FIRST STAGE OF PASSING THE Sound. (Hart and Barbour.) ascertain the relation of the uterus to a tumor in that portion of the body; to replace the organ from some mal-position; and, finally, in rare cases, to find the po- sition of the fundus uteri, when it is not revealed on a bi-manual examination. The ordinary sound is cumber- Some, and too long for convenience in using it com- bined with a bi-manual examination. At such a time a short sound, about nine inches long, will be very useful. See Fig. Io. * Having previously warmed and oiled the tip, the opera- tor guides it along the palmar surface of his finger in the vagina to the cervical canal; then, by depressing the han- dle of the sound, the point readily enters the uterine cavity if the latter is directed forward. Force must not be used, 2O A///VOA’ SC//ēC/CAA, G VAWE CO/COGY. but the handle held lightly between the thumb and fingers. If the fundus lies posteriorly, the tip, which is on the same side as the rough surface on the handle, should be directed jº, * \\leº § ºr º .* º *NS §) Wy - §§ § § º N; *\!/? ! - ... ſº KººVW §2. % §§ sº ºA backward. See Fig. 8. When the body of the uterus forms an acute bend or angle with the cervical canal, some little difficulty may be encountered, but is easily overcome after the sound is in the cervical canal by raising the fun- dus with the finger, so as to straighten out the angle; and AN/APFA. AEAAV7/A/, D/A GAVO.SYS WITH THAE SOUAVD. 2 I - in some rare cases the instrument must also be bent to correspond with the flexion, or even given two curves, one for the perineum, the other for the direction of the cervical canal. - A decided increased depth of the uterus usually points to the presence of some growth in that organ, or its adhe- Sion to some tumor, which is drawing it up, and stretching out the cavity. In the former case the uterus is low down FIG. 9. SECOND STAGE OF PASSING THE SóUND, when THE UTERUs is TowARD THE FRONT. (Hart and Barbour.) in the pelvis from the increased weight; in the latter, the cervix is apt to be high up, and hard to reach. If it is due to the presence of a sub-mucous fibroid, the examiner will meet with some difficulty in introducing the probe, owing to the obstruction in the cavity. Where a fibroid is suspected, it can almost always be diagnosed by bi-manual palpation. Place the patient well over on her left side in Sims's position, and with the aid of his speculum intro- duce the probe – not the sound—very gently, so as to avoid all unnecessary irritation. Much information can be gained in this way regarding the size, attachment, and amount of bulging in the cavity. If this is not suffi- cient, the cervix can be dilated, the uterus forced down lored with the ty, and its interior exp to ascertain the relation of the 1C C3HV1 e 1S necessary A///VO/º SUAEG/CAA, G VAWECOLOG}^. t i to the pelv finger. When uterus to some growth, place the patient on her back, and 22 111 º T ('uosduțS ‘N ‘V) 'Noſ LvNIWwxGI "Ivn NVW-Ig v 9NIxvW NI CINQoS L'HoHS （Io ºsn ºor '91 （I ！*，-* ŹŹź Ź22 £22:$3$22 x·* •■■■■■■>.■ 。、: ！º，---- •Tae -！º， º ！！！！！！！！！！！ *， *）（.*?）. ！cº • …º.º .*（.* Źſ ź • • • • Źrae;، ، ، ſae，Źź¿??¿? ¿? *aeae º， saeaeºſ， ¿?????? * };zziſſſſſſſ|\\Y ºſ) {ķį *** --， Note lation to the tumor, and, as 11] re one or both hands are applied to the latter, motion of º the fundus uteri communicated by the sound will give an introduce into the cavity a moderately stiff sound. the direction of the cavity REPLAC//VG THE UTEA’U.S. 23 approximate idea at least of the connection of the uterus with the growth. Mo attempt should ever be made to replace the uterus with the aid of the sound, if there are any signs of latent cellulītis. This is a rule with no exception, nor should this instrument be used when simpler means will accom- plish the same end. Peaslee's sound, which is large, thick, and less liable to injure the uterus, is best for this purpose. Place the patient well over on her left side in Sims's position, with the hips raised about three inches higher than the level of her shoulders. Introduce the N FIG. II. Soun D PROPERLY TURNED. Fig. 12. Sound IMPROPERLY TURNED. - (Hart and Barbour.) § sound, and, with the help of the fingers of the opposite hand to push up the fundus, gently rotate the instrument, carrying the handle round in a circle about six inches in diameter. Never turn the sound on its long axis, for in this way the point describes a circle, and exerts more force in the uterine cavity. But if the handle of the sound describes a circle, the point rotates in a smaller one in proportion to the size of the former. (Compare Figs. II and I2.) In many cases examination with the speculum follows the digital examination. There are three principal va- rieties in common use: the cylindrical, or Ferguson, the 24 MIAWOR SOVIPG/CA L G VAWECO/LOG V. bivalve, and Sims's. The small Nott speculum is best for young unmarried women, and is also very good for exam- FIG. I.3. REPLACING THE UTERUs witH THE Sound. 1, 2, 3, Successive positions of the sound and uterus. (Hart and Barbour.) ining the rectum. The smallest Ferguson speculum is preferred by some on account of the reflecting surface FIG. I.4. FERGUson SPECULUM. increasing the amount of light admitted into the interior. The bivalves, of which Cusco's and Graves's are very good THAE USE OA' THE SPECULUM. 25 examples, are most used. Sims's speculum has many ad- vantages, but requires an assistant to hold it. The various contrivances invented to hold the instrument are expensive, can only partially serve the purpose, and, in fact, are sel- dom used by the inventors themselves. Although an invaluable and indispensable instrument, its use is natu- rally restricted to a great ex- tent to specialists, and the performance of certain oper- FIG. 15. NoTT SPECULUM. ations. ;. \ | FIG. 16. GRAVES's SPECULUM. Used as a Bivalve or a Sims Speculum. Dr. Danforth remarks: “I have found Hunter's Self- retaining Sims Speculum of great service in working 26 A///VOA’ SC//&G/CAM, GPAVECOZOG P. Without a nurse. Having become accustomed to the in- Strument, I have been able to do as well with it as with the ordinary Sims speculum. Have found it especially useful when called upon to make an application for the relief of a hemorrhage, curetting the uterus, or placing a tampon, when a competent assistant could not be obtained. In my obstetrical practice, have also had occasion to use the instrument, and with great satisfaction in every case.” i. = . |||ſiºn º h | Dº T. º FIG. 17. HUNTER’s MoDIFICATION of SIMs's SPECULUM. In using any speculum, the examiner should select one corresponding to the size of the vagina. This is of con- siderable importance. If too large, it is very painful. If too small, particularly if a bivalve, the vaginal folds drop down, making it very difficult to obtain a good view of the os uteri, besides the liability of severely pinching them between the blades on withdrawing the instrument. A physician who needlessly hurts his patients is not likely to be very popular with them. Before introducing the Ferguson speculum, smear it with vaseline, and hold the cylinder between the thumb and 7HAE USE OF THE SPECULUM. 27 second and third fingers, while the forefingers of both hands separate the labia. These are held well apart by one hand, while the point of the speculum depresses the perineum, and glides downward and backward into the vagina. This instrument is very apt to catch on some portion of the nymphae and bulb of the urethra when the point is introduced, and hurt the patient. This can easily be avoided if the operator always takes the simple pre- caution to look through the speculum as it is being intro- duced. Any tendency to impinge against the nymphae Y CopMAN & SHURTLEFF, BOSTON, FIG. I8. CUSCO's IMPROVED SPECULUM, Fold.ING HANDLEs. or urethra can then be seen at once and prevented. A speculum should always be introduced gently, particularly if there are any sensitive spots in the pelvis, and the point directed towards the cervix, the position of which has just been ascertained by the finger. The use of the cylindrical speculum exposes a patient much more than the bivalve, though in both the patient occupies the dorsal position. Moreover, the bivalve gives a much more satisfactory view than the cylindrical. In the great majority of cases, then, a good bivalve speculum will be the best for the general practitioner. This instrument, having been well warmed and smeared 28 M/AWOR SURGICAL G VAWECOLOGY. with vaseline, is held in one hand, with the forefinger a little over the end as a guide. Fassing the hand beneath the sheet, and without raising the latter, the finger guides it from between the cleft of the nates over the perineum into the vagina. Introduce the long diameter of the oval extremity of the speculum through the vulvar opening, antero-posteriorly, and turn it so the blades correspond to the vesical and rectal walls after one third has entered the vagina; when fully in, partially expand the blades to re- tain the instrument. Now press the apron, formed by the sheet over the knees, back between the thighs, without raising it, and fold it around the speculum. With a little practice, this can be done without any exposure of the FIG. 19. BozEMAN’s UTERINE DRESSING FORCEPs (SELF-HOLDING). external genitals, and gives the patient the feeling that her person is protected. The os can then readily be brought into the speculum by raising or lowering the end, or expanding the blades a little more. The latter, however, need not be expanded so far as to cause a pain- ful stretching of the vaginal vault. The mucus can be wiped away with absorbent cotton, held by a pair of dress- ing forceps having a bend in the shank, so that the hand of the operator does not obstruct his view. In some cases of endocervicitis, the mucus in the cervical canal is so tenacious that the cotton will not remove it. However, the canal can usually be cleansed by persistent Syringing with one of Goodyear's uterine syringes, by attaching a short piece of rubber tubing to the nozzle and employ- ing suction, or by twisting up the mucus with bits of dry 7 HAE O/SE OF SIMS’.S. SAEA, CULUM. 29 sponge." In many cases I find nothing is so simple and effectual as the Roux spoon curette, which twisted round in the canal clears it very thoroughly from mucus. Before making any application, a towel should be tucked between the buttocks to catch any fluid which may escape and soil the clothing. This is particularly important where Pinus Canadensis, hydrastis, or iodine and glycerine are employed. Before withdrawing the speculum, the blades are to be partially unscrewed, but not enough to let them come to- gether and pinch the vaginal folds. The sheet is then pulled forward over the speculum, and the latter removed behind it. If a tampon has been inserted, it is held in place by the dressing forceps, while the speculum is with- drawn over it, and then the instruments are removed. A digital examination is now made with the finger, to be sure that the tampon is in proper position. The physician who Davidson rvases co, Tºfflºº FIG. 20. UTERINE SYRINGE. is at a loss to know where to put the bits of soiled cotton will find Murdock's turtle cuspadore very convenient. The successful use of Sims's speculum depends largely on the proper position of the patient. She should lie well over on her left side, the left arm extended a little behind her, the thighs flexed on the abdomen, and the upper limb thrown a little over and above the lower one. Any con- stricting bands about the waist should be loosened. Be- sides a slight cant downward to the right side, the end of the table or chair toward the operator should be a couple of inches higher than the end occupied by the patient's shoulders and head. This allows the anterior vaginal wall to drop forward as the posterior is retracted by the specu- * The peroxide of hydrogen has been recommended for this purpose; but the writer has not had much success with it, and the preparation is very unstable. 3O MIMOR SURGICAL GPAVECOzog P. lum. The same object may be obtained in a simpler way, for the general practitioner, by raising the patient's hips on a hair pillow about three inches thick. The sheet is thrown over her, so that one corner is folded over the upper limb and buttock, while a towel is tucked in be- tween the thighs and under the hips to protect the cloth- ing. The operator now takes the speculum, which has been previously warmed and oiled, in his, right hand; the forefinger, as a guide, projecting a little over the con- cavity of the blade which is to be introduced, while the left hand holds the opposite blade to steady it. It is then passed over the perineum into the vagina edgewise; after FIG. 21. SIMS's SPECULUM. Wom AN’s Hospital PATTERN. the blade has partially entered, the concavity is turned to- ward the anterior wall, and care taken to direct the point of the instrument well back against the posterior wall of the vagina. Gentle, but firm, steady traction is then made backward and a little upward, the nurse or assistant mean- time lifting the superior labium with the fingers of her left hand, while the right hand grasps the shank or central por- tion of the speculum, the blade resting over the junction of the thumb and index finger. Beginners often have some trouble in using Sims's speculum, which would be easily obviated by keeping the inside blade well against the posterior wall while introducing it, and then giving the point a slight forward twist to tilt the cervix out of the THE USE OF SIMS’S SPECOWLOVM. 3I hollow of the sacrum. After the physician has exposed the cervix, the nurse holds the instrument in whatever po- sition is desired. He sits behind the patient on a chair or FIG. 22. CLEVELAND’s SPECULUM. stool of a suitable height. At his right is the cabinet, and a basin of warm water, in which lie the depressor, dressing forceps, tenaculum, and sound or probe, or, if an opera- FIG. 23. CLEvelAND’s SPECULUM. tion is to be performed, whatever instruments he may de- sire. In the latter case, his assistant sits on the right to hand the instruments, etc." Numerous modifications of * The best Sims specula that I have seen are those known as the wo- man’s Hospital pattern, in five sizes, manufactured by Hazard, Hazard, & Co., New York. 32 MIMOR SURGICAL GPAVECOLOGP. the Sims speculum have been tried with a view to doing away with an assistant. These have not been very suc- cessful. I prefer Cleveland's modification to any others I have yet seen. Tampons, are used for various purposes, but chiefly for the application of medicinal agents to the cervix and vagina. It is not necessary to make them of absorbent Cotton. A fine quality of clean white cotton will answer every pur- pose unless the absorbent quality is particularly desired, and is much less expensive. The great objec- tion to cotton, the absorbent espe- cially, is that it packs down and feels like a foreign body in the vagina, so that Some patients are unable to wear it. In these cases, particularly if a disinfectant prop- erty is desired, marine lint, which is a good quality of tow, makes an excellent substitute. Where elas- ticity, and comfort for the patient, are desired, antiseptic wool is pref- erable. This is also best suited to some chronic inflammations of the pelvic tissues, where cotton cannot be borne. A good way to make tampons is to unroll a sheet of unglazed cotton, and then re- roll it tightly; when the roll is about an inch thick, separate it from the rest and tie to it strings of strong linen thread ten inches long at intervals of an inch and a half, then cut the roll midway between the threads. This will make a number of tampons an inch thick by an inch and a half long, a good average size for general use. I much prefer to use two or three small tampons to one large one. They can be introduced more i A PAE LICA TYC)/V OF A LOW/DS OR POWDEA’.S. 33 easily, with less loss of a fluid application, and can be placed in the pelvis to better advantage. A good way to make a long flat tampon, corresponding to the shape of the vagina, is simply to cut a layer of the wool into pieces an inch wide and two and a half inches long, tying the thread to one end. If fluids are to be applied, such as glycerine, or combinations with iodine, calendula, hydras- tis, etc., a tampon is saturated in the liquid, and the excess Squeezed out enough to avoid dripping before introducing it, particularly if containing iodine, hydrastis, or tannin, which would badly stain the patient's clothing; or if it is of an acid or caustic nature, in which case it should be squeezed dry, and a neutral- izing agent applied on tampons immediately after to avoid irritating the vagina or external parts. Liquids can be applied nicely to the cervical canal or uterine cavity for corporeal endometritis, by winding a bit of cotton over Emmet's applicator, dipping it in the fluid, introducing it within the canal, and then with- drawing the stylet so as to leave the cotton in the cervical canal. This can be withdrawn, if necessary, by the dressing forceps, or a lº thread previously tied to it, but often comes away of itself. Sometimes the liquid is so squeezed out of the cotton while introducing it through the external os that very little of the medicament is applied to the canal itself. A /* The author has devised a cervix syringe for these cases which has proved very useful. After thor- oughly cleansing the cervical canal, the syringe can be used like Emmet's applicator, and the liquid forced into the cotton after it is in place; but I usually introduce the syringe as far as the angle only, and then gently force the liquid out all around the canal. If the cotton is to be i* : 3 34 MIAWOR SURGICAL G VAWECOLOGY. the carrier of powdered substances, such as tannin, alum and Sugar (equal parts), iodoform, etc., the tampon is moistened in glycerine or smeared with vaseline, and then rolled in the powder before it is introduced within the DAVIDSON RUBBER CO, FIG 27. POWDER-BLOWER MADE BY DAVIDSON RUBBER CO. speculum. Powder can also be applied to good advantage with an ordinary clean insect-powder gun. Ointments are smeared on a tampon, or injected into the posterior cul-de-sac of the vagina. This is becoming a favorite method with me for treating many cases. In recent inflammatory affections of the pelvic organs, a tam- pon will irritate the parts, but the presence of the ointment can do no harm by its mechanical effect. An excellent feature in using cerates is that patients can easily apply the ointment themselves after the usual hot water or cleans- ing douche. This is a great advantage in cases where the continued local action of a drug would be beneficial, and where patients live at a distance or cannot afford to come as often as desired to the physician's office. A serious objection to the use of ointments has hereto- fore been the lack of a suitable instrument to apply them. copMAN & SHURTLEFF. Hè FIG. 28. SOUTHWICK's OINTMENT INJECTOR. The author's injector overcomes this difficulty, and is ea- sily filled; if the ointment tends to stick to the instrument, warming the latter a little in hot water will prevent it. My ordinary direction for a patient is to take a vaginal douche at night, and after getting into bed to insert a THAE USA, OF CAE/PA 7TES. 35 dram and a half (a teaspoonful and a half, marked on the piston of the syringe) of the appropriate cerate as far as the syringe will enter the vagina. If the introitus be patu- lous, as in most multiparas, she can place a little dry ab- sorbent cotton in the lower part of the vagina, and support it by a napkin if necessary when on her feet the next day. Otherwise, some of the ointment may run out and soil her clothing. When the local action of a drug is desired, not by act- ual contact with the surface but by absorption, as in pelvic peritonitis, cellulitis, ovaritis, etc., a rectal application offers Some advantages over the vaginal; chiefly on account of the ease with which the rectum retains and absorbs the drug in comparison with the vagina, which has a very lim- ited power of absorption. For this reason, less ointment is required for a rectal than for a vaginal application. The rectum should be first cleared by an enema, after which about a dram of the ointment can be applied with the ordinary vulcanite suppository injector. The writer does not wish the reader to infer that tam- pons are not used. Far from it: they are often invalua- ble to support the uterus, and thus promote circulation; but in some cases they are injurious, and in others of no use. It is in such cases, and where the continued action of a local application is desirable, that he recommends the use of ointments. In making applications to the cervical canal and cavity of the uterus, a whalebone applicator or probe is wrapped with cotton dipped in the liquid, and applied once or twice to the canal. The mucus must be removed first, as previously described. Pencils of iodoform, tannin, etc., are also introduced within the canal. Astringents are most often used for endometritis; and caustics, such as iodized phenol, ni- tric acid, iodine, etc., for subinvolution and vegetations with consequent metrorrhagia. The use of an applicator wrapped with cotton requires a patulous canal. Where the 36 4///VO/& SO/PG/CA L G VAWECOZOG V. canal is small, gelatine or cocoa-butter pencils, inserted with the aid of an instrument made for the purpose, are FIG. 31. AN INSTRUMENT FOR INSERTING THEM IN THE CERVICAL CANAL OR URETHRA. - very popular with some gynecologists. Those most fre- quently used are iodine, gr. v.-x.; iodoform and tannin, gr. v., gr. iij , iodoform and alum aa, gr. v.; Hydrastis Canadensis, gr. v.; and I might add bichromate of pot- ash, I X, or 2 x., gr. v. It must be remembered, however, that the great majority of cases for which these applications to the uterine cav- Fig. 32. Recrat Ont- ity are made depend almost entirely on MENT INJECTOR. tº º causes quite independent of the mucous membrane of the cavity, such as Subinvolution, displace- ment, lacerations of the cervix, etc.; and consequently the causes need to be removed rather than drugs applied, which often do more harm than good. The question of making local applications, in the great majority of cases applying for treatment, is one which must be settled by the physician himself. While a judi- cious use of them is to be advised, harm is often done by harsh measures. In the use of homoeopathic remedies we occupy a vantage-ground, and can well afford to dispense with the much harsher methods which the old school are compelled to use. Let us use our vantage-ground, care- fully select our remedies, and with rest, cleanliness, and § ----------. . . .'; sº PAW iDSON R J B 38.R CO. I, OCA1/, A PA/LACA 7TWOAVS. 37 simple accessory treatment, we shall be surprised to find how much more successful we are than our neighbors who stand aloof. Prescribing one carefully selected remedy FIG. 33. SouTHWICK's GYNEcoLogiCAL CASE. cannot be advocated too strongly. Not only will the re- sults be better, but more accurate for future reference. A list of the more common applications is here given, with the conditions for which they are employed, for the convenience of those who wish to use them. It seemed best to give the indications for each, as the local treat- ment used by some practitioners seems to be summed up in glycerine and iodine for every case. Many physicians recommend the use of the same medicine locally which is given internally. This, however, hardly belongs to those remedies used with the express purpose of producing local effects. ALUM. Where a powerful astringent is desired. It is good for profuse leucorrhoea, relaxation of the vagina, and slight erosion about the os. In these cases it should be diluted one half with pulverized sugar, iodoform, or Some other substance. Powdered alum will often check oozing of blood from the surface. 38 MIMOR SURGICAL G VAVECOLOGY. BELLADONNA can be used in the form of cerate, Sup- positories, tincture, or fluid extract. Is useful as a mild narcotic in acute inflammation or congestion of the pel- vic organs, with much aching or throbbing in the vessels, in which case it has also a curative effect; also, for the pelvic neuralgiae of chronic pelvic cellulitis or similar con- ditions. Watery extracts evaporated to the strength of the alcoholic are preferable, because less irritating. For local use, I have the solid extract of belladonna rubbed in a mortar with sufficient water and glycerine to dilute it to the strength of the ordinary fluid extract, mixing this in the proportion of half a dram or one dram to an ounce of glycerine for an application. The cerate is best applied by Smearing it on tampons of cotton or wool. BORACIC ACID. Its action is the same as borax, but more powerful. May be used in cerate, powder, or solu- tion in hot water. It is an excellent, non-irritating, odorless disinfectant. It is good for clear, albuminous, or lumpy, but not for yellow leucorrhoea. (A solution of one dram of the bicarbonate of soda, – saleratus, – to a pint of water, as an injection, is also useful for this leucorrhoeal discharge, due to profuse secretion of the glands in the cervix.) Sir James Simpson recommended a solution of five to ten grains to an ounce of hot water in the “pruri- ginous eruption which appears on the mucous membrane of the vulva, and extends up along the vagina as far as the cervix uteri,” also in eczema of the vulva. Dr. J. Heber Smith finds it useful in these cases. BOROGLYCERIDE is among the most valuable of all the applications to the pelvic organs, either diluted twice its bulk with glycerine, or in the form of boroglyceride cerate. It is usually put up in bottles containing a fifty per cent solution. It is an excellent antiseptic, and is particularly valuable for all aphthous inflammations of the vagina and cervix. It is one of the best applications to chronic ero- *s LVD/CATIows For LoCAL APPLICATIows. 39 sions of the cervix, and is useful for offensive leucorrhoea and itching of the parts. If the pruritus be severe, and there are no fissures or excoriations, the addition of three drops of the oil of peppermint to the boroglyceride and glycerine, the whole well warmed and mixed, will be very helpful in many cases. - BROMIDE OF POTASH in a saturated solution is some- times applied on a tampon for its soothing effect. CALENDULA, an excellent application where there are any solutions of continuity, as in erosions of the cervix when very red and bleeding easily; besides its use as a cerate, or in tincture, it is an excellent remedy to mix with the water used for injections in any abrasion of the mu- cous surface. Following some surgical operations after the patient has used the ordinary cleansing douche, I di- rect her to mix two teaspoonfuls of the tincture with half a pint of warm water, to inject it while lying on her back, and retain it from twenty minutes to half an hour. The non-alcoholic preparation is preferable. Dr. Conrad Wes- sellhoeft questions whether there is any actual proof of the value of calendula. CARBOLIC ACID is used chiefly as a disinfectant, in the form of a two or five per cent douche; the stronger solu- tion for very fetid discharges, or leucorrhoea of gonorrhoeal origin, the weaker for ordinary disinfecting purposes. It has also been used as a mild caustic and stimulant for erosions of the cervix. CHLORAL HYDRATE is a good anaesthetic, and also pos- sesses disinfectant properties. It is highly recommended in cancer of the cervix, applied in the form of a solution, one dram to the ounce of glycerine, or stronger if neces- sary. It is one of the best deodorizers of iodoform. CHROMIC ACID. 5i. to 3i. of water. Dr. Danforth says: “I have found chromic acid one of the best remedies; have used it in the treatment of cervical endometritis, – 4O M/AVOA’ SOVAEG/CA/C G PAVE CO/COG P. especially in cervical catarrh coexisting with a laceration.” Dr. J. C. Kirk, in the “Practitioner,” finds it the best ap- plication for endometritis characterized by a profuse dis- charge like the white of an egg. He uses equal parts of chromic acid and water, and applies it once a week. The author must warn the reader against such a strong Solu- tion. Excellent as the remedy is, such a solution should only be employed in the most obstinate and very excep- tional cases. ELATERIUM has been recommended for chronic inflam- mation and congestion of the pelvic organs, on account of its power to produce a discharge of serum. A com- bination of this with jequirity is said to constitute the “orange flower” so generally advertised. On account of the great variation in strength of elaterium, a one per cent cerate of elaterine, Merck, is recommended to be used cautiously in making the first applications. EUCALYPTUS GLOBULUS. One dram of the oil (im- ported) to an ounce of glycerine, or the strong watery extract. This is a useful application in cases of profuse leucorrhoea, and superficial erosions about the OS with congestion of the cervix. Besides being antiseptic, it is a very excellent disinfectant, and useful as an injection for all offensive discharges from the vagina and for cancer of the uterus. Belladonna is sometimes combined with it, if there is also much active congestion, and throbbing and pain in the pelvis. GLYCERINE is the chief agent used in local applica- tions. It has a great affinity for water, and consequently its application in congested conditions of the pelvic or- gans is followed by a profuse watery discharge, making it necessary for the patient to wear a napkin. It is an excel- lent auxiliary, as well as vehicle with which to mix some other remedy in the treatment of acute, subacute, and chronic inflammatory conditions. The physician should IAWD/CATIONS FOR LOCAL APPL/CA TVOAVS. 41 warn his patient of the watery discharge following its ap- plication. It is important to use a fine quality. Price's and Bower's are the best. HAMAMELIS is an excellent application for Soreness in the pelvis, swollen and tender ovaries, erosions of the cervix when sore and easily bleeding, vaginitis, venous engorgement, and piles. The cerate is the preparation I usually employ, though the watery extract diluted with an equal amount of glycerine is desirable as an application or injection. When a soothing effect is desired, iodoform is a good adjuvant. HYDRASTIS can be used in powder, tincture, or cerate, in cases of profuse stringy leucorrhoea, endocervicitis, and erosion of the os. Equal parts of the extract and boro- glyceride is a very valuable application for chronic gonor- rhoeal vaginitis and endocervicitis. It is often combined with glycerine, one part of the tincture to four of the gly- cerine. The ordinary fluid preparations produce an al- most indelible stain, and the patient should be instructed to wear a napkin. Colorless preparations can be obtained, however, and are quite popular. Among these may be mentioned Luytie's hydrastis. IODINE. Churchill's tincture is the best for applica- tions. It is employed chiefly as an alterative and absorb- ent in cases of chronic cellulitis with exudation, chronic metritis with enlargement of the uterus and cervix, and sub- acute and chronic ovaritis. So long as there is acute in- flammation, and the exudation is very tender to the touch, local applications on tampons are counter-indicated. In applying the ordinary tincture of iodine undiluted, care must be taken not to let it touch the vulva, as it will cause sharp burning sensations for a few minutes. The cervix . or vaginal vault may be painted by a camel's-hair pencil, or a bit of cotton wrapped round a stick dipped in the iodine, and the surface touched with it. In either case, be 42 A///VO/º SOW/CG/CA/C G PAVE.CO/LOG P. * careful that all excess is removed, so that there will be no dripping, and no fluid running down the vagina after the application. This should not be repeated oftener than once a week. Dr. Danforth finds Churchill's compound tincture and iodized phenol useful in chronic corporeal endometritis and Subinvolution. In these last cases, he believes it is generally necessary to effect some preliminary dilatation of the uterine cavity by tupelo, or sea-tangle tents. A more common method of application is to mix it with glycerine, one part iodine to eight or more of the former. The addition of ten drops of tincture of aconite, or fifteen grains of chloral hydrate, is useful in cases of much sore- ness and aching in the pelvis. Dr. Emmet" recommends, in hemorrhage from fibroid tumors, the local application of the tincture to the uterine cavity by means of a little cotton wrapped round a probe, and Saturated in the iodine. Methyl iodide has been recently recommended instead of iodine, as it is said to combine the absorbent qualities of the latter with some anaesthetic properties. IoDIZED PHENOL. Dr. Robert Battey” suggested this combination, made by gently heating two parts of crys- tallized carbolic acid with one of iodine. It is a mild escharotic, alterative, and a favorite application of some physicians to the endometrium for subinvolution, and chronic metritis, and to the cervix for erosions, endocervi- citis, etc. This is sometimes diluted by adding an equal bulk of glycerine: I consider this dilution necessary for its use within the uterine cavity. IODOFORM has excellent antiseptic and some anaes- thetic properties. The odor, which is an objection to it, may be counteracted by chloral hydrate, oil of peppermint, or balsam of Peru, one drop to the dram, or a couple of Tonka beans may be kept in the powder. It is useful as a * Principles and Practice of Gynecology, 3d ed., p. 572. 2 American Practitioner, February, 1877. IAWD/CATIONS FOR LOCAL APPLICATIO/WS. 43 dressing after operations, for erosions of the cervix, and to destroy the virus of chancroids. The application of iodine is sometimes alternated with a tampon saturated in the following mixture: iodoform, one dram; chloral hydrate, twenty grains; glycerine, one ounce. Recently iodol has been introduced as a substitute for iodoform. IRON. The perchloride or persulphate is sometimes used as a styptic where iodine, tannin, or alum fails. JEQUIRITY. A powerful vegetable caustic. Dr. Porter has found this more satisfactory in the treatment of granu- lations of the uterus than any of the liquid or solid caus- tics. He macerates five fresh beans in two ounces of cold water for two days, then adds an equal amount of hot water, filtering it as soon as cool; one part of this is mixed with four of cold water for an application. Con- siderable pain is likely to follow the application: a fresh preparation must be used each time. NITRATE OF SILVER. Perhaps no remedy has been more abused in gynecological practice than this. Some of the most inveterate cases of ovaritis that I have seen have been the result of persistent cauterization of the cervix with lunar caustic. Since the profession has be- come acquainted with the true nature of the so called “ulcerated cervix,” and found it was in reality due to a laceration, the barbarous treatment of “burning the ulcer out " has largely been abandoned. It is doubtful whether it should ever be applied to the cervix if there is ovaritis present. Solutions of five, and, less often, of ten to twenty grains to the ounce, will be found helpful in stimulat- ing severe erosions to healthier granulation. They are touched with cotton wrapped on a wooden stick, the same as in the application of iodine. The cervix is afterwards dried with cotton, a tampon smeared with vaseline pushed up against it, and the speculum withdrawn. It is particu- larly useful in vaginitis of a virulent type. In these cases 44 MIMOR SURGICAL GPAVECOLOGY. the solution should be applied through the Ferguson or cylindrical speculum. Pour in a teaspoonful of a solution of twenty grains to the ounce, (in very severe cases, half a dram to the ounce is used by some physicians,) and as the speculum is gently withdrawn, swab the vaginal walls thoroughly with the cotton-stick; when the tube is almost out of the vagina, depress the end, and allow the fluid to run out in a cup. Now reintroduce the instrument, and insert a long cylindrical tampon well smeared with vase- line, withdrawing the speculum over it. This silver solu- tion may be applied once a week, milder ones being used as the case improves. It is hardly necessary to add, that all solutions of nitrate of silver should be kept in colored glass, and protected from the light. OPIUM is sometimes added to applications for its sooth- ing effect. It is much inferior, however, to a rectal sup- pository containing a small amount of the drug. PINUS CANADENSIS. The aqueous extract is a popu- lar application for catarrhal leucorrhoea, endocervicitis, and a relaxed flabby condition of the vagina. It is essen- tially an infusion of hemlock bark, a mild astringent, and stains linen almost indelibly. PLANTAGO AND BORACIC ACID cerate is a valuable application for pruritus vulva and pruritus ani, for acute vaginitis and vulvitis, erosion of the cervix, and clear albuminous leucorrhoea. SANGUINARIA in the form of a powder has been used with considerable success for erosion of the cervix and endometritis. It is said to be the chief ingredient of a certain “Red Powder” very popular with some practi- tioners in New York City. The author can recommend equal parts of Sanguinaria, myrrh, and hydrastis, mixed so as to form a fine powder, as very superior to iodoform for the ordinary dry treatment with antiseptic wool tampons, Zwp/CATIONS FOR LOCAL APPLICATIONS. 45 and also as an efficient application to catarrhal conditions of the vagina and cervix, and for erosions. TANNIN is an excellent astringent for erosion of the cervix, profuse leucorrhoeal discharge, and relaxation of the vaginal wall forming cystocele or rectocele. In the last case, moisten a long, slim tampon in glycerine, or smear it with vaseline, and roll it in finely powdered tan- nin, so that the latter will come in contact with the entire length of the vagina after it is introduced. In recent sub- involution of the vaginal wall, - i. e. when it follows soon after confinement, — this treatment may prove curative. It often gives great relief in cases of procidentia refusing an operation. Here the uterus must be replaced, and a large tampon used, supported by a T-bandage. Instead of tannin, I have sometimes used a strong decoction of white-oak bark, or a dilution of the fluid extract, as an astringent injection. Matico might be preferable to either. Dr. Porter recommends baycurn, one dram to an ounce of glycerine. ZINC OLEATE is useful for pruritus vulva with excoria- tions, and as an astringent to the cervix and vagina. When the parts are excoriated, or if there is fetid leucorrhoea, equal parts of oleate of zinc and iodoform is an excellent application. This is best applied through a speculum with a powder-blower. The physician should be particu- larly careful to be sure that the oleate of zinc is made from pure castile soap, and never from oleic acid. The preparations furnished by Otis Clapp and Son have given me satisfaction. The use of severe caustics, such as nitric acid, perni- trate of mercury, bromine, and the chloride of zinc, has not been mentioned. The particular point to be observed in their use is, that all excess of fluid must be very care- fully removed, and, as a rule, the surrounding tissues pro- 46 MINOR SURGICAL GPAVECOLOGY. tected by the use of a neutralizing agent. They are very rarely called for; and the physician in ordinary practice, unless expert in their use, had better leave them entirely alone. The worst case I have seen of recto-vaginal fistula was the result of these, applications and a little dripping of the caustic on the posterior vaginal wall. In another case, a tampon was Saturated in a strong solution of caus- tic potash and applied to the cervix. When the patient rose from the recumbent position, some of the fluid ran out, causing intense pain. Sloughing of the vagina followed, with consequent cicatricial contraction so that a No. IO ca- theter could scarcely be passed along the canal. I would earnestly caution any one against their use who is not perfectly familiar with the details of their application. The proper use of hot water is almost indispensable in the treatment of nearly all uterine diseases. The shriv- elled appearance of the hand after soaking it in hot water is familiar to every one. Its action on the pelvic tissue is similar, contracting the capillaries and decreasing the pelvic congestion. It is indicated, therefore, in all inflam- matory and hyperaemic conditions of the pelvic organs, acute or chronic, i. e. metritis, pelvic peritonitis, pelvic cellulitis, and congestion of the uterus from any cause except pregnancy. In menorrhagia, it will often arrest the flow. It has been used by Loewenthal" before and during the menses, to suppress the flow in chlorosis. When the ovaries are prolapsed and inflamed, and in some cases of salpingitis, hot water douches may fail to benefit, and even aggravate the symptoms. Under such circum- stances they must be discontinued. The hot water douche is often of great value in treatment, but is far from being a sovereign remedy. Too much stress cannot be placed upon the proper ad- ministration of the douche, which will be given in some detail, as it does not seem to be thoroughly understood * Gazette de Gynécologie, June 1, 1888. - 7THAZ ATO 7 - WA 7'EA’ DOC/CAHAE. 47 by all the profession. As a rule, it should be given at night on retiring, but some cases require it in the morning as well. It is almost impossible for a woman to give it to herself with the same benefit she would receive with proper FIG. 34. SouTHWICK's MoDIFICATION of BAKER’s PAN TO AVOID TILTING. aid. Much better results will be obtained from the use of a Davidson's syringe than from the fountain," although it is much more difficult to use, and not so practicable on FIG. 35. FIG. 36. REYNOLDS's SIPHON BED-PAN. RESERVOIR FOR WAGINAL DOUCHE. account of the assistance it requires. Care must be taken that the nozzle is not made of metal, as the latter collects the heat and soon becomes painful, but always of vulcan- ite, with the holes on the sides of the tip, and without a ! Emmet, Principles and Practice of Gynecology, 3d ed., p. 117. 48 M//VOR SOVRG/CA / G V/VECO/LOG V. perforation in the point of the tube. Unless the patient lies on a very firm mattress, place a small thin board under her, and on this the bed-pan; otherwise, when the patient's hips rest on the pan, one side tilts up and the other sinks down, allowing the water to run over and wet the bed. A good bed-pan can be made of tin, with a rubber tube attached to the bottom, through which the water can drain off, as fast as it collects, into a pail at the side of the bed. Her hips should be elevated two or three inches above the level of her shoulders, to have the aid of gravity in empty- ing the pelvic veins. Not less than six quarts of water should be given at a time, as hot as she can bear it, with the bag or reservoir of water two or three feet above the patient, and the injection tube well up in the cul-de-sac of Douglas. In the beginning she may not be-able to bear it over IO5° F., but it can soon be increased to I 12° F., or even more. The hot-water douche must be used till she has fully recovered; towards the end of treatment, the temperature may be lowered to 75° F., and the quantity lessened as well. The douche should be given daily, ex- cept during two days before and after the menses, and the addition of a table-spoonful of glycerine to the last pint of water is often very useful to increase the effect. I may add here, that the way it is often given by the patient sitting over a water-closet amounts to nothing more than washing out the vagina. The three important, ºvoss, ºrg. or, better, essential points in using the Fig. 37. Davidson's hot-water douche, are the position of the SYRINGE. patient (i.e. recumbent, with the hips elevated), the quantity of the water, and its temperature; while Dr. Emmet would add a fourth, a Davidson's instead of the fountain syringe. In connection with the hot-water douche, it may be well to refer to another method of applying heat and cold, in the shape of hot-water or ice bags to the spine, which was SPINAL ICE AWD HOz-WA 7ER BAGS. 49 introduced by Dr. Chapman. In pelvic disorders, either the heat or the cold is applied to the spine over the lower dorsal and lumbar vertebrae. THE ICE-BAG is said partially to paralyze the nerve- centres or ganglia, and lessen the nervous currents in the vaso-motor nerves arising from them. The result is that the blood-vessels supplied by those nerves dilate, and allow an increased flow of blood to pass through them. The ice-bag has been used, therefore, for suppressed, de- layed, and scanty menstruation; and, as it has been use- ful for neuralgia, it may prove a good adjuvant in treating ovarian neuralgia. I have seen great relief follow rubbing the spine with ice in attacks of extreme nervous irritability and restlessness verging on nymphomania. It is also said to be useful to control leucorrhoea. THE HOT-water BAG (not above 120° F.) has an opposite effect, and is supposed to stimulate the vaso- motor nerves. The arteries contract, and the supply of blood is diminished. It has proved effectual in menor- rhagia and metrorrhagia even when ordinary local treat- ment has failed; and ought to be a valuable aid in the same class of cases as those requiring the hot-water douche, if not used in connection with it. The mechanical treatment of uterine displacements has been warmly discussed among physicians. Specialists in general advocate it, while those less familiar with the sub- ject condemn it. The fact is, that the use of pessaries is by no means a simple matter in all cases; and, further- more, women who wear them do not always obey di- rections. Pessaries are to be considered an important adjuvant to further treatment, rather than as effecting a cure in themselves. In many cases I have found them indispensable. A serious objection to them is the care and mechanical knowledge necessary to procure a perfect 4 50 M/AWOR SURGICAL GPAECOLOGY. fit. A pessary which does not fit is almost sure to do harm. The mechanical gynecology so ably advocated by Drs. Hodge and J. Marion Sims has been overdone, and reaction may carry treatment to the other extreme; but this is no reason for entirely rejecting an aid in treat- ment which is so often invaluable, until at least as good a substitute can be found. - By mechanical treatment is meant some form of uterine support: either vaginal, as pessaries; abdominal, in the shape of pads or belts; or a combination of the two. It has a distinct place in gynecology, and certain rules are to be carefully observed. A mere tyro cannot use it to much advantage; as care, a knowledge of what is needed, and how to apply it with a certain amount of mechanical ingenuity, are essential. The serious objection to mechanical treatment is, that it may be used to the exclusion of all other, while not infrequently constitutional or local treatment at the same time is of equal importance. - The most important factor is the use of pessaries. The varieties of these are almost numberless, as not a few phy- sicians have sought to immortalize themselves by making some instrument of slightly different shape, and dubbing it with their names. Space forbids anything like an enu- meration. The principles and rules to be followed in using them are the same, and only those in most common use will be mentioned. If the reader understands these, he will have no difficulty in using others. In all cases where the pelvic tissues are sensitive to the touch, a pessary must not be inserted. It would then prove a source of irritation, and increase the inflammation already present. It is absolutely essential that the pes- sary be made to fit perfectly each individual case. The vaginae of different women vary quite as much as the hands, feet, or any other part of the body. We can no more expect all gloves to fit the same hand, than all pes- AºA. TACO WAE /ø.S/OZV PAE.S.S.A./R/E.S. 5 I FIG. 38. Bow Curved. FIG. 39. HARDING's. FIG. 40. HodgE’s. FIG. 42. THOMAS's MoDIFICATION OF SMITH's. FIG. 43. GEHRUNG's PESSARY. FIG. 44. TALIAFERO’s PESSARY. saries the same vagina. It is this fitting the pessary to the patient which measures the practitioner's success in 52 A///WO/C SUAEG/CA/C G PAVECOZOG P. using it, and requires the most skill. We cannot buy fixed sizes, and merely select the corresponding one: almost always some change is necessary. In order to ascertain the proper size, the uterus must be replaced; the physician can then roughly estimate with his finger the length and breadth of the vagina, the depth of the pos- terior cul-de-sac, and breadth of the vagina behind the pubes. The presence of a tender spot or prolapsed ovary should be noted. This gives an approximate idea of what is wanted. As retro-displacements are the most common, they will be considered first. In the great majority of cases, a carefully adapted Albert Smith pessary made of hard rubber will be the best. In some cases where the uterus is congested and sensitive, a Hofmann's soft rubber pessary can be worn tem- 7 porarily with relief when the hard rubber cannot be endured. But “a fit” must be had first; for this purpose, a pessary made of block tin, or, pref- erably, copper wire covered with pure gum rubber, should be used, as it admits of easy moulding or bending with the fingers, and will retain the shape given it. One of these is selected according to the measurements taken by the finger. The posterior portion, which occupies the cul-de-sac, is curved and widened according to the depth and breadth of the latter, and the height to which the uterus is raised. This is ascertained by raising the uterus on the finger to a position that is comfortable to the patient. More than this should not be done, as unduly crowding the organ up interferes with the circulation, and produces the same discomfort as when it sags down. It should be raised enough to give comfort, and allow free circulation without torsion or compression of the blood- AºA 77 YAVG PESSA AC/ES. 53 vessels. The upper extremity, i. e. the posterior portion, of the pessary, should be rounded to press up between the utero-sacral ligaments. In some cases complicated by prolapse of the ovaries, a thickened bulb-like expan- sion of the posterior portion, or a square instead of a round shape, is preferable. It is also made to correspond to the width of the vagina, and curved so that the anterior // . *- sº 6% Jº-T----> *---~ FIG. 46. RETRoversIon PESSARY SUPPORTING THE UTERUs. extremity is directed toward the pubic arch, while the tip is bent downward a little to avoid pressure on the ure- thra. The breadth of the anterior portion depends on the amount of space behind the pubic arch. Women who have given birth to many children, and whose vagi- 54 M/AWOA” SURGACA/C G PAVAZ.CO/COG P. ** nal walls are relaxed, require as a rule a broader shape. Should there be some tender spot, the instrument must be moulded so it will not press upon it. Having replaced the uterus, one of the pessaries men- tioned is bent, or moulded, as nearly as possible according to the above suggestions, and we are ready to introduce it. Place the patient on her left side in Sims's position. Thoroughly oil the pessary, and hold it from the convex side between the thumb and index finger, the tip of the finger on the inner margin of the broad or posterior end, the thumb on the corresponding outer margin. Stand a little behind the patient, and introduce the pessary edge- wise in the vulva, pressing it well back on the perineum. When about two thirds of the instrument has entered the vagina, rotate the pessary, so as to bring the convex curve posteriorly, and keep the upper end crowded well back against the posterior wall by the index finger, which is kept in the same place on the pessary; it then readily glides into place behind the cervix. This last is impor- tant, as the upper end of the pessary is otherwise very apt to slide up anterior to the cervix, and cause consider- able pain. Its introduction through the vulva is not in- frequently painful; but once in, if properly fitted, it is not felt. The anterior end is then placed behind the pubic arch, where it naturally lies, and is kept in place by the perineum. & - A pessary which projects in the least from the vagina will irritate the vulva, and is not a proper instrument. It should never stretch the vaginal wall, and the tip of the finger must always readily pass all around it except be- hind the cervix, where it is out of reach, but undue stretch- ing will at once be detected. The pessary often acts by taking up the slack in the utero-sacral ligaments; and by drawing the cervix up and back, the fundus tips forward and the uterus will not descend. The instrument must not press much on or stretch the utero-sacral ligaments, as it A Z TT/AVG PAESSA/º/E.S. 55 may then cause atrophy of them. Next instruct the pa- tient to cough or bear down; if this does not dislodge the pessary, have her get up, walk around, cross her limbs, sit down in a low chair, etc., and ask her whether she can feel anything anywhere in the “front passage"; finally, re- examine to see if the instrument is still in place. When properly adjusted, it will not be dislodged, and the patient is not able to feel it. If it slips down in any way, or if the patient can detect it, it does not fit, and must be re- adjusted. Always instruct her how to remove it, if any pain is caused, by hooking the index finger into it behind the pu- bes, drawing down a little to dislodge it, and then steadily upward and outward. Be careful to tell her that she has one inserted, and, if of soft rubber, to have it examined once a month; if of hard rubber, every two months. Tell her to return in a week. If she has found it in the least uncomfortable, the pessary does not accurately fit, and the necessary changes must be made to make it fit. If she has been unconscious of its presence, and experienced great relief, the fit is good, and it should be reproduced in hard rubber." This may be done by the instrument-maker; but not every physician can con- veniently send the block-tin or soft-rubber model pessary away, and he must mould it himself. Carefully remove the one inserted, without bending it. Select another of the same size in hard rubber. Smear it well with vaseline, and heat it over a spirit lamp, or an ordinary kerosene lamp, till the rubber softens, then mould it into exactly the same shape as the one just used, and plunge it in cold water for a couple of minutes to set it. With a little care, the fingers will not be burnt. It is introduced in the man- ner just described. These pessaries do not interfere with * The soft rubber pessaries soon become very offensive, but can be read- ily disinfected by washing thoroughly, and allowing them to soak a few hours in an ethereal solution of iodoform. 56 A///VO/º SOVRG/CA/ G PAVECOZOG P. the marital relations. Sterility depending on displacement is often cured by this treatment. FIG. 48. THOMAS’s ANTEversion PEssary. I (G. 47. THoMAs’s OPEN CUP An older and often inferior instrument to the FOR ANTEveRSION. Open cup. Closed. FIG. 49. THOMAS's ANTEFLExIon. Fig. 50. THOMAS's ANTEFLEXION PES- FIG. 51. GRAILLY HEWITT's ANTEveRSION SARY, witH STEM. PESSARY. Anteversions are more difficult to treat than retrover- sions. Thomas's open cup, Harding's anteversion, Grailly Hewitt's, Cutter's, and in rare cases Gehrung's pessaries, A/V7'Aº VE AES/O/V AAESSA/8/A2.S. 57 will be the best as a rule. They are selected, introduced in a similar manner, and the same tests are to be applied to these as to the former ones. Here, of course, the fun- FIG. 52. CUTTER’s RING PESSARY. dus is to be lifted up in front of the cervix, and the cross- bar or rim of the cup lies anterior to the uterus. The old form of Thomas's anteversion pessary is introduced closed, º, ... wwwº *), M. . Yºu!! FIG. 53. THOMAS's OPEN CUP ANTEVERSION PESSARY, SUPPORTING THE UTERUS. and the crossbar drawn up in place by a silk loop previ- ously attached to it. Anteversion pessaries are removed by drawing on the rubber ring lowest in the vagina; the łast mentioned pessary closes, and the open cup turns 58 . M//VOR SOV/PG/CA/L G. VAWAECOLOG V. over in extracting. With the exception of the large, hard rubber ring for prolapsus, the anterior margin of which rests against the pubic arch, and the posterior upon the Loop. Thomas's Modifica- Cup. tion of Loop. FIG. 54. CUTTER’s PESSARIES. FIG. 55. DONALDSON's PESSARY. posterior vaginal wall, the ordinary hard rubber and elas- tic ring pessaries will eventually do more harm than good, as they act by distending and stretching the vaginal walls, instead of the lever action exerted by the various modifi- cations of the Hodge pessary. In some cases, where the uterus seems to be perfectly relaxed, and without any tone whatever, becoming retro- or ante-verted if raised from either position, the intra-uterine stem may be used in connection with the ordinary pessary. “s In all cases of uterine displacement, a well-fitting ab- dominal bandage or supporter is a great help, by taking off the weight of the intestines. For the same reason, the dress and skirts should hang from the shoulders, and, if patients insist on wearing corsets, they must be very loose and pliable. A retroversion is rarely found where the cul-de-sac of Douglas is very shallow, or there is a lack of perineal support. Here the ordinary vaginal pessary is of no use, and we must resort to a vagino- abdominal supporter, or cup and stem, such as those of Cutter or Thomas. MacIntosh's supporter is also very useful in many of these cases. All pessaries having an external support are a great annoyance and source of irri- STAE/l/ /*A.S.S.A/e/AE.S. 59 tation to the patient, who will endure one for the simple reason that it is the lesser of two evils. Stem pessaries are inserted with the aid of a stylet through a speculum. After the end of the stem has en- FIG. 56. H. SIMs's PESSARy. tered the external os, I usually withdraw the speculum over the stylet, maintaining pressure on the latter, and introduce the finger in the vagina to push the stem up. This is quite necessary when there is a bend in the uterus which bars the entrance of the stem till the organ is raised and straightened by the finger. The stem must always be shorter than the cer- vical canal, and as a rule by a quar- "mº ter of an inch, and it is well to tie a piece of strong linen thread to it six inches long, so that the patient can re- move the stem in case of pain. When introduced, the cup should rest close against the cervix. In anteversion of the uterus, the stem will not slip out. In posterior positions of the uterus, a tampon or pessary arranged to receive the base of the stem will be necessary to retain it. Most of the abdominal supporters found in the market are constructed on false principles, being concave to con- form to the outward curve of the abdominal wall. I would as soon think of applying a truss curved to fit and cover a hernial sac, as such a supporter. The latter should be Frg. 57. ORDINARY STEM PEssary. 6O M/MOR SURGICAL GPNECOLOGY either straight, or, better, a little convex, so as to press the abdominal wall gently but firmly upward, and a little inward over the hypogastric region. It then acts as a kind of temporary shelf to keep off the weight of the intestines, and pressure when coughing, strain- ing at stool, lifting, etc., from the contents of Sº the pelvis below. When carefully fitted, I have - seen great relief from them, not only in uterine ºr displacements, but also in various acute and Peocipestra chronic inflammations in the pelvis. Not all women can wear an abdominal supporter. Those with broad hips, bulging considerably between the trochanters major and crests of the ilia, are best adapted to them, as the supporter is not likely to stay well in place on a Straight-hipped woman. I have had the most satisfaction from an inexpensive Supporter, which can be made by any ingenious woman in the following way. The patient must first remove her corsets, loosen all the clothing above the hips, and lie down with the pelvis a little higher than her shoulders, and the limbs straight. A firm linen towel is then to be pinned tightly over the hips next to the skin, the same as the binder after confinement, taking care that it is per- fectly smooth, and the lower edge an inch and a half below the trochanters. This holds up the abdomen, and affords a perfectly smooth surface, over which a pattern of firm cotton cloth or the supporter itself can be fitted. The latter should be made of a piece of light-weight but firm Russian crash about thirty-two by thirty-eight inches, i. e. wide enough to fold double, and go around the pa- tient. If the crash cannot be obtained, a firm piece of drilling is a good substitute. Firmness is very important, and for this reason flannel, india-rubber sheeting, ordinary cotton cloth, etc., are totally unfit for the purpose. It is folded double, not merely to make it firmer, but especially to have all seams Sewn inside, and not press next to the AB DOM/AVA L SUPPOR 7 EA’.S. 6I skin. This is fitted smooth and tight over the first binder, by folding over the upper border in places, and cutting out the slack cloth in the hollow of the back in a concave line. A V-shaped piece an inch and a half wide and two inches and a half deep is cut out from the lower margin over each trochanter, and a couple of pieces of strong elastic webbing stitched in. This keeps it snug, and also allows more motion to the limbs. Underneath each gore is a lappet of cloth to prevent chafing the skin. Two but- tons are sewed on at either side, to which the stocking supporters are attached, keeping the Supporter from slip- ping up on the hips. Ten or a dozen small black or brass buckles, and as many pieces of firm webbing an inch wide and three inches long, are sewed on its ends, which lap over in front and a little to the right side. This allows more perfect adjustment to the form. In some women the ilia project anteriorly, and the abdominal walls are so thin they would not receive sufficient support from a simple binder. In these cases, a pad is needed corresponding to the shape of the hypogastrium, and thick enough to ex- ercise gentle pressure, as if the hand were there holding up the bowels. If the pad be thick, curled hair is the best material; if thin, a folded linen napkin answers the purpose. This pad or cushion should be separate from the supporter, and fastened to it by safety-pins. This allows the former to be washed, and, by having two or three extra ones, the patient can wear a clean supporter as often as she likes. Instead of the firm webbing and buckles fastening the supporter in front, some of my patients, who prefer to have it open over the back, put in eyelets and lace it with elastic lacing so that the Sup- port will not bind, but yield more to the movements of the body. - - Sometimes three or four may have to be made before a close-fitting supporter is obtained, which stays in place and gives comfort to the wearer. - - 62 MI/VO/º SU/PG/CAL G V/VECOLOGY. 'It is not uncommon for women to neglect their instruc- tions to report at stated intervals. They feel so comfort- able, the necessity is not apparent, or they forget it. In the course of some years, or less time perhaps, the patient calls again; and the physician finds the pessary so em- bedded that it is very difficult to remove it. The best way to take it out is to put the patient in Sims's position, intro- duce Sims's speculum, divide the tissues if they have united at any place over the pessary, carefully insert the director or probe beneath, raise it up, and then extract it. If it has merely embedded itself in the tissues, lying in a sort of groove, pass a strong silk loop through the anterior extremity; as this is gently drawn upon with one hand, introduce the index finger up behind the cervix, if possi- ble, and press down on one side of the ring, thus giving it a little twist, so as to dislodge it from the groove, and from behind the cervix. * The following axioms can be laid down for the use of pessaries: — I. Never introduce a pessary if inflammation be present in any portion of the pelvis. 2. Always replace the uterus first. - 3. Carefully measure the vagina, and mould the pessary to it. Never introduce the instrument with the idea of allowing the vagina to conform to the pessary. 4. Introduce it with the patient lying well over on her left side, with or without the aid of Sims's speculum. 5. Tell your patient what has been introduced; instruct her how to remove it if pain is caused, and to report at fixed intervals. 6. If the cul-de-sac of Douglas is very shallow, it must be stretched first by wearing tampons, or no vaginal pessary will stay in place; neither will it if there be no perineal support. In these cases a Cutter, Thomas, or MacIntosh pessary, having a support from an abdominal belt, must be worn. A)/LA TA 7TMOAW OF THE CE/º V/X. 63 7. A pessary which slips down between or projects from the vulva is displaced. 8. The pessary must not stretch the vagina, but space enough always be left to sweep the tip of the finger easily around it next to the vaginal wall. 9. The clothing must be supported from the shoulders. IO. Absolute cure by merely wearing a pessary is the decided exception to the rule. Other measures are not to be neglected. Dilatation of the cervix is an operation which the gen- eral practitioner is sometimes called upon to perform. It may be gradual, by tents; or rapid, by instruments for dilatation or incision. As the latter is seldom necessary, and is more of an operation than the former methods, it will not be considered here. - The gradual method, by tents, is a favorite with many. The tents most used are made of Sponge, laminaria, or tupello. Sponge dilates much more rapidly than the others, but requires great care on account of the danger of decomposition and septic inflammation. Its meshes penetrate the lining of the cervical canal to a certain extent, so that after removal the canal is somewhat de- nuded, and the distended glands destroyed. It is there- fore preferable if endocervicitis is present, and in case of subinvolution or hypertrophy of the cervix the sur- face is in a better condition to be acted upon by local remedies. Spiegelberg has recommended the introduc- tion of the Sponge tent as a means of differential diag- nosis between chronic inflammation or sclerosis of the cervix and incipient cervical cancer. In both, the tissue might feel hard to the touch, and the diagnosis be ex- tremely difficult. In cancer, the tissue would be firm and unyielding, and comparatively unaffected by the sponge tent, while in hyperplasia it would be softened and re- lax. Should experience confirm this as a reliable test, 64 M/AWOR SOV/CG/CA/C G PAVECOZOG P. it would become a valuable aid in establishing the diag- nosis. - - g Laminaria, or sea-tangle, requires much more time to dilate, and is more powerful, than sponge. It does not expand as much in proportion to its size, but there is much less danger of decomposition. Tupello tents unite the advantages of the preceding ones, and expand very evenly. With the exception of the cases mentioned under Sponge tents, tupello is prefera- ble to either sponge or laminaria. Sponge tents expand more than the others, about three times their diameter; laminaria, not quite twice; while tupello enlarges to fully twice its size. Sponge and tupello swell in about twelve hours; laminaria requires eighteen or twenty. Dr. Emmet has found tents made from the pith of cornstalks excellent to exercise an alterative effect on the lining membrane, and also to apply iodine to the cervical canal by im- mersing the tent just before introducing it into the canal. They have, however, very little dilating power. Dilatation of the cervical canal is indicated when there is not a free exit for fluids from the uterine cavity, as in dysmenorrhoea, associated with a long, small canal, a con- striction, or some flexure in it; when there is not a free entrance to the uterine cavity, for the same causes that render local applications very difficult or impossible, and is not unfrequently associated with sterility; and, finally, in cases needing a digital examination of the cavity, such as fibroids, polypi, retention of placenta, or a dead foetus. All tents are introduced in the same way. Sponge re- quires more celerity, as it swells rapidly, and the sides roughen, thus increasing the difficulty. As with the sound and pessaries, tents must not be used if any inflammation is present; contrary to the former, however, it must be an invariable rule never to introduce a tent at the office, but always at the house. The danger of subsequent inflam- mation, though slight, is too great to take any additional THE USAE OF TEAVTS. 65 risk by departing from the above rule. The patient should remain in bed from the time of introduction till thirty-six or forty-eight hours after removal of the tent. This may seem a needless caution in many cases, but an ounce of prevention sometimes saves many a pound of cure. Before introducing the tent, direct the patient to take a five per cent carbolized vaginal douche. Without any delay place her in Sims's position. A bivalve speculum may be used, but Sims's is preferable. After exposing the cervix, seize the anterior lip with a tenaculum, and draw it down a little to straighten the canal and steady the uterus. Probe the canal carefully to ascertain its direction and probable size. If any blood escapes afterward, wait twenty-four hours, when there are no urgent symptoms calling for dilata- tion. Otherwise, select a tent which will readily enter the canal, and pass through the internal os. A common mistake is to choose a tent which fits too tightly; during the efforts of in- troduction it swells, and increases the difficulty. This is particularly true of sponge tents. Seize the base of the tent firmly in the dressing for- ceps, or impale it on a tent carrier, taking care not to entangle the latter with the twine, bury it in a pot of carbolized vaseline, and insert it quickly in the canal. Do not allow the tip of - the tent to touch the fundus, or it will be forced out by uterine contraction. It should just enter the uterine cavity, and that is all; i.e. only about an inch and a half or three quarters should be introduced. Sometimes the finger must hold it in place till a couple of flat cotton disks, saturated in glycerine, can be placed against it to insure retention. The speculum is then carefully withdrawn. Sponge and tupello tents may be left for twelve hours, 5 66 M//VO/º SURG/CA/L G. PAVE.CO/COG V. laminaria for eighteen or twenty. All tents are inserted in the same way. When laminaria tents are preferred, and considerable dilatation is desired, several small ones may be introduced, one beside another, forming a little bundle or fagot. In removing a tent, put the patient in Sims's position, introduce the speculum, seize the projecting tent with the dressing forceps, give a little twist to loosen, and then withdraw it, making counter pressure at the same time with the fingers of the other hand on the cervix. As con- siderable force is sometimes necessary, it is not wise to direct the patient to remove it by the loop of twine. The operator can now make a digital examination of the cavity, remove the polypus, incise the capsule of a fibroid tumor, use the curette, or accomplish whatever was the object of dilatation. - The cavity should be cleansed afterward with a three per cent solution of carbolic acid, and calendula cerate (made from petrolatum or vaseline) freely applied to the upper portion, which will bathe the lower as it melts and runs down. Though I have not had occasion to use it, I believe the addition of enough muriate of cocaine to the calendula cerate to make it four per cent would be excel- lent to allay the irritation. A dry tampon can then be placed against the cervix, or, if a serous discharge is de- sired, it is soaked in glycerine, and the speculum with- drawn. The patient must be particularly careful to avoid exposure to cold, and remain in bed till all Soreness has ceased. - º Anaesthesia is not necessary for the introduction or re- moval of a tent. The dilatation necessarily causes some pain, and it is customary to insert a rectal suppository of one fourth grain of morphine when the tent is introduced. Where dilatation is undertaken for dysmenorrhoea, steril- ity, etc., also in some relaxed, flabby conditions of the ute- rus, stems of hard rubber or glass (Wylie's or Thomas's) AOLES AWOR THE USE OF TEAVTS. 67 are inserted afterward to insure a patulous canal, or straighten the organ, as the canal is liable to contract again, and may require two or three dilatations to insure any permanent effect. Galvanic stems made "of alter- nate beads or plates of zinc and copper are also worn for amenorrhoea and defective de- ~-Q velopment of the 'uterus. FIG. 6o. Galvanic The same rules for the use of tents apply ***** to stem pessaries, except that the latter are more perma- nent, and should be removed during the menstrual period, or if the least pain is experienced from them. If the fündus tips forward, the base of the stem rests against the vaginal wall, and is self-retaining; but when the fundus lies suffi- ciently backward to direct the stem toward the axis of the vagina, the instrument will drop out, unless supported by a cup-shaped pessary made for that purpose. The following rules should be observed in the use of tents : — I. Always introduce the tent at the patient's house, and keep her in bed from that time till thirty-six hours after its removal. In very exceptional cases, she may leave her bed in twenty-four hours. - 2. Never introduce a tent if there is any sensitiveness or Soreness in the pelvis, or pregnancy suspected. 3. Use careful antiseptic precautions. 4. Never follow one sponge tent immediately by another, or introduce a sponge tent against a wounded surface. 5. Remove sponge and tupello tents in twelve hours, laminaria in twenty at the latest. 6. Be careful in every detail, and do not be afraid of too much precaution. Serious results have sometimes followed this operation. By rapid dilatation is meant the performance of the operation at one sitting, lasting half an hour if necessary, but usually much less time. It may be accomplished by a series of carefully graduated sounds, or the diverging 68 M//VOR SURG/CAM, GPAVECOLOGY. blades of some instrument, within the cervical canal. The best examples of the former are the hard rubber bougies of Hegar, about eighteen in number for ordinary pur- poses, and ten or twelve more up to a diameter of twenty- | W | d º : - six millimeters when unusual dilatation is required. The smallest is about the size of a fine probe, and the suc- ceeding numbers increase one half a millimeter respect- ively. Professor Fritsch of Breslau uses steel sounds of similar gradation. They can be used through the specu- OPERATIO/W OF RAPID DILA 747/Ov. 69 lum, the cervix being seized by volsellum forceps for counter pressure, or introduced like the sound without the speculum, the hand outside crowding the fundus down on the dilator like a glove over the finger. This latter method is recommended by Professor Fritsch. I have never tried it, but believe it more theoretical than practical for the general practitioner. - For a minor degree of dilatation of a very small cervi- cal canal, these graduated bougies serve an excellent pur- pose; but as a rule too much force is necessary where many are introduced, and I prefer to use an instrument with diverging blades. Dr. Goodell is a zealous advocate for rapid dilatation of the cervix uteri, and has done much to bring it into notice in this country." The Ellinger dilator, as recently modified by him, is an admirable instrument for this purpose, but is much more expensive than Wylie's modification of Sims's, which is a popular instrument. The latter is better adapted to cases of acute anteflexion of the uterus. The former is made in two sizes, the Smaller for use in very small canals, while the larger is much more powerful. The smaller instru- ment can be used, for a minor degree of dilatation, — i. e. up to a quarter of an inch, – at the office, without anaes- thesia, or to prepare the way for the larger one. For thorough dilatation the patient must be anaesthe- tized, and just before the operation a suppository contain- ing one grain of the watery extract of opium is inserted into the rectum. She is then placed on her back or side in a good light, a speculum introduced, and the vagina swabbed or irrigated with a five per cent solution of carbolic acid. The cervix is seized with a strong tenacu- * Goodell’s Lessons in Gynecology, p. 190, 1890. Transactions of Phila- delphia Obstetrical Society, 1878. For operation and statistics in dysmen- orrhoea and sterility, see lecture by Professor Goodell in the Medical News, Dec. 12, 1885. 7o MINOR SURGICAL GPNECOLOGY. lum, and, if the larger Ellinger dilator will not enter the cervical canal, the smaller one is introduced as far as it will go, the blades separated a little for a moment, then closed, and slipped a little farther in, and the same pro- cess repeated till the os internum is passed. The handles are now gradually brought together, and held there for a couple of minutes. This dilator is withdrawn, and re- placed by the larger one; the handles are slowly screwed together until, according to Dr. Goodell, the scale shows a dilatation of an inch to an inch and a half. Many oper- ators do not care to dilate over three quarters of an inch, and think half an inch enough for the majority of cases. The margin of the cervix must be watched for any lacera- tion, which rarely happens. If there is marked flexion in the canal, Dr. Goodell recommends the dilator to be intro- duced with its curve in the opposite direction to the flexion, without rotating the uterus, and the final dilatation to be then made. After the necessary degree of expansion is reached, the ether is withdrawn, and the dilator kept in place for about fifteen minutes, when it is closed, removed, and the vagina again irrigated. The after treatment is the same as for tents. If the case was one of retroversion or flexion, it would be well to use a carefully adjusted pes- sary for a short time. In some cases of pin-hole os ex- ternum the small dilator will not enter, and the OS may be nicked or forced open by the boring motion of the closed points of a pair of straight scissors. In rare cases, it is necessary to repeat the operation, but, as a rule, the canal does not return to its former condition. A slight dis- charge of blood may follow the operation for a few days, and the patient must remain in bed till all soreness has subsided. The middle of the inter-menstrual period for dysmenorrhoea, or in the last third for sterility, is the best time to operate. Very excellent results will be obtained in some cases of dysmenorrhoea, but not so much can be hoped for in sterility. - THE USE OF THE CORETTE. 7I Rapid dilatation is much more effectual than by tents, but patients will not always consent to an operation. It is preferable to gradual dilatation in cases of menor- rhagia, depending on retained Secundines, polypus, etc., where the cervical tissue is soft and relaxed, admitting of easy expansion. The canal may also be stretched for the use of the curette, or for irrigation or applications to the uterine cavity. The use of the curette deserves men- tion in this chapter, as the operation is not infrequently necessary, can be easily performed with proper care, and is gen- # # erally followed by excellent results. The : ; counter indications are the same as for : 5 the sound, pessaries, tents, etc. The à # one main indication is a persistent me- }: s ; trorrhagia in spite of carefully selected ||# 3 # remedies. This may depend on reten- É à J, tion of a portion of the placenta, as after à tº 3. an abortion at about the fourth month º É of gestation, fungoid degeneration of the º gº endometrium, and diffuse sarcoma of the mucosa of the uterine cavity, which is so rare that very few physicians meet with it. Sims's sharp curette, with a stiff shank, will be necessary to remove en- larged Nabothian follicles in severe cases of endocervicitis. * One of the most important uses of the curette is the removal of tissue from the endometrium for microscopic examination and the correct diagnosis of otherwise doubt- ful cases. As a rule, the dull wire curette is the best to use, and the least likely to do harm. After the usual anti- septic irrigation with a five per cent solution of carbolic acid, or one in four thousand of corrosive sublimate, the 72 MIAWOR SURG/CAM, G VAWECO/LOG V. patient should be placed in Sims's position, Sims's specu- lum inserted, the cervix seized with a strong tenaculum, or . volsellum forceps, and drawn a little forward to straighten the canal. The dull curette is now introduced to the fundus, and drawn downward and outward, going over the entire cavity in routine order, so as not to miss any portion. It is then irrigated with warm carbolized water, Io8° to 110° F., taking care there is a free escape for the fluid through the os. If there is any bleeding after this, the cavity can be swabbed out with pure tincture of iodine applied on cotton wound over the probe, and afterwards two or three tampons crowded against the cervix to insure against hemorrhage. Should this fail to arrest bleeding, half a dram of iodine can be injected into the cavity with a Buttle's syringe, after irrigating the uterus with hot water (I 12° F.). If bleeding continues in spite of this, a one to four, or even stronger, solution of the persulphate of iron can be used, which is the routine practice of Dr. A. Martin. The iodine is usu- ally effectual, however, and is much safer than the iron. With either drug great care must be taken to secure a pat- ulous canal, and prevent any forcing of the fluid through a Fallopian tube by a sudden contraction of the uterus. Anaesthesia is rarely necessary, but the patient must be enjoined to remain in bed while there is any pelvic sore- ness. In exceptional cases the dull wire curette is not firm enough to remove the polypi or adherent bits of placental tissue. In these cases I have used Martin's modification of Roux's curette with much satisfaction. The scraping action of this instrument is around the uterus, rather than from above downward; otherwise, the operation is per- formed in the same way, but with ether. The use of Simon's sharp spoon curette, with inflexible shank, is restricted almost entirely to the removal of can- cerous masses, and is too formidable an operation to be given in a brief résumé of minor surgical gynecology. A2/SEA.S.E.S OF THE URETHRA. 73 CHAPTER III. DISEASES OF THE URETHRA. NFORTUNATELY there is not much accurately and positively known about these diseases by the majority of the profession, and reflex neuroses are some- times so prominent as easily to mislead the physician in his diagnosis. Fissure of the anus has caused decided symptoms of cystitis. Mal-position of the uterus, or dis- ease of the pelvic organs, such as cellulitis of the utero- sacral ligaments, are common causes of dysuria, and therefore liable to cause error in diagnosis. Many a woman has been treated for cystitis, when only the urethra was affected. Disease of the urethra, on the other hand, may give rise to various reflex phenomena, such as vaginismus, chorea, or even epileptiform convulsions." The most common of the diseases under consideration are the following : — Vascular or neuromatoid growths. Prolapse of the mucous membrane or urethra. Laceration of the urethra, or fissures at the neck of the bladder. Inflammation of the urethra, i. e. urethritis. The vascular or neuromatoid growths may be flat or pedunculated, more often the latter, and closely resemble a polypus. They are very vascular, bleed easily, and are exquisitely sensitive. As a rule, only one is present, but there may be more, varying in size from a small pea to a * A curious case of this kind, which was cured by an operation, is re- corded in Emmet's Principles and Practice of Gynecology, 3d ed., p. 759. 74 AN/SEA.S.A.S OF 7THE UAEA 7TA/A’A. large cherry. Although the favorite seat is at the external meatus, they may be found in any part of the canal. The chief symptoms are pain in the urethra on touch- ing it, pain when walking, and agonizing pain on voiding urine, particularly the last few drops. This last symptom is the most important, and may lead to a suspicion of stone in the bladder; but in this case the pain is less acute, and more like a deep-seated aching or sore pain. There is not infrequently present much reflex irritation of the bladder, uterus, vagina, or rectum. The diagnosis is easy if the growth is seen in the orifice of the urethra on parting the labia, but when it lies con- cealed in the urethral canal it is not so simple a matter. In the former case, the excessive sensitiveness to touch FIG. 65. SKENE’s ENDoscoPE. will distinguish it from other conditions, such as syphilitic excrescences or partial prolapse of the urethral mucous membrane. If the dysuria cannot be accounted for in any other way by careful examination, the urethra may be opened by Emmet's method, and the mucosa exposed. It is neither difficult nor dangerous, and in no other way can the same amount of information be obtained. In many cases a diagnosis can be made without slitting the urethra, and is of course preferable, though it may be necessary afterward to open the urethra for treatment. 7'OWMOA'S OF 7TH/A2 O’RA, 7A/AEA. 75 The lower portion of the canal can be examined in a sim- ple manner by bending a couple of narrow hair-pins at right angles, and using them as retractors in the canal, while light is reflected in the urethra by an ordinary head mirror. A self-retaining Jarvis nasal speculum is some- times serviceable. Skene's endoscope is sometimes a use- ful instrument for examining the urethra. Do not dilate the canal before using the endoscope, and if the examina- tion is likely to be very painful, inject a little four per cent solution of cocaine within the canal a few minutes before- hand, but always remember the blanched appearance which is likely to result from its application. The local treatment in all these cases is essentially the same, wherever the growth is found. The tumor may be removed with scissors or fine forceps, and the base touched with an actual cautery or the point of a sharpened match dipped in nitric acid, which is immediately neutral- ized by applying a piece of cotton soaked in a solution of bicarbonate of soda. * As little tissue as possible should be removed or cauter- ized, as the resulting cicatrix is liable to contract, diminish the calibre of the canal, and in time cause cystitis. These growths are prone to return, though the greatest care may have been taken in their removal. 3. The following plan" has been recommended as giving excellent results, but the author has not tried it. Mix enough water with a little Vienna paste to moisten and thoroughly soften it. Dip a little ball of cotton on the end of a probe into the paste, and apply it to the polypus or caruncle with light pressure till the tissue is blackened. One application is often sufficient. Protect the surround- ing parts with collodion, or cotton wet with acidulated water. Fifteen minutes after the application, wash the place with a little glycerine, then soap and water, and finally insert a small tampon in the meatus. 1 Homoeopathic Journal of Obstetrics, p. 162, March, 1888, 76 DISEASES OF THE URE THAA. If the urethra has been opened, and the mucosa is per- fectly healthy, excepting the polypoid growth, it may be closed at once, as soon as the excrescence is destroyed; otherwise, it is better to wait till the mucous membrane is in a normal state, and close it in the same way as an ordinary fistula. If the growth is large, has a broad base, and is very vascular, it is better to ligate it to prevent hemorrhage, which is sometimes excessive. Immediate removal followed by the remedy is far better than to reverse the order in treatment. Prolapse of the mucous membrane or urethra is readily recognized. The symptoms are very similar to those just given for excrescences of the urethra, but the dysuria is not as severe. The diagnosis of urethrocele is easy from the rolling-out of the mucosa at the meatus. It is not as sensitive as a growth, has no pedicle, and can be re- duced with a large sound. It may form a complete circle around the urethra, or project from one side, more espe- cially the anterior wall. The history of the case usually dates from child-bearing. The treatment of these cases, until quite recently, was to excise or cauterize the prolapsed tissue. The results, however, are seldom permanent, and in a few months the patient is often as bad as before. The best plan is to incise the urethra from the vaginal surface, draw out the slack membrane through the open- ing till all the urethrocele has disappeared, insert silver sutures, cut off the Superfluous tissue, and close the wound. The operation for prolapse of the urethra is somewhat similar, the object being to denude enough longitudinally in the incision to make the urethral canal of the same calibre throughout, and prevent the formation of any pouch for the accumulation of urine. The diagnosis of fissures at the neck of the bladder must be made chiefly by exclusion, as there are no char- acteristic symptoms peculiar to this lesion which cannot URE 7THA’/ ZY.S. 77 be found in other affections, such as the early stages of cystitis. In some cases the fissure can be seen through the endoscope as a small grayish ulcer. If internal reme- dies fail, the production of a vesico- or urethro-vaginal fistula is necessary to give the muscular tissue rest. Dila- tation of the urethra has also been recommended, and is said to be very beneficial for spasm of the bladder." It is worth bearing in mind for chronic cases where remedies fail to relieve. - Laceration of the vesical opening of the urethra, as the result of dilatation, is an obstinate and almost incurable affection. It is characterized by incontinence of urine. As the treatment of this lesion is surgical, and not likely to be of interest to the general practitioner, the reader is , referred to Emmet's article on the subject.” Urethritis, either acute or chronic, is often the result of gonorrhoeal infection: under these circumstances, it must be treated similarly to gonorrhoea in the male. The thick yellow pus which can be pressed from the meatus by stripping the urethra from above downward with the tip of the finger on the vaginal surface is characteristic of gonorrhoea, as well as Soreness of the urethra to touch. The discharge need not be very yellow or profuse, even in recent cases, when the attack follows a mild infection from an old gonorrhoea. The suddenness of the attack within forty-eight hours after coitus is very important to remember. The presence of gonococci in a careful micro- scopic examination establishes the gonorrhoeal origin of the disease. (See chapter on Endometritis.) Urethritis may also result from traumatism, or exposure to cold. The history of the case, frequent and painful micturition, with heat and burning in the parts, will be sufficient for a diagnosis. The chemical and microscopical examina- 1 See Emmet, Principles and Practice of Gynecology, 3d ed., pp. 743, 751, 757. * Ibid., p. 763. 78 - IX/SAEA.S.E.S OF 7 HE URAE 7THA’A. tion of the urine should not be omitted. Injections must be employed with caution, lest the discharge, if any, be driven into the bladder, and cystitis result. Perfect rest, tepid sitz-baths, and bathing the parts several times a day, are essential. If the physician is desirous of making a local application, the extract of Pinus Canadensis, or hy- . drastis, with the addition of a little impure carbolic acid, may be tried. Should this prove insufficient, equal parts of carbolic acid and glycerine, applied on cotton wound % over a probe to the urethral canal, seldom fail to cure. As this application causes some burning, especially when it FIG. 66. SouTHWICK's CERVIx SYRINGE. is made with Braun's or the author's cervix syringe, it is a good plan to first inject a six per cent solution of cocaine into the urethra, and smear the vulva freely with vaseline before applying the carbolic acid. Even then a small wad of cotton should be held under the urethra to catch any drippings. The old school use sandal-wood oil in the acute stage, with some success. Another excellent application is a cerate of hydrastis, calendula, or iodoform: the first, if the discharge is of a catarrhal nature; calendula, if the disease occurs in the puerperal state and the discharge is purulent, which may be due to the presence of some laceration or linear ulcer; while iodoform is better for the chronic than acute stages. The cerate may be applied by winding a little cotton over a probe, and smearing it with the proper ointment. It is then introduced within the urethra, and allowed to remain for a few minutes. The same remedies may be applied in solution with a syringe. Neither is so neat, however, as to introduce a slender gelatine suppository, properly 7A/A2/8A PAE UT/CS OF ÖRAE 7'HA’/7/.S. 79 medicated, which is partly retained by the bulbous expan- sion of its point, and allowed to dissolve. An injection of a four per cent solution of cocaine has also been used for temporary relief from distressing tenesmus. The diet should consist of simple wholesome food, with- out condiments. Milk is the best drink. All alcoholic beverages must be strictly avoided. Should the urine be excessively acid or alkaline, the free use of soda-water or lemonade may tend to correct it. THERAPEUTICS OF URETHRITIS. | Aconite. Retention or suppression of urine, from cold, espe- cially in children, with Crying and restlessness. Painful, anacious, zerging to urinaſe. (Borax.) Micturition painful, difficult, drop by drop, urine scandy, fiery, scalding hot, red or dark colored. (Apis, ars., bell., cann. ind, cannabis saf., canth., capsicum, merc. cor,” nux vom.) Arsenicum. Burning in the urethra during micturition. (Acom., can. saf., canth.) Involuntary micturition. (Arnica, bell., causf., cicuta, hyoSc., opium, puls., stramonium.) Urine scandy; passed with difficulty; burning during emission. Suppression or retention of urine. (Acon, camph., hyosc, stramonium, tere- binthina.) Hamaturia. (Arnica, canth., carbo animalis, colch, ham., millefolium, petroleum, phos.) Albuminuria, uraemia. Belladonna. Atropine is preferred by some.” Retention of terine, zwhich passes only drop by drop. (Acon., canth., merc. cor., nux wom.) Urine becomes turbid (chelidonium), with reddish sediment. (Carb. veg, kreos., meg., sepia.) Red, sandy sedi- ment, or like brick-dust. (Arnica, cinch., coccus cac., ſycop., nat. mur., nux vom., nuphar, phos.) Involuntary micturition. (Arnica, ars, caust, cicuta, hyosc., opium, puls., stram.) Atropine 6 x. (3x.*) is one of the best remedies for the acute symptoms of gonorrhoeal urethritis with concomitant heat and inflammation in the vagina. Belladonna 1 x. is a rarely-failing remedy for nervous dysuria.” * Dr. J. Heber Smith. * Hughes's Therapeutics, Part II. p. 257. 8O D/SEA.S.E.S OF THE URETHRA. Berberis vulgaris.” Burning, cutting, or stinging pain in the urethra (of the female especially) during and after urinating; frequent desire. - - Camphor I x. This remedy is highly recommended by Dr. Hughes for acute strangury of a spasmodic form. The symptoms are urgent and very painful. It is also beneficial if the symptoms have followed the application of a cantharides blister (or after over- action, of apis mel. low”). This remedy usually relieves promptly if at all. || Cannabis sativa. Compare with Cannabis Indicus. Burn- ing, smarting in the urethra from the meatus backward; poste- riorly stitching while urinating. The urethra feels inflamed and sensitive to pressure along its whole length. (Arg. nit.) Burn- ing while urinating, but especially just after (angust. , ant. tart., canth., conium, equisetum) stitches and tearing sensations in the urethra. || Cantharis. Violent pains in the bladder, with frequent urging; intolerable tenesmus. Zenesmus of the bladder. (Merc. cor, capsic., Colch.) Violent burning, cutting pains in neck of blad. der. Passage of blood from the urethra, or bloody urine. (Ars, arnica, Colch., ham., mez., millefolium, petroleum, phos.) Vio- lent burning, cutting pains in the urethra before, during, and after micturition. (Ant. tart, can. sat., conium, staphis.) Urine scald's her, passes drop by drop. (Acon., bell.) Urging to urinate, with burning sensation in urethra. This is a very effectual remedy for inflammatory dysuria, but Dr. Hughes states that he has had better success with copaiba and eupatorium purpureum. Dr. J. Heber Smith believes better results might be obtained in some cases if cantharis were tried in the 2 x. dilution before hastening to other remedies. Copaiba." Irritation in the neck of the bladder and urethra in old women. - Dulcamara.” Burning in the meatus urinarius while urinating. Constant desire to urinate, with an unpleasant sensation of bearing down towards the vesical region and urethra. Urethritis and cystitis when caused by cold and dampness. 1 Dr. L. L. Danforth. 2 Dr. J. Heber Smith. ZTA/AA’AA’Aº O/7/CS OF OZACA, ZAZ /ø/ ZY.S. 8I Equisetum. Bladder feels sore, tender, and as if distended, not relieved by urination. Constant desire to urinate, and much burning in the urethra during, and pain after, the flow of urine. (Apis, canth., can, sat.) Urine scanty and high colored. (Acon, apis.) Compare eupatorium purp., mitchella, and hydrocotyle. Eucalyptus globulus.” Dr. Woodbury believed he cured several cases of vascular tumors of the urethra with this remedy. Gelsemium. If this remedy should prove as successful in the female as in the male to arrest urethritis, especially gonorrhoea, in the very beginning of the disease, it will rank as one of our best remedies. It must be given low, - q, or I X. dil., - to obtain prompt effects (especially in the first week”). Il Merc. cor. Zenesmus of the bladder. (Canth, caps, colch.) Urine suppressed. (Acon., hyos., stram.) Frequent urination; passed in drops with much pain. (Acon., bell., canth.) Urine scanty, bloody; albuminous (Osm., phos., phyt., plumb.), contain- ing filaments, flocks, or dark flesh-like pieces of mucus. Urethra/ fever. (About the best remedy, and very much oftener indicated than is generally thought.”) Nux vom. (Good as an intercurrent remedy.”) Painful, in- effectual urging to urinate (canth.); urine passes in drops (acon., be//, canth.) with burning and fearing in urethra and neck of blad. der (apis, canth., can. Sat., caps.). Urine pale, later thick, whitish, purulent; reddish, with brick-dust sediment. Constipation and &/ind hemorrhoids. || Populus. This remedy has promptly cured when canthari- des, cannabis Sativa, and other remedies have failed, though ap- parently well indicated. It seems to act best in a low preparation, such as populin I X. trit. Urination is painful, with hot scalding Sensations, especially during pregnancy. It is also a useful remedy for cystitis. The author has found it a good remedy for tenesmus of the bladder after ovariotomy. Sulphur.” Cutting pain in the urethra when urinating. Red- ness and swelling of the orifice of the urethra. 1 Dr. J. H. Woodbury, New England Medical Gazette, June, 1875. * Dr. J. Heber Smith. * 3 Dr. L. L. Danforth. 82 DISEASES OF THE URE THRA. Thuja. Judging from its action on various excrescences, it would seem to be applicable to those of the urethra, though the provings do not indicate so marked an action on this region as do many other remedies. The following remedies may be consulted for further study:- Antimonium tartaricum, apis, arnica, benzoic acid, berberis, Cal- carea carbonica, capsicum, causticum, clematis, colocynth, conium, copaiba, eupatorium purpureum, ferrum, hepar sulphur, hyoscy- amus, lilium tigrinum, lycopodium, natrum muriaticum, natrum sulphuricum,’ nitric acid, pulsatilla, sanguinaria, Sarsaparilla, sepia, sulphur, thiaspi bursa pastoralis (especially good for running away of urine in little jets, after urethritis and sensitiveness of the sper- matic cord to concussion in walking or riding”). 1 Dr. J. Heber Smith. CYSTYZY.S. 83 CHAPTER IV. CYSTITIS. HE pathology and etiology of cystitis, or inflamma- tion of the bladder, in the female, is similar to the same disease in the male; except that in the former there are the additional causes of displacement of the uterus, either irritating or preventing the complete evacuation of the bladder; the prolonged retention of urine after par- turition; too early closure of a vesico-vaginal fistula; and the habit of retaining the urine an undue length of time, - a more common cause in women than in men. As the disease is not peculiar to the female, the reader is referred to the standard text-books on medicine and surgery for more detailed descriptions than will be here given. The treatment varies a little, however, as the organ is much more accessible. Symptoms. – In the acute form, frequent micturition, only a few drops being voided at a time with much strain- ing or tenesmus afterward, is one of the most prominent symptoms. The bladder often seems intolerant of even a very small amount of urine. In the chronic form, how- ever, the organ often contains a large quantity, which fre- quently becomes ammoniacal. In both there is more or less dull, aching pain in the region of the bladder. The patient may be unable completely to evacuate the viscus in chronic cystitis, so that it is always a good rule to intro- duce the catheter in suspected cases. Sometimes a quart of offensive alkaline urine will be withdrawn in this way. On standing, the urine separates into a clear fluid above, 84 CYSTITIS. with a varying amount of mucus or pus at the bottom of the vessel. Under the microscope are seen epithelium, pus, and blood corpuscles. Membranous exudations are Sometimes present. . Pyelitis may have very similar symptoms to cystitis, but the differential diagnosis of pyelitis is made by the lumbar pain, the even admixture of pus with the urine, the acid reaction, the absence of ropy, gelatinous mucus, and the presence of “tailed” cells,” or “epithelium from the pelvis of the kidney, distinguishable by the frequent occurrence in a cell of clearly defined dark-colored, round granules, and of two nuclei.”” Flint,” however, does not believe the character of the epithelial cells can be relied on to differ- entiate the two diseases. Dr. Conrad Wesselhoeft expresses the following excel- lent opinion. The chief distinction is in the marked dif- ference and locality of pain. In pyelitis there is very little if any tenesmus, only a frequent desire to empty the bladder; in cystic inflammation, even if chronic, there is much tenesmus. The absence of vesical mucus and preponderange of clear pus point to pyelitis. The lum- bar pain in pyelitis is theoretical; it ought to be there, but is rarely, if ever, present. Both forms may occur together. The Prognosis becomes more grave in proportion to the duration of the disease. The acute form usually termi- nates within a week or ten days; the chronic may last for years, and end fatally if left to itself. If the disease has not extended to the kidneys, a cure may be expected in the majority of cases. The diet should be the same as in the preceding chap- ter, on Diseases of the Urethra. The free use of milk is of great importance. Mineral water charged with carbonic 1 Loomis, Practical Medicine. * Da Costa, Medical Diagnosis. 3 Flint's Practice of Medicine. AºA'ZGA TYO/V OF THAZ B/CAA)/OAZA’. 85 acid gas is also useful. Dr. Ludlam warmly recommends Clysmic spring water. . Washing out the bladder is an indispensable aid to in- ternal remedies in the treatment of chronic cystitis. No local measures whatever are necessary in the acute form. The following rules should be observed : — - I. Use a fountain syringe, and inject slowly. 2. Proportion the quantity of tepid fluid to the tolerance of the bladder. 3. The irrigation may be repeated one to four times a day, according to the severity of the case. 4. Use either the double-current catheter, or a two- way stop-cock. Dr. Mundé states that pure water should not be used, as it is liable to irritate the bladder." An excellent way to wash out the bladder is to use a two-way stop-cock, or the T shown in Figure 67. CODMAN & SHURTLEFF, BOSTON. FIG. 67. INSTRUMENT For WASHING OUT THE BLADDER. Introduce a large gum elastic catheter, somewhat short- ened, into the bladder, the larger the better if it does not cause an undue amount of pain. Connect this with the long arm of the T (A B), and the syringe with the up- right or body of the instrument (D). Attach a piece of three-sixteenths-inch rubber tubing, about eighteen inches long, to the short arm of the T (C). Now let the water run slowly in from the syringe; when it escapes from the rubber tubing, compress the latter between the thumb and finger; this forces the water into the bladder. As soon * Dr. C. Wesselhoeft is of the opinion that strictly pure water can be employed. 86 CPS 7/77S. as the patient feels a slight distention, remove the pressure 1 rom the rubber tube, and the bladder will empty itself. This may be repeated till the water returns clean from the bladder. Meantime the medicated fluid has been prepared, and, as soon as the washing is finished, is poured into the syr- inge, and injected in the same way. It may be retained one to five minutes, and then allowed to escape. Non-alcoholic preparations are preferable. They may be prepared by diluting the solid extract with water and glycerine, or evaporating the watery extract to the re- quired strength. The following are recommended, which should never be strong enough to give pain: — Hydrastis, I : IO of the tincture, or the muriate of hy- drastine two grains to the ounce of water, if the urine is loaded with mucus. - Dr. L. L. Danforth uses muriate of hydrastine, about five grains to the pint, as an injection into the bladder in chronic cystitis, with great benefit. He has just been treat- ing a patient with this medicine who is nearly well. It is dissolved in warm salt water. Before passing a catheter to wash out the bladder, he injects into the urethra a four per cent solution of coca- ine; passing the catheter will then be painless. This will also relieve strangury. The bladder should be thoroughly emptied before injecting any medicated solution. Calendula, I : IO of the tincture, if the urine is bloody and contains a quantity of pus. An infusion of these remedies is also excellent. Common salt and water, one dram to the pint, has been warmly recommended as a cleansing fluid. If there is much suppuration, a one per cent solution of carbolic acid, or one in five thousand of corrosive sublimate, is ex- cellent. When the urine is ammoniacal and offensive, either the solution of carbolic acid, or half a dram of di- lute nitro-muriatic acid to a pint of water, may be used; THERAPE UT/CS OF CYST/7Z.S. - 87 if acid, the same amount of saleratus instead of the acid. A Solution of quinine has also met with some favor." Dr. L. L. Danforth has found the following combination very excellent for a continuous soothing injection, — one which has power to allay irritation and check pus forma- tion It is advised by Sir Henry Thompson. B. Soda biborat. . . . . . . . 3 i. Aquae, Glycerini . . . . . . . ad 3 iſ. M. et S. One table-spoonful to a four-ounce injection of water. Sir Benjamin Brodie found pareira brava very useful where there was a tendency to profuse mucous secretion. Sir Henry Thompson recommends a strong decoction of triticum repens,” which is also well spoken of by Grailly Hewitt.8 - I have had no experience with this remedy, but refer to it because it comes from such excellent authority. If there is no improvement after a sufficient trial of carefully selected remedies with proper irrigation of the * Mr. Nunn finds a solution of quinine very useful for injections in the bladder, when the urine is loaded with pus and intensely offensive, the blad- der being irritable, with a frequent desire to urinate. He uses it in the fol- lowing manner. Dissolve twenty grains of the disulphate of quinine in twenty-five ounces of water, by the aid of a few drops of dilute sulphuric acid, or a teaspoonful of common brown vinegar. Of this solution, inject two or three ounces, and let it remain. — Zondon Zancet, Feb. 23, 1878, p. 27O. - Mr. J. Knowlsley Thornton reports two cases of irritation of the bladder after ovariotomy treated very successfully by the quinine solution, two grains to the ounce, dissolved with a few drops of dilute sulphuric acid. Three ounces were injected, and in a few seconds two were withdrawn, leaving one ounce in the bladder. — Zondon Zancet, June 1, 1878, p. 786. * Boil four ounces of triticum repens in a quart of water, gently reducing it to a pint; strain and cool; let a third part be taken three times a day. Reynolds's System of Medicine, Vol. III. p. 476. * Diseases of Women, Vol. II. p. 481, 1883. 38 CPSTY7/S. bladder, the production of an artificial vesico-vaginal fis- tula, i.e. cystotomy, affords the best prospect of cure. It may be done with the thermo-cautery, but incision is preferable.” It is needless to say, that displacements of the uterus should be corrected, and if cystocele be present it will almost invariably be necessary to operate on it in such a way that no pouch will be left for the retention and decomposition of the urine. THERAPEUTICS OF CYSTITIS, Compare the remedies mentioned for urethritis. For acute - - º ſ Syphilis. - | Extensive ulceration, 3 The local application o | | chemical agents. Acquired 4 Traumatism. | Parturition. | Sloughing, - . Impaired vitality from ty- phus or scarlet fever, | l Small-pox, etc. The Diagnosis is easy. The patient has had no men- strual flow, though the usual symptoms attending the menses have been periodically present. There is also disturbance of the nervous system, with backache, and a sense of pressure on the bladder and rectum. Some- times there is an obscurely fluctuating tumor in the hypo- gastric region. These symptoms, in girls, point to an imperforate hymen or cervical canal, with an accumula- tion of menstrual fluid behind it. In another class of cases, the physician is consulted on account of inability to perform the sexual act, which is not due to vaginismus. Physical examination shows the genital canal more or less occluded in a part or the whole of its course. With one finger in the rectum and a sound in the bladder, the vagina is felt between them as a fibrous cord, and some- times a fluctuating mass above it. Treatment. — If the examination reveals an imperforate hymen, with the menses retained behind it, the membrane should be perforated with the fine needle of an aspirator, and a small quantity of the imprisoned fluid drawn off, at intervals of three or four days, until the cavity is emptied I 54 A 7TRAE.S./A. by as many operations. The action of the aspirator can then be reversed, and the vagina washed out with warm carbolized water. After the patient has fully recovered, the hymen can be partially removed. The best time for using the aspirator is about ten days after the menstrual symptoms have subsided, i. e. about midway between the periods. The hymen should never be incised with a bistoury, allowing the fluid to gush freely out, as many fatal cases in consequence have been recorded. In atresia from other causes, the treatment must likewise be surgical. Unfortunately, the results are very discour- aging when atresia exists to any great extent. No matter how much care may be taken in splitting the vesico-recta\ Septum, dissecting upward, and forming a vagina, this canal is almost sure to contract again in a short time, in spite of every precaution to keep it open. It is very seldom, if ever, of any use to the patient, who will have to bear much suffering in vain attempts to keep the canal open. It may be laid down as a safe rule in practice, that when the vagina is very nearly or completely occluded for two or more inches, no attempt need be made at restoration. When in such cases the menstrual fluid has formed a soft, semi-fluctuating tumor above the atresia, we shall do well to follow the suggestion of West, to aspirate the tumor from the rectum. Septic infection and metro-peritonitis has been known to occur, however, with fatal consequences. In view of this, it would be advisable seriously to consider the suggestion of Lawson Tait,” to remove the uterine appendages. Should the reader desire to inquire further regarding the restoration of the vaginal canal, he is re- ferred to the works of Drs. Emmet” and Thomas.3 1 Diseases of Women, and Abdominal Surgery, p. 94, 1889. ? Principles and Practice of Gynecology, p. 188, 1884. * Diseases of Women, p. 220, 1880. THE TREATMENT OF FISTULE. I55 FISTULAE, The genital canal, i. e. the uterine cavity and vagina, may be connected by one or more apertures, of variable size and shape, with the urinary tract, — i. e. the ureters, bladder, and urethra, – or with the rectum. These open- ings are termed fistulae, and named according to the parts connected, such as vesico-vaginal, uretero-vaginal, vesico- uterine, recto-vaginal fistula, etc. In the great majority of cases, a fistula is the result of parturition, rarely from the unskilful application of the forceps or the performance of craniotomy, and almost always from delay in operating after the presenting part has become impacted. The tissues lose their vitality, a slough of varying extent ensues, and a fistula, which may be no larger than a pin or involve the entire base of the bladder, is the result. Fistula may also follow an abscess, cancerous, syphilitic, and phagedenic ulceration; the latter more especially in connection with severe continued fevers producing deficient nutrition. The Diagnosis is not difficult. The continuous dis- charge of urine, the irritation of the vagina, vulva, and thighs produced by it, and the strong urinous odor, direct the attention to a urinary fistula; while, if there is an escape of faeces into the vagina, especially during an attack of diarrhoea, the fistula is of the faecal variety. Digital examination usually reveals the opening with an eroded margin, giving a granular or velvety impression to the finger. Very rarely, the fistula may be so small that the finger cannot detect it, and then Sims's speculum must be used so as to bring the vaginal walls into view. If of the vesical variety, the bladder may be injected with milk, which is readily seen as it escapes through the fistula, and indicates its site. The Treatment is entirely surgical. In the recent state, before the urine has become alkaline, and there are phos- I 56 AYS 7'OWZAZ. phatic deposits on the margins of the fistula, there is a chance for spontaneous cure if the opening is small. This is very materially aided by copious warm water douches, twice or thrice daily, to which calendula has been added in the strength of one table-spoonful of the tincture to a pint of water. Though I am not aware that it has been tried, it seems as if the application of calendula cerate to the margins of the fistula, after each douche, would be ben- eficial. Not only would it promote the healing process, but also protect the granulating surfaces from the urine. A mild solution of the nitrate of silver can be used occa- sionally to stimulate the edges of the fistula. If phosphatic deposits are present, they must be carefully removed. The urine should be kept acid and diluent, by the use of some acid, such as benzoic, and drinking water freely. It is of the utmost importance that the health of the patient be as good as possible before operating. Plenty of fresh air, exercise, and a generous diet will materially contribute to this, and to the success of the operation afterwards. The division of cicatricial bands, etc., during the pre- paratory treatment, belongs to the surgical treatment, and will be found in the books referred to for the description of the operation. The operations of Drs. Sims' and Em- met” do not differ essentially from each other, and deserve the preference. The latter has written one of the most exhaustive monographs º on this subject in the English language, to which the reader is referred for the reports of many difficult and interesting cases. Dr. Bozeman has modified the operation, by devising a new button Suture, and an apparatus for operating on the patient in the knee- chest position. - 1 Hewitt's Diseases of Women, edited by H. Marion-Sims, Vol. II. p. 453, w883. 2 Principles and Practice of Gynecology, p. 817, 1884. 8 Vesico-Vaginal Fistula, 1868. THE Z RAEA TMEAV7" OA' A'ſ STUL4. I 57 Few operators, however, have met with more success in the treatment of this affection than the late Professor Gustav Simon of Heidelberg. His method differed very materially from that of Sims, and is considered with those of other operators by Hegar and Kaltenbach." Hofmeier * has written an excellent chapter on urinary fistulae, in which he describes more especially those opera- tions practised by the late Professor Schroeder. 1 Die Operative Gynākologie, p. 596, 1889. * Gynākologischen Operationen, p. 135, 1888. I58 PUBERTY AWD THE CLIMACTERIC PERIOD. CHAPTER X. PUBERTY AND THE CLIMACTERIC PERIOD. HE advent and close of the menstrual life of a woman are so often attended by phenomena peculiar to these periods, and distressing to the patient, that a brief con- sideration of them may not seem unnecessary. Puberty is the mile-stone which marks the transition from girlhood into womanhood. During it, the sexual or- gans undergo development, and menstruation commences. With the climacteric period, or change of life, these con- ditions are reversed; the sexual organs atrophy, and the menstrual discharge ceases. Both these periods are in- fluenced by climate, heredity, and habits of life. In very warm climates the menses appear much earlier than in very cold countries. In some families, there is an heredi- tary tendency to menstruate very early or late in life, and for the discharge to be scanty or profuse, which must be considered in forming an estimate of the normal condition. It is apparent, therefore, that no definite age can be as- signed as the normal time for the appearance, cessation, duration, or the quantity of the menstrual discharge. The establishment of the flow, however, is more rapid and con- stant than the period of its cessation. The average age of its appearance is fourteen years and two months; of ces- sation, between forty-two and forty-five years; and of its duration, four days and a half. The quantity varies so much with different individuals, that it is best considered normal so long as no ill effects of any kind are experienced in consequence. MEASTRUATIO/W. I 59 At puberty, the entire system feels the great change that is taking place; not only are there active growth and local development, but there is also called into play a remark- able amount of nervous energy. This is very largely due to the intimate connection of the ovaries with the sympa- thetic nervous system; hence it is not uncommon for chorea, hysteria, or even epileptic spasms, to appear at this time, not to mention the general condition of nervous erethism. With the establishment of the menses, aided if necessary by proper medication, these symptoms usually disappear. Menstruation, which is characterized by the periodical discharge of blood from the female genitals once in twenty- eight days, depends on the presence of the ovaries, and is supposed to coincide with the rupture of a Graafian folli- cle. It therefore marks the child-bearing period in women, though instances are recorded of impregnation before the first menses have appeared. The flow of blood comes from the uterine cavity. The superficial and glandular epithelium of the modified mucous membrane lining the cavity undergoes fatty degeneration once a month, disinte- grates, and is cast off, leaving the capillaries exposed and readily ruptured, causing the discharge of blood." The blood pressure in the capillaries and the congestion of the pelvic organs being relieved, the flow ceases; and the lin- ing membrane of the uterus is reproduced by the prolifer- ation of cells, which were beneath the former or superficial layer. At the climacteric period the change is retrogressive. The Graafian follicles no longer ripen and cast off ova. The menses become very irregular, and finally cease to appear. While the duration of this period is very variable in different persons, it commonly lasts from two to four years. As might be expected, nervous derangements are very common, especially those of the vaso-motor system. 1 Annual of the Universal Medical Sciences, Vol. IV. p. 53, 1888. I6O PUBERTY AWD THE CLIMACTER/C PERIOD. The organism seems to contain a superabundance of blood, and the patient suffers from congestive headaches, impair- ment of memory, severe flushings like hot water running over her; she becomes over-anxious, and is easily worried. Besides this, nutrition may become perverted, leading to the development of fibroids in the unmarried or sterile, and more commonly cancer in fruitful women, when a severe laceration of the cervix uteri is a focus of irritation. Malignant disease may develop in either if there is an ele- ment of heredity. Obesity is of common occurrence. Al- though this “change of life” is beset with many ailments, chiefly mental, and various neoplasms are far more likely to develop then than at any other time, the patient will, as a rule, enjoy good health afterwards, if she has taken proper care of herself during the climacteric. Proper hygiene will do much to relieve the various complaints of women at these periods, which mark the rise and decline of their greatest physical vigor. The periodical losses of blood to the system at puberty, and the demands for increased nutrition, require hearty food in abundance. Meat, milk, and eggs are important articles of diet. Fresh air, sunshine, and exercise are all necessary to the best physical development, unless we de- sire to have our girls grow up like bleached celery stalks, and unfit to meet the responsibilities of life. Not less important at this time is absolute physical and mental rest during the monthly flow. If its real value to them in after life could be half appreciated, there would be no grudging the time seemingly thrown away. As the hygiene of pu- berty has already been discussed in the opening chapter of this book, there is no need of repeating it here. The hygiene of the climacteric is at once suggested by the patient's condition. Very little beef is to be eaten when there are symptoms of local congestion. Eggs, fish, poultry, game, and vegetables are in order. If there is a tendency to obesity, which the patient desires to counter- \ CHLOROSIS. I6I act, all food containing much starch, sugar, or milk should be avoided, and water drank sparingly if urea is in excess; fruit, such as oranges, grapes, cherries, and berries, may be eaten ad ličitum, if they do not disagree with the pa- tient. Plenty of exercise in the sunshine and open air is always advisable. Pleasant society, cheerful surroundings, and enough to do merely to occupy the time without un- due fatigue, will materially relieve the mental symptoms. Having briefly reviewed the subject of this chapter in a general way, it may be well to consider here in more de- tail some of the anomalies characteristic of each period of life. - Among the symptoms which precede the first menstrual fiow for weeks and even months, such as dizziness, epis- taxis, general nervousness, etc., the writer has occasionally noticed albuminuria. While this may have been inde- pendent of the age of the patient, the fact that the general health was little if at all affected seemed to indicate that the kidneys participated in a measure in the congestion and hyperaemia of the sexual organs. Though treatment for it is seldom necessary, further than recommending the free use of milk and beef, careful supervision of the pa- tient and an occasional examination of the urine for casts should not be neglected, lest parenchymatous nephritis develop unawares. Arsenicum, belladonna, mercurius corrosivus, nitric acid, and phosphorus are remedies likely to be beneficial. - CHILOROSIS. Chlorosis is a disease found in girls at or near the age of puberty, the most characteristic feature of which is the anaemic appearance of the patient. Indeed, the resem- blance to anaemia is sometimes so close in practice that the dividing line cannot be drawn between them. It gives a better picture of the disease to call it a special form I I 162 PUBERTY AAWD THE CLIMACTER/C PERIOD. of anaemia. Dr. Flint' states that there is a reduction in the percentage of haemoglobin of the red blood corpuscles, without a corresponding decrease in the number of the latter; and Virchow lays much stress on the arrested de- velopment of the vascular system, particularly the aorta. The microscopical examination shows an abnormal pale- ness of the red elements, without much diminution of their number; sometimes there is a relative increase of the leucocytes. There are frequently poikilocytes and less microcytes and megaloblasts.” Chlorosis is believed to have a nervous origin, as its appearance so often dates from some impression on the nervous system, from the fre- quency of nervous symptoms, hysteria, etc., in its early development, and, finally, because those remedies which are most effectual in combating it are particularly adapted to the treatment of nervous diseases. Dr. Ludlam lays much stress on the importance of a lymphatic constitution, and scrofula, as a predisposing cause. Perhaps its most prominent symptom is amenorrhoea. With this there is a greenish pallor of the skin (hence the old term green-sickness); hysteria in some of its protean forms, or general nervousness; perversion of appetite, and morbid cravings for chalk, slate-pencils, pickles, etc.; car- diac palpitation and blowing sounds over the heart and carotids; headache, and a varying amount of mental irri- tability. There are often associated with these symptoms others which denote much disturbance of the stomach, particularly ulceration of the stomach. These are pain after eating and localized sensitiveness of the stomach. Hemorrhage from the stomach does not occur in half the cases of ulceration of that organ,” and it is a serious mis- take to count on that as a deciding symptom, as some writers affirm is necessary. Hyperacidity of the stomach 1 Practice of Medicine, p. 378, 1884. * Jaksch, Klinische Diagnostik, p. 28, 1889. 8 Ewald, Verdauungskrankheiten, p. 248, 1889. CAZZLO/PO.S./.S. I63 contents, as shown by the tropaeolin or methylin violet tests, commonly accompanies ulceration of the stomach, and in connection with the above symptoms is of great importance in diagnosis. I have been much interested in the simple treatment of such cases by the distinguished Professor Oser, and can recommend it from personal observation of many of his cases in the Vienna hospital. He insists on absolute rest in bed. The patient is not allowed to sit up, or even talk. She receives no food, except iced milk in small quantities, at short intervals. Medicine is rarely given. Many cases are practically cured in two weeks, i. e. are well enough to be about without discomfort, though of course it will not do to indulge the appetite freely in all kinds of food and drink. Although closely resembling it, chlorosis should not be confounded with the anaemia which often precedes or ac- companies incipient tuberculosis in girls of a scrofulous habit. : The most reliable points of the differential diagnosis àe- zzween chlorosis and anaemia are the marked tendency of chlorosis to relapses, greenish pallor of the skin, the fre- quency of fugitive neuralgic pains, nervous or mental symptoms, hysteria, chorea, or epilepsy, its origin from mental causes, and the absence of emaciation. In some cases, as has been stated before, the distinction between chlorosis and anaemia is practically impossible. The Prognosis is favorable, as a rule, if the disease is not grafted on a scrofulous constitution; but it exhibits little if any tendency to spontaneous cure, and may there- fore last a number of years without treatment. The general treatment consists in building up the pa- tient's health by food, exercise, etc., as already described in the hygiene of puberty. 164 POBERTY AND THE CLIMACTER/C PERIOD. THERAPEUTICS. Aconite has been mentioned as a remedy for chlorosis resulting from fright; and Dr. Hempel thought well of it for the same dis- ease complicated with tuberculosis and accompanied by a sallow or greenish complexion, deeply flushed cheeks, palpitation, dyspnoea, and stitches about the chest. The writer believes that constitu- tional remedies would be necessary intercurrently with aconite. Argentum nit. Dr. von Grauvogel' found this remedy of great benefit in affections characterized by shortness of breath and cardiac palpitation, without organic disease of the heart or lungs. Dr. Hughes adds, Sallowness rather than pallor of the complexion. A feeling of lassitude, trembling, and the tendency to muscular twitchings or convulsions preceded by great restlessness, also point to this remedy. Arsenicum. Dr. J. Heber Smith considers this an important remedy in the third decimal trituration. Excessive debility, fre- quent fainting. Patient is easily vexed, anxious, restless, and chilly. Soreness of the scalp with headache, better in the open air and from bathing in cool water. Face swollen, skin waxy, pale, yellow or grayish color. Itching eruption on the skin. Burning or lancinating pains in pelvic region. Amenorrhoea, scanty pale menses, or, instead of them, thin, whitish, offensive discharge. Asthmatic breathing and cardiac palpitation. In some cases it is necessary to give the remedy in material doses, | Calcarea carb. is an important constitutional remedy for girls of a scrofulous diałhesis zwith tendency to obesity and glandular enlargements. (Calc.//hos.) The girl has a morbid craving for chalk, pickles, etc.; takes cold easily; is subject to acidity of the mouth and stomach, and palpitation of the heart after eating; though apparently strong and healthy from the accumulation of fat, the muscles are weak, and she tires from little exertion. | Ferrum. While this is a great remedy for anaemia, many physicians consider it equally good for chlorosis. Dr. Hughes recommends ferrum redactum 1 x. or 2 x.; Dr. Jousset, ferrum acet. or protoxalate 1 x. ; and Dr. Ludlam praises the citrate of 1 Lehrbuch der Homöopathie, $$ 27.1–292. THERAPAE UTYCS OF CHLOROS/S. 165 iron and strychnia 3 x., as superior to either remedy alone." Dr. Holcombe finds the phosphate of iron very useful. The unalterable . protocarbonate of iron known as “Blaud's Iron,” and so highly lauded by Niemeyer, is the form of iron which I have found most effective in anaemia and chlorosis. The rapidity with which pa- tients with chlorosis will improve under this preparation of iron is often remarkable. I fancy that the imported silver-coated pills stamped “Blaud” are the most reliable preparation.” The mucous membranes are very pale, particularly of the mouth. There is great pal/or of the face, with occasional sudden red ſlushes, with dizziness; ringing in ears; palpitation of the heart; dyspnoea, and often chilliness, with fever towards night or in the evening. Chlo- rosis with erethism of blood. Helonias has been found a very useful remedy for debility, or chlorosis following diphtheria. The sensation of weakness, dragging, and weight in the sacrum and pelvis, with great languor and prostration, are also excellent indications for this remedy. Mental depression, irritability, debility, and increase of phosphates in the urine.” (Picric acid.) Ignatia. When the disease is due to mental or emotional causes, with changeable disposition, tendency to crying, and brood- ing over imaginary trouble, in sensitive or hysterical women. I have found it invaluable for chlorosis following mental emotion, such as disappointment in love, which the physician ought always to bear in mind. Dr. J. H. Smith finds ignatia 2 x. trit. an invalu- able intercurrent remedy. Phosphorus. Chlorosis, from depressing mental influences, too rapid growth, or self-abuse (china), especially in girls of a tu- berculous habit (calc. car. or phos.), chronic cases, and puberty delayed; palpitation of the heart from emotion ; great weakness and prostration of the whole system. She is sleepy in daytime, restless before midnight, and perspires easily, especially at night while asleep. - Plumbum was advocated by Dr. Winter” as a remedy for inveterate chlorosis with severe constipation, extreme muscular 1 Confirmed by Dr. B. F. Betts. 2 Dr. L. L. Danforth. 8 British Journal of Homoeopathy, Vol. III. p. 278. 166 PUBERTY AWD THE CLIMACTERIC PERIOD. weakness, variable pulse, want of breath, and great oppression of the chest from exertion or walking. He believes it aids the action of iron, and thinks it should precede it in the treatment of chlorosis in early life, unless the disease has been caused by the loss of blood, when iron must be used first. Pulsatilla was a favorite remedy for chlorosis with Dr. Jahr. Although an excellent medicine for some of the symptoms inci- dent to this disease, constitutional remedies will be almost in- variably necessary to effect a cure. The patient complains of chilliness, or dry, burning heat, especially at night, without thirst. She also suffers from palpitation, drawing, tearing pains, shifting about from place to place, and feels better in the open air. | Sepia. Menses scanty or absent; great bearing down in /.ypogastric zegion ; yellow, milky, excoriating leucorrhoea ; sensa- tion of sinking or emptiness of stomach. (Cimicif., ignat., pet., puls., sulph.) The patient suffers from hemicrania, the pain usu- ally darting from the left eye, over the side of the head toward the occiput, and is relieved by eating. There is also much bodily prostration, and a tendency to herøetic eruptions. Sulphur has many warm friends, both as a constitutional rem- edy for chlorosis, and as an aid to the action of other medicines. Dr. Leadam praises it highly, and states that he has cured patients with it in a short time, after long-continued treatment with iron had failed. The symptoms which may call for it are numerous, but the more important are the following: rush of blood to the head, with cold feet; pressive headache in the morning; loss of appe- tite, with feeling of fulness in the stomach after eating a little ; con- stipation; oppression of the chest ; palpitation, especially at night; frequent flushes of heat; night-sweats, and feeling of great pros- tration and weariness. The following remedies have been recommended by various physicians : — & Alumina, antimonium crude, (belladonna), (chamomilla), china, cimicifuga, coffea, conium, cuprum (after abuse of iron, worse in warm weather), cyclamen, ferrocyanuret of potassium, graphites, kali carbonica, lycopodium, natrum muriaticum, nux vomica, Senecin, sepia. { CHOREA, HPSTEAEIA, EPIZEPSP. 167 Some very interesting cures of chlorosis by calcarea carbonica, China, cina, Cyclamen, ferrum, graphites, ignatia, ipecac, natrum muriaticum, nux vomica, phosphorus, phosphoric acid, pulsatilla, and sepia, with additional remarks on some of the remedies, can be found in Rückert's K/inische Erfahrungen, Supplement, pp. 597–609. Most of them are cases reported by Dr. Cl. Müller in the Homöopathische Vierteljahrschrift, No. 8, pp. 428-443. CHOREA, HYSTERIA,1 OR EPILEPSY. The characteristic features of each of these affections are presented in the following table, but not in the sense of differential diagnosis, as chorea is usually recognized with- out difficulty. Chorea. Aysteria. Epilepsy. Consciousness not lost. Muscular twitch- ings and tremors more or less continu- OllS. Is less at night. Consciousness lost gradually, but not completely. Complete intermissions, with attacks of Sobbing, laughing, Sighing, tonic and clonic spasms alternate; less often it simulates paralysis with tonic muscular Contraction. Attacks may be preceded by hysterical symp- toms, but no aura, epileptic cry, foaming at mouth, or facial Spasms; the pupils react read- ily. Paroxysm not followed by a semi-comatose condition, but quite constantly by the profuse Secretion of pale, watery urine. Not common at night. Consciousness entirely and immediately lost. Complete intermissions of apparent health between attacks preceded by aura. With a shrill cry, the patient falls unconscious, foaming at the mouth, livid face, distortion of counte- nance, and very little re- action of the pupils to light. Paroxysms followed by heavy sleep, headache, and mental dulness. Occurs often at night. These affections, developing at or near puberty, prob- ably spring from the same source, the extreme excitability * Dr. Mary Putnam Jacobi has made an interesting study of hysteria in the Medical Record, Oct. 2, 9, and 16, 1886. For further information con- cerning these diseases, the reader can consult to advantage Pepper's System of Medicine, Vol. V. I68 POBERTY A/VD THE CLIMACTER/C PER/OD. of the nervous system, which is not entirely under the control of the patient. The paroxysms or attacks are worse at or just before the menstrual period. The author wishes to emphasize the fact, that hysteria is a functional . disorder of the nerve centres, and does not depend on the uterus or ovaries, as was once believed, though the latter may not be in a normal condition. Whatever the under- lying causes are, they are not thoroughly understood; but the disorder is obvious. g h Trance and Catalepsy, i.e. swooning away into an ap- parently lifeless condition for a period varying from a num- ber of hours to several days, belong among the curious manifestations of hysteria. Volumes might be written on this subject, but only those forms likely to be met with at puberty will be discussed here. - 77te Prognosis of these various nervous anomalies de- pends upon the Severity and regularity of the paroxysms; as a rule, it is favorable, unless the attacks continue after the flow appears at regular intervals. Epilepsy is the most intractable of the three conditions mentioned. General Treatment. — Mental rest, and the careful avoid- ance of everything which excites the patient, is one of the first requisites in treating the case. General hygiene, as described in the introductory chapter, is also of great importance. Dr. C. Hering made this observation, that “in all mental diseases it is the most sure sign of recovery if abscesses appear.” How true it is, the writer is unable to affirm. The Faradic current has been successfully used for the treatment of chorea and similar forms of muscular spasm, also to rouse the patient from a cata- leptic state. The brush electrode would be useful to de- tect feigned epilepsy; for in the genuine there is complete loss of sensation, while if it were feigned the pain excited by the brush would at once rouse the malingerer. The treatment of a patient during an hysterical attack requires some seemingly harsh measures. Be sure you are right, TRAEA TMEAV7" OA” Aſ YSTE/P/A. I69 and then go ahead, is no truer of any other condition than this. . - - A very simple and effectual method of detecting feigned unconsciousness is to press with the thumbs on the Supra- orbital ridges with gradually increasing pressure. The pain is so great, no one can stand it longer than a few minutes. I have found it will bring some hysterical patients out of an attack sooner than anything else, such as pressure in the ovarian region, which has been recom- mended. The attacks of hysteria are largely due to a lack of the will power of the patient, who gives way to them on slight provocation, with very little if any attempt at self-control. The most effectual plan of treatment is through fear, or to make the patient forget herself by exciting her temper. Sympathy, and the comforting remarks of pitying friends, are very prejudicial to the welfare of an hysterical patient. The author refers only to recent cases of hysteria, devel- oping at or near the monthlies in young women, and not to chronic bedridden cases, where the patient may have really lost control of her will. In all cases, however, con- fidence in her ultimate recovery, if she will earnestly try, must be encouraged; and any act or word of the physi- cian to the contrary, so that she loses faith in him, will render all his efforts unavailing. The following cases may serve to illustrate the principles of treatment. - A professional friend was called to see a girl subject to hysteria, during one of her attacks. Recognizing it at once, he called for some red pepper, and without any ado told her to put out her tongue, and at once threw on a pinch of the pepper. Without paying any attention to the spitting of the surprised and wrathy patient, who at once forgot her hysterical symptoms, he directed the mother, in a very positive way, if the girl ever had another - attack, to give her a heaping teaspoonful without delay. The patient has not had hysteria since. * - * I7O POWBAE/PTP AAWD THE CL/MACTE/e/C PA. RZOD. Another physician of my acquaintance was much an- noyed by a similar case. Asking the attendants to leave the patient alone with him a few minutes, he seized her hand in a firm grasp with the peremptory remark, “Are you not ashamed of this nonsense? Stop it at once, or I'll crush your hand.” Being a man of far more than ordinary physique, and speaking in a very stern manner, the desired effect was produced, and there was no further trouble. A large number of the patients in a female ward of a well known hospital were attacked with hysteria. It spread among the cases like an epidemic, and there was no little difficulty in treating it. Finally, the attending physician had a stove brought into the room, a number of cautery-irons heated in it, and directed the house Surgeon to thoroughly cauterize every case of the new disease the moment the attack began. Care was taken to make some show of the heated irons, and to have each patient understand the directions given in regard to them. There were no more hysterical attacks. g It is needless to add that the teaspoonful of red pepper would not be given, nor a patient injured or actually cau- terized; but the physician must make her thoroughly believe that the measure will be carried out in good ear- nest, for the least suspicion of a sham destroys all the moral effect. The emetic properties of apomorphia hypodermically have also been used to advantage. Dr. Emmet has found the following plan useful to cut short an attack of hysteria. About an ounce of the tinc- ture of asafoetida is mixed with a basin of hot water, and stirred up thoroughly, close to the patient's nose. This is very likely to induce vomiting, or call forth some pro- test from the patient, who is assured that the cause of offence will not be removed until she endeavors to control herself. TREA TME/WT OF HI}^STAEAE/A. I71 In an interval between the paroxysms, when the patient often lies in an apparently unconscious condition, (though almost invariably it is feigned, and can be detected by a close observer,) she is placed on the left side in Sims's position, and the asafoetida and hot water given very slowly as an enema. The object of this is twofold. It serves to allay reflex irritation, and absorbs the flatus, which is often generated in large quantities. It is necessary, therefore, to give a large enema, and encourage the patient to retain it as long as possible, aided by the pressure of the nurse's hand and a folded napkin against the anus. The bed-pan should receive the evacuation, as the exertion of getting up might cause another attack in spite of the patient's efforts of self-control. When the rectum is not filled with faeces, the insertion of a long rectal tube to draw off the flatus is very beneficial, while the prolonged sound of es- caping flatus, the moment the abdominal muscles begin to contract preparatory to an attack, so mortifies a sensi- tive patient that she will exert every effort to lie perfectly quiet and behave herself. There is no disease which depends so much on the tact of the physician for its successful treatment, as hysteria. Before he tries the above-mentioned measures, he should endeavor to win the perfect confidence of his patient; but not through sympathy. The greater the confidence of the patient, the more readily can she be taught to exercise her will power and self-control. Sometimes her surround- ings must be entirely changed to free her from depress- ing influences, the gossip of neighbors, etc.; while some agreeable occupation — the study of music, painting, or the languages — will serve to divert her attention from herself. - Daily salt-water baths, followed by vigorous friction of the skin, or massage, are excellent adjuvants. In long- standing cases of hysterical paralysis or muscular con- tractions, rest, diet, and massage should be thoroughly 172 PUBERTY AND THE CLIMACTERIC PERIOD. tried. These cases, however, are not peculiar to either puberty or the climacteric, and will not be considered here. In the Treatment of Epilepsy during an attack, there is little to be done, except to prevent any injury. A piece of soft wood or cork should be kept between the teeth to prevent biting the tongue. Menstrual epilepsy, i. e. epi- lepsy at the menstrual periods, which is the only form considered here, is often associated with hysteria, and, unless it disappears soon after the age of puberty, is Scarcely ever cured. In these cases, the ovaries have been removed with varying results. Sometimes perma- nent cure follows the operation, but not so uniformly that any absolute promises of recovery can be made. The only suitable cases for this treatment are those where the ovaries are enlarged and very sensitive, i. e. diseased, and where the patient is entirely free from epilepsy between the monthly periods. This also applies to menstrual chorea or hysteria remaining after the regular appearance of the menses, which resists all other treatment. Hysteria and epilepsy may be combined, forming what is known as hystero-epiſepsy, in which the hysterical mani- festations may predominate. As hysteria may very closely simulate any form of disease in which the nervous system is implicated, so hystero-epilepsy has a very wide range of forms As it does not properly belong to a work of this character, the reader is referred to any of the excellent works on the subject. In cases of petit mal, or epilepsy, it is well to remember that confining patients strictly to a very light diet, as stale bread and milk, and meat not more than once or twice a week, has very often an excel- lent effect. - The remedies for chorea, hysteria, and epilepsy overlap each other, and to save space are given together. It is needless to remark that medicines applicable to the treat- ment of chorea, hysteria, or epilepsy, during middle life THERAPEv7/CS OF CHOREA, Ezc. I73 or independent of the menstrual flow, are also useful for the treatment of menstrual epilepsy, or during the age of puberty, if the symptoms show a proper correspondence to the remedy. The references, therefore, are not limited to the menstrual forms occurring at the age of puberty, or at the climacteric. THERAPEUTICS OF CHOREA, HYSTERIA, AND EPILEPsy.1 (Compare classification of remedies for these diseases, at close of the Therapeutics.) Agaricus has been useful for both chorea and epilepsy. The symptoms indicate its use in the former rather than the latter malady. Involuntary muscular twitchings, either slight or severe, of the face (cic., bel/., ign., nux vom.), hands, or gluteal muscles; sensitiveness of the spine (cimicif, phos.), especially in the lumbar region; itching, burning, and redness of the toes, as if frost-bitten ; tremor of the hands; involuntary movements only while awake. It cured a case of hysteria characterized by sharp, agonizing, cut- ting pains in the Cervico-dorsal region, holding the patient like a Cramp for ten or more minutes.” | Argentum nitricum has proved useful for epilepsy, though the precise symptoms calling for it in this disease are not clearly defined. Dr. Gray of New York asserted that “ epilepsies origi- nating in the brain may be promptly and durably cured by a few Small doses, while those proceeding from abdominal irritation can be barely palliated by large quantities.” Epilepsy from fright (gels., opium, stram.), during the menses (cimicif.), pupils dilated a day or two before the paroxysm; periodical trembling of the body; chorea-like convulsive motions of the limbs; great forgetfulness. Arsenicum. Dr. Hughes styles it the prince of remedies in chorea and neuralgia. Trembling and weariness of the limbs; 1 There is an exhaustive and able article on the Homoeopathic Treatment of Epilepsy, by Dr. J. Baertl, in the Homöopathische Vierteljahrschrift, p. 234, 1862. Translated in the British Journal of Homoeopathy, Vol. XXII. * Dr. J. Heber Smith. I 74 PUBEA’TP AMD THE CLIMACTERIC PER/OD. uneasiness of lozeer limbs, cannot lie still at night; palpitation, aspecially at night : burning sensations internally or externally ; Sensation of warm air streaming up into the head, preceding the epileptic attacks; frequent starting in and from sleep ; great weak- ness and prostration. The patient walks the floor at times inces- Santly, and will not suffer herself to be left alone, is brooding, anxious, and suspicious." *.. Belladonna. Sulphate of atropia is preferred by many physi- cians. Menstrual epilepsy, from sudden suppression of the flow (Gels., glonoine, veratrum vir.), or with scanty menstruation. Intense cerebra! congestion ; face glowing red, hot, and swollen, convulsive movements of the muscles of the face and mouth. The right hand clutches at the throat; intense headache, then epilepsy; finally, menstrual flow. In two cases” of this kind, reported cured by atropia sulph., there was a great deal of pain in the left ovarian region. - Bromide of Potash has held high rank in the treatment of epilepsy, but is not likely to be required for the cases considered here. It is a palliative in large doses only, and rarely, if ever, cures the patient; while the after effects of the drug, impairing the intellect, and producing the well known acne, if pushed to excess, seem to counterbalance the benefit derived from palliation. Unless life or reason be endangered, the faithful trial of a carefully selected remedy, which does not cause such disastrous after effects, is recommended. . Calcarea Ars. Dr. C. Hering” wrote of this in 1849 : “From no remedy have I obtained such good results in cases of epilepsy.” It has not been proved, but is probably very simi- lar to calcarea carb., which has some reputation in epilepsy.” Dr. S. Worcester states that he has found it very valuable in young children. The constitutional symptoms are of prime importance, such as a scrofulous diathesis, tendency to obesity, profuse per- spiration, with feeling of weariness and prostration. To these may 1 Dr. J. Heber Smith. * Raue, Record of Homoeopathic Literature, p. 252, 1875. * British Journal of Homoeopathy, Vol. VII. p. 564. 4 Ibid., Vol. XXII. pp. 246, 248. Case in Hoyne's Clinical Therapeutics Vol. I. p. 386. THERAPEUTICS OF CHOREA, ETC. I75 be added: the sensation, before the attack, of something running in the arm, or from pit of stomach, down through abdomen into the feet; great anxiety, and palpitation of the heart; frightened, apprehensive mood, and forgetfulness. Caulophyllum. Chorea at puberty. Hysterical or epilepti- form spasms at puberty, from menstrual irregularities, especially in persons subject to rheumatism of the small joints, as the wrists and fingers. Causticum. Dr. Jahr praises it for mild cases of chorea. . If ignatia fails in the treatment of minor cases of chorea, caused by sudden fright, he gives causticum. Dr. Goullon” reports a long-standing case of epilepsy cured by this remedy, in the third dilution. Epileptic attacks, during the time of puberty, with delay of the first menses; also worse during the new moon. (Silicea.) Cicuta vir. Though the symptoms of this drug resemble an epileptic attack, it only seems to have a palliative effect. The menses are delayed, and there is a spasmodic state if they do not appear. The larger muscles of the limb and trunk seem to be most involved; convulsions, with loss of consciousness, with opis- thotonos; paroxysms, with swelling of the stomach, as from violent spasms of the diaphragm ; hiccough, Screaming, red face, trismus, loss of consciousness, and distortion of the limbs; pupils dilated and insensible. | Cimicifuga. Menses irregular, delayed, or suppressed ; hysterical or epileptic spasms at the time of the menses, espe- cially in rheumatic subjects; nervous shuddering; tremor all over the body. Cocculus ind. This promises to become a good remedy for epilepsy,” as well as hysteria. Cures of the former by it in the form of a strong tincture have been obtained by M. Felix Planat.” The patient is most subject to attacks at the time of the menses. The flow is scanty and painful; menstrual headache, with vertigo, 1 Allgemeine Hom. Zeitung, Vol. LXIX. * Experiments with picrotoxine, the active principle of cocculus indicus, show that it will produce genuine epilepsy. — London Medical Record, May 15, 1883. * Hughes's Pharmacodynamics, p. 420, 1886. I76 PUBERTY AAVD THE CLIMACTER/C PERIOD. nausea, and accumulation of flatus, especially at night; involun- tary motions of right arm and leg, which cease during sleep, Dr. Jousset” found that both cocculus indicus and picrotoxine caused epilepsy, and thinks he obtained good results from it. Cuprum. Drs. Bayes, Bähr, Jahr, and Jousset consider it an excellent medicine in epilepsy; and Dr. Baertl mentions cases cured by it. The convulsions are extremely violent. Dr. Hughes commends it for the final steadying of the muscles in chorea, after the use of cimifuga, agaricus, or stramonium ; and adds as a char- acteristic of cuprum in nervous disorders, that they begin with cramps in the extremities, especially in the fingers and toes; spasmodic dyspnoea before the menses. At the periodical acme, with calc. phos. intercurrently.” * Hydrocyanic acid. Dr. Hughes” recommends this drug on account of the very great similarity of the symptoms to epilepsy, and states that it is his practice to give from five drops of the third decimal attenuation to three drops of the second decimal, three times a day. He has also found it useful for the vertigo of epileptics, when not amounting to the petit mal. Dr. S. Wor- cester states that his experience with the remedy has not been satisfactory, but does not say whether he employed the drug in a high or low potency. It appears to be chiefly applicable to acute cases.” - Hyoscyamus. Menses preceded by hysterical or epileptic spasms; laughing loud, uninterrupted; profuse sweat and nausea. During the menses, convulsive trembling of the hands and feet; headache; profuse perspiration, and nausea; pale flow, with convulsions; lascivious mania. Drinking is liable to renew the paroxysms. Ignatia. Recent cases of hysteria, chorea, or epilepsy, due to mental emotions, without hereditary predisposition. 1 Monthly Homoeopathic Review, p. 104, Feb. 1, 1881. 2 Dr J. Heber Smith. * Transactions of World's Homoeopathic Convention, Vol. I. p. 177, 1876. 4 In an excellent lecture on epilepsy, Dr. J. Rutherford Russel does not speak favorably of hydrocyanic acid, and mentions the following remedies: Bell., cupr., ars., maja, lach., (nit, silver,) nux vom., pulsatilla. — Annals Brit- ish Homaropathic Society, p. 258, Vol. III. THERAPEC/ZYCS OF CHOREA, ETC, 177 Moschus. Dr. Hughes writes: “I know nothing which so rapidly dissipates an hysterical attack, even when it has gone so far as unconsciousness, as moschus. It is equally potent for pal- pitation caused by nervous excitement, without organic disease of the heart. It needs to be used in about the third decimal trituration.” Dr. J. Heber Smith terms it an indispensable remedy in hysteria. Oenanthe croc.” Dr. S. Worcester writes favorably of this drug for epileptic convulsions. The pupils are dilated ; the face 1 Girl, aet. 16. At nine years of age she was seized with spasmodic jerk- ings, salivation, and with absolute unconsciousness during the spasms. For a year they were controlled by bromide of potash, and did not return till she was nearly twelve years old, when she had a number of attacks at night, and the menses appeared on the following day. From this time she had frequent attacks during the day, and nearly every night a number during sound slum- ber. The menses were very irregular, sometimes skipping a number of months. The patient became debilitated, jaundiced, and had an imbecile expression; appetite capricious. The attack ceased on taking Cenanthe croc.; the appetite became good; menses regular, and every appearance of health restored. The remedy was continued for six weeks. – DR. W. A. DUNN, O. S. Zuzestigator, p. 238, Sept. 1, 1882. Girl, aet. I4. She had been sick two years, and treated, without any im- provement, by large doses of potassium bromide, etc. She came under my care, April 6, 1884. Her attacks were epileptic in character; began with a cry; she then fell and became unconscious; had clonic spasms in the limbs, with frothing at the mouth, and rolling of the eyeballs; the hands were clinched with the thumbs inside. During the attack, rectum and bladder were sometimes emptied. The attacks came three or four times a week, or it might be only every two weeks. After the attack she slept five or six hours, and then complained of heaviness in the head, and a feeling of exhaustion, as if she had been beaten; the memory was somewhat impaired. During the attacks she was now red, now pale, in the face. She was well developed, but had not had her menses. Cupr. met. 24 x., bell. 6 x., ignatia 6 x., and puls. 30, were given with little benefit. The attacks became a little less frequent, but still were quite violent. On November 2, the spasm was ziolent in the face, and during it the face was of a leaden-gray color, and appeared swollen. Oenanthe croc. 6 x. was prescribed, three drops morning and evening, for nine days; then to wait four days, begin again, etc. Until December 7, there was no attack. In January and February, 1885, there were two insignificant attacks each month. In April, May, and June, an attack each; and later she was quite well. Memory is good; all the functions are normal; the color of the face is good; and when I saw the girl in 1886, she stated that the first menstruation occurred fourteen days before, and that she was quite I 2 I78 PUBERTY AWD THE CLIMACTERIC PEA/OD. ſº livid and turgid, and rapid convulsive twitchings of the facial muscles. All the symptoms are worse from water. (Compare cases and references below.) Platina. Spasmodic affections of hysterical women subject to melancholia; spasms from sexual erethism; nymphomania; menses too profuse. - Plumbum." Drs. Hughes and Bähr rank plumbum with cuprum as one of the remedies from which the most can be ex- pected in chronic cases of epilepsy. A cure of one case which had lasted thirteen years has been recorded,” and also a second,” successfully treated by this remedy. Pulsatilla. First menses delayed or scanty; hysteria, with constantly changing symptoms; patient complains of constant chilliness, or dry burning heat, and feels better in the open air, Where there is a decided anaemic condition, pulsatilla is not as useful as where the system is well nourished, and can afford the loss of menstrual blood. In the latter case, the remedy is of great benefit as a stimulant to the menstrual flow, and to promote the establishment of the menses at regular intervals. The writer's experience has been, that if the third decimal dilution fails to produce the desired effect, lower dilutions or the tincture will also fail. \ Stramonium. Nymphomania ; metrorrhagia; loguacity, sing- ing and praying; hysteria, preceded by great sensitiveness; sexual excitement; chorea or epilepsy from fright; trembling of the limbs; twitching of the hands and feet, or of the tendons; cata- well. She used oenanthe croc. until August, 1885; and then I gave her, as a final prescription, sulphur 30, three drops morning and evening. —DR. OSCAR HANSEN, Allgemeine Hom. Zeitung, Vol. CXIII. Nos. 2–6, 1886, translated in Aſomatopathic Recorder, p. 168, November, 1886. For further information, the reader is referred to the Homoeopathic Re- corder, Sept. 15, 1886; the British Journal of Homoeopathy, p. 459, July, 1874; Dublin Medical Journal, and Hale's Therapeutics, p. 505, 1880,- where a good description of the post-mortem appearances caused by this powerful poison can be found. - 1 A case of epilepsy, from lead-poisoning, is reported in the New England Medical Gazette, p. 166, 1867. 2 Monthly Homoeopathic Review, Vol. XIII. p. 574. 3 Ibid., May, 1878. CLASSIFICATIOM OA REMED/ES. I 79 lepsy (cannabis indica); convulsions, aggravated by water (hyosc, Oenanthe). Veratrum viride. An exceedingly useful remedy for acute Suppression of the menses, in plethoric women, with intense cere- bral congestion. (Acon., bell, gels., glon.) The arterial ex- citement is great ; twitchings and contortions of the body; Opisthotonos. Dr. Cooper * has found it useful for chorea. The following remedies for the diseases under consid- eration have been recommended by various physicians: Apilepsy. — Arg. nit., alumina, ars, artemisia,” bell, bufo.,” calc. ars, calc. carb., causticum, cicut. vir, cinch., cocc., Colocynth, cupr., hydrocyanic acid, ignatia, kali brom., lach., lil. tig., lyc., nit. ac,” anamthe croc., opium, Žumb., phos. ac., Secale cor, silicea,” stram., Strychnia,” (nux vom.,) Sulph. Aſysteria. — Apis, asaf, aurum, bovista,” cimicºſ., cocc., coni., graph., hyosc., ignatia, mag. mur., moschus, nux mosch, plat., puls., tarentula, theridion, Sepia, valerian, zincum val. 1 British Journal of Homoeopathy, Vol. XXXIV. p. 272. * Nothnagel, Ziemssen’s Cyclopaedia, Vol. XIV. p. 288. 8 Raue, Record of Homoeopathic Literature, p. 226, 1872. * Cinchonidin will produce true epilepsy. — Mondon Medical Record, May I 5, 1883. 5 Girl, aet. I4; had epileptic spasms for the last three years when going to bed, and sometimes after she was in bed. Spasms generally lasted from half an hour to an hour and a half, and were both preceded and followed by unusual faintness. In the daytime she was frequently attacked with vertigo. The fits were suppressed whenever the patient rode in a carriage, and this suppression was proportionate to the length of the ride. Nitric acid 4 x., two doses a day, cured her. — HoyNE’s Clinical Zherapeutics, Vol. I. p. 452. 6 C. Dunham, Transactions N. Y. State Homoeopathic Society, 1871; also Lectures on the Materia Medica, Vol. I. p. 335. 7 Hughes's Pharmacodynamics, 1886, p. 694. 8 Girl, aet. 21, pale, cachectic; has had spasms for a long time, which occur before the menses or after mental emotion, and are preceded by tearing and stitching from the left shoulder to the elbow. They are especially violent at night, and when at rest. Spasms sometimes twice a day. She is seized first with constant yawning, followed by stitches in the throat, sensation as if the tongue were cut through with a knife, accompanied with painful tensions in the mouth, and convulsions of all the facial muscles, after which spasmodic weeping and laughter with suffocation, constriction, or distention of the I80 PUBERTY AWD THE CLIMACTERIC PERIOD. Chorea. – Agaricus, ars, calc. carb., caust., cimicſ, cocc., *., hyosc., ignatia, naja, phos. ac., stram., sulph., tarentula, Zerałr. Zwir, zincum, zizia aur.” - Aſymphomania is fortunately not a common complaint, and is mentioned here as one of the neuroses. A person suffering from this trouble is to be pitied, and not consid- ered at all responsible for her words or actions. The fol- lowing remedies are the most useful for this affection: — Agaricus, arsenicum, canth., china, grat, hyosc., lach, lil. tig., lycopod, murex, nux mosch., origanum, picric acid, phos., platina,” raphanus sativus,” Sabina, stramonium, veratr. alb., zinc. In a limited number of cases, which might be termed emissions in women, i.e. orgasm and discharge of fluid, platinum has proved the best remedy in my practice. Silicea has been useful. Acric acid, bromide of potash, argentum nitricum, petroleum, and salix nigra" (fluid extract of the buds) are well worth studying. The Headaches P which sometimes attend the menstrual period are very distressing, but fortunately are usually throat; and, lastly, with spasms of the chest, and dark red face. Bovista 18 cured her. — HoyNE’s Clinical Zherapeutics, Vol. II. p. 488. * A very interesting case, cured by phos. ac., is reported by Hempel in Baehr's Therapeutics, Vol. I. p. 176. * Hale, New Remedies. 2d ed., p. 1079. * Dr. Edward Blake, British Gynecological Journal, 1886, p. 508. * Dr. E. M. Hale reports two cases of sexual erethism cured by this rem- edy in fifteen-drop doses of the fluid extract once in four hours. The cases were characterized by erotic sensations and obscene dreams, commencing a few days before menstruation, continuing through it, and for a few days after; left ovary tender or painful; no erethism in the inter-menstrual period except as stated above. In one case there was intense urethral erethism causing the erethism; in the other case, burning, tingling, and itching of the clitoris. – Mew York Medical Times, January, 1889, p. 300. The author has used salix nigra 30 m t. i. d, successfully in a severe and chronic case of sexual erethism and neuralgia, where platina and silicea had failed. 5 The reader is referred to a very interesting and carefully written article on the Treatment of Headaches, by Francis Black, M.D., in the British Jour- nal of Homoeopathy, Vol. V. p. 325; also Vol. XXII., by the same author; and “Headache or Migraine,” by Dr. Trinks, Homöopathische Vierteljahr- schrift, Vol. IV. p. Ioo, translated in the British Journal of Homoeopathy, Vol. XXI. pp. I and 276, 1863. --- THERAPEUTICS OF MEMSTRUAZ HEADACHE. 181 curable if they are not hereditary, and the causes can be removed. Prominent among the latter are plethora, ova- ritis, and uterine displacement, besides the usual causes of headache when it is independent of the monthly flow. Too much stress cannot be laid on the importance of removing any abnormal condition of the sexual organs. before a cure can be promised. The headaches are of various types, and the same reme- dies for the more common forms of headache are appli- cable here according to the symptoms. Not only is it necessary to repeat the medicine at short intervals during the attack till there is improvement, but also to give it at intervals afterwards, to avoid or break up the tendency to recurrence of the paroxysms. In obstinate cases, some constitutional remedy, such as baryta carb., calc. carb., graph., natrum mur., sepia, silicea, or sulphur, must be carefully selected, and used persistently for months if necessary, before the patient can be cured. THERAPEUTICS. Aconite. An admirable remedy for congestive headache due to sudden suppression of menstrual discharge. After fright, or sudden exposure to cold. Restores the menses of plethoric wo- men after their suppression from any cause. Congestion of brain, anxiety; face hot and red or pale. Carotids pulsate strongly. Restlessness, with cerebral congestion. Pulse full, strong." Belladonna. Severe throbbing, pulsating headache before or during the menses; also, if this severe throbbing or stabbing pain follows a sudden suppression of the flow in Žethoric subjects. The face is red and hot, and not infrequently there is much weight or bearing down in the pelvis. Cactus has been commended for pressive headache in the vertex, resulting from menorrhagia, also for a similar headache at the menopause. Cimicifuga. Vertigo, fulness and du/Z aching in the zertex; 1 Dr. L. L. Danforth. I82 PUBERTY AND THE CLIMACTER/C PERIOD. dull aching, especially in the occiput, with sense of Soreness in that region ; intense aching, sore pain in the eyeballs ; headache worse during the menses from motion and indoors, better in the Open air ; shooting pains in the ovaries, tenderness over the uterus, and irregular, delayed, or suppressed menses. Cocculus is highly esteemed for menstrual headache in hys- terical women, when the head feels empty and hollow, and there is inclination to vomit with much nausea, especially when rising up, and with flatulent distention of the abdomen; much confusion in the head. Cuprum. Spasmodic dyspnoea before the menses; also rush of blood to the head, intense pain extending from the neck into the occiput; Cramps in the abdomen, with nausea and vomiting ; headache begins twelve to twenty-four hours before the flow, and is better when the latter is established. Gelsemium. The writer has had prompt results from the 1 x. or 2 x, where it failed in higher potencies. If gºod is to fol- low, relief is experienced after two or three doses. As a rule, it needs to be reinforced by some constitutional remedy given in the intervals between the monthlies. Before or with suppressed menses, congestion of blood to the head; severe pain in the head and face, of a neuralgic or spasmodic type, vertigo, blurred vision (iris), nausea, and vomiting; profuse emission of clear urine, which relieves the headache ; sometimes a feeling of stupor or drowsi- ness; less frequently chilliness precedes the headache, which is worse from lying down. | Glonoine. The chief remedy for sudden suppression of the menses in plethoric women, or with scanty menses, accompanied by intense cerebral congestion; violent throbbing headache increased by every motion; head feels full, face red, pulse full and quick; throbbing from neck extending into occipital region. Especially often indicated in cases with albuminuria. The glonoine con- gestion is more static as in the kidney, where it causes albuminuria by blood pressure with stasis in the glomeruli and convoluted tu- bules with the passing through their walls of the liquid constituents of the blood." (The congestion of acon., bell, and gels., is not so 1 Dr. J. Heber Smith. THERAPEUTICS OF MENSTRUAL HEADACHE. 183 intense as glonoine ; but the actual pain is more severe, and the symptoms of fever and inflammation are much more prominent.) Graphites. A good constitutional remedy; menses scanty or delayed; flow often pale ; swelling and induration of the ovaries without much local inflammation ; violent headache with eructa- tions and nausea during the menses, or tearing pain in the epi- gastrium at this time. Constipation, stool dark, large and knotty, half-digested, and offensive ; skin eruptions exuding a watery, sticky fluid. Ignatia." Severe pressing headache during menstruation, with frequent spasmodic yawning, and emission of watery urine every few minutes. It is best adapted to nervous, hysterical women. Natrum mur. Headache before, during, or after the menses, with depression of spirits; heavy pressive pain in the forehead over both eyes; severe bursting headache, also dull, pressive, stupefying headache ; headache in School-girls (phos., ac.), espe- cially in the morning. The characteristic constipation, emaciation, and sense of prostration, as well as the presence of itching erup- tions on the skin, are additional indications for this remedy. Pulsatilla. Dull, pressive headache, with bruised sensation in the forehead, at the age of puberty before the first menses have appeared, or when the flow is delayed and scanty. The patient is depressed mentally, and complains of chilliness in the daytime, and dry, burning heat without thirst at night. The headache is relieved by pressure, and by walking slowly in the open air. Sanguinaria. Menses at the right time, with scanty flow, and severe throbbing headache, extending from the occiput over the head to the frontal region, especially the right side; vertigo ; face red and hot, less often pale, with disposition to vomit; eruption on the face of young women with menstrual troubles, and especially a Scanty flow. - | Sepia. One of the best remedies for the radical treatment of obstinate cases with the following indications: heavy pressive pain in the left orbit and left side of the head, with darting pains over the left side of the head, better after eating; morning nausea ; 1 The Ignatia Headache: Dr. Shuldham, Monthly Homoeopathic Review, Vol. XV. I84 PUBERTY AWD THE CLIMACTERIC PERIOD. sinking, “gone" sensation in the stomach; bearing down in the pelvic organs; menses irregular or scanty; sexual instinct in- creased ; fetid perspiration about genitals, axillae, and soles of feet; moth spots or yellowish discoloration of the skin; itching, herpetic eruptions. The constitutional symptoms are more important than those relating solely to the headache. The following remedies are also useful : — Apis (headache with right-sided ovarian irritation), baryta carb., calc. carð., cannabis Sat., cham., cyclamen, iris vers. (sick headache preceded by a blur before the eyes), lachesis (headache with left- sided ovarian irritation), naja, natrum carb., muz zom., platina, senecio, Silicea, suſphur. Zoothache is sometimes a distressing complication of menstru- ation: Dr. Hering recommends the following remedies, to which a few mentioned by Dr. Baehr, but not by the former physician, are added. The latter are marked by a star, and are not to be considered any more characteristic than the other remedies. Toothache before Menstruation. — Arsenicum, * acon., * bell., * cham., * puls. Zoothache during Menstruation. — Calc. carb., cham., carbo veg., lachesis, natr. mur., * Sepia, phosphorus. Zoothache after Menstruation. — Bryonia, calc. carb., cham., phos. Aphonia or weakness of voice, coming on at each menstrual period, has beeu cured by gelsemium." Dr. Richard Hughes men- tions antimonium crudum when it occurs every time the patient is exposed to heat. Deafness with the menstrual period, menses scanty, hearing better out of doors, has been cured by kreosote 2 x.” The Anomalies of the C/imacteric Period (menopause) may be considered as those of perverted nutrition, such as the development of obesity, benign or malignant growths, and disturbances of the vaso-motor System causing flush- ings, local congestion, etc. Hysteria Sometimes appears, 1 Meyhoffer, Chronic Diseases of the Organs of Respiration, p. 230. 2 Ussher, Homoeopathic Journal of Obstetrics, p. 319, July, 1889. THERAPEUTICS OF THE CLIMACTERIC. 185 and there is marked irregularity of the menses both in time, character, and duration of the flow. The growth of neoplasms, as well as the derangement of the menses, have already been mentioned in treating of the various forms, and need not be repeated here. The hygiene has been described in the beginning of this chapter, so there only re- main for consideration those remedies peculiarly applicable to vaso-motor disturbances, which play such an important part in the sufferings of the climacteric period. When the monthly congestion of the pelvic organs and the flowing have permanently ceased, atrophy of these structures gradually progresses from year to year. Conse- quently, inflammatory diseases common to the menstrual or child-bearing age are very rarely if ever seen in the post- climacteric period, Uterine fibroids, which may have de- veloped, scarcely ever increase after the flow permanently ceases, and, as a rule, slowly decrease, or even disappear. The suffering incident to uterine displacement is much re- lieved ; chronic metritis and ovaritis gradually undergo spontaneous cure. Procidentia, especially if complete, seems to be an exception to the rule, and is very seldom benefited by the “change of life.” THERAPEUTICS.1 Aconite is more often indicated in the commencement of the climacteric in robust, plethoric women, where there is arterial ten- sion ; pulse quick, full, hard, and strong; patient is timid, anxious, restless, complains of vertigo, fulness and heavy feeling in the fore- head, sometimes epistaxis of bright red blood, and the senses of smell and hearing are morbidly acute. Drs. Hughes and Leadam urge the employment of only the medium or higher dilutions, on account of the great liability to produce aggravations with the low attenuations. 1 Dr. Richard Hughes has an excellent article “On some Remedies for Climacteric Sufferings,” in the British Journal of Homoeopathy, Vol. XXIV. p. 619, 1866. § I86 PUBERTY AAWD THE CLIMACTERIC PAER/OD. | Amyl nitrite. Flushings of the climacteric when lachesis fails; heat and throbbing, with sensation of intense fulness in the head; much throbbing in the ears; flushing of the face ; choking, constricted feeling about the throat. The thirtieth potency acts remarkably well for flushings of the climacteric." Argentum nit. Dr. C. Hering marks the following symp- toms: metrorrhagia, with nervous erethism at change of life, also in young widows and those who have borne no children; returns in attacks; region of ovaries painful, with pains radiating to the Sacrum and thighs; memory impaired; vertigo and buzzing in the ears, and general debility of the limbs, and trembling; boring pain in left frontal eminence, or dull pressive pain on the vertex, relieved by binding something tightly on the head (silicea). Cactus. Pressive, burning weight on the vertex (when from loss of fluids, china and ferrum) if lachesis fails; sense of oppres- sion or constriction of the chest or heart, palpitation of the latter. Calcarea fluorica. In two obstinate cases of flushing of the face and free perspiration resisting other remedies, I have cured with the calc. fluorica 6 x., which appears to influence the vaso- motor tract powerfully, even to controlling bleeding from the throat and pulmonary vessels.” Caulophyllin 3 x. Dr. Ludlam states that he has often pre- scribed this remedy for post-climacteric nervous conditions, with excellent results; attacks of “great nervous tension and unrest, with wakefulness, and a propensity to work and worry over little things.” The presence of rheumatism of the smaller joints would be an additional indication for it. Cimicifuga 2 x. Restless and unhappy state of mind; the patient feels grieved and troubled, with sighing (ignatia), is irrita- ble, cannot sleep; vertigó ; fulness and dull aching in the vertex; sinking at the stomach (hydrocyanic ac.). Coffea. All the senses are very acute; patient cannot bear pain; mind very active, cannot sleep nights (Passiſ?ora incarnata) on account of thinking, hears the least Sound ; a general condition of marked nervous excitement. 1 L. L. Danforth. • 2 Dr. J. Heber Smith. THERAPEUTICS OF THE CLIMACTERIC, 187 Gelsemium 1 x, or 2 x is an excellent remedy for the con- gestive headaches of the climacteric. The attack often begins with drowsiness, or perhaps chilliness, then severe pain, usually of a neuralgic or spasmodic form, sometimes pulsation of the carotids, and accompanied by vertigo, blurred (iris) or double vision, occasionally by nausea and vomiting, and is relieved by the profuse emission of watery urine. t Glonoine has been warmly praised for congestions of the head, and flushings limited to the face, also for its characteristic headache; violent throbbing in the head, or from neck into the occipital region; head feels full, face red, and the pulse is full and quick. Helonine. An excellent uterine tonic; profound melancholy, with sensation of weight and Soreness in the uterus ; dragging, aching, and weakness in the sacral region, with marked debility. Jaborandi 1 x. Dr. Hughes mentions this remedy for flush- ings at the climacteric accompanied with sweating. || Lachesis. The chief remedy for flushings at the climacte- ric (amyl nitrate, kali brom., magnesia mur., sang., sepia, strontia carb., silicea); also hot vertex, metrorrhagia, and fainting at this time (china, nux vom., ferrum); there is painful distention of the abdomen from flatulence (carbo veg, China, lach., kali carb.), and the patient can bear no pressure of the clothes. Not infrequently there is considerable irritation from the left ovary, which is swollen, indurated, or is the site of neuralgic pains. She wakes in the morning with vertigo and a sense of great exhaustion or weakness of the body, and at times suffers from headache extending into the root of the nose, or, less frequently, one-sided or occipital pain, extending into the neck and shoulders, sleeplessness. The patient is nervous, anxious, loquacious, in a weakened condition, and feels worse when the discharges do not appear. - Sanguinaria. Dr. Jousset" considers this the principal rem- edy for migraine or hemicrania, especially at the climacteric in women whose menses are profuse. He uses from the 12th to the 3oth dilutions; vertigo, rush of blood to the head with buzzing in the ears, and flushes of heat; headache in paroxysms, beginning * Matière Médicale Exper. et de Thérapeut. Positiv., Tom. II. p. 596, 1884. I88 PUBERTY AAWD THE CLIMACTER/C PERIOD. in occiput, it spreads upward and settles over the right eye; headache, with nausea and chilliness, followed by flushes of heat extending from the head to the stomach; sometimes bilious vomit. ing, short shooting pains in the head, and shivering. The headache is better in the open air, from lying down, and from sleeping. It is an excellent remedy for flushes of heat at the climacteric, and fetid corrosive leucorrhoea at this time (kreosote, nit. ac.). The following remedies are also useful: — Sulphate of atropia, or belladonna, China, Crocus, digitalis, ferrum, kali brom., lyco- podium, nux vom., physostigma, polygonum,” sepia,"sulphur, Sul- phuric acid, theridion, valerian, veratrum viride. 1 Dr. A. E. Small states that he has found the infusion of smartweed the best remedy for superficial ulcers and sores on the lower extremities at the climacteric period, both locally and internally.— Practice of Medicine, p. 815, I886. A MEAVO/C/CAH CEA. I89 CHAPTER XI. AMEN ORRHOEA. IKE other anomalies of the uterine discharges, insuf- ficient or absent menstruation is not a disease in itself, but an expression of some abnormal condition of the system, when it occurs during the generative life of a woman, except during pregnancy and lactation. In the latter, it is purely physiological, and need not be con- sidered here. Its forms and etiology are outlined in the following table: — ſ Suppressed flow Amenorrhoea Scanty or de layed flow Retention of flow Plethora. Mental emotion, such as fright, anxiety, dis- appointed love, etc. | Cold and wet, such as wetting the feet dur- ing the menses. Exhausting diseases, such as tuberculosis or chlorosis. * Sea voyage, or change of climate. | Lack of ovarian stimulus, mental strain, and overwork. Local inflammation, such as ovaritis. Imperfect or non development of the sexual organs. Atrophy of the uterus or ovaries. Lack of fresh air, exercise, and good whole- U some food. Occlusion of some portion of the genital canal. If congenital, it is usually at the entrance of the vagina; if not congenital, the occlusion is most common in the up- per third of the vagina.” The causes of the first two forms may produce either 1 See Atresia of the Vagina. I90 AMEAVORRACEA. condition, though most often the relations are as classified above. Suppression of the menstrual flow, from mental emotion, cold, wet, or tuberculosis, is one of the most common dis- orders the physician is called upon to treat. Amenorrhoea, associated with a slight cough, emaciation, or rise in tem- perature, for any length of time, should always be looked upon with grave suspicion, especially in scrofulous sub- jects, as it is not infrequently the forerunner of phthisis. The effect of a Sea voyage on emigrants, in producing amenorrhoea, is due to the poor fare on shipboard, and the change of climate on their arrival, rather than the voyage itself. The latter, in fact, is one of the best reme- dies for this condition in those who have been overworked mentally and physically, and need absolute rest: among these belong school-girls just entering on their menstrual life, and young women who have been compelled to study hard, in addition to the demands of society and fashion. The nerve force is diverted from the natural channels, and some derangement is sure to follow. On personal inquiry, the writer has been surprised to find the prevalence of amenorrhoea in young women from sixteen to twenty in our colleges and seminaries. This is not invariably the case, however. Dr. Hall, of Vassar College, informs me, that, of sixty-six girls who had studied hard preparing for college, thirty-seven report little or no inconvenience at any time during their men- strual histories; eleven have improved since their first menses, and have little or no inconvenience now ; seven are slightly more inconvenienced than at first, two de- cidedly more so; and nine, who are somewhat troubled, report no change since the menses were first established. Dr. Hall thinks the few disturbances of the menses which occur are due to change of climate and surroundings, rather than study. Excluding defective development, she has found these cases the most difficult to treat while pur- TREATMENT OF AMENORRACEA. I9 I suing their studies; next to these, amenorrhoea depending on ovaritis has proved very stubborn. The lack of fresh air, exercise, and proper food very commonly leads to defective nutrition and chlorosis. Nature is obliged to close the safety-valve, and retain the blood for the use of the body, just as in exhausting diseases. This is partially compensated for by a watery leucor- rhoea, instead of the usual flow. It need not be viewed with apprehension, but rather shows that the monthly congestion of the pelvic organs is taking place, and that Nature will again assert herself when the organism can afford to lose the menstrual blood. The Prognosis of amenorrhoea depends largely on the exciting cause. If the latter can be removed, the prog- nosis as to cure is very favorable; indeed, there are comparatively few incurable cases. The General Treatment is indicated by the above; i. e. remove the cause. For the treatment of scanty and pain- ful menstruation the reader is referred to the chapter on Dysmenorrhoea. The hot-water foot-bath described there for the congestive form is very useful for suppression of the flow from cold and wet. If due to a low vitality of the system, or chlorosis, hygiene is of prime importance. Do not force the flow in anaemic girls. Build them up, and when Nature can afford the loss of blood the men- strual flow is almost sure to appear. Well ventilated sleep- ing apartments, exposure to the sun's rays, with exercise in the open air, either walking, riding horseback, or playing tennis, but never to such an extent as to make the patient feel exhausted afterwards, plain nutritious food, mental zest in School girls, physical rest at the time of the ex- pected monthly, and early retiring hours, are very essential for a cure. Milk and cocoa are the best drinks; strong tea and coffee are sometimes positively injurious, particularly the I92 A MAZAWORRAE/CEA. former. An inquiry into the patient's habits of eating and drinking will often give a clue to the best method of treat- ment. These measures may be aided by a change of air or a sea voyage. In short, the great object is to develop robust health and strength, and Nature will see to it that the menses return without the interference of art. Here, forcing remedies and powerful emmenagogues would do positive harm. The patient may be in fairly good health, but suffers from Sudden suppression of the menses; the symptoms are those of cerebral, and, less often, pelvic congestion, dizziness, flushed face, epistaxis, together with a feeling of fulness and weight in the pelvis, especially at the time when the next period should appear. In these cases, mild emmenagogues are admissible just before and at the ex- pected time; enemas of quite warm salt and water, and the hot foot-bath, are excellent adjuvants. - In the old School, apioline, ergot, savine, nux vomica, and quinine are popular remedies; and quite recently perman- ganate of potash, two grains three times a day after eating, has met with some favor, especially for amenorrhoea follow- ing sea-sickness. The peroxide of manganese, sometimes recommended instead of the permanganate, is not suffi- ciently reliable in its composition. Santonine in ten-grain doses at night is reported to be a reliable emmenagogue, particularly in chlorotic patients; also dram doses before meals of a saturated tincture of the seeds of Lappa major. Polygonum hydropiper is another remedy likely to prove one of the very best emmenagogues in the pharmacopoeia. In large doses it has been known to cause abortion. Be- sides these, a combination of aloes, iron, and nux vomica has been largely used, as well as guiacum in ten-grain doses. Dr. Braithwaite' has used stem pessaries with good results, the mechanical irritation exciting the flow. Ex- cellent as these may seem from a physiological standpoint, 1 Annual of the Univ. Med. Sciences, Vol. I. p. 62, 1888. A.ZAZCZYº/C/7 P^ A'O/º A.lf ÆAO/8/8A/CEA. I93 they are inferior to the following remedies, if a careful selection be made. - The Faradic current is useful in some cases, but the indi- cations for it have not been clearly defined. Begin with it about a week before the time for the flow to reappear, and employ a mild current every other day, about twenty min- utes at a sitting, till the flow appears, or the menstrual epoch has passed. Place one pole — it makes no differ- ence which — on the hypogastric region, the other over the sacrum. This is also worthy of trial in non-development or atrophy of the Sexual organs. As a rule, however, the prognosis will be very unfavorable in such cases, unless the treatment be commenced at or near the usual age of pu- berty, which is very seldom done, as the patient generally does not apply to the physician till a much later period. To be of any benefit, the Faradic current should be used three times a week for Some months, and no stronger than the patient can easily bear. (See chapter on Electricity in Gynecology.) It is well known that victims of the morphine habit com- monly have entire arrest of menstruation." Whether this be due to the action of the drug itself, or secondary to its effects, the author cannot say. It is not improbable that morphine may find an important place in treating amenorrhoea. In infantile or non-developed uteri, the wearing of gal- vanic stem pessaries, i. e. alternate beads or disks of copper and zinc on a flexible stem, has sometimes proved benefi- cial. It is necessary for the patient to wear Thomas's cup pessary’ to retain the stem. While the uterus may increase in size to a considerable extent, and the treatment appear to be a perfect success, yet it has been found in some cases to return to its former condition in a few months after the treatment was discontinued. In view of this fact, it is 1 Stephens, Obstetric Gazette, August, 1888. I3 I94 A MAZAVOA’RA/CEA. necessary to be cautious before promising a cure by electrical treatment. The question naturally arises, When does amenorrhoea in young girls demand interference? As a rule for all cases, so long as the patient is perfect/y well, leave her alone to Mature aided by good hygiene. But when the menses are scanty and painful, or there is not a drop of menstrual blood, notwithstanding she has had all the symptoms of menstruation for a continuous number of monthly cycles (imperforate hymen), a thorough examination is impera- tively necessary without further delay. Unless there is a faulty or inflamed condition of some of the pelvic organs, local treatment is inadmissible, and quite uncalled for, as then amenorrhoea is but a symptom of the general condition of the patient. As in dysmenorrhoea, the medical and hygienic treatment should be of a constitutional character, every symptom be- tween the menstrual epochs being carefully considered. If the flow fails to appear, continue the same plan of treat- ment until about a week before the period should come, and then substitute Some remedy having a more decided action in promoting a menstrual flow. This may be aided by hot foot or sitz baths, which are of little or no use in the interval. It is hardly necessary to add, that while the patient is improving in general health, and there is a decrease of morbid symptoms, the same remedy had better be continued. Even if the flow does not appear for two or three months, Nature will assert herself in time. THERAPEUTICS. | Aconite is an invaluable remedy for sudden suppression of the menstrual flow, from a chill, fright, or vexation, with the usual congestive phenomenon (actea spic., bell., glonoine, lycopodium, plat., puls.), especially in plethoric women. Ovaritis may accom- pany it, with painful urging to urinate, and high ſever, also anxiety 7 HE /*A PE O/ZT/CS OF AMEAVOA’A’AſOEA. I95 and great restlessness. The best results from it will be obtained when it is given promptly at the time of the exciting cause. If a number of days have elapsed, and the next period does not appear, pulsatilla is generally more suitable ; less often, lycopodium. Rückert records a case of six months suppression in a plethoric young woman, with precordial anguish and asthma, which was entirely relieved by aconite. Ammonium carb. Menses too early, too weak, too short. Flow too profuse at night. Blood too dark, clotted, colicky pains, backache, pain in the back and uterine region, toothache, profuse watery diarrhoea." Belladonna. Amenorrhoea in plethoric women; sudden sup- pression of the flow, with much pressure and throbbing in the head (acon., glon.), haematermesis; feeling of 70eight and fulness in the pelvic organs (apis). When amenorrhoea is due to plethora, Dr. Hughes recommends belladonna in the intervals, and aconite at the periods; epistaxis, tickling in the nose; drawing pains from the sacrum extending down the thighs, much bearing down in the pe/vis, and profuse sweat before the menstrual flow, feeling of coldness, wakefulness. Berberis vulg. Menstruation too weak, too short, blood watery, slimy, grayish color. During menstruation severe labor-like pain in the lumbar region. Bursting headache, and bearing down pains.” . * || Calcarea carb. A very important remedy for delayed men- struation in scrofulous girls, those who are fleshy, weak (with large abdomens), fair complexion, perspire very easily about the head, and are subject to acidity of the stomach and constipation. There is reason to believe this remedy may avert the development of tuber- culosis in these cases. Dr. Ludlam says, “Abundant experience has satisfied me that the calcarea carbonica is perhaps the most prominent and useful remedy for the relief of those menstrual irregularities which are incident to pectoral disease.” || Cimicifuga. Dr. Cowperthwait” esteems “this more gen- erally useful in all classes of amenorrhoea than any other remedy,” 1 Dr. Conrad Wesselhoeft. * Textbook of Gynecology, p. 397, 1888. I96 A MEAVOR/?AICEA. better than pulsatilla, and always gives it when there are no special indications present. Nervous women subject to rheumatism, neu- ralgia, myalgia, occipital headache, flashes of pain, and soreness of the eyeballs. Menses irregular, delayed, or suppressed from cold or mental emotions. Neuralgia of the uterus. Pains dart from side to side. Aggravation of mental symptoms at time of the menstrual periods. Bearing down, dragging, and soreness of the pelvic Organs. Cocculus. Menstruation too early, abdomen distended with Contracting, cutting pain, or painful pressure, as if from stones. Menstruation, which had been absent one year, immediately re- appeared. Suppressed menstruation,” with pressing abdominal pain, flatulence, and general weakness. Scanty, irregular, painful menstruation. Dysmenorrhoea with a profuse discharge of clotted blood and subsequent hemorrhoids. Uferine cramps, with sup- fressed, irregular menstruation and sero-purulent bloody discharge.” Conium. Similar to cocculus. Menstruation suppressed, too weak, delayed. Labor-like pains during menstruation with bear- ing down. Colic. Vaginal discharge whitish and excoriating. Sore and painful breasts with the menses. Burning, soreness, and aching in uterine region.” Glonoine. Sezere throbbing in the head, and pale face, with amenorrhoea, particularly in plethoric women; the cerebral con- gestion is intense from the sudden suppression. This remedy acts very promptly, if at all, and is very useful at the climacteric period. || Graphites ranks near pulsatilla as a remedy for delayed or tardy menstruation, with scanty, pale flow. Dr. C. Wesselhoeft, who has recorded a number of cases of insufficient menstruation treated by it,” thinks it is better adapted to patients over thirty years old, and is to the climacteric what pulsatilla is in youth. Dr. Dudgeon has shown its application to amenorrhoea with in- 1 Dr. Stens relates an interesting case cured by cocculus 30. Suppression of the menses in a young girl was accompanied by periodical mania, with intermissions of two or three weeks. – Allg, Hom. Zeitung, Vol. LXXXIX. No. I 5. - 2 Dr. Conrad Wesselhoeft. 8 New England Medical Gazette, Vol. XI. p. 459. THERAPEUTICS OF AMEWORKHOEA. I97 durated ovaries,” and Hahnemann recommended it for delayed menstruation associated with great constipation. The stools are offensive, dark, half-digested, and lumpy, united by mucous threads. The skin is unhealthy, with excoriations, fissures, or itching blotches, from which exudes a corrosive, sticky, watery fluid. The patient tends to obesity, and her troubles to become chronic. Dr. Bön- ninghausen” mentions it for amenorrhoea, with itching or ecze- matous spots between the fingers. Kali carb. Some of the older writers state that they prefer it to pulsatilla. Menses do not appear at the age of puberty, or are scanty, of a pungent odor, acrid, and cause an eruption on the thigh ; menses suppressed, with anasarca or ascites. Dr. Jahr states that he has had some cases which could only be brought around by this remedy. The characteristic symptoms of sac-like swelling between eyebrows and lids, the susceptibility to cold, the Sticking, Stitching pains, and aggravation of the symptoms at two or three o'clock in the morning, will aid in selecting the remedy. Lycopodium 200. For amenorrhoea in young girls, after sulph., when the skin is sallow, bowels constipated, urine dark, with brickdust-like sediment, sour taste, afternoon aggravation. Loud rumbling of flatus in the bowels. Bloated after eating. Amenorrhoea, with rheumatic pains.” Magnesia carb. Scanty and delaying menses, of thick, pitchy consistence and dark color; more profuse at night than in the daytime. Natrum mur. The first menses are delayed or scanty. The patient is depressed mentally, and suffers from severe headache, Constipation, is emaciated, and very easily fatigued. || Pulsatilla. While this is the chief remedy for amenor- rhoea from exposure to cold and wet, or for a flow which is scanty, too late, and of short duration, it is often abused by prescribing it, in every case, as routine practice. It is very useful for delayed first menses in girls of a mild, tearful disposition, who are in fairly good health; menstrual suppression complicated with ophthalmia 1 British Journal of Homoeopathy, Vol. XXXI. p. 183. * Allg. hom. Zeitung, Vol. XXXIV. p. 252. 8 Dr. B. F. Betts. 198 º A MEAVOR/PA/CEA. or supra-orbital neuralgia. The general symptoms should be con- sidered in selecting this remedy. Dr. A. E. Small records a case , cured by puls. nut., when puls. nig. had failed. The menses were delayed and irregular, and the young woman suffered from severe pain in head, back, and stomach, with great restlessness. Senecin 1 x. has been recommended by Dr. Holcombe” for retarded or suppressed menstruation. The patient is nervous or hysterical, and does not sleep well. Sepia. Menses are scanty, flow dark. Dr. Jahr recommends it, next to pulsatilla, for the delay of the first menses, if there is a leucorrhoeal discharge instead, with determination of blood to the chest, and a pale face. It is an excellent remedy for the dis- colorations of the skin and face in women subject to menstrual derangements. Serpentaria virg. Dr. Marcy” states that he has often used this medicine for suppressed and delayed menses from cold, vio- lent emotions, and the debility consequent on fevers, with marked SU1CCCSS. - Sulphur. Dr. Jahr ranks sulphur with pulsatilla for insuffi- cient menstruation with pale flow. There is pressure in the pit of the stomach during the menses, and the patient is subject to flushes of heat, cramps in the calves of the legs and soles of the feet, with burning in the latter at night, rush of blood to the head, and heavy, pressive frontal headache, especially in the morning, or on the vertex, like a heavy weight on top of the head. The following remedies are less frequently useful : — Alumina, Apocynum can., Arsenicum, Apis,” Arnica," Aurum, 1 Practice of Medicine, p. 814, 1886. 2 U. S. Medical and Surgical Journal, Vol. VIII. p. 44. * Theory and Practice, p. 512. - * Dr. J. R. Coxe (Hering's Amer. Arzpfg., p. 287) reports a case of amen- orrhoea which had lasted for six years, cured by apis. It was associated with violent headache, rush of blood to the head, delirium, swelling or oºdema of the legs, and some swelling of the abdomen. 5 Girl, aet. 18, brunette, well developed; menses suppressed by a chill fifteen months previous. Pulsatilla, graph., sep., sulph., and rhus given with- out benefit; no symptoms except headache, slight pressive pain in the breast. AD/GEST OF REMEDIES POR AMEAVOR/RHCEA. I.99 Baryta carb., Digitalis, Leptandria, Bryonia, Dulcamara, Manganum,” Carbo veg., Euphrasia,” Mercurius, Castoreum,” Ferrum, Nitric acid, Causticum, Strychnia et ferri Nux mosch,” Chamomilla,” citr. 3 x.,” Opium," China, Hellebore, A hosphorus, Cicuta, Helonin, Plumbum, Cimicifuga, Hyoscyamus, Podophyllum, Cocculus, Agnatia,” Aolygonum hydro- Cuprum, (Iodine), piper,8 Cyclamen, Lachesis, Rhododendron, The use of arnica 12, three days before the menstrual period, was followed by the appearance of the flow, and the following monthlies were more pro- fuse than the first. — RücKERT, AZinische Erfahrungen, Vol. II. p. 219. 1 Amenorrhoea with painful tympany, the menstrual blood escaping only in drops owing to uterine tenesmus. Nervous, hysterical women. —DR, FARRINGTON. * Menses suppressed, bearing-down pains, bloating and pressure in the epigastrium, menses preceded by colic, crampy abdominal pains, uterine hemorrhage with labor-like pains, dark clotted blood (china). —DR. CONRAD WESSELHOEFT. - * This cured a case reported by Dr. W. P. Defriez, characterized by the peculiar symptom, which had been constant for some months, menses regular in time, but last only one hour. The flow at the next monthly after the use of euphrasia lasted a number of hours, and the second one was normal. * Dr. Ludlam praises this combination for chlorosis, also ignatia. — Dis. Women, p. 108, 1881. * Cured too frequent and scanty menstruation, flow every three weeks, light colored, watery, dull headache, better indoors, decidedly worse out- doors. — DR. GEORGE ROYAL, U. S. Medical Investigator, January, 1889. * This promises to be an excellent remedy for scanty, irregular, or sup- pressed menses from cold, with the characteristic mental and head symp- toms. Dr. H. C. Houghton relates a case of suppression of the flow by a bath, followed by intense labor-like pains, fainting at acme of pain, recover- ing with a start, and agonizing expression of the face. — HOYNE’s Clinic, Therap., Vol. II. p. 96. " Amenorrhoea from fright, with great drowsiness. * Dr. A. E. Small has known an infusion of this plant (smartweed), in five-drop doses, to succeed in delayed menstruation when many other reme- dies had failed, and has used it with “more than ordinary good results.” – Practice of Medicine, p. 815, 1886. It has been used with some success to produce abortion in the early 2OO A /l/EZVO/º/CAHOEA. Rhus tox., Silicea, - Veratrum vir., Sabadilla, Strontia, Xanthoxylum,” Sarsaparilla, Veratrum alb., Zincum. As a help in selecting a remedy, the following digest has been prepared for suggestions to the reader: — Amenorrhaea, with bleeding in some other portion of the body than the uterus at the menstrual epoch. — (See Vicarious Men- struation.) Bell, bry, (ham.), lach., millefolium, phos., puls., sulph., veratr. alb. Amenorrhaea with Cardiac Disturbance.— (Compare remedies for chlorosis and debility.) Ars., iodine, lach., (lycopus v.); also acon., apis, bry, caust, Cimicif., cupr., kali Carb., lil. tig., nux mosch. A memorrhaea with Cerebral Congestion or Headache. — Acom., bel/., ferrum, gels., glon., (macrotin), merc., (nat. mur.), opium, (silicea), sulph., verat. alb., verat, vir. - Amenorrhaea, with Dropsical Symptoms. – Apis, apocynum can., ars., calc. carb., hellebore, kali carb., merc. Amenorrhoea with Gastric Affections. – Aletris, ars., (china), helonine, lycop., puls. ; also kali carb., lach., nux mosch., nux vom., podo. A memorrhaea with Mammary Symptoms. – Bry., cºmicifuga, (china), conium, cyclamen, dulcamara, phos., ſºuls., rhus tox., (silicea). A memorrhaea with Merzous Ahenomena, chiefty Hysterical. — (See Puberty and the Climacteric Period.) Causticum, cicuta, cimicifuga, cocculus, (coffea), cuprum, (cypripedium), ferrum, (gels.), hyosc., (theridion). Amemorrhaea with Congestion of the Pelzic Organs. – Acon., àell, cauloph., merc., puls., sepia, Sulph. A memorrhoea with Skin Eruptions. – Carbo veg., dulc., graphites, kali carb., Sarsaparilla, sepia, sulph. Flow Absent or Delayed in girls old enough to menstruate. — months of pregnancy. The author has been informed by those who have used it that it was quite efficient in strong doses of the tincture or fluid extract. 1 Dr. C. D. Williams, U. S. Medical and Surgical Journal, 1871, p. 35; and Raue, Clinical Records, p. 179, IS72, and p. 178, 1875. DIGEST OF REMEDIES POR AMEAVORRACEA. 20 I Acon, baryta carb., apis, calc. carb., cimicifuga, digitalis, droscera, graph, Kali carb., nat. mur., puls., sepia, silicea, sulph. Flow too Early and Scanty. — (Compare Dysmenorrhoea.) Alum., (ars.), carbo veg., cauloph., manganum, nitric ac., phos., silicea. - A low too Zate or Delayed, and Scanty. — Amm. carb., aurum, baryta carb., conium, Cyclamen, dulc., graph., (lachesis, Scanty, may be too early, too late, or regular, like sepia,) lith. Carb., mag. Carb., nat. mur., put/s., Sarsap. - A/ozy Jntermittent. — Apocynum, causticum, Crotalus, hyosc., puls., Sabadilla. - Flow at Irregular Periods. – Apis, cimicifuga, iodine, nitric ac., Illl)& mosch, Sabadilla, Sabina, Senecin, Staphisagria. A low suppressed from Chlorosis. – (Compare chapter on Pu- berty and the Climacteric Period.) Ars., calc. Carb., China, conium, cyclamen, ferrum, ferrum et Strychnia, ignatia, nat. mur., phos., plumbum, puls. - Plow suppressed from Cold and Wet. — Aconife, bell, cimici- fuga, dulc., glonoine, nux mosch., puls., rhus tox, Senecin ; also Cauloph, cham., gels., sepia, Sulphur. - Flow suppressed from Debility. — (Compare Chlorosis.) Aletris, ars., China, helonin, nat. mur., Senecin. $ Flow suppressed from Mental Emotion (fright, anger, chagrin, disappointment, etc.) – Aconite, causticum, (china), coloc., conium, hellebore, ignatia, lycop., Opium, pulsatilla. A/oze, suppressed from Owaritis. – Acon., afts, bell., cimicif., coni, lil, tig, (phytolacca), (podophyllum), thuja, zincum. Zeucorrhaa in place of the Menses. – (Alumina), arsenicum alb., China, cocculus, nux mosch., phos., (ruta grav.), Senecin, sepia, silicea. 2O2 MEAVORRHAG/A AAWD METRORRAAGIA. CHAPTER XII. MENORREHAGIA AND METRORRHAGIA. HE former term means profuse menstruation; the latter applies to a discharge of blood from the gen- itals, between the menstrual periods. Neither can be considered a disease in itself, but is secondary to or Symptomatic of other diseases, such as : — Fibroid tumors of the uterus. Polypoid degeneration of the endometrium (endome- tritis prolifera or hyperplastic endometritis). Retention of the placenta after abortion. Subinvolution. Ovaritis. - Engorgement of the portal circulation. Cardiac disease and valvular insufficiency. Telluric influences, such as malaria. In short, a persistent flow of blood from the uterus is offen due to some neoplasm or growth within that organ, if its history does not date from pregnancy. There are some women who naturally flow very profusely, and yet are not well unless they do. Such persons are liable to have the monthly period come on in three or four months after confinement, and flow so severely as to make them anaemic, hysterical, and seriously interfere with their ulti- mate recovery, unless the discharge is controlled in some IIla I) 11621. The quantity is so variable, that the question whether the patient is flowing too much should be decided by its effect on the organism. If a woman flows profusely, and is pale, weak, anaemic, has white ears, complains of dizzi- TREATMEAVT OF MEAVORAAAG/A. 2O3, ness, and the mucous membrane of the mouth and tongue is pale instead of pink, there is reason to believe it is due to loss of blood. In all cases of profuse and persistent flowing, an examination should be made without delay to ascertain the cause, and, if possible, to remove it. Some cases depending on the presence of foreign growths, such as fibroids, will partially, and occasionally wholly, yield to treatment, so that the patient will pass safely through the climacteric without having to submit to a surgical oper- ation. In other cases, profuse flowing is one of the first signs of malignant disease of the uterus, either of the cer- vix or fundus. In case of any doubt, it is always a good plan to curette the uterine cavity and have the shreds of tissue carefully examined by an expert pathologist. As a general rule, if profuse flowing persistently returns after curetting thoroughly a second or third time, and if the curette has removed each time bits of friable tissue, the disease is malignant, and radical treatment, such as vaginal hysterectomy must be employed, if at all, without delay. The importance of curetting the uterus in frequent and profuse flowing, especially if near the climacteric, must never be overlooked, either from the point of diagnosis or treatment. A bloody discharge from the uterus after the climacteric is very characteristic of malignant disease, even though the cervix be apparently perfectly healthy. In such cases there must never be any hesitation about dilat- ing the cervix, exploring, and curetting the interior of the 11teru S. In many cases, a surgical operation cannot be avoided; and the physician should be careful in making such prom- ises. This question will be considered under the proper chapters (see Fibroid Tumors, Polypi, Uterine Cancer, etc.). The Diet should be generous: milk, eggs, beef in some form, or a good extract of it; mutton chops; strong broths and soups, in small quantities, but often. Lemonade, 2O4 MEAVO/C/CAHA GAA A/VD METRO/8R/HA G/A. oranges, and grapes are refreshing to the patient, and the acid in them seems to have a beneficial influence. Stim- ulants are to be proscribed, as they often do more harm than good, except in rare instances temporarily to revive a patient with tendency to syncope. Where there is marked anaemia I have sometimes seen good effects from the use of beef, wine, and iron; but in the very great majority of cases patients will do much better without it, if the physician carefully selects (/e one remedy, and properly feeds his patient. Local Treatment. — In many cases very little, if any, is necessary other than the removal of the growths, if present. The proper remedy, carefully selected, will prove the best styptic. Douches of hot water will sometimes diminish the flow temporarily; and the benefit to be derived from the hot-water spinal bag must not be forgotten. The douches can be repeated as often as three times a day if necessary, and if the patient does not feel exhausted after- ward. In severe cases, a vaginal plug may be resorted FIG. Ioo. Roux CURETTE USED BY DR. A. MARTIN. to, as a temporary measure. Styptics, astringents, etc., have no curative value, and cannot always be depended upon, even when applied directly to the source of the hemorrhage. Among the simplest applications are tampons Squeezed out of a saturated solution of alum, and crowded close against the cervix. When these are taken out, pledgets of glycerine should be inserted, to soothe the dry, puckered condition of the vagina. Obstinate cases, depending on polypoid degeneration (hyperplastic endometritis) will re- quire thorough curetting, and the intra-uterine applica- tion of iodine, either by Buttle's or Braun's syringe, or by cotton wrapped tightly round a uterine probe or sound. 7 RAEA 7//E/V7" OA; MAEAVORA’A/.4 G/4. 2O5 If the hemorrhage returns in a few weeks, and will not yield to remedies, the curette should be used again, and the persulphate of iron applied in- stead of the iodine, preferably in a solution of one part of iron to three of water. Dr. Martin of Berlin uses fifteen drops of undiluted iron with Braun's syringe. Though I have often seen him do this, I should fear serious results in the hands of a less competent person; and believe the diluted preparation quite as effica- cious, and far less hazardous. An invariable rule, never to be forgotten in all injections into the uterine cavity, is to have the cervix well dilated ; even then, if the in- ſº jection tube be not double, so as to provide à for a return current, it may contract, and the f imprisoned fluid cause great pain, or escape # through the Fallopian tubes into the perito- É neal cavity. ſº Sometimes a change of air alone will cure à the patient. º H- I have seen a lady well advanced in the cli- macteric flow very profusely and continuously at the sea-shore, without receiving any ben- efit from local or internal treatment, even from Curetting the uterus and the application of iodine. But on removing four or five miles inland, the hemorrhage ceased in a short time, and she became perfectly well. If the bowels are constipated, and hinder free portal circulation, they should be emptied by enemas. Raising the foot of the bed a couple of inches, and keeping the head and shoulders low, tends to lessen the amount of blood in the pelvis. Plenty of fresh cool air, cool food and drinks, in the most severe cases, are advisable. [...} Gº. <ſ [.. H [...?" 2O6 AMEAVO/P/PA/AG/A AAWD A/E TROA&RAIA G/4. In some cases of metrorrhagia from an atonic condition Qf the uterus, the Faradic current has been employed with success." - The therapeutics of the old school are rather limited, so far as any reliable internal medicines are concerned, for uterine hemorrhage. Ergotin is the main reliance, which is sometimes combined with the oxide of silver. Digitalis is employed when the flowing is due to cardiac disease and valvular insufficiency. The fluid extract of cotton root (gossypium radix), reputed to be commonly used among the negroes in the South to produce abortion, is another good remedy. The muriate of hydrastinin” is one of the most recent claimants for consideration, in preference to the fluid extract of Hydrastis canadensis. Half a dram to a dram of the aqueous ten per cent solution is given hypodermically twice or three times a week in the inter- menstrual period, and more frequently or even daily during the flowing. It has succeeded where ergotin has failed, and promises to become a valuable remedy. A favorite prescription of Dr. Mundé's for metrorrhagia from subinvolution of the uterus is equal parts of the fluid extract of ergot and gossypium radix with a smaller pro- portion of cannabis indica.” 1 Mrs. —, aet. 30. Has had three children, and one abortion at three months. Since the latter, has suffered from slight but constant discharge of blood from the uterus. A careful examination showed there was no portion of the placenta retained, neither a tumor nor polypus of the uterus to ac- count for it. Irrigation with hot water, ergotin, liquor ferri, and plugging of the vagina were tried, without success. The hemorrhage still continued. As the last resort, electricity was used. One pole of the Faradic current was placed on the hypogastrium, the other was applied to the neck of the uterus. The patient complained of pain, but the bleeding stopped in five minutes. It recurred in three days, but disappeared after a more prolonged application of the current; and the patient recovered completely, under a tonic and hydro-therapeutic treatment. — DR. RAMOS, Bulletin Général de Thérapeutique, No. 1, 1886. t * Falk, Hydrastinin bei Gebärmutter Blutungen, p. 295, Archiv für Gynā- kologie, Heft 2, 1890. * Cazeaux and Tarnier's Obstetrics, p. 1083. THERAPE UT/CS OF MEAVORRAAGIA, ETC. 207 THERAPEUTICS. Generally speaking, the remedies applicable to menor- rhagia and metrorrhagia are also valuable in the therapeu- tics of abortion. The efficacy of medicine is beautifully illustrated in its effect on uterine hemorrhage, if it be of non-puerperal origin; but in the majority of cases one remedy alone will not be sufficient to cure the patient. New symptoms may arise, others be cured, and a second or even a third remedy must be substituted for the one previously given. In prescribing for the conditions under consideration, the ovarian symptoms accompanying the flow are of great importance, and should be carefully ascertained. Arsenicum." Menses too early, too profuse ; exhausting menorrhagia ; hemorrhage, with lancinating, burning pains, espe- cially in the right ovary. If there is also chronic endometritis. It is not a common remedy, but has proved curative in some obstinate cases in material doses.” || Belladonna.” The uterine and menstrual symptoms re- semble Sabina, but the general condition of the patient is charac- teristic of bell. Great pressure downward in the genita/s, as if the contents of the abdomen would protrude through the vulva (lil. tig., plat., sepia); menses too early and too profuse (calc. Carb., nux vom.); bright red (ham., ipecac.), or thick, decomposed, dark red Blood which feels hot to the parts; burning, throbbing in the right ovary; tremulous feeling through the whole body. Gentle pres- sure on the uterus, or motion of the hands and feet, causes vertigo and nausea, without retching or heaving. Dr. Carroll Dunham recommended it for offensive metrorrhagia, and for extremely offensive menstruation in young unmarried women. Bryonia.” Menses irregular; too early and too profuse, with dark red blood; splitting headache, worse from motion. Flow 1 Hughes's Pharmacodynamics, 4th ed., p. 250. 2 Hahn. Mat. Med., Part I. p. 18, Ars. 8 Hahn. Monthly, December, 1870, Dr. O. P. Baehr. 4 Dr. L L. Danforth. 2O8 MEAVOR/RHA GIA AAWD METRORRHAGIA. increased by least motion. Uterus engorged and tender to touch; great sensitiveness throughout pelvis, worse in right ovarian region. Sharp, stitching pain in right side, aggravated by Coughing or moving, or even deep inspiration; can hardly bear the least touch of affected parts. Have just had a patient, a married lady, who was taken with flowing within a week from the date of cessation of the normal period ; she flowed profusely. The symptoms corre- sponded to those of bryonia as given above. Improvement at once commenced, and patient was speedily cured. | Calcarea carb. is an invaluable remedy. It is indicated by the general conditions and symptoms of the patient, rather than those peculiar to the sexual organs. Menses too early, last too long, and are too profuse” (bell., nux vom.); leucorrhaea like milk (conium, lyc., fºuls., sepia, Sulph. ac.), with itching and burning in the genitals, strumous diathesis, and tendency to pectoral dis- orders; feet feel cold and damp; much sweat on labia, and sweat- ing of the feet. Dr. Guernsey recommends calcarea, and also silicea, for menorrhagia in nursing women. Calcarea phos. is especially useful in the menorrhagia of young girls. It is superior to calc. carb. in such patients. Menses occur too frequently, every two or three weeks, and patient flows profusely ; is much weakened thereby. Leucorrhoea increases in ratio that menses diminish. Every cold causes rheumatic pains; acne, full of yellow pus; school-girls who have frequent attacks of headache and too frequent and too profuse menses.” | Chamomilla. The mental symptoms are important. Zhe flow is dark and clotted; the clots large, and associated with evere labor-like pains in the uterus ; drazºling, griping pains from the sacrum or small of back forward to the pubic bones. The pains are followed by the discharge of clots. The menses are too early, profuse, and sometimes offensive. The metrorrhagia is in paroxysms. China. This remedy is not only of great value in relieving the debility from loss of blood, but it also has symptoms of its own, 1 Hahnemann states that, if the menses appear at the regular period, or later, calcarea will do no good, even if they are not scanty. * Dr. L. L. Danforth. THERAPEUTICS OF MEAVOR/PA/AGIA, E Z C. 209 resembling crocus. It can be given with advantage between the periods, in case of anaemia, – here I prefer the second or third trituration of the bark, - while some other remedy, such as crocus, is used instead at the time of the flow. Cases of malarial origin, where the symptoms show a marked periodicity, and also for women suffering from sexual excesses. Profuse perspiration at n ight; patient complains of being chilly, with thirst before or after the chil/; menses too early, profuse, black clots, with spasm in chest and abdomen. - Cinnamon." Well recommended by Dr. Winterburn, where the flow comes on Suddenly, is profuse, even, and of a bright red color. Give freely as an infusion.” - || Crocus.” Bearing down before menstruation. Metror- r/agia of daré, viscid, stringy blood, in black clots, worse from Zeast motion; functional menorrhagia, particularly in young wo- men. I prefer the 2 x. dilution. - Digitalis. Where the flow is secondary to engorgement of the portal circulation,” especially if from cardiac disease, and the symptoms present indicate digitalis. Symptoms of passive venous congestion prevail; the face is pale or livid, and the skin cold. In these cases, it may be necessary to use it strong enough for physiological effects. - Erigeron.” Premature and profuse menses. Metrorrhagia, with violent irritation of rectum and bladder. Very profuse flow of bright red blood ; every movement of patient increases the flow. (Bry.) Hamamelis 2 x. If the flow be passive, small amount, but Continuous, color usually dark, may be bright. If there be a hem- | Arndt's System of Medicine, Vol. II. p. 393. Dr. Moffat states that it induced metrorrhagia in a lady medical student, who tried to ascertain if it would cause it. — Morth American journal of Aſomatopathy, May, 1883. * Dr. J. Heber Smith. * Hughes's Pharmacodynamics, 4th ed., p. 443. Dr. Conrad Wesselhoeft considers it a good remedy, * Cardio-Uterine Remedies. – E. M. HALE, M. D., American Homaeopathic journal of Gynecology and Obstetrics, August, 1885. 3 Dr. L. L. Danforth. I 4 2 HO MAEAVO/P/PA/AG/A A/V/D AZZ ZZeO/P/PA/4G/A. orrhagic diathesis, and tendency to venous engorgement, menorrhagia associated with sub-acute ovaritis, the blood slowly trickles away, and is not coagulated. Dr. D. Dyce Brown recommends hama- melis for uterine hemorrhage, especially if abortion is threatened, or if it follows abortion. The flow is more often dark, venous (erigeron, arterial), but he does not limit its action to any color of the discharge. Ipecac. Menses too early, profuse, and of bright red blood, which coagulates readily. It is accompanied by nausea, great weakness, and cutting, griping pains in the abdomen. f | Magnesium carb. Menses delayed. The discharge is usually viscid and glutinous, but may be coagulated. A peculiar symptom, often verified, is that the ſlow is more profuse at night than in the daytime. Murex purp.” Menses come too frequently, and are too profuse in young women of full habit and good-natured. TNitric acid “ has been found very useful for menorrhagia or long continued passive or irregular hemorrhage, after abortion (secale cor.), confinement, or at the climacteric (vinca min); bearing down in hypogastrium, pain down the thighs, needle-like pains in the body; urine strong, like horse’s urine ; aching in the rectum, after stool; loss of strength and appetite ; headache : weak, irregular, sometimes rapid pulse, and other symptoms of anaemia; flow shreddy and dark-colored. Dry dyscrasia existing with tendency to menorrhagia." | Nux vomica. The mental and other general symptoms are important. The menses are too early and too profuse; during the menses, nausea in the morning, with chilliness, attacks of faintness, and pressure fozeard the genita/s. The symptoms are worse in the morning after eating, from motion, and in the open air; great irritability of the nervous system. 1 Monthly Homoeopathic Review, Aug. 1, 1870, p. 473. 2 IDr. B. F. Betts. * Dr. Ludlam reports a case of menorrhagia with remittent fever, and a very obstinate case of menorrhagia alternating with convulsions, cured by nitric acid 6x. — Diseases of Women, pp. 262 and 266. 4 Dr. J. Heber Smith. THEAEA PEC/TICS OF MEAVORRAAGIA, ETC. 2 II | Platina. Menses too early and too profuse, last too long, discharge dark and thick may be clotted, and accompanied with bearing-down pains in the abdomen (bell, sepia). There is increased sexual desire, particularly after the flow ceases; also painful sensitiveness and constant pressure in the mons veneris and genital organs; body feels cold, except the face; * hypersensitive- ness and irritability of the genital organs; the patient has the most exalted self-esteem ; premature development of sexual instinct; and for older women when the metrorrhagia is associated with melancholia. Il Sabina. Dr. Hughes recommends its use both during and between the periods; * metritis accompanied by flooding; * menses too early, too profuse, last too long; hemorrhage from the uterus in paroxysms (trillium), worse from motion, blood dark and clotted, or may be light-colored and florid; after abortion or labor; pain from back to pubis. Increased sexual desire. Hering states that the metrorrhagia is increased by the least motion, but often better from walking. || Secale cor. has been recommended for uterine hemorrhage, when the uterus is atonic and hyperaemic, in doses of the tincture sufficient to secure uterine contraction. It is also useful in dilu- tions, but in either case the preparation must be fresh. Hemor- rhage from the uterus, worse from the least motion; discharge black, fluid, and very fetid, also if it is attended with labor-like pains. Dr. Kafka “states that he has used ergotin in many cases of profuse menstruation, especially for women who have given birth to many children near together, when the flow was perfect/y painless and increased by the least active or passive motion, and never has known it to fail. | Trillium. Hemorrhagic diathesis; flow returns every fort- night (plat.), with yellowish creamy leucorrhoea during the inter- vals; the flow is of bright color, sometimes with clots, and comes in gushes on the least motion (sabina). It is especially suitable to the climacteric, and has been used with success for uterine hem- * C. Dunham, Lectures on Materia Medica, Vol. II. p. 135. * Hughes, Manual of Therapeutics, p. 283. * British Journal of Homoeopathy, Vol. XXI. p. 342. * Allgemeine Hom. Zeitung, No. 55, p. 114. 2 I 2 ME/WOR/CAHA GIA AAWD METRORFAZA GZA. orrhage depending upon the presence of fibroid tumors." Men- struation too early and too profuse, irregular, flowing for two weeks. Pain in hips, short breath, palpitation, restlessness in legs. Hips and legs feel as if they would fall apart.” Tarantula has been recommended by Dr. Jousset, if the type of the fever accompanying a menorrhagia is intermittent.” Nitric acid 2 x has been used successfully for similar cases. The following remedies are less frequently used, but may be referred to if none of the preceding ones seem to be indicated:– Acon, after fright,” aloe, annbra, ammon. carb., apoc. can., argentum, arnica, borax, bovista, bryonia, caust., carb. veg., carbol. ac., Cimicifuga, coffea, cyclamen,” erechthites, erigeron, ferrum, * Ludlam, Diseases of Women, p. 998. * Dr. Conrad Wesselhoeft; also Investigator, Vol. II. p. 1. * Jousset, Lectures on Clinical Medicine, p. 46. * Girl aet. 14 years, 6 months. Grown rapidly, tall for her age, brunette. She woke at night, thinking she heard burglars in the house, and was much frightened. This was six weeks after her last menses. She had previously been irregular, flow every three weeks. First menstruation was at twelve and a half years of age. The day after the fright the flow appeared, dark, fluid, painless, odorless at first, in two weeks became offensive, and has remained so since. She is neither restless nor nervous, has no chills or fever, usually soiled two or three napkins a day, staining them through. Symptoms of anaemia are now present, as dizziness, throbbing headache over left orbital region, and doughy pallor of skin. The flowing had continued without interruption for nearly four months, and three excellent allopathic physicians had been unable to stop it. . I gave her aconite 3 x. once in three hours. She began to improve im- mediately. The headache ceased permanently after a few doses. The flow rapidly diminished, first ceasing at night, then in the day, and after the third day stopped for good. She had no other treatment of any kind with the ex- ception of three two-grain doses of china I x trit. at the time the discharge ceased. The next monthly had a tendency to become protracted, but a few doses of aconite arrested the discharge, and the girl has remained perfectly well. * - 5 Mrs. The menstruation was very profuse, obliging fier to lie down, and always accompanied by the discharge of a membrane; flow pro- fuse, dark, and clotted. Eighteen months previously she had a miscarriage, and was ill for five weeks; since then she has had this menorrhagia, and thirty-six hours after the flow commences a little membranous bag is dis- THERAPE UT/CS OF MEAVOR/CAAG/A, EZ C. 2 I 3 gelsemium,” helonias, hepar Sulph., hydrastis,” hyosc., ignatia, io- dine,” ferrum, kali carb.,4 kali phos,” kreosote, Aycop., laurocerasus," millefolium, merc., nat. mur., phos., puls., rhus tox., ruta grav., sepia, silicea, sulph., ustilago,” veratr. alb., Vinca m. I X.,” zinc. In patients predisposed to hemorrhage, i. e. of a hemorrhagic diathesis, Dr. Ludlam recommends one of the following remedies : china, ipecac, Sabina, platina, Secale Cor., ferrum, nux vom., nat. mur., hamamelis, trillium, rhus tox., Calc. Carb., bell., Crocus, carb. veg., phos., ars. alb., Sulphuric acid, nitric acid. charged, rarely in shreds, and without pain. Cyclamen 3 x. was given, the membranes appeared only once afterwards, and the menses became normal. — DR. A. C. POPE, Monthly Homa'op.tthic A'eview. 1 Dr. H. W. Champlin prescribed it successfully for metrorrhagia follow- ing intermittent fever and the use of quinine. — Medical Advance, December, 1888. - * Hydrastis has been recently considered almost a specific for menorrhagia and metrorrhagia, in doses of twenty drops of the fluid extract three or four times a day. Though many cases have been reported, the exact symptoms indicating the drug have not yet been defined, and it must be used empirically. Dr. Wilcox has given a summary of Schatz's paper (who introduced it for uterine hemorrhage), the results of other experimenters, and brief records of forty-three cases, in which he employed the remedy with generally good effect. (See New York Medical Journal, p. 199, Feb. 19, 1887.) * Induration of the uterus, menses too late, too profuse with cutting colic during stool, backache. —DR. CONRAD WESSELHoEFT. - * Protracted profuse menstruation (Goullon, Jr.), delayed menstruation with abdominal pains and profuse menstruation (not uncommon where the habit of sweetening the stomach with bicarbonate of soda or potash pre- vails). —DR. Con RAD WESSELHoEFT. * Dr. Whittier, Homoeopathic Journal of Obstetrics, November, 1888. * Dr. J. L. Arndt has found this very useful in the tincture for severe uterine hemorrhage, with extreme prostration, especially at or after the climacteric, and reports three cases in Hoyne's Clinical Therapeutics, Vol. II. p. 300. The symptoms calling for it are too early and too profuse men- struation; blood thin, liquid; with stupor or coma, and nightly tearing in the vertex. 7 Dysmenorrhoea with pain and swelling of the left ovary, also excessive menorrhagia, dark coagulated blood. —DR. Conrad WESSELHOEFT, from DR. Burr, Observer, September and August, 1868. The author can also recommend it for long continued lochial discharge of the above description. * Dr. Hughes has found this useful to check passive uterine hemorrhage occurring in women long past their climacteric. — Manual of Pharmacody- namics, p. 909, 1886. 2I4. MAEAVOR/º/HA G/A A/VD METRORAEAAG/A. If associated with a scrofulous diathesis, he uses calc. carb., Calc. phos., hepar, silicea, baryta carb., iodine, phytolacca, carbºr veg, mezereum, merc. Sol., merc. iod, nitric, muriatic, or sul- phuric acid. An obstinate cases of passive uterine hemorrhage, when carefully selected remedies fail, try those of an anti-syphilitic nature; such as kali iod., thuja, merc. precip. ruber, and nitric acid. An chronic cases associated with ovaritis, which may have pre- ceded the abnormal flowing, try bell., colocynth, hamamelis, lilium tig., lach., carb. veg., sepia, conium, veratr. vir., platina, merc. Cor., pulsatilla. * Menstruation oftener than once in twenty-eight days, and scanty. — Asafoetida, (Cactus,) carbo an., mangan. acet., phos., Sarsapa- rilla. Menstruation oftener than once in twenty-eight days, and pro- fuse. — Aloe, amm. Carb., arg. nit., ars., bel/., borax, bovista, bromine, bry, calc. carð., Canth., Carbo veg., caust, cham., china, Cocc., Cycla., pecac, kreosote, mezereum, mur. ac., muz zom., flat., sabima, stannum, Sulph., trillium. Menstruation delayed beyond twenty-eight days, and scanty. — Acon., alumina, amm. Carb., aur., bov., cocc., coni., drosc., dulc., euphrasia, graph., helonias, lycop., lith. Carb., mag. Carb., fºuls. A/en.struation delayed beyond ZZºenty-eight days, and Arofuse. — Chelidonium, ferrum, kali iod., staphisagria. Menstruation protracted. — Acon., Calc. carb., Carbo an., caust., china, crocus, ham., lycop., mez., flux 20m., Aſaf., Sabina, Secale, silicea, trillium, ustilago. Menstruation irregular. — Arg. nit., Cimicifuga, iodine, nit, ac., nux mosch., puls., silicea, staphisagria, Sulphur. Blood bright red. — Acon., bell., brom., cinnamon, erigeron, Aam., hyosc., ipecac, millefol., sang., trillium. A/ood decomposed, dark red (fluid). — Bell., bry., carbo an., hamamelis. Blood black, almost inky. — Cactus, canth., cyclamen, kali nit., secale, sulphur. JBlood black and clotted. — Amm. carb., cham., china, cimicif., coffea, crocus, cyclamen, ignatia, kreosote, lach., lycop., mag. carb., platina, puls., Sabina, Secale, ustilago. REMEDIES AWOA MEMORAEAA GIA, ETC. 2 I 5 Alood dark, viscid, stringy. — Cactus, crocus, amm. carb., cyc/a- men, ignatia, mag. carb., platina. Blood, offensive odor. — Bell., bry, carbo veg., caust., cham., helonias, ignatia, Áreosote, sang., Secale, (silicea), (sulph.). A/ood acrid, makes thighs sore. — Amm. Carb., aurum, Carbo veg., caust., kali carb., lach., rhus tox., Sarsap., Sulphur. Fxhaustion or fatigue during or after the ſlow. — Alumina, amm. carb., ars. alb., Carbo an., China, Cocc., erigeron, ferrum, helonias. We/Z only during menstruation. — (Mental condition, stan- num.) Zinc. A/oze, on/y in the morning. — Sepia. Flow only in the morning and evening. — Phellandrium. Foze, more profuse early in the morning. — Bovista. Flow only during the day. — Caust., puls. A/oze, during the day and especially 70%ile walking. — Puls. Flow ceases in afternoon. — Magnes, carb. Flow lessens in afternoon. — Magnes. carb. Flow increases in afternoon. — Sulphur. Flow worse at night. — Amm, mur., bovista, mag carb., zinc. Flow only at night. — Bovista.' Only in the evening, coffea. 1 Miss , aet. 33. Previous health fairly good. The menstrual flow appeared at proper time, but did not cease. It was painless, slightly clotted, of a brighter red than during the menstrual flow proper, and in sufficient quantity to necessitate a change of cloths every four or five hours. The marked features of the case were: absence of aggravation from moving about ; the decided increase of the flow at night in bed; the appearance of the discharge, as the continuation of the normal catamenia, and the total absence of any local or constitutional symptoms to account for its existence. Ipecac, nux vom., secale, cham., millefolium, puls., and ars. were given till the time of the next monthly, which amounted almost to flooding; Sabina and china also failed. A very careful physical examination revealed nothing ex- cept a relaxation of the vagina near the cervix; the uterus high up in the pelvis, congested, and perfectly movable. The condition of the patient was now desperate. A pledget of lint soaked in dilute tincture of iron was placed against the cervix, and the vagina firmly packed. This did no good, nor did the injection of two drams of dilute tinct. muriate of iron into the cervical canal; ergot in formidable doses was of no effect. Bovista 4 x. trit. every half-hour was then given; uterine contractions were produced at short in- tervals after the third dose. She continued to improve from this time, and \ 216 MEMORRAAGZA AAD METRORRHAGIA. Flow ceases at night. — Caust., (puls.). Alozº, ceases on Zying dozen. — Cactus grand., causticum. A/oz0 only during sleep or absence of pain. — Mag. carb. ! Flow between the periods. – Ambra, bell, bovista, (caust.), hepar, mangan. acet., silicea. Zuring menstruation, nausea. — Apoc. cann., capsicum, ipecac, kali bichromicum, nux vom., puls., viburn. op. Zuring menstruation, diarrhoea. — Bovista, causticum, (erig.). Auring menstruation, eruption on the skin. — Dulcamara, kali carbonica, Sarsaparilla. - A/02, less on motion. —Cyclamen.” A/oze, worse on motion. — Argentum metallicum, cocculus, cof- fea, crocus, erigeron, nitric acid, pulsatilla, sabima, secale, trillium, ustilago, zinc. -- made a perfect though slow recovery, with the help of ferrum, ars, crocus, and cocculus. There has been no return of the hemorrhage. — DR. W. WESSELHOEFT, AVew Zngland Medical Gazette, Vol. II, p. 461, 1876. Mrs. — Menstruation always profuse. After bearing children, her catamenia became a fearful menorrhagia, completely exhausting her. There was nothing particularly characteristic, further than a wonderful flow of blood, and an amelioration during the daytime when on her feet, and an aggravation at night when lying down. This condition continued for months; all remedial agencies brought no relief through allopathic thera- peutics, further than terrible spasms of the uterus, apparently brought on by an indiscriminate use of ergot. After exhibiting remedies as they occurred to me, and then only palliatives, as they would not control the hemorrhage, I administered bovista, and she recovered. During this trouble her attend- ant advised her to become pregnant, which seemed impossible, although dur- ing thirteen months, to use her own words, “we never tried to prevent.” Three months after taking bovista she became pregnant, when they did try to prevent, and was delivered, at full term, of a fine healthy boy. — DR. ISAAC COOPER, Hahnemanmiam Monthly, p. 168, November, 1874. 2 Mrs. , aet. 44; always well till within two months. The flow had continued all through each month ; discharge pale and watery, at first dark and clotted ; general appearance somewhat exsanguinated; mouth, tongue, and lips pale; she always felt best when moving about; the ſlow almost ceased as long as she was moving about at work, but as soon as she sat down quietly in the evening the ſlow reappeared, and continued after she went to bed. Cycla- men 2 x. relieved her promptly; she improved in general, and continued so, the menses returning monthly until March, 1873, when the troubles of the last year reappeared. After two doses of the same remedy, she remained well. — H. RING, Raue's Record of Homaropathic Literature, p. 233, 1874. REMEDIES FOR MEMORRAAGIA, ETC. 217 Flow too profuse at the climacteric. — Zachesis, laurocerasus, nitric acid, secale cor., trillium, ustilago," vinca minor. 1 Mrs. , ast. 4o ; had always been subject to profuse menstruation, sterile; was a large, fleshy, flabby, bloated-looking woman, with a very sal- low complexion, inclined to be (and formerly had been) dropsical from excessive 'loss of blood; profuse menstruation, which seems to her to be principally “water and clots”; she says there is no outward flow when she lies still, but the clots pass out of the uterus when she gets up, and also water; she feels so full in the uterus that she must rise to get rid of the clots, she received sabina, which did not arrest the flooding. At my second visit in the afternoon she seemed better, and I believed that sabina was the right remedy. But she ſlowed fearfully during that night; when I saw her in the morning she was no longer able to rise to get rid of the clots; the flow still continued; she was very low, scarcely able to speak aloud, and in a most critical condition. Ustilago maidis, in the tincture, was prescribed mixed with water. From the moment of commencing to take it she improved; but she had been so reduced by the enormous loss of blood that it was two or three weeks before she was able to sit up a little. After six months there has been no return of the trouble; she has improved in health, and her old trouble seems to have left her for good. Hale in his “New Remedies” gives, as a characteristic, menorrhagia at the climacteric period; active and constant flowing, with frequent clots. – DR. J. H. P. FROST, Hahnemannian Monthly, p. 145, November, 1874. 218 V/CARIOUS MEASTRUATIOA. CHAPTER XIII. VICARIOUS MENSTRUATION. - This name has been given to a periodic flow of blood from Some other portion of the body than the uterus, at the menstrual epoch. As a rule, it is from some mu- cous membrane. There is, however, scarcely any part of the body from which it has not been known to occur. The most common places are the nose, stomach, hemorrhoidal tumors, lungs, breasts, and ulcers. Instead of a discharge of blood, there may be a serous transudation, and the pa- tient suffers for the time with a profuse watery diarrhoea. Cases of genuine vicarious menstruation are quite rare, so much so that its existence has been doubted." The most common cause is a poor state of health, or faulty nutrition. In other cases, it seems to be due to high arterial tension, and a slight discharge of blood may pre- cede the regular flow from the uterus by a few hours. In a case of this kind now under my care, it comes from the right nipple.” When it is seen in young women who have never men- struated normally, it is well to make a careful examination, and be sure that there is no obstruction to the flow of blood from the uterus. If for a number of successive months the blood comes from the lungs, there is reason to fear tuberculosis will follow, especially in scrofulous women, or those having an hereditary taint. 1 British Gynaecological Journal, pp. I 51, 177, 188, 1886. 2 This case was cured by pulsatilla. THERAPEUTICS. - 2 I9 The general treatment of vicarious menstruation is just the same as for amenorrhoea, to which the reader is re- ferred. The importance of constitutional remedies and treatment must never be overlooked. i THERAPEUTICS. || Bryonia. Besides other symptoms which may be present, it is applicable for vicarious menstruation in the form of epistaxis; also, for suppression of the menses with epistaxis (Carlsbad water, ham., puls., sepia) in women accustomed to too early and too pro- fuse menstruation (calc. carb.). The blood is florid, and the bleed- ing is most often in the morning, sometimes waking the patient from sleep. While bryonia is especially applicable to the above, it should not be forgotten in other forms of this affection, as clinical experience shows it is one of the chief remedies. Ferrum. Dr. Leadam's favorite remedy; anaemic women subject to fiery red flushing of the face ; suppression of the menses with haemoptysis (dig., millefolium, phos.). | Hamamelis. Vicarious menstruation of dark or venous blood from the nose, mouth, stomach, or hemorrhoids. The pres- ence of varicose veins, and a fluid rather than clotted condition of the blood, are additional indications. | Pulsatilla. Epistaxis, haematemesis, or expectoration of pieces of dark coagulated blood, with suppression of the menses. The pressive throbbing headache, palpitation, chilliness, and the above symptoms, with scanty or delayed menstruation, are addi- tional indications for this remedy. Dr. Kapper reports an in- teresting case cured in six weeks by this remedy. The principal symptoms were violent headache, dazzling before the eyes, twitches in the nose, fightness of the chest, fulness of the mammae, and oppression of the stomach, followed by violent epistaxis and flow of blood from the breasts, with relief and cessation of all the symptoms. These symptoms had been repeated for a number of successive months. The girl was apparently well, eighteen years old, and had never normally menstruated ; warm sitz-baths, leeches, and purgatives had been tried without any benefit. 1 Zeitsch. f. Hom. Klinik, Vol. I. p. 106. 22O V/CA/C/OO.S ME/VSTROYA TVOAV. The following remedies are less frequently uséſu!: – Alumina, belladonna," calcarea carbonica, calcarea phosphorica, Carlsbad water, digitalis,” kali carbonica, lachesis, lycopodium,” natrum muriaticum, phosphorus, sanguinaria, Senecio,” sepia, Sul- phur, veratr. album. 1 Belladonna has been serviceable in one case with determination of blood to the head; the hemorrhage was always from the throat or chest. — DR. J. HEBER SMITH. 2 Dr. W. H. Hoyt reports a case cured by digitalis, characterized by the following symptoms : pain in and about the chest, and sometimes epistaxis before the menses, followed by choking spasmodic cough at night, and the expectoration of a solid, bloody mass of mucus with immediate relief. This mucus was very difficult to detach, and often presented a rusty, black, and clot-like appearance. —7%ransactions AV. Y. State Society, 1869, p. 319. * Dr. Leadam reports a case cured by lycopodium. The patient was sub- ject to very irregular menstruation; in the intervals, first serum and then blood oozed out of the right nipple. — LEADAM, Z)iseases of Women, 1874, D. 33. - * The menses appeared at the age of fourteen; the patient was regular till sixteen; since then for three years the menstruation has entirely ceased, and instead she has hemoptysis, spitting blood for one day during every month. Pulsatilla I x, three times a day was given for twenty days; it was then five weeks since she last spit blood, but the menses did not appear; she then re- ceived senecio 1 x. two drops three times a day, and the flow appeared on the tenth day after using senecio. —DR. HARMAR SMITH, Homaropathic World, p. 537, Dec. 1, 1882. (Though not positively stated, it is inferred that the case was permanently cured, or it would not have been reported as a case of vicarious menstruation cured by senecio.) J) P.S.)/A2A/OA’AºAſOEA. 22 I CHAPTER XIV. DYSMENORRHCEA, OR PAINFUL MENSTRUATION. IKE leucorrhoea, this is not a disease in itself, but a symptom ; i. e. it is secondary to some primary affec- tion. It has been classified, for convenience of description, as neuralgic, ovarian, congestive, obstructive, and membra- nous dysmenorrhoea; but these forms so often overlap one another, that frequently a case cannot be positively assigned to any one of them. The pathology is not well under- stood, and eminent physicians have very different opinions concerning it. Fortunately, this does not interfere with the successful treatment of a large majority of these cases. It would seem that hyperatesthesia of the nerves, or per- turbation of nerve force in and about the uterus, plays an important part in nearly all cases of dysmenorrhoea. The same causes producing neuralgia in other parts of the body produce a similar condition in the pelvic organs." In other cases, the hyperaesthesia may be caused by the inflamed or engorged ovary or uterus, which is relieved by the escape of the menstrual blood. This is not unlike the pain of any localized inflammation, such as a whitlow, which is relieved by lancing, and the escape of blood. It is of importance to remember that dysmenorrhoea coming on several days before the flow is often associated with salpingitis. The theory of obstruction to the escape of the men- strual flow, as a cause of painful menstruation, will hardly * Anstie, Neuralgia, and the Diseases that produce it, p. 69. 222 J) VS/A2/VOA’A’AIOE.A. account for so large a portion of cases as some authors have thought. How many times physicians observe pa- tients having a pin-hole OS, or an extremely small cervical canal, who do not suffer much during the menstrual period, while others having a much larger canal are in agony at such times. The cervical canal may be large enough in uterine flexions; but the bending of the cervix on the body of the uterus will more or less occlude its canal, the calibre of its blood-vessels become altered, and a varying degree of engorgement of the blood-vessels results. The con- ditions are then similar to the preceding form. It is noticeable, that, when the site of flexion is above the vagi- nal junction, the dysmenorrhoea is more often severe, and not always relieved by enlarging the canal by incision. When the flexion is below the vaginal junction, or the con- traction at the external os, i. e. where the circulation is not disturbed, dysmenorrhoea is rare. The pain caused by the mechanical dilatation of the uterus, and subsequent contraction to expel its contents, which have accumulated in consequence of a spasmodic stricture at the internal OS, occlusion of the canal by a polypus, or from any other cause, cannot be ascribed to a nervous origin. Another argument in favor of nervous irritability or hyperaesthesia as the cause of painful menstruation is, that the most effectual medicines in its treatment are among the best for the treatment of nervous disorders in other parts of the body. The dilatation of the inferior seg- ment of the uterus, by parturition or instruments, can be compared to nerve-stretching for neuralgia, or dilatation of the urethra for cystalgia. There is little positively known concerning the etiology or pathology of membranous dysmemorrhoea. It must be accepted, however, as a clinical fact, that apparent shreds of membrane, or casts of the uterine cavity, are expelled A'ORMS OF A) YS//A2/VOA’Aſ’AſOE.A. 223 with great pain, and that this form of membranous dys- menorrhoea is often exceedingly difficult to cure. The varieties of painful menstruation mentioned are convenient for purposes of description, and are therefore given in the following table:— Forma. Btiology. Jymptoms. Prognosis. Neuralgic dys- memorrhoea. Ovarian. Congestive. Obstructive, Patients subject to rheumatism or neuralgia. Anything which depress- es the system, or ener- vating habits leading to neuralgia in other parts of the body, may cause it here Laceration of the cervix uteri. The same as for chronic ovaritis. Particularly, re- peated and severe cauter- ization of the cervix with nitrate of silver. Inflammation in or about the uterus; dis- placement of the latter; any cause producing con- gestion, such as the pres- ence of a fibroid tumor or polypus; slow circula- tion in the portal vein; mental shock; the action of cold and wet, espe- cially at the time of the menses, or in plethoric women. The latter is a very common cause of congestive dysm enor- rhoea in girls, while ute- rine displacement is a more frequent one in later life. Congenitally small cer- vical canal, or contrac- tion of the latter after the application to it of strong The pain is of a sharp, fixed character, usually local, and less often in dis- tant parts of the body. It varies in intensity, some- times appears before the flow, and may stop with, or continue during, the dis- charge. There is often pain at in- tervals between the menses; it commences a few days before the flow, and dimin- ishes with it. The pain is dull, aching, and often ac- companied by depression of spirits, nervous phenom- ena, and sympathetic dis- turbances in the breasts. Severe pain comes on suddenly during the period, with a decrease or arrest of the flow, and considerable fever in proportion to the amount of congestion or inflammation. The usual menstrual symptoms appear, but with very little, if any, discharge of blood. The latter gradu- If the patient has not been subject to neuralgia for a long time, and can be built up to a high standard of health, recovery is probable; otherwise it is doubtful. Unless the case is a recent one, recovery is improbable, espe- cially so if the ovari- tis followed cauteri- zation of the cervix with nitrate of silver. Sterility is common. Good if the cause can be removed. Good in the great majority of cases. DJ’.S//EZVOR/CAHOEA. Forzzz. Etiology. Symptoms. Prognosis. caustics; bending of the canal on itself, as in retro- flexion; a polypus or fibroid in the cervix, en- croaching on its canal; occlusion of any portion of the vagina; endome- tritis is almost always present in consequence of the pent-up fluids in the uterine cavity. e ally collects in a few hours, and distends the uterus. Spasmodic, labor-like pains are excited till the uterine contractions overcome the obstruction, and there is a gush of the imprisoned blood, with one or two clots, which relieves the pain. In some cases of marked obstruction, the process is repeated till menstruation ceases. Pain commences with the flow, gradually increases in severity, and becomes Membranous. By some means, the lining membrane of the uterine cavity is cast off, either entire or in pieces. The true causes of this affection are not known. It would seem as if it might be called a variety of endometritis.” labor-like, till the mem- brane is discharged, and then ceases. The flow is then more profuse, and is followed by a variable amount of leucorrhoea. As a rule, unfavor- able. * Fibrinous endometritis forms a complete cast, very similar to that of membranous dysmenorrhoea. The outer surface of the former cast, which is usually solid, is smooth; while the surface of the latter cast, which is hollow, i. e. it forms a sac with three openings, is rough and papillary. A micro- scopic examination will readily show the difference. (Compare Orth, Diag- nosis Path. A nat., p. 255) Dr. Kleinwaechter in the Wiener KZinik, February, 1885, quoted in American Journal of Obstetrics, p. 1115, 1885, terms it exfoliative endometritis. Dr. Alexander J. C. Skene agrees with him that the membrane is an exfoli- ation in mass of the mucous membrane of the uterus at the menstrual period. — M. Y. Medical Journal, December, 1885. A’O/8MS OA' DYSMEAVO/PA’AſOEA. 225 DIFFERENTIAL DIAGNOSIS. AVeuralgic. Ozvariazz. Oöstructive. Congestive. Memôramous. Pain not ex- pulsive. No constitu- tional disturb- ance, such as fever or inflam- mation. Flow steady; develops gradu- ally, and is ha- bitual. Examination reveals no phys- ical cause for pain. Pain com- Inen CeS SOI ſhe days before the flow, and does not affect it. No constitu- tional disturb- ance, such as fever or inflam- mation, Flow steady, dates from an attack of ovari- tis, or exposure during menstru- ation. One or both ovaries are usu- ally enlarged and inflamed; nervous symp- toms and sym- pathetic irrita- tion of the breasts; nausea and vomiting. Pain expul- sive, labor-like, finally followed by discharge of blood and clots, which relieves the pain. Constitutional disturban ce slight. Flow usually in terrupted; may be congen- ital, or have slowly devel- oped. Examination with finger or probe during menstruation shows an ob- struction to the flow. Pain comes suddenly during the period. Constitutional disturbance, h e a d a ch e, flushed face, and fever, in propor- tion to severity of congestion or inflammation. Flow dimin- ished, or arrest- ed, comes on suddenly, dur- ing a period, in WOrnen a CCUIS- tomed to pain- less menstrua- tion, and is not habitual. Examination reveals conges- tion, or a vary- ing amount of inflammation in or about the uterus The discharge of the membrane is suf- ficient to distinguish it. It is recognized from blood clots, fibrin casts, or early abor- tions, by the discharge of only one membrane during the period, its characteristic elements under the microscope, and its recurrence each month. I5 226 D}^S//E/VOR/8A/CEA. The successful treatment of dysmenorrhoea depends very largely upon the removal of the cause. In most cases an examination is necessary, in order to treat the patient intelligently. In young unmarried women, or girls, the advisability of it may be questioned. When, however, pain continues to a marked degree, throughout the period, and is repeated from month to month, in spite of carefully Selected remedies, an examination must be made. In young girls, enough information can often be obtained through the rectum, instead of the vagina, i.e. a displace- ment of the uterus, cellulitis, or ovaritis; but if an ex- amination per vaginam is necessary after this, ether should be used. It is an important fact, as Dr. Emmet has shown, that, of all married women who had dysmenorrhoea in early life, 71.90 per cent were sterile. It is a false delicacy which allows diseases and consequent suffering to become established, which might have been cured at their com- men Cement. - In some cases marriage has a very beneficial effect, especially if followed by parturition. It is quite unnecessary here to go into the details of the treatment of inflammation in or about the uterus, of dis- placements, or other causes which will be found elsewhere in this book. Although many authors admit they are forced, at times, to use suppositories of morphia and bella- donna, all unite in condemning the use of anodynes as a most pernicious practice. Neuralgic Dysmemorrhaea should receive the same gen- eral treatment as neuralgia occurring in other parts of the body. Not only is a nourishing, generous diet important, but often a change of air, outdoor exercise, or a sea voy- age is very beneficial. The passage of a large sound through the cervical canal, the day before the expected monthly, may entirely relieve the patient from pain; and if this fails, rapid dilatation * is advisable, provided reme- * See chapter on Minor Surgical Gynecology. TREATMEAT OF DYSMEMORRHCEA. 227 dies are ineffectual. Electricity in this, as in the following form, will sometimes promptly relieve the patient." Ovarian Dysmemorrhaea is very stubborn to treat, and likely to be attended by sterility. The only local treatment advisable is that used for ovaritis, such as hot sitz-baths, and soothing vaginal injections. Unless complicated with some of the other forms, dilatation of the cervical canal would probably be useless. . Under this head may be mentioned a form of scanty and painful menstruation in young women or girls in whom there is a marked tendency to amenorrhoea, or progres- sively diminishing menstrual flow. This seems due to non-development of the ovaries, and tends to atrophy of them ending in sterility, or immature development of the genital organs. Here, again, nutrition of the System, rest from mental work, outdoor air, and exercise are of prime importance, and may alone suffice. This will be shown by the increase of the menstrual flow, and pro- portionate decrease of pain. Besides the removal of any focus of irritation in the pelvis, Dr. Emmet recommends the use of a small sponge-tent, immediately before the expected period, to bring on the flow. Electricity has sometimes proved useful, by passing a Faradic current be- tween the hypogastric and sacral or lumbar regions, the electrodes being placed externally, or by one electrode in the cervical canal and the other on the hypogastrium, espe- cially when the galvanic current is employed; or by wear- ing the intra-uterine galvanic stem pessary, composed of alternate layers of zinc and copper plates. Congestive Dysmemorrhaea is much more susceptible to treatment. Any deviation of the uterus from its normal position must be corrected; and if the flow has been sup- pressed by exposure to cold or wet, measures must be taken at once to bring it on. The best way to do this is to have the patient prepare for bed, and, sitting on the edge, 1 See chapter on Electricity in Gynecology. r 228 - J) PS//EAVOR/?AICEA. Soak her feet in hot water and mustard, with blankets well wrapped around her, till the skin begins to perspire. The action of the skin may be hastened by drinking hot weak tea, or hot water with a little essence of ginger, while the temperature of the foot-bath is increased gradually by the addition of a little more hot water. A bottle of gin is very often kept in the house as a remedy for scanty or suppressed menses. When perspiration commences, the patient lifts her feet out of the water, keeping them in the blankets, without stopping to wipe them, and lies back in bed. This, with proper medicines, is usually sufficient, unless some few days have elapsed, when it is of little use to try it before the time of the next period. In the in- terval between, copious hot-water vaginal douches, with an occasional application of glycerine to the cervix, are useful to allay the tendency to passive congestion. The injurious effects of tight lacing, and heavy dresses suspended from the waist, in obstructing free circulation in the abdominal veins, must not be overlooked. The weight of the dresses should come on the shoulders, by buttoning the garments on a waist or skirt-supporter; while, if it is a rule to have the corsets fit loosely enough to pass the hand easily up beneath them after lacing, little harm can be done. Chapman's spinal ice-bags are sometimes very useful for dysmenorrhoea, with scanty and tardy discharge. Use one for half an hour, once or twice a day, when the pain CO (Il eS. Obstructive Dysmemorrhaea, of all the forms, is the most difficult to cure by any other than local treatment. It may also be noted, that it is not nearly as common as has been supposed, as any physician can ascertain by passing a sound during menstruation and while the pain is present. Medicines are of little avail till after the exciting cause has been removed, and then seldom necessary. The removal of a small fibroid or polypus, the straightening of the t TRAXA TMAZZVZT OF D PSMEAVORRAIOE.A. 229 uterus, or dilatation of its canal,” is followed by very marked and prompt improvement or cure. As a rule, dilatation is the most effectual, and in cases of flexion is superseding the treatment of incising the cervix, which was so ably advocated by Simpson and Sims.” One great reason for this is the slight amount of risk involved. It must, as a rule, be thorough to be effectual, and followed by the occasional use of an intra-uterine stem, of glass or hard rubber, to prevent a possible contraction of the canal. - - Membramous Dysmemorrhaea is, of all forms, the most difficult to cure. Local treatment, except as it may relieve various complications, is of no use. Dilatation of the cer- vix, just before the period, has been tried, to facilitate the extrusion of the membrane; but this, like anodynes, is often merely palliative, except as it allows the blood to escape more freely, relieves congestion, and, in turn, may possibly avert the tendency to hyperplasia of the lining membrane of the uterine cavity. It is possible that the intra-uterine application of the negative pole of the gal- vanić current might have an alterative effect on nutrition, and thus prove beneficial. The current, however, must be very weak. t The Medical Treatment of dysmenorrhoea, excepting the obstructive and membranous varieties, is usually quite satisfactory. In the dominant school the valerianate of ammonia has quite a reputation for dysmenorrhoea in hysterical young women, but it is merely palliative. Hydrobromate of hyoscine (gr. 1 — 128) every two hours till the pain is lessened, or three doses have been taken, is a popular remedy of Dr. Goodell. He also recommends bromide of ammonium and potash with aromatic spirits of ammonia and camphor water or aromatic spirits of ammonia and ether. I believe, however, these will prove 1 See Chapter II. - * See Notes on Uterine Surgery, by Marion Sims, M. D. 23O D}^SMAEAVOR/PA/OEA. only palliative. Recently, antipyrin in ten-grain doses well mixed in half a glass of water, all taken at one draught, has proved very useful to relieve the severe pain of dys- menorrhoea, particularly the neuralgic form. In some cases an additional dose of ten grains may be given half an hour after the first, if there has been no relief. It will be generally found that, if comparatively prompt relief does not follow the first dose, antipyrin is not likely to re. lieve, and a third dose should not be given. The effect of antipyrin is largely palliative. It is a powerful drug, and should never be used indiscriminately. Not infrequently one remedy must be given between the periods, and another at the time to relieve the pain. The clinical value of the remedies is very much injured, however, when more than one is used. As a rule, the intercurrent remedy should be directed to the cause of the dysmenorrhoea; whatever that may be, its removal is absolutely essential to a permanent cure. THERAPEUTICS. Aconite." Congestive dysmenorrhoea, in consequence of Sup- pression of the menses, especially from fright (lycopodium) or vexation, in plethoric women, accustomed to profuse flowing. Ovaritis may be present. The pain is sharp and cutting; the vagina hot, dry, and sensitive (belladonna), with painful urging to urinate. The patient is very restless, and tosses about ; thirsty, and the pulse full, hard, and strong. 1 Girl, aet. 22. Strong and plethoric. Has always had severe, agonizing dysmenorrhoea. Violent cutting pains in the back and loins, like labor pains, for the first two days. On the third day, violent cutting pains in the abdo- men. On the last day very severe pressive headache. Menses every three weeks, discharge copious and dark. Belladonna helped the backache, pul- satilla the abdominal pains, ignatia the headache; but they only proved palliative. Suspecting inflammatory irritation as the cause, I gave aconite 6, The pain soon ceased. She had two doses of aconite the next month. The flow then became regular every four weeks, and painless. This was thirteen years ago, and she has had no return of it in that time. — DR. ELB, Zeitschrift für Hom. KZinik, Vol. I. p. 4. THE RAAE O/T/CS OF D PSMAZAVO RA’AICEA. 23 I Ammonium carb." (The acetate is preferred by some physicians.) Recommended by Dr. I. T. Talbot” for dysmen- orrhoea in persons of nervous, sanguine temperament, when the pain is cramp-like, confined to the uterine region, and occurring for the most part before the flow, with pallor of the counte- nance. The flow is blackish or clotted, too early and abundant. Diarrhoea or cholera-like symptoms at the beginning of the menses. Menstruation too early, too weak, too short, blood too dark, small clots, colicky pains; during pains, bearing down with cutting abdominal pain, backache.” Dr. H. H. Read found this remedy not only cured the dysmenorrhoea, but also had an excellent effect on the general health of a patient who suffered from Cramps and diarrhoea coming three or four days in advance of the menstrual flow. Several remedies had been given previously, without any relief. Belladonna. Atropine is sometimes used instead. Dr. Dun- ham “found it a very effective remedy for the following symptoms. Very severe pain, dragging, and pressing down in the pelvis; also Cutting pains through the pelvis, i. e. horizontally, not around it like sepia and platina. These pains are paroxysmal, and precede the menstrual period from six to twenty-four hours. The ovary, 1 Miss L. S., age 25, a school-teacher, of large frame, coarse fibre, dark complexion, with tendency to adipose, has suffered for three years with dys- menorrhoea. Menses are regular as to time, rather profuse, natural in color, somewhat inclined to be offensive in odor. Leucorrhoea in inter-menstrual period. For the first twelve or eighteen hours of menstruation she has se- vere cramping pains low in the abdomen, accompanied with nausea, vomit- ing, and diarrhoea. The bowels move three or four times, usually loose and profuse, (she is habitually constipated,) but the vomiting continues through- out the first day. Ammonium carb. c. m. (H. S.), one dose. Two weeks after taking the amm. carb., menstruation appeared at the regular time. One stool at the commencement, freer than usual, but not diarrhoea; slight nausea, but no vomiting. She taught all this first day of menstruation, which she had not been able to do before for many months. Six weeks later, menstruation normal and painless; no nausea, no vomiting; no fur- ther trouble to this time, now more than a year. No report regarding the leucorrhoea was made. She received but one dose of the remedy. – C. W. BUTLER, M.D., Homatopathic Physician, p. 84, February, 1888. 2 New England Medical Gazette, Vol. IV. p. 56, 1869. 3 Dr. Conrad Wesselhoeft. * Lectures on Materia Medica, Vol. I. p. 262, 1878. 232 AD PS//EZVO/P/8A/CEA. more often the right, is inflamed and prolapsed, making defecation painful at this time. It should be given just before the menstrual epoch, and, if necessary, be persevered with for many consecutive months. - It is also useful for sudden suppression of the menses from cold, with severe bearing-down pain and throbbing in the hypo- gastric region; flushed face, throbbing headache, and difficult or painful micturition. Borax. The action of this remedy on the uterus is not thor- oughly understood. It has been successfully used for membranous dysmenorrhoea," but is by no means a specific for it. The best results from it have been obtained from the pure substance in from three to five grain doses. This use of the remedy is said to have originated with Dr. Henry Bennet. . Dr. Guernsey gives “fear of downward motion ” as a great characteristic of this drug. Dys- menorrhoea with sterility.” The menses are too early and profuse, with nausea and colic ; /eucorrhaea like the white of egg (amm. mur., bovista, Calc, phos., mez.), with sensation as if warm water were ſlowing down. It may be chronic and acrid, accompanying sterility with great nervousness. # | Caulophyllin. Spasmodic pains in the uterus and various parts of hypogastrium. The flow is either normal or scanty, in patients subject to rheumatism of the small joints. It is also use- ful for moth-spots on the face in women subject to menstrual irregularities or leucorrhoea (Sepia). Dr. D. Dyce Brown thinks highly of it, both at the time of the pain and between the periods. | Chamomilla. Neuralgic dysmenorrhoea (coffea). The flow is too early, too profuse, and offensive (belladonna); drawing pain 1 Dr. A. H. Tompkins, New England Medical Gazette, December, 1879. Two cases of membranous dysmenorrhoea cured, one with five-grain doses of the crude drug, the other with 2 x. trit. Transactions N. Y. State Homoeopathic Society, Vol. X. p. 279. The first attenuation was used. Case of radical cure reported by Dr. E. M. Hale, British Journal of Homoe- opathy, Vol. XXIX, p. 748, 1871. In this case pure borax was given, in five-grain doses, three times a day. 2 Hahnemannian Monthly, March, 1880. . THERAPEUTICS OF D PSMEAVORRACEA. 233 from sacral region forward; griping, pinching, labor-like pains in the uterus, followed by the discharge of large clots of blood; the patient is impatient, irritable, and very sensitive to pain. | Cimicifuga. Macrotin, an impure resin (not the active principle), obtained from the tincture, is preferred by many prac- titioners. Rheumatic dysmemorrhaea, i. e. dysmenorrhoea in pa- tients subject to muscular rheumatism, and an apparent metastasis to the uterus, which is irritable, and feels sore or bruised on ex- amination. Dr. Dewees, in the old School, introduced guaiacum as a remedy for this condition.) Menses irregular, delayed, or sup- pressed; hysterical or epileptic spasms at the time of the menses; pains in ovarian region shoot upward, in uterine region from side to side; bearing down and tenderness in the hypogastric region; limbs feel heavy. | Cocculus. Dr. Edward Blake considers this the best remedy for dysmenorrhoea, as well as for menstrual colic from flatulence generated by the intestinal walls, more often at night, and espe- cially during menstruation and pregnancy. Menses too early, with cramps in the abdomen, and colic pains; great weakness during the menses (amm. carb., Carb. an.), severe headache on third or fourth day of the flow ; light and noise intolerable, and accom- panied by nausea, like the heaving up and down of the stomach in sea-sickness; sudden cessation of the flow, followed by severe spasmodic pains; dysmenorrhoea in girls and childless women; flow may be scanty, or very profuse, with pain in the breasts, rest- lessness, groaning, vomiting ; small pulse, and great weakness; leucorrhoea between the periods. Scanty, irregular, painful men- struation. Dysmenorrhoea with a profuse discharge of clotted blood and subsequent hemorrhoids. Uterine cramps with suff- pressed, irregular menstruation and a sero-purulent bloody dis- charge. The last is a favorite indication.” Dr. Lobeth praised it as a remedy between the monthlies, but did not value it as highly during the monthly epoch. Dr. Hartman esteemed it very highly ; but in extremely severe cases, when the attacks resembled epilepsy, he used cuprum metallicum instead. Collinsonia is a good remedy, especially between the periods, 1 Dr. Conrad Wesselhoeft. 234 A) VS//E/WO/P/PHOEA. . for dysmenorrhoea associated with passive congestion of the uterus, hemorrhoids, and constipation. Colocynth. Severe left-sided ovarian dysmenorrhoea, causing the patient to double up ; colicky pain two or three days before the menses, extending below the navel to the genitals, relieved by warmth, and associated with cold feet. The pains are also relieved by flexing the thigh on the abdomen. | Gelsemium I x. is best given in hot water, a teaspoonful every fifteen minutes, and less often as soon as there is any im- provement, which will be sure to follow, if at all, after three or four doses are taken, provided the remedy was administered as soon as the pain commenced. It is one of the very best remedies for spasmodic dysmenorrhoea ; but, as a rule, some other remedy, such as caulophyllum, is required between the menstrual periods to effect a cure. Severe, sharp, labor-like pains in the uterine region, extending to the back and hips (cimicif., secale cor.); dys- menorrhoea, preceded by sick headache, vomiting ; congestion to the head; confused vision; deep red face; bearing down in the abdomen; the patient passes large quantities of limpid, clear urine, w/ich relieves the headache. It is esteemed very highly by Dr. D. Dyce Brown." Hamamelis has been praised as a remedy for ovarian dys- menorrhoea. There is severe pain through the lumbar and hypo- gastric regions, and down the legs; the ovaries are Sore and painful, the veins distended, and the flow profuse. Nux mosch.” When there are severe lumbar pains running down the thighs the flow is dark, clotted, with bearing down, drowsiness, fainting easily. Symptoms worse from exposure to dampness, getting the feet wet, etc. Pulsatilla is an excellent remedy for dysmenorrhoea, given between the periods, rather than at the time of pain when some other medicine is often more applicable. It is particularly useful for suppression of the menses from wetting the feet, and is always to be remembered with aconite in congestive dysmenorrhoea from * He recommends gels., cauloph., xanthox., cimicif., cocc., cupr., and ig- natia, in his lecture on the Diseases of Women, at the London School of Homoeopathy. — Monthly Homaropathic Review, p. 464, Aug. 1, 1881. * Dr. J. Heber Smith. THAEA’AA’A, U 7/CS OF D VSMEAVORRATOE.A. 235 this cause ; also for delayed, scanty, and painful menstruation. The pain is constrictive, labor-like, more often in the left side of the uterus, and obliges the patient to bend double. In aconite, the discharge is bright red, and the patient inclined to plethora. In pulsatilla, the discharge is dark and clotted, and the patient of a lymphatic temperament. • , Senecia.” Painful menstruation, with scanty flow (cactus, conium, graph., puls., sepia), and urging to urinate, worse at night; menses irregular. Dr. J. Moore* emphasizes this remedy in his list of remedies for dysmenorrhoea. Sepia is chiefly useful as a remedy between the periods where there is passive congestion of the pelvic organs (also Sabina); severe bearing down in the latter, and yellow or milky excoriating leucorrhoea worse before the menses. - Silicea" is an excellent remedy, not often prescribed for dys- menorrhoea and other diseases of women, because the symptoms of the female organs in our present provings do not point directly to the disease. It is, however, one of those deep acting remedies which is often to be prescribed by general or constitutional symp- toms rather than the local ones. It must never be forgotten that 1 If there is dysmenorrhoea, with the usual flow, Dr. W. H. Holcombe prefers caulophyllum.–U. S. Medical and Surgical Journal, Vol. VIII. p. 44. * Monthly Homoeopathic Review, p. 671, Nov. 1, 1871. 8 Miss , aet. I7. Always well and strong previous to a very severe attack of diphtheria. After this there developed extremely severe dysmen- orrhoea. She feels tired all the time, has a vivid imagination, complains of hunger but has no appetite at the table, though sometimes the appetite is inordinate, and she is subject to diarrhoea on taking a little cold. Before menstruation she suffers from a profuse watery diarrhoea, attacks of blindness with stupor, face flushed, profuse flow of involuntary urine; be- comes very nervous, irritable, cries much and wants to be left alone. Agoniz- ing dysmenorrhoea with nausea and vomiting before the flow. The pain is worse with the slightest motion and returns severely with any motion. The Dain is chiefly for the first eight or nine hours, goes off when the flow is fairly established, but returns on motion. The flow is exceedingly profuse, of a dark color, and the patient finally has an exsanguinated appearance. She has attacks of dizziness, throws off the bed-clothes, and cannot bear to have them over her. I prescribed carefully for her for a year and a half without any effect, and then gave her silicea 3 x. This remedy alone cured her of the dysmenorrhoea and nearly every other symptom in four months. She has remained well for two years and a half up to the present time. 236 AXP.SME/WORAE/HOE.A. in treating diseases of women we may palliate with remedies and fail to cure if medicines are not employed which exert a powerful effect on general nutrition and organic changes of tissue. Menses too early or too late, with diminution or increase of the flow, which is apt to Smell strong and be acrid, acrid leucorrhoea causing smarting. Diarrhaea before menstruation. I have also cured the opposite condition of constipation before the menses with silicea. Joy coldness of the whole body when the flow commences, coldness during the flow, especially icy coldness of the feet, colicky pain in the abdomen, burning, soreness or itching of the external genitals. Unhealthy skin, slight injuries fester and heal slowly. Nymphomania or increased sexual desire. Eruptions on the back of the head. Arofuse, sour-smelling sweat only on the head with great sensitiveness of the scalp. Headache worse from mental exertion, light, motion, talking, and cold air; better from warmth. Pale, earthy-colored face, offensive sweating of the feet. Scrofulous iudividuals. Skin dry, except the head and feet. Veratrum vir." Dysmenorrhoea; menses preceded by in- tense cerebral congestion in plethoric women. It has been recom- mended for spasmodic dysmenorrhoea at or near the climacteric, six drops of the first decimal in half a cupful of hot water, a tea- spoonful every fifteen minutes till the patient is relieved. || Viburnum opulus p" is best given in hot water, at inter- vals of ten or fifteen minutes. It is one of the best remedies to allay the pain, but often requires some other intercurrent remedy to effect a cure. Cures of membranous dysmenorrhoea from its use have been reported.” Before the menses there is bearing down, aching 1 The following case of long standing had been treated by able physicians without relief: menses regular in time, quantity, and character, but preceded for three days by terrible menstrual colic; pain extends all over the body; head and face look bloodshot, as if the vessels might burst; pain runs into the head from the neck; pulsation in head, neck, and carotids; sight disappears at times, everything moving in confusion before her eyes; tongue feels heavy, but is clean and natural, great thirst: pulse full and bounding. Verat. vir. 1 x. was given in five-drop doses every half-hour for six hours, at the time of pain. In four months she was perfectly well. — DR. EGGERT, AVorth American journal of Homaropathy, November, 1873. 2 Dr. J. C. King, Hahnemannian Monthly, p. 80, 1877. 8 Dr. T. C. Hunter, Hahnemannian Monthly, January, 1875. THERAPAE UTYCS OF D PSMEAVOR/8A/CEA. 237 in sacral and pubic region; excruciating, crampy, colicky pains in hypogastrium ; much nervousness; and occasional shooting pains in the ovaries. The pain and nervous restlessness continue during the flow with nausea. Dr. E. M. Hale' considers it almost a specific for neuralgic and spasmodic dysmenorrhoea. Viburnum prunifolium in fluid extract; one teaspoonful in half a glass of water acts quite magically in the congestive and neuralgic dysmenorrhoea of young ladies. I consider it superior to Viburnum opulus. Of the above solution one teaspoonful should be taken every twenty minutes until relief is obtained.” Xanthoxylon. This remedy promises to become almost a specific for neuralgic dysmenorrhoea, with very severe pain extend- ing down the genito-crural nerves, down the anterior surface of the thighs, and chiefly left-sided, though in recent provings” the right ovary was particularly affected. Menses too early ; profuse ; and the ovarian pain was followed by profuse milky leucorrhoea. Zincum val. is a favorite remedy with some physicians for neuralgic dysmenorrhoea in very nervous, hysterical women. Dr. E. E. Marcy * has found the cyanuret of zinc very useful in a number of cases. He was led to use it by the symptoms of a case of poisoning.” Ovarian pain accompanied with nausea and neuralgic headache, sleepless, low-spirited. Neuralgia of the ovary worse during the menses. (Zinc. met. relieved during the menses." 1 American Observer, April, 1874. 2 Dr. L. L. Danforth. * Publications of the Massachusetts Homoeopathic Medical Society, Vol. VIII. p. 228, 1885. * North American Homoeopathic Journal, Vol. II. p. 100, 1852. * A young lady, aged twenty-two, took two grains of the cyanuret of zinc twice a day, and was attacked with cramp-like pains in the uterine region; severe pain in the back; colic pain in the bowels; vertigo; convulsive move- ments in various parts of the body; great restlessness and nervousness; oppressed and rapid respiration; frequent and feeble pulse. 6 Mrs. , aet. 34. Childless; at menstrual periods has excruciating, drawing pain in left ovary. Pain usually accompanied with nausea, vomit- ing, and headache. Cured by zinc val. 2 x. . Mrs. Near climacteric, had syphilis in younger years. During menses has drawing, gnawing pain in right ovary extending through to back 238 D VSA/E/VO/P/PA/CEA. Other Æemedies for Consultation. — Agnus castus," alumina,” apis,” argentum nitricum,” ars, asafoetida,” berberis vulg.," cactus grandiñora, calcarea carbonica," cannabis indica” I X.,” coffea, col- to right of spinal column just above sacro-iliac symphysis. Zinc. val. 2 x. always relieved. — CORRESTA T. CAN FIELD, M.D., ZYansactions of American Institute, p. 259, 1888. Mrs. O., aet. 30. Fair complexion, nervous and hysterical, had for years a stinging and tensive pain in the right inguinal region during the menses, ac- companied by pain extending to the stomach, vomiting, pain in the right hypochondriac region, and hysterical spasms, which would often assume an epileptiform character with complete loss of consciousness. Uterus normal. Instead of the proper menstrual flow there was profuse leucorrhoea. Ano- dynes had been unsuccessfully employed and general anaesthesia used in severe attacks. Valerianate of zinc 3 x. was given. The hysterical symp- toms and the pain ceased, but the leucorrhoea continued. The valerianate of zinc at the time of the menses and pulsatilla in the inter-menstrual period cured the case. — Medical Current, March, 1889. 1 Recommended by Dr. Winterburn, in Arndt's System of Medicine, Vol. II. p. 402, for obstructive dysmenorrhoea. * Colic accompanying menstruation, trembling, lassitude, feeling as if everything would fall out, vaginal discharge after menstruation like bloody serum. Dr. Conrad Wesselhoeft. 8 Miss º, aet. 32. Dysmenorrhoea for several years; during the period severe, spasmodic, bearing-down, labor-like pains, which last a whole day, and are followed by a scanty discharge of dark bloody slime for twenty hours; great emaciation; wax-like skin; poor appetite; regular but hard stool; croc., puls, sabina, and sulph. were of little service. Apis 3, a day before the period, which was much less painful, and the blood of better consistency. Apis repeated before the next two periods completely cured her. —DR. J. R. CoxE. HERRING, Amerikamische Artzmeipräſungen, p. 287. 4 Dr. John Moore, Monthly Homoeopathic Review, p. 671, Nov. 1, 1871. 5 This remedy is not well enough known. Labor-like pain in the uterus, also cutting and bearing down, returning at intervals. Menstruation too early, scanty, and short. Dr. Conrad Wesselhoeft. 6 Menses too weak, too short. Blood watery, slimy, grayish color; dur- ing menstruation severe labor-like pains in lumbar region, bursting headache, and bearing-down pains. Dr. Conrad Wesselhoeft. 7 Dr. J. T. Kent speaks well of calc, phos. in too frequent and painful menstruation, especially at puberty, and if brought on by exposure to wet— Homaropathic World, p. 554, Dec. 1, 1884. - 8 Too strong profuse menstruation with violent pain and clots, also for organic disease with hemorrhage. Dr. Conrad Wesselhoeft. See also Bos- ton Medical and Surgical Journal, Vol. VI. p. 153. 9 Dr. Carfrae speaks highly of it. — Hahnemannian Month/y, Vol. VII. p. 269, 1872. REMEDIES FOR D PSMEMORRHOEA. 239 linsonia, conium,' cuprum,” graphites, hyoscyamus, *ignatia,” kali carbonica,” lachesis, lilium tigrinum, magnesia muriatica, mille- folium,” naja, natrum muriaticum, nitrate of amyl,” muz vomica,7 1 Dr. John Moore, Monthly Homoeopathic Review, p. 671, Nov. 1, 1871. 2 Dr. D. Dyce Brown, Lecture on Diseases of Women, Monthly Homoe- opathic Review, p. 464, Aug. 1, 1881. 3 Mrs. , ast. 26, married and sterile; excitable temperament. For fifteen years from the commencement of her scanty menstruation, had been attacked at every period by violent spasms and labor-like pains lasting sev- eral days. Various remedies did no good; ignatia cured before the next period, and she has been well since. Dr. Hilberger, who reported the case, believes that ignatia is the best remedy for dysmenorrhoea originating in irritability of the nervous system, rather than congestion of the uterus. – RücKERT's A7inische Erfahrungen, Supplement, p. 590. 4 Dr. H. Goullon mentions this remedy for dysmenorrhoea in women who menstruate profusely with an intermitting pulse. — Allgemeine Aſſom. Zeitung, Vol. LXXX. p. 7, 1871. I always give to girls who suffer from dysmenorrhoea a dose of Kali carð. daily for a week before the approaching menstruation, especially when they menstruate copiously, and there are intermissions in the wave of the pulse; sepia, on the contrary, is indicated for scanty menses, unilateral headache (migraine), weakness of sight, nausea, hard stool; pulsatilla, dysmenorrhoea with chilliness, gastric complaints (vomits after everything), pressure on the precordial region, soft stool; graphites and ferrum have simultaneously constipation and anaemia. — DR. H. GOULLON, Jr., in Allg. Hom. Zeit. Translated in the Journal of Homoeopathic Clinics, p. 130, September, 1869. * An infusion of this plant and a single application of iodized phenol apparently cured a case of membranous dysmenorrhoea (?). —DR. E. M. HALE, Aſomalopathic /ournal of Obstetrics, January, 1886, p. 20. * For scanty and painful menstruation, congestive dysmenorrhoea, where viburnum opulus and caulophyllum fail. — DR. E. M. HALE, Hahnemannian Monthly, p. 407, 1877. - 7 Fraulein —, aet. 26. Without any known cause menstruation became painful at seventeen; has been treated nine years unsuccessfully by the op- posite school; has to go to bed; severe cramping, pressive pain from the uterus towards the navel, sometimes extending to the stomach, and then it causes great nausea; chill and heat with the latter, general redness of the face; nux. vom. Io was prescribed; the flow appeared in three weeks, and lasted five days; there was no pain, nor did it recur afterwards. – SCHWARTZ, RüCKERT's A7inische AErfahrungen, Vol. II. p. 238. Fraulein , aet. 20. Dysmenorrhoea for four years following the abuse of saffron. Since then the flow is always profuse and weakening; eight days before the period, the pain begins in the abdomen; lancinating, tearing, and bearing down in the pelvis; it is most severe two hours after the 24O DJ’.SMEAVOR/CAHOEA. phosphorus," phytolacca,” platina,” rhus tox., Sabina, Sarsaparilla,” Secale cornutum (expulsive forcing pains with dark, coagulated, or Scanty discharge), silico-fluoride of calcium,” sulphur,” strontium carbonica,” thuja, ustilago,” veratrum album. flow commences; the cutting and tearing extend from the pelvis to the knees; the patient cannot straighten the lower limbs, which are spasmodically and painfully flexed; the hypogastrium is very sensitive to pressure. Prescribed nux. vom. p, six drops in water, four spoonfuls of it each day for eight days before the period. There was improvement at the next monthly, and in a few months the patient completely recovered. — Abid. * This remedy has been considered one of the most important for mem- branous dysmenorrhoea, and is advocated by Dr. Eaton. * Dr. John Moore, Monthly Homoeopathic Review, p. 671., Nov. 1, 1871. * Menses began at the age of eleven years, and with the exception of one year the patient has had dysmenorrhoea for twenty years; the monthly be- gins early in the morning with bitter vomiting, diarrhoea, fainting fits, very cold perspiration, dreadful pain in the back, thighs, and hypogastrium; has to go to bed; pain lasts two days, and goes off the third; the left nipple is retracted, with extreme sensitiveness of the left breast, and severe pain in it extending down the left arm. She was given twenty-four powders of sarsa- parilla 30, one to be taken at night. The next menstruation was painless, the first time for fifteen years; the breast was still very painful, but was relieved by a higher dilution. She remained well at time of reporting the case, a number of months afterward. —DR. J. C. BURNETT, Homatopathic World, p. 62, Feb. 2, 1880. * Silico-fluoride of calcium (lapis albus) is an important constitutional rem- edy for dysmenorrhoea in scrofulous subjects. Dr. Whiting of Danvers, Mass., writes me: “I think it is best indicated in subjects of a lymphatic temperament with indurated glands, when the pain precedes the flow; patho- logically, I have found chronic congestion of the cervix uteri to such a degree as to very much contract the canal. If the flow is not attended with pain till the day of termination, at which time severe forcing pain expels large clots, strontium carb. is the remedy”; also if “the pain comes on in from three to five days after the flow.” He kindly sent me the record of the following case of dysmenorrhoea, for which he gave sil. fluor. calc. 200, dose at bedtime. Miss , aet. 34; she had measles at twenty; since then has had pain at commencement of menses so severe for first day or two as to cause syncope. Professor Safford found the cervical canal so minute she 5 Particularly recommended by Dr. Ludlam for membranous dysmenor- rhoea from repelled eruptions. Also Dr. D. Dyce Brown, reference, p. 239. 6 Dysmenorrhoea with pain and swelling of the left ovary, also excessive menorrhagia of dark, coagulated blood. Dr. Conrad Wesselhoeft. See also article by Dr. Burt, Observer, Sept. and Aug, 1868. AºA. MAZZO/ES FOA’ D P.S.)/AC.VOA’/t’AſOEA. 24. I A’emedies to be given between the Periods for Dysmemorrhaea. — Caulophyllum,” cimicifuga," cocculus,” collinsonia,' hamamelis," ignatia, kali nitricum,” nux vomica," platina," pulsatilla," sabina, sepia," sulphur," xanthoxylon fraxineum. Ovarian Dysmemorrhoea." – Apis (right ovary), belladonna (right ovary), Calcarea carbonica, cactus grandiflorus, colocynth (left ovary), hamamelis, kali iodatum, lachesis (left ovary), mer- curius, naja (left ovary), platina, plumbum aceticum, thuja, vespa (left ovary), xanthoxylon fraxineum. Acheumatic Dysmemorrhoea.”— Aconite, bryonia, macrofin, nux vomica, rhus toxicodendron. s AVeuralgic or Spasmodic Dysmemorrhaea.” – Aconite, agnus Castus, ammonium Carbonicum, apis, asclepias tuberosa, atropine, cactus, Cannabis indica, Castoreum, caulophyllum, coffea, collin- Sonia, cuprum, ge/semium, hamamelis, hyoscyamus, ignatia, lilium tigrinum, magnesia carbonica, moschus, macroſſin, natrum muriati- cum, nux vomica, platina, pulsatilla, thuja, veratrum album, zera- trum viride, viburnum opulus, xanthoxylon fraxineum. Congestive Z29smemorrhaea. — Aconife, belladonna, bryonia, cocculus, Collinsonia, gelsemium, glonoine, hamamelis, Kali car- bonica, lachesis, nux moschata, Žulsatil/a, Sabina, Secale, sepia, zeratrum viride, xanthoxylon fraxineum. Membranous Dysmemorrhoea.— Apis (during the attack), borax, could not pass the finest probe; patient otherwise healthy. Four months later she wrote: “I have been waiting thoroughly to test the medicine before writing you. The first month after taking it I had none of that terrible nausea, and but little swelling of the mammae, but they were still very sore; pain at the period did not last so long, but was equally intense; next month there was a still greater improvement, with no pain the first day as usual, but on the second day instead, though it did not last so long; third month no premonitory pain, no swelling of mammae, no sensitiveness; have not lost a meal this month, and have had no nausea. For first day and a half no pain, not even an uncomfortable feeling; but after working hard all day, had an hour and a half slight pain, but slept all night, while as before I would have been tortured for two or three days and nights. I can live and be happy, should I not improve more; but I think that the medicine will cure me.” - 1 Dr. D. Dyce Brown, Lecture on Diseases of Women, Monthly Homoe- opathic Review, p. 464, Aug. 1, 1881. 2 Dr. John Moore, Monthly Homoeopathic Review, p. 671, Nov. 1, 1871. 8 Compare Ludlam, Diseases of Women, 5th ed. I6 242 J) PS//EAVOR/PA/CEA. bromine, bryonia, calcarea carbonica, chamomilla, collinsonia, cy- clamen, guaiacum, hydrastis canadensis," iodine, millefolium (?), phosphorus, Sulphur, viburnum opulus. When membranous dysmenorrhoea can be dated from some repelled or repercussed skin eruption, the following remedies may be borne in mind as possibly useful; sulphur, is the best as a rule. . - “Affrom an eruption /ike urticaria.”— Arsenicum album, rhus toxicodendron, urtica urens. “Aſ from an eruption like ‘hives.”— Apis, belladonna, chamo- milla. - “Affrom a herpetic or vesicular eruption. — Cantharis, rhus toxicodendron. « Affrom a squamous or scuſſy eruption. — Borax, arsenicum, nux moschata, dulcamara, silicea, sepia. “Af a scrofulous or unclassable eruption. — Sulphur, calcarea carbonica, calcarea fluorica, mercurius, hepar Sulphur. “Af syphilitic. — Thuja, nitric acid, mercurius iodatum, kali iodatum, mezereum. - “Aſ from suppressed rubeola, or if it alternates with oph- tha/mia. — Pulsatilla. Or in the former case especially. — Cuprum aceticum. “Af it is erysipelafous. – Belladonna, cantharis, rhus toxicoden- dron, apis.” ” 1 Jordán reports a case of membranous dysmenorrhoea, which had been treated for eighteen years without benefit from tannin pencils, intra-uterine cauterization with sulphate of copper, iron baths, bloody dilatation of the cervix, opiates, etc.; cured by taking the fluid extract of hydrastis cana- densis for one year. Twenty-five drops were given twice a day, beginning eight days before each menstruation. The case was completely cured. — Centra/blaſt fºr Gymäkologie, No. 2, p. 33, 1890. * R. Ludlam, M. D., Transactions of World’s Homoeopathic Convention, 1876, Vol. II. p. 975. * Recommended by Dr. Gray in drop doses of the tincture. — Transac- tions AV. Y. State Society, 1873–74, p. 384. DISPLACEMENTS OF THE SEXUAL ORGAAVS. 243 CHAPTER XV. DISPLACEMENTS OF THE SEXUAL ORGANS. º | "HESE can be briefly classified as follows: — Vagina, } Uterine dis- placements, Prolapse of the anterior vaginal wall; i.e. cystocele. Prolapse of the posterior vaginal wall; i.e. rectocele. ſ The fundus tipped back and cervix forward without flexion of the uterine axis; i.e. retrozersion. The fundus tipped back and cervix bent down with flexion of the uterine axis; i.e. retroflexion. The fundus tipped forward and cervix backward and upward without flexion of uterine axis; i. e. anteversion. The fundus tipped forward and cervix bent downward and for- ward with flexion of uterine axis; i.e. anteſlexion. The fundus tipped to right or left side of the pelvis, without flexion; i.e. laterozersion. - - The fundus tipped to right or left side of the pelvis, with flexion of the cervix and body; i.e. lateroflexion. ; First degree. Uterus sags down so that the cervix rests on the pelvic floor with Prolapsus uteri, slight retroversion. Or Second degree. Uterus descended so that “falling of the the cervix presents at the vulva with womb,” retroversion. Third degree, or procidentia. Uterus par- tially or entirely outside of the vulva. Complete when the fundus has escaped through the cervix so that the endome- trium forms its external covering. Incomplete when the fundus has not es- caped from the cervix. Inversion of the uterus, The ovaries sometimes become displaced either in or near the cul-de-sac of Douglas, and very rarely have been known to enter hermial sacs. º Before entering into the discussion of the abnormal posi- tions of the uterus, it may be well to state that the normal position of the uterus cannot be said to be in one definite 244 DISPLACEMEAVTS OF THE SEXUAL ORGAAVS. place. The organ swings in the broad ligament with con- siderable mobility. Hence the height of the fundus uteri will depend on the amount of urine in the bladder and . whether that viscus is distended or empty. The amount gº sº º §§ § º . ) º & • £%. ſº º , Nº. (§ W. º FIG. Io2. Normal position of the uterus and dotted outlines of the fundus, showing the extent of the various positions and mobility of the uterus within normal limits. U, uterus; B, bladder; R, rectum; P, perineum ; S, symphysis. of pressure from above will also affect the position of the uterus. Hence, while a fixed definite position of the uterus cannot be given as the only normal one, a position can be shown in which the uterus is most commonly found and from which it can vary, and yet be in a normal position anywhere within these limits. See Fig. IO2. CA USA.S OF UTE/e/AVE DISPLACE MEMTS. 245 Displacements are very rare before puberty, infrequent before marriage, more so after, and most common after child-bearing. Prolapsus of the vagina is almost invari- ably caused by sub-involution and relaxation of the vagi- FIG. Io9. Form with bony pelvis drawn in outline, with contents of true pelvis in a darker line to show their relation to the brim of the pelvis and to the abdomen. U, uterus; T, Fallopian tubes; O, ovaries; B, bladder; S, symphysis pubis. nal walls, associated with a laceration of the perineum. The latter also favors cystocele, as the perineum no longer supports the base of the bladder. Distention of the blad- der from habitual long retention of urine, and chronic constipation, tend to produce cystocele and rectocele, especially in the conditions just mentioned. When the uterus sags, or is forced low down in the pelvis, the length 246 DISPLACEMAA/TS OF THE SEXOAZ ORGAAWS. f of the vagina is diminished in proportion, and conse- quently tends to roll out. The causes of uterine displacement are much more com- plex, and are classified in the following table: — Laceration of the perineum. Relaxation of the vagina as in sub-involution. Weakness of the uterine ligaments. Morbid conditions of , Tumors of the uterus. the uterus, espe- || Chronic congestion. cially those increas- Hyperplasia or sub-involution. ing its weight, Lack of tone or relaxed condition of uterine tissue. Tight or heavy clothing supported from the abdomen. Tumors, or a distended bladder, crowding the uterus out of place. Sitting in easy-chairs, the pelvis tilted a little back- ward and the body bent forward, so as to allow Lack of sufficient Sup- port to the uterus, U ſ Force acting on the ! the weight of the abdominal organs and forces uterus from above, exerted on them to act directly on the fundus uteri. Straining at stool. Falls or jumping. Undue exercise, such as lifting, reaching, and too long walks, especially when the bladder is distended. Dragging of prolapsed vagina. Abnormally short vagina, especially a short anterior wall. Cicatrices or contracting masses of lymph in the pelvic peritoneum or areolar tissue. r Traction on the ute- < ruS, In only very rare cases are uterine displacements of congenital origin. - Displacement of the ovaries may be secondary to that of the uterus, or from increased weight in consequence of congestion, inflammation, and enlargement. The symptoms of prolapsus vagina are a sense of drag- ging in the pelvis, and a feeling of Something protruding between the labia. In fact, the patient usually states that she thinks she has “falling of the womb.” On inspection, the anterior, posterior, or both vaginal walls are seen to roll down into the vulvar commissure if the patient is told to force down. If there be any doubt as to the nature of POSTERIOR DISPLACEMEAV7'S OF THE UTER OS. 247 the presenting part, the finger in the rectum will enter the pouch, and establish the diagnosis of rectocele, or the sil- ver catheter in the bladder of cystocele. In the latter, the catheter passes directly downward into the vesical pouch, which often contains a variable amount of urine. The patient not being able to empty the bladder below a certain level, the residual urine becomes ammoniacal, and cystitis develops as a consequence of the cystocele, which cannot be permanently cured without removing the cause. A surgical operation' only will cure these cases, except in very rare instances of acute vaginal prolapsus follow- ing confinement. There is scarcely any danger, and a properly selected operation carefully performed is almost sure to bring relief. If the patient positively refuses to submit to an operation, a large, hard, or an inflated rubber- ring pessary, tampons of antiseptic wool or oakum medi- cated with some astringent, such as glycerine and tannin, alum, or fluid extract of white-oak bark, may be used, and supported, if necessary, by a T-bandage. This same treatment applies to prolapsus of the Second and third degrees. - - A cyst of the vagina on the anterior wall may easily be mistaken for a prolapse of the base of the bladder or ure- thra. A differential diagnosis is easily made by intro- ducing a sound into the urethra, and feeling it in situ with the finger in the vagina. The sound at once enters the pouch of a cystocele or urethrocele which will not be the case if a cyst is present. The cyst will be felt easily as a round, marble-like protuberance between the finger and the sound. Should a cyst become troublesome to the patient, incise it and dissect out the cyst; pack the cavity with iodoform gauze, or, if it is small, bring it together with continuous buried catgut sutures. 1 For the operation for cystocele, see Emmet, Principles and Practice of Gynecology, p. 358, 1884; and Hegar und Kaltenbach, Operative Gynākol- ogie, p. 689. For laceration of the perineum, see page IO2. 248 D/SPLACEMEAV7S OF 7HE SExvAz Orca A's. RETROVERSION AND RETROFLEXION OF THE UTERUs. These have similar symptoms, except that very frequent and Sometimes painful micturition is much more common in the former than in the latter. In each, there is back- ºS # S. -2&%2. GBſ § ºº: #: Cºſé &Mºs º \ , , ... ----------------~~~~~ * * * * * * * * * * * ~~~~ * * * * * - **** ----- FIG. Ioa. Retroversion of the uterus, dotted outline, showing the normal position. I, II, III, - show the position of the uterus in the three degrees of retroversion. ache, a sense of weight in the pelvis, inability to walk any distance, and going up and down stairs is very fatiguing to the patient. Inability to walk any distance, with bear- ing down in the pelvis, is a very characteristic symptom of uterine displacement, particularly if it has existed for Some time. Dysmenorrhoea and tenesmus of the rectum AºA27'A'O VEA’.S/OAV OA; 7 A/A2 O ZTAEA’ U.S. 249 are sometimes present. Less often the local symptoms are not marked, but there are spinal irritation and exceedingly severe headache just before or during the menses. In FIG. Io;. Retroflexion of the uterus, dotted outline showing the normal position. U, uterus; R, rectum; P, perineum; B, bladder; S, symphysis. acute cases resulting from a fall, the pain is very severe, and the patient unable to walk. On examination the fundus is felt more or less prominent in the cul-de-sac of Douglas, and the space anterior to the cervix is empty. In retroversion, which for convenience of description is divided into the three degrees shown in Fig. IO4; the cervix points upward against the base of the 25O D/SPZACEMEAV7'S OF THE SEXUAL ORGAAVS. bladder; in retroflexion, the cervix is more nearly or quite in the axis of the vagina, Fig. 105; the fundus is posterior in both instances. Too much stress cannot be laid on the fact, that the bimanual eramination and the accurate outlin- ing of the body of the uterus is absolutely essential in making a diagnosis of uterine displacement. (See Fig. 106.) This ~$ sº All, “’ {}, .3% Ż Sºlº/*.*& S2's sº ſº. à % Sº sº º, - *º - % %2 - º ºğsº > * yi Ş T. § •. * . * * SiSº &º • W # # sº º- ºr. Fº: sº / - \ º + w s -> -> -- ~~ ~. º W ~ --> | : W N -sº f $º: .. º S. § § |; §§º l §§ Sºg * * * § * > s S ...” §º ºis ºr s • . º jº § 3. ,3 $s. º §jº Jº's º: l) * º,"ll, s/ FIG. Ioff. DIAGNoSIs of RETROFLEXION BY BIMANUAL ExAMINATION. (Hart and Barbour.) last statement may seem quite superfluous; but the writer has repeatedly seen eminent practitioners place one hand behind them, the forefinger of the other in the vagina, and, with their eyes rolled up to the ceiling, make a diagnosis (?). The prominence of the cul-de-sac of Douglas may give rise to the suspicion of a small pedunculated fibroid on the posterior wall of the uterus; but the passage of the uterine sound will at once decide the diagnosis; for if it is a fibroid, the uterine cavity will not occupy the centre of this tumor. (Compare Fig. I 15.) An enlarged prolapsed ovary in this THA, U.S.E O/* TAZAZ SO UAVD. 25 I 'situation would be sensitive, Smaller than the fundus uteri, and movable if not fixed by adhesions. FIG. Ioy. FIRST STAGE OF THE INTRODUCTION of THE Sound. (Hart and Barbour.) For purposes of treatment, these displacements can be di- vided into two classes, the reducible and the non-reducible. 252 DISPLACEMEAVTS OF THE SEXUAL ORGAAVS. In the latter the fundus may be fixed by adhesions, or Some local contraction of tissue in the posterior wall of the Wº: $º 㺠§º * FIG. IoS, SEconD STAGE of THE INTRODUCTION of THE SOUND IN A RETRoverTED UTERUS. (Hart and Barbour.) uterus may spring the organ back immediately after re- placement. Prolapse of the ovaries with fixation, inflam- mation of the cellular tissue, shallow posterior pouch of the vagina from the attachment of the latter near the tip of the cervix, and the presence of a fibroid or other tumor THE USE OF THE SOUAVD. 253 causing the displacement, are very troublesome compli- cations. Fortunately, most displacements can be reduced at once with prompt relief to the patient. Place her in Sims's posi- *~ FIG. Io9. METHOD OF REPLACING RETRovERTED UTERUs witH THE SOUND. 1, 2, 3, the successive positions of the sound and uterus. (Hart and Barbour.) tion" with her clothing loose about the waist, the bladder and rectum empty, and the hips slightly raised; stand behind the patient, and pass the first and second fingers of the right hand along the posterior vaginal wall; make gentle pressure against the fundus uteri upward, a little to one side of the sacral promontory; at the same time with the upward pressure or tapping on the fundus instruct the 1 See chapter on Minor Surgical Gynecology. 254 DISPLACEMEAVTS OF THE SEXUAL ORGAAVS. patient to breathe out vigorously or cough; this throws the cervix in the opposite direction, and materially assists in rotating the uterus on its transverse axis particularly in the FIG. IIo. Nott's UTERINE EI.Ev ATOR AND DEPRESSOR. knee-chest position; as the fundus recedes, keep the middle finger in place, and put the forefinger on the anterior lip of the cervix, pressing it well up into the hollow of the Sacrum. If necessary, the sound can be used to help ele- ºf "~ **** * * * * ******* * * * * * * * * * *- :4.*\º ū ſ: - #!º ... ºſſilſillº ;:...--~~~~------- 4- "ºff" * FIG. III. The knee-chest position for reducing posterior displacements of the uterus. I, retro- verted uterus; II, uterus replaced by atmospheric pressure; V, vagina; P, peri- neum; B, bladder; S, symphysis pubis. vate the fundus." (Figs. IOZ, IO3, IO9.) Sometimes Nott's elevator (Fig. I IO) is useful to elevate the fundus, as well as to press the anterior wall away from the Sims speculum so as to obtain a view of the cervix. The same manoeuvre may be tried with the patient in the knee-chest position. (Fig. I I I.) Some authors recom- 1 See chapter on Minor Surgical Gynecology. *. TRAEA 7TMAEAVT OF DASP/LA CAEMEAVT.S. 255 mend introducing one or two fingers in the rectum to push up the fundus, but this is scarcely ever necessary. When the fundus is so large and heavy that it does not readily º: º, , ºf & º, i. tº W. --~~~ • FIG. I. 12. RETROVERSION PESSARY SUPPORTING THE UTERUS. slip up, it is a good plan to hook a tenaculum or volsellum forceps into the cervix, and draw it down a little, so as to gain more room to press the fundus up. Unless something is used to keep the uterus in place, it will become displaced again in a few minutes after the patient takes the erect position. It does little good, there- fore, to reduce this dislocation without applying a splint, i. e. a pessary (Fig. I 12), if there is no inflammation; or, if the latter be present, tampons can be placed around the 256 DISPLACEMEAVTS OF THE SEXUAL ORGANS. cervix. These are best made of non-absorbent cotton, antiseptic wool, oakum, or sponge, and medicated with glycerine, iodine, belladonna, or some preparation to al- lay pain, such as chloral hydrate, conium, or hyoscyamus. These tampons should be removed in twelve hours, or earlier if pain is excited, and followed by copious hot- water injections. - Dr. L. L. Danforth says that where there is much congestion of the cervix uteri, tampons medicated with the following glycerole are very effective in relieving engorgement: — P& Glycerine . . . . . . . . . . . Švii. Boro-glyceride . . . . . . . . . . 3i. Pulv. alum . . . . . . . . . . . 3SS. Pulv. acid boric. . . . . . . . . . 5i. Extr. belladonnae . . . . . . 3ss. M. et label formula. Or the following: — B& Boro-glyceride . . . . . . . . . . 3SS. Glycerine & e º 'º º . . . Oj. M. et add. Acetate aluminum © e g 3i. M. et label formula. A well adjusted abdominal belt to take off the weight of the intestines is a great help." The uterus must be re- placed and tampons inserted from three to four times a week, unless it increases the inflammation; then the case must be treated as if it were pelvic cellulitis, and no manip- ulation attempted till the inflammation has subsided. If a pessary is fitted, tampons are unnecessary except to allay any local irritation. In uncomplicated cases, if the pessary is well adjusted, the patient need not be seen more than I See chapter on Minor Surgical Gynecology. A)/S/2ZA CEMAAV7' W/TA/ ADA/ESAOAV. 257 once in one or two months. Care must be taken that the pessary does not fit too tight, and press hard on the utero- sacral ligaments, which in time might be overstretched and become atrophied in consequence. Another caution the writer wishes to impress deeply on the reader. Always examine the position of the uterus very carefully, with the pessary in place, about three or four weeks after inser- tion and a “fit” has been obtained. It is a matter of great surprise that in many cases the fundus uteri will be bent back over the end of the pessary, producing re- troflexion. The pessary does not then fit, and must be removed. In retroflexion of the uterus some combination of the intra-uterine stem and the ordinary pessary is often neces- sary. The stem straightens the uterus, and the physician must see to it that it is done, and that the angle of flexion has disappeared; otherwise, the uterus may be raised and held up in the pelvis by the pessary, but the fundus will bend over the upper end of the supporter, become irritated, and the patient suffer much discomfort or pain from it. Divulsion of the cervix is occasionally beneficial. The above treatment also applies to those cases where the uterus at once returns to displacement after being replaced, either from changes in its parenchyma, or from slight and lax adhesions. Displacement of the uterus with partial or complete fix- ation is tedious to treat, and requires great patience on the part of both physician and patient. (Fig. I 13.) No force which causes much pain and suffering should be used to replace the uterus. It is very apt to cause inflammation of the peritoneum, of the cellular tissue, or the tearing of adhesions, which might result in hematocele. An excellent method of treating these cases is that of graduated pressure by tampons of antiseptic wool or non- absorbent cotton. Place the patient in the knee-chest position, or a modified Sims's, having her lie at least one I7 258 D/SPLACEMEAVZS OA. THE SAEXUAL ORGAA.S. third over on her abdomen, and the hips elevated not le:s than three inches above the level of the shoulders. Intro- duce a Bozeman's or Sims's speculum, and, in addition to º 2 º' º § t "itſ {\tº\º d º % iſſº S §§§ $3.x: º- - § T-- º tºº | | | | | º-ºº: - sº ">~ §§§ y )\jº º - § t º º , | } ºil. ſ º * ~ . º - ſº Crºſſ- FIG. I.13. Retroflexion of the uterus with adhesions and prolapse of the ovary. U, uterus; R, rectum ; P, perineum; S, Symphysis; B, bladder. the atmospheric pressure, push up the fundus uteri so as to put the adhesions on the stretch ; now take dry disks of the wool or cotton, and make a pyramid or column, the base of which rests against and below the fundus, and the apex against the rami of the pubis and the pelvic floor. The object of this is to exert elastic pressure on the adhe- sions, which gradually stretch and yield. This is not a AX/SP/LA CAEA)/A2 AV7' W/7CAZ A DAZZ.S/OAV. 259 vaginal plug, and must not be used in such a way as to pack, distend, and stretch the calibre of the vagina. This column of dry wool or cotton is allowed to remain forty-eight hours; it is then removed, a vaginal douche of hot water taken, and another cotton column put in. Of course, none can be worn during the menstrual period. This course of treatment may have to be pursued for three or four months before there are any signs of im- provement, but soon after that the uterus will be found a little more movable. This gradually increases till the fundus can be thrown forward, and a pessary worn with ease. It has been the writer's experience, that, after some mobility is once Secured, progress is much more rapid. This same treatment applies to prolapse and fixation of the ovary, though it is less satisfactory, and also where the posterior vaginal pouch is too shallow. Until the lat- ter can be stretched sufficiently to gain greater depth, an ordinary vaginal pessary cannot be worn, and it is neces- sary to give external support with some other pessary, such as Cutter's, if the cotton is not used. *. In nearly all cases of uterine displacement with either partial or complete fixation, massage is likely to be very beneficial." This can be combined, if desired, with the method just described, or with electricity." The latter is more especially desirable for atonic conditions of the mus- cular apparatus and for displacement with an exudation in the pelvis. The writer places much confidence in mas- Sage, if properly given by an experienced physician. The treatment of displacement of the uterus cannot be dismissed without allusion to more radical measures should the treatment above described prove insufficient. In case of peritoneal adhesions, Schultze” has for some years been in the habit of breaking them down in the following man- * See special chapters on these subjects. * Zeitschrift für Gebürtshilfe und Gynākologie, Band XIV. Heft 1, 1888. 26O DISPLACEMAAV7'S OF THE SEXUAL ORGAAVS. ner, with the aid of anaesthesia. The patient is placed in the lithotomy position with the intestines and bladder thoroughly emptied. Two fingers are introduced into the rectum which is irrigated with warm water during the manipulation. After making a careful exploration of all the pelvic organs, the body of the uterus is raised gently up toward the abdominal wall, - the thumb in the vagina is sometimes necessary, - till the fundus is above the prom- ontory of the sacrum. The uterus is then seized with the other hand on the abdominal wall, and pressed forward into place. A pessary is afterward inserted in the vagina to insure retention of the uterus in its proper position. The writer desires to emphasize the fact that this stretch- ing of the adhesions must be very carefully performed. Schultze reports brilliant results, which few if any other gynecologists have been able to equal, and the method is regarded as very severe by many operators, who look upon laparotomy and ventral fixation as much safer. The great advantage of the latter method is, that hemorrhage can be controlled and the peritoneum properly cleansed, if neces- sary, in case of injury to the blood-vessels in breaking up the adhesions. Should the latter be extensive, the writer would prefer this operation to Schultze’s method. He would, moreover, earnestly warn the physician against Schultze’s procedure in case of salpingitis complicating the displacement, particularly if the pelvic inflammation be traced to puerperal or gonorrhoeal origin. If the cervix is flexed on the body of the uterus so sharply as partially to close the canal, and cause retention of fluids above, dysmenorrhoea, or sterility, it can be dilated by Goodell's method.” Electricity has been tried with some success.” The reader 1 See chapter on Minor Surgical Gynecology. 2 E. H. Grandin, “Electricity in Uterine Flexions,” New York Medical Journal, p. 701, 1888; also an article by A. L. Smith, American Journal of Obstetrics, p. 561, 1888. I)/SPLACEME/VT WITH A DAIESIOM. 261 is referred for particulars to the chapter on Electricity in Gynecology. One of the best cures for any form of uterine displace. ment is pregnancy, but the patient must take unusually good care of herself after delivery. She ought not to stand on her feet till after the first three weeks of the puer- perium; and any work, lifting, or reaching, for the suc- ceeding six months, should be absolutely prohibited. The uterus must be examined occasionally during this period, any tendency to displacement corrected, and, if necessary, either a pessary or tampons worn. In connection with the treatment of posterior displacements, see also the treatment of prolapsus uteri. The operation of shortening the round ligaments for in- veterate cases of posterior displacement, i. e. Alexander's operation," has not been tried sufficiently as yet to be re- garded other than as an experiment,” so far as remote results are concerned, without mentioning the difficulty of finding the round ligaments, which may be too weak to be of service. Dr. Mundé” mentions it favorably, however, and refers to a number of operators who report successful cases, while others report unsatisfactory results.” * The method has been modified by Dr. J. H. Kellogg, who reports a num- ber of successful cases in the Proceedings of the Michigan State Medical Society, 1889. His modification consists essentially in cutting down on the canal parallel with Poupart's ligament, instead of at the external ri ng, drawing down the ligament, folding it over the canal, and stitching it there to secure a firm anchorage. * Dr. Polk publishes a report of fifteen cases of Alexander's operation, in thirteen of which the uterus had remained in place so far as he had been able to ascertain. This paper, containing a description of the operation, as well as its discussion by the New York Academy of Medicine, can be found in the Medical Record, July 3, 1886. Compare also his article on Hysterorhaphy and Alexander's Operation, in the American Journal of Obstetrics, p. 1271, º and the Transactions of the American Gynecological Society, p. 250, 1889. - * Annual Univ. Med. Sciences, Vol. II., 1888. * Compare a very complete résumé of the literature in Jähresbericht tiber Geburtshulfe und Gynākologie, pp. 424–429, 1889. 262 DISPLACEMEA/TS OF THE SEXUAL ORGAAVS. An operation which offers many advantages over short- ening the round ligaments is that of ventral fixation, i. e. attaching the fundus of the uterus to the abdominal wall. The disadvantages of the former operation are the difficulty of finding the round ligaments, weakening of the inguinal canals, the length of time required for the wound to heal, and the impracticability of the operation when there are adhesions of the uterus posteriorly. Dr. Winckel,” who is opposed to the operation, believes it only substitutes one anomaly, anteversion, for another, which may produce quite as much discomfort as the original retroversion. Ventral fixation, on the other hand, is a simple and safe operation, if all the precautions in performing laparotomy are properly observed.” So far as present records go, the Operation is very effectual, and can be employed to advan- tage, even though the uterus be bound down by adhesions. The opening and closing of the abdominal wound are the same as for ovariotomy. After opening the peritoneal cavity in the Ordinary manner, any adhesions interfering with the mobility of the uterus are broken down by spon- ging, or with the fingers, and the fundus uteri is brought up to the abdominal wound a little over an inch and a half above the symphysis pubis. The uterus is now held in this position by a uterine staff for that purpose, or by the fingers of an assistant in the vagina, while the peritoneal surface of the fundus is gently scraped over a space the size of a dime, where adhesion to the abdominal wall is intended. A suture of catgut or silkworm gut is passed from the abdominal wound through the recti muscles and underneath the peritoneum of the fundus uteri between the insertions of the Fallopian tubes. The edges of the peritoneum are now brought together from below upward 1 Diseases of Women, p. 336. * See paper by the author in the New England Medical Gazette, August, 1888; also a paper by Dr. Kelly, in American Journal of Medical Sciences, May 5, 1889. VEVZRAZ Fºx Azrow. 263 with a continuous catgut suture, till the wound is closed over the new location of the fundus uteri. The latter is now snugly secured by the single catgut suture, the finger makes a final exploration of the abdominal cavity to be sure that no loop of intestine has passed over the upper margins of the broad ligaments where there might be a possibility of strangulation. After this the wound is closed and dressed, the same as after an ordinary laparotomy, with the exception of packing the vagina with a strip of iodoform gauze to Support the uterus. Removal of tubes or ovaries is, of course, an easy matter if necessary. Leo- pold's' method of passing a suture through the fundus is more effectual, and much more simple, than the original modification of Ohlhausen's method by Sänger,” in which Sånger employs three sutures on each side of the uterus, corresponding to the broad ligament, round ligament, and Fallopian tube. In the cases I have operated on, there has been no difficulty in obtaining firm adhesion, and the uterus has remained well up in the pelvis. - Even though patients may feel quite well after this op- eration, they ought to take plenty of time, and not be in a hurry to go around again for at least a fortnight after the wound has healed, and all tenderness is gone and the temperature normal. For a few weeks afterwards it is not uncommon for them to pass urine more often than usual. It sometimes happens that a large and very heavy uterus will either cause a dimple in the abdomen, or in time stretch out the adhesions at the site of fixation. For this reason a laceration of the perineum should be repaired, if present, before performing ventral fixation, so as to give as much support as possible to the uterus in its new position. This operation has not interfered with pregnancy in any case to 1 Centralblatt für Gynākologie, No. 1 1, 1888. 2 See translation by the writer in Homoeopathic Journal of Obstetrics and Gynecology, May, 1888, p. 219, from Centralblatt für Gynākologie, No. 2, 1888. Most of the bibliography will be found in it. 264 DISPLACEMENTS OF THE SExvAL ORGAA's. my knowledge, and cases have been known to go to full term and pass through labor with no unusual occurrence. Since ventral fixation has been devised, Schücking" has presented to the profession his method for the radical treatment of posterior displacements of the uterus. It consists in passing a suture through the uterine canal, fundus uteri, and anterior fornix of the vagina, after the uterus has been replaced, and with thorough antisepsis. By tying this suture the uterus is forced into exaggerated anteflexion. He reports good results, but the writer be- lieves the method too dangerous and unreliable to recom- mend it till further clinical evidence establishes the value of the operation. ANTEVERSION AND ANTEFLEXION OF THE UTERUS. The symptoms produced by these conditions are very much alike; backache and rectal irritation are far more frequent in the former than in the latter. Both are usually accompanied with much vesical irritation, difficulty of walk- ing, dysmenorrhoea, sterility, leucorrhoea in consequence of the interference with circulation and subsequent con- gestion of the uterus, and pain in and about the pelvis. Diagnosis. – On bimanual examination, the fundus uteri is found impinging too far forward on the bladder, and, if the displacement is very marked, it lies down on the an- terior vaginal wall so as slightly to depress it. If it is a case of anteversion, the cervix is pressed up against the sacrum in proportion as the fundus tips down in front; if anteflexion, the cervix is bent forward in the vaginal axis, forming an angle with the body (Fig. I I4). This flexion of the cervix on the body of the uterus may be so acute as to constrict or occlude the cervical canal, and to cause sterility or dysmenorrhoea without marked displacement of the fundus uteri. It is important, therefore, to ascertain 1 Centralblatt für Gynākologie, March 24, 1888. AAVTE VERSIO/W AAWD AAVZEAZAEXIOM, 265 always the relations of the cervix with the body of the uterus in every examination for the diagnosis of a displace- ment. The introduction of the uterine probe sharply curved, if necessary, will at once enable the examiner to % tº I | N. * Tº º Tºrº ſ Wºjlº) ºf º ſ jº £6 W º §º * - ** s. FIG. II.4. Anteflexion of the uterus, dotted outline showing normal position of the fundus. U, uterus ; R, rectum; P, perineum; B, bladder; S, symphysis. decide whether the protrusion is a fibroid tumor, cel- lulitic exudation, or the fundus uteri. (Fig. I 15.) In the latter only is there a cavity which the probe readily enterS. The uterus is replaced, with the patient in the dorsal position, and the hips well raised to take off the weight of 266 DISPLA CAEMEATS OF THE SEXUAL ORGAAVS. the viscera above; the operator then introduces the first two fingers of the left hand into the vagina, presses up the fundus, and at the same time endeavors to push it up with the fingers of the right hand placed externally be- low the uterus. Having succeeded in raising the fundus, it is held by the fore or middle finger in the vagina, and the hand externally, as the finger of the former pulls FIG. I.15. PoSITION OF FIBROID TUMoR SIMULATING ANTEFLExION. (Leblond.) the cervix from behind forward. The organ can now be kept in position by vaginal tampons anterior to the cervix, or an anteversion cup pessary." Gehrung's" or Hewitt's anteversion pessaries are excellent in some cases, but the former is liable to become displaced. The writer has suc- ceeded best with Thomas's open cup, or his modification of the Hodge pessary for anteversion. If vaginal support cannot be given, one of Cutter's anteversion pessaries is often useful, and this may be combined advantageously with an abdominal belt." In case there is a flexion of the cervix on the body of the uterus, causing sterility or dys- menorrhoea, dilatation of the cervical canal, by Goodell's method," can be tried; and, if this fails, incision of the posterior lip of the cervix will be necessary to straighten the canal.” Intra-uterine stem pessaries of vulcanite or glass have been worn for this purpose, sometimes success- 1 See chapter on Minor Surgical Gynecology. 2 See Notes on Uterine Surgery, by Dr. Marion Sims. JA TERA/L FLEX/OAV. 267 fully; but they are liable to excite inflammation, and re- quire very careful watching. Among the best instruments of this class are Dr. Thomas's cup-and-stem pessary," and that of Dr. Marion Sims. Quite recently, Dr. Graily Hewitt has proposed to straighten the canal by remov- ing a longitudinal strip of mucous membrane from the posterior surface of the cervix, and bringing the edges together with sutures. The cervix is thus drawn back, the FIG. I. 16. THOMAS’s OPEN CUP ANTEVERSION PESSARY SUPPORTING THE UTERUS. canal straightened, and its patency increased without mu- tilation. Success in the treatment of anterior displace- ments is measured largely by the perseverance of both physician and patient. They require far more care and ingenuity than retroversion or flexion. Lateral Flexion of the uterus results from the shorten- ing of one of the broad ligaments, and is diagnosed by bimanual examination of the uterus, and the use of the probe. It is very difficult to treat, and requires the use of the cup-and-stem pessary. Fortunately these flexions seldom cause much disturbance. * See chapter on Minor Surgical Gynecology. 268 D/SPLACEMEMTS OF THE SEXUAL ORGAM.S. PROLAPSUS UTERI. Prolapsus uteri in either of the three degrees mentioned is readily diagnosed. (Fig. I 17.) The symptoms of the first degree are the same as those accompanying retro- version, except that the sense of weight and bearing down is much more marked. The uterus not uncommonly Sags low down in the pelvis, producing much discomfort, without marked posterior displacement of the fundus. In the Second degree, rectal and vesical irritation is prom- inent among the patient's complaints. She feels the pro- trusion at the vulva, either of the cervix, or the cystocele or rectocele, which commonly come down in advance of the uterus. In the third degree, the symptoms are most marked, and the patient states that there is a large mass outside the vulva. Walking is very difficult, and cystitis not uncommon. Congestion with consequent enlargement of the uterus becomes more marked in the successive de- grees. When the uterus has remained for some time outside of the vulva, the mucous membrane covering it becomes pale and thickened, resembling the skin proper. Ulcerations from friction, and cicatrices where they have healed up, are very common in chronic cases. The Diagnosis of the First Degree is readily made by bi- manual examination. The finger at once impinges on the cervix, and the entire uterus is felt to be much longer in the pelvis. In the second degree the os is felt at the vulva, and prolapse of the vaginal walls is almost invari- ably present. A peculiar and very rare form of hyper- trophy and elongation of the cervix might be mistaken for prolapsus, though the two are more often associated with each other. The elongation is due to peculiar alterations of the cervix and blood-vessels, rather than to an actual increase of tissue, as was once supposed. Inspection is sufficient to diagnose the third degree of prolapsus. The presence of the cervical canal, the passage of the sound in A ſº O/LA PSC/S (WTAEA’A. 269 the bladder over the anterior surface of the uterus, and the empty pelvis, as shown by the tip of the finger in the rec- tum meeting the Sound at the fundus of the bladder with S. \ … WiN))) → ; # = SJ s * S. FIG. I.17. Normal position of the uterus contrasted with the dotted outlines of that organ in its position in the three stages of prolapsus uteri as numbered. U, uterus; R, rec- tum; B, bladder; S, symphysis; P, perineum. no intervening body, make a positive diagnosis from any other condition. - The Prognosis, as regards cure, is not very favorable in the worst cases. The first and second degrees can often be cured permanently. The Treatment varies somewhat with the form. The first degree is managed in the same way as retroversion. 27O DISPLACE.j/FAWTS OF THE SEXUAL ORGAAWS. If there is a laceration of the perineum, an operation" must be performed, no matter what the form of prolapsus is, as no vaginal pessary can be retained. In the second degree, in addition to the measures taken for the preceding form, it is often necessary to operate on the rectocele or cys- tocele; the former by Emmet's,” the latter by Emmet's* or Simon's 4 method. In complete prolapsus after the child-bearing period, Neugebauer” has united the anterior and posterior vaginal walls. This is known as Le Fort's op- eration. Martin's operation" is also excellent. But what- ever method is selected, the operation should be performed as early as possible, – as the longer the duration of the pro- lapsus, the greater the probability of its recurrence, — the vagina narrowed high up, and the new perineum extended well forward toward the urethra, if permanent results are to be obtained. Catgut, properly prepared, in continuous buried 6tage sutures, is better than silk, or even silver wire, if the Simon-Hegar or Martin operation is performed. The operation is often a failure within a year in elderly women, as the tissues stretch out and the uterus returns to its former position. In an excellent résumé of the oper- ations for prolapsus at the Berlin Frauenklinik, during four and a half years, Cohn" has shown that in operations for to- tal prolapsus uteri only 40 per cent remained cured. This low rate of success should be considered in comparing the operation with ventral fixation; shortening the round liga- ments is not suitable for complete procidentia. Of the patients operated on in the clinic, 56.6 per cent had no re- 1 Emmet, Principles and Practice of Gynecology, 1884, p. 358. e * Ibid., p. 374. 3 Ibid., p. 362. * Hegar und Kaltenbach, Operative Gynākologie, 1889, p. 689. * Centralblatt für Gynākologie, Nos. I and 2, 1881. 6 Martin, Frauenkrankheiten, Auf. II. p. 149; also Volkmann’s Vorträge, pp. 183, 184. The reader will find very full descriptions of perineal opera- tions in Zweifel’s book, Krankheiten der aussere Genitalien und die Dam- risse, Cap. XII., 1885. 7 Ueber die primären und definitiven Resultate der Prolapsoperation, Zeitschrift für Geburtshilfe und Gynākologie, Bd. XIV. Heft 2, p. 500, 1888. AA’OLA P.S US OWTAE/º/, 27 I turn of the prolapsus within the period of nearly five years after the first operations. Of those patients operated on in private practice, chiefly the operations of Professor Schröder, 86.7 per cent, remained cured. The difference in the percentage of recoveries lies largely in the fact that the latter class could take better care of themselves, have better food, and not be subjected to much bodily exertion. The practical deduction would seem to be, that only half of the operations for prolapsus uteri among the middle and lower classes are permanently successful. In connection with the above statistics, it should be remembered that they are based on the results of operations by men of very unusual skill and long experience. Should the patient not be fit for an operation, or refuse to submit to one, astringent tampons of alum or tannin, or a decoction of white-oak bark, may be tried. These can be retained in place by a T-bandage if necessary, and must be renewed every day. They are seldom curative, but will add much to a patient's comfort. In other cases, an ab- domino-vaginal supporter is beneficial, such as Cutter's or MacIntosh's, or the abdominal supporter" previously mentioned. - When the uterus has protruded from the vulva for a considerable length of time, it becomes very much en- larged, and cannot be easily replaced. The best plan is to put the patient in bed, apply glycerine dressings every other day to the prolapsed organ, and douche it twice daily with five quarts of water at I IO* F. Calendula ce- rate is a useful application to the erosions or ulcerations. Within a week, the uterus will be so much smaller that it can be readily returned within the pelvic cavity in the fol- lowing manner. Place the patient on her back, with the thighs flexed on the abdomen, and the hips slightly ele- vated ; raise the uterus a little, and let it rest in the hand a short time to allow the venous blood to return to the See chapter on Minor Surgical Gynecology. 272 DISPLACEMEv7s OF THE SEXUAL O/CGA/VS. pelvis, and then replace it in the same way as if it were a hernia of the intestines, i.e. return first that part which came down last. The organ is then retained by some of the methods just mentioned for that purpose. In many cases, however, this is no easy matter, and it is far better to have an operation performed. In women over sixty years of age, it is best not to perform the usual operation, but simply close the vaginal outlet, leaving a small open- ing for the escape of any discharge. This will be suffi- cient to retain the uterus, and make them comfortable during the few years they are likely to live. In inveterate cases of posterior displacement or pro- lapsus of the uterus, which operations on the vagina fail to relieve, Dr. Olshausen recommends opening the abdomen, and stitching the fundus of the uterus to the abdominal wall with silver wire.” One case was a failure, but others were cured in this way. (See page 262.). INVERSION OF THE UTERUS. Inversion of the Uterus is, as the name signifies, a turn- ing inside out of that organ, so that its cavity is lined with peritoneum, and directed toward the abdominal cav- ity, with which it is continuous, while the external covering consists of the endometrium. It may take place slowly in consequence of the traction of a pedunculated fibroid or polypus, but in about eighty-eight per cent of the cases it follows the third stage of labor. It may be divided into the acute and chronic forms: acute when the inverted uterus has not undergone involution; chronic after this stage has passed, and when it is caused by a tumor. Acute inversion belongs to the province of the obstetri- cian, and need not be considered here, though the manner in which it is produced may be of interest.” It is believed 1 Centralblatt für Gynākologie, No. 43, p. 698, 1886; Nos. 2, 3, 5, and 11, 1888. * Dr. Henry Crampton has an interesting article on “Inversion of the JAW WAEA’.S/OAV OA' TA/A2 UTEA’O.S. 273 there is a localized weakness, or a paralysis of some por- tion of the uterine wall, probably at the placental site, or, in case of a tumor, a fatty degeneration or loss of tone about the site of attachment. In either case, the weak portion of the uterine wall sinks into the uterine cavity from the traction on the placenta or on the tumor, or from abdominal pressure with a corresponding depression on its peritoneal surface. The inverted portion, aided by mus- cular contraction of the uterus and abdominal pressure, increases, sometimes slowly, or so rapidly that complete inversion may take place at Once; or, again, it may be arrested so that only one angle or horn of the uterus is inverted as far as the internal os (incomplete inversion), or through the external OS (complete inversion), which is the more common form. The chief symptom of inversion is very profuse menorrhagia and metrorrhagia, producing great anaemia and weakness. Besides this, there are the bearing down and pelvic pains, so characteristic of other uterine displacements. The Diagnosis is not difficult. There is no fundus felt in making a bimanual examination in the usual manner. The sound will not enter the cavity by the side of the tumor at any portion of its circumference to a depth of two and a half inches. If the tumor is drawn down by a slip-noose over it (volsellum forceps or tenacula will tear out and cause bleeding), the finger in the rectum can feel the de- pression on the peritoneal surface of the tumor, and a sound passed into the bladder at once impinges on the rectal finger, showing that the body of the uterus cannot lie between them. Furthermore, the external surface of the tumor bleeds easily, and is sensitive to the prick of a needle. A careful examination of this kind will distin- guish it from any polypus or pedunculated fibroid, the Uterus after Parturition,” and tabulates the records of one hundred and twenty acute and one hundred and four cases of chronic inversion, in the American Journal of Obstetrics, pp. 1009 and I 146, 1885. I8 274 DISPLACEMEAVTS OF THE SEXUAL ORGAA.S. only conditions for which it could be mistaken by the most superficial examiner. The Prognosis is unfavorable for most cases, in conse- quence of the loss of blood, unless the displacement can be reduced. On the average, two out of three can be suc- cessfully treated in this way. The duration of the inver- sion, even if it be for many years, should not deter the physician from careful and persistent efforts at reposition. The Treatment may be classified as follows:— Immediate, by the hand or instrumental aid. Reposition, | Moderate, elastic pressure applied continuously. Thomas's operation Amputation. The obstacle to reposition is the contraction of the cervix and uterine tissue, especially about the region of the inter- nal OS, forming a ring around the prolapsed mass. If the inversion be caused by a tumor, the latter must be removed if not malignant, and then the following measures can be tried. Before attempting replacement of a chronic in- version, it is well to build up the patient's strength, and hold the hemorrhage in check by vaginal irrigations of hot water (II.5° F.). If the patient does not object to taking ether, and relays of competent assistants can be had, the immediate method of reposition by the hand can be tried first. In preparation for this, the vagina should be distended by the colpeurynter, or a Barnes bag placed well up in that canal. If neither of these is at hand, packing the vagina full daily with antiseptic wool might be tried. This makes room for the operator's hand, and, in six cases, has been known to cause reposition. This yill have to be continued for ten days, or longer, till the vagina is somewhat expanded; then, having the patient anaesthetized, and in the lithotomy position on a table, seize the fundus of the uterus in the right hand, crowding the fingers up, as far as possible, along the base of the tumor. The fingers are then expanded to press the zyvERSION OF THE UTERU.S. 275 ring out as the fundus is crowded up, and the left hand makes counter pressure on the abdominal wall. A cone of wood about four inches long is sometimes very useful for counter pressure. When one person becomes tired, another takes his place, till the ring yields, and the fundus is finally completely replaced. As the hand is soon tired, Bryne's repositor, an ingenious cup and stem instrument, can be substituted with advantage. In other cases, hooking one or two fingers in the peri- toneal depression per rectum, and exciting counter pressure with the thumbs, has been tried successfully. Dr. Noeg- gerrath advised indentation of one horn of the inverted fundus, and to crowd this upward as a wedge in the canal, reducing the displacement in this way. If these efforts are unavailing after two or three hours of well-directed taxis, provided the patient's condition admits of such long manipulation, she should be put to bed, and a colpeurynter, or vaginal tampon, used to secure what has been gained. If the fundus has risen through the external Os, though it is not completely replaced, Dr. Emmet advises bringing the lips of the cervix together temporarily with silver sutures, so as to keep what has been accomplished, and in hopes it may undergo self-reposition. If repeated attempts of this kind fail, elastic pressure tnay be tried. Some operators prefer to try this method first. The two principles involved are elastic pressure on the inverted fundus, and counter pressure on the abdominal wall. The first is met by applying a cup to the fundus, with a firm, slightly curved stem, to which are attached four elastic bands, two passing in front and two behind, to be fastened to a firm abdominal bandage. Adhesive plaster is useful to keep the bandage in place. Counter pressure can be exerted by layers of cotton batting, placed over the hypogastrium, and secured by a broad, firm bandage over the pelvis, similar to the obstetric binder, being so applied as exactly to meet the pressure from below. 276 DISPLACEMEAVTS OF THE SEXUAL ORGAAVS. While an old-fashioned wooden stethoscope has been successfully used, the cup and stem repositor of Thomas or Bryne is preferable to exert pressure on the fundus. The latter must not only be in the direction of the axis of the inverted uterus, but also in the axis of the pelvis. This can be regulated to a nicety, as well as the amount of pressure, by tightening one or more of the elastic bands. In order to keep the uterus from bending on itself, it is padded, on all sides, with antiseptic wool; the cup reposi- tor is then applied to the fundus in the vagina, packed around in the same way to prevent slipping, and finally the elastic bands are adjusted so as to exert only a mod- erate pressure. The instrument must be removed and reapplied each day to observe the effects, and note any tendency to sloughing. This method should not be abandoned till it has been tried at least three weeks. Galabin" recommends a very excellent apparatus de- signed by Dr. Aveling for reducing chronic inversion of the uterus. It is essentially the same as those mentioned, in having a curved stem and cup attached to four rubber bands. The abdominal bandage and adhesive plaster are not needed with this apparatus. Inversion” of the uterus has been successfully treated, in a similar way, by fastening to one end of a smooth piece of broomstick a soft, thick rubber ring (doughnut pessary) which would fit the vagina loosely, and when inserted lie against the fundus uteri; a piece of soft rub- ber tubing was tacked on the other end, which projected about two and a half inches from the vulva; the two forming a T-shaped instrument, the wood the upright part, and the tubing the arms of the T. This tubing formed an elastic strap for exerting pressure against the fundus, and was fastened to an abdominal bandage by safety pins. Pressure in any desired direction, and to any reasonable 1 Galabin's Midwifery, p. 625, * Dr. F. W. Johnson, American Journal of Obstetrics, p 815, 1884 AX/SP/A CAEME/WT OF 7 HE O VA AC/ES. 277 amount, could be readily regulated by tightening or loos- ening either the anterior or posterior end of the tubing. The instrument was adjusted, and the patient kept on her side. Once in twenty-four hours it was removed, cleansed, a hot vaginal douche given, the instrument replaced, and the patient put on the opposite side. As the fundus re- ceded, smaller pessaries were used till it was within the cervix. A small round stick was then substituted for the piece of broomstick; and, instead of the pessary, a rubber cap, such as is used on chair-legs, was slipped over the end, and over this were tied two or three layers of a rub- ber bandage. This formed the pad, which was placed against the fundus, and made to follow it up to its proper place. One case of twenty-three months' duration was thus reduced in ten days; another, of two and a half months, in two days. The majority of these cases can be reduced by the above measures. If they are not successful and the life of the patient is sufficiently endangered to require ampu- tation of the inverted uterus if it is not replaced, Thomas's method may be tried," of opening the abdominal cavity, in- Serting an instrument similar to a glove stretcher into the peritoneal opening of the fundus, stretching the ring of constriction, and returning the uterus to position by the efforts of taxis already described. The last resource of all is amputation.” The mortality of the latter operation is about thirty-three per cent. DISPLACEMENT OF THE OVARIES. Displacement of the Ovaries is of common occurrence. In rare instances, the ovary has been known to enter hernial sacs, as well as the peritoneal cavity of the inverted uterus. The most common displacement is prolapsus into 1 Diseases of Women, p. 440, 1878. 2 Hart and Barbour's Manual of Gynecology, p. 380, 1886; also Hegar und Kaltenbach, Operative Gynākologie, Vol. II. p. 133, 1889. 278 DISPLACEMENTS OF THE SEXUAL ORGAAVS. the pouch of Douglas, or at one side of it, and when fixed by adhesions, and complicated by retroversion or flexion, it is exceedingly difficult to treat successfully. The treat- ment is essentially the same as that for displacement of the uterus with fixation. Small lumps of fecal matter high up in the rectum often hurt the patient on pressure, and may give rise to a false diagnosis of ovarian displacement. In such cases, espe- cially when associated with a posterior displacement of the uterus, the writer would earnestly advise copious enemata thoroughly to clear the entire rectum of all fecal matter before making a positive diagnosis. It is not enough for the patient to have had an ordinary stool a few hours before the examination. The normal position of the ovaries, like the uterus, is very variable;' but they may be considered prolapsed when they lie below the level of the junction of the cer- vix with the body of the uterus, assuming that organ to be in a normal position.” The frequency with which prolapse of the ovaries.is as- söciated with posterior displacements of the uterus sug- gests that the latter drags the ovaries after it. This, with chronic congestion and increased weight of these organs, accounts for the etiology of nearly all cases. Jolts and falls are also said to cause it. The Symptoms are those of pelvic pain radiating in vari- ous directions, painful coition and defecation, with general nervousness and irritability. * As the result of about twenty post-mortem examinations of nulliparae from fifteen to thirty years of age, and a number from one to fourteen years old, Waldeyer believes that, in the normal position, the ovaries lie just below the middle of the linea innominata, with their long axis perpendicular when the body is in an upright position. The ureters are close under the hilum of the ovary. He states that the uterus is in a position of anteversion and anteflexion when the bladder is empty, and confirms the views of Schultze and His. – WALDEYER, Die Zage der immern weiðlichen Beckemorgame bei AVulliparen, Anatomischer Anzeiger, No. 2, 1886. * For palpation of the ovaries, see chapter on Diseases of the Ovaries. AN/SPAA CAE/MAZAVT OF THE O VA/º/E.S. 279 The Prognosis for recovery is fairly good for recent cases without adhesions, and doubtful with the conditions reversed. - The Treatment consists in rest during menstruation, avoidance of sexual excitement, and the regulation of the bowels so as to secure a daily movement. Hot water, vaginal douches, glycerine and hamamelis, either on wool tampons or mixed with the last pint of water used as a vaginal douche so as to form a strong Solution, and Sup- positories of belladonna, iodoform, or similar substances, are useful to allay the congestion and sensitiveness. When the ovary can be replaced by having the patient occupy Sims's position with the hips raised, and gently crowding the ovary up with the finger, a pessary with a broad or bulbous extremity to fit in behind the cervix will be found beneficial. It should be removed from time to time, to ascertain if the ovary remains in position: when So, the pessary need not be replaced. - Dr. Danforth makes the following excellent remark concerning the treatment of uterine displacements: “The employment of the “knee-chest position,' or “genu-pecto- ral position,’ in the treatment of uterine displacements, is, I am satisfied, too much neglected. A retro-displace- ment, which cannot be overcome with the patient in the left latero-prone (Sims's) position, can often be accom- plished with comparative ease by the adoption of the knee- chest position. I am satisfied, too, that physicians are prompted to insert a pessary after partial replacement merely, and before the congestion and tenderness of the uterus are sufficiently reduced to tolerate this instrument, Many of these cases are of long standing, the uterus having been in its abnormal position for months, or even years. It is impossible to reduce such a displacement at once; repeated attempts are necessary, and the correction of the difficulty will only be accomplished after persistent treat- ment. Provided the uterus is not fixed by adhesions, the 28O DISPLACEMEAVTS OF THE SEXUAL ORGAA/S. knee-chest position and a well adjusted tampon (moistened with a glycerole of belladonna or other medicine) in the posterior cul-de-sac will gently and permanently begin the task, which can only be considered accomplished when complete reposition is effected. The tampon may be worn for twenty-four hours, then removed, and a hot douche taken. If possible, the patient should visit the physician daily for the first few treatments. Each day will see some improvement. The patient should be directed to assume the knee-chest position half a dozen times or more dur- ing the day, in her own home. The corsets should be removed, and the patient maintain the position for a half- minute, or longer if possible. This attitude of the body favors by gravity the disgorgement of the pelvic veins, and aids materially in the restoration of the uterus to a healthy condition." After a sufficient length of time has been spent in this gradual, but very effective treatment, the uterus will regain its normal position, tenderness will have disappeared, and often, to the surprise of the physi- cian, a pessary which seemed so necessary at first will not be required at all. Pessaries are no doubt important adjuncts to treatment, but they are abused, or rather the women who wear them.” If the ovary is prolapsed and adherent, the same local treatment is advisable; and, in addition, elastic pressure may be tried by means of cotton wool, as described for the treatment of retroversion with adhesions. Equally good results cannot be expected, as the ovary is too small a point d'appui for the column of cotton to act on with advantage. Ordinary pessaries cannot be worn for these non-reducible cases, as the ovary is too sensitive to toler- ate even the slight pressure or friction of the unavoidable COntaCt. Massage is often of signal advantage in treating displace- ments of the uterus. The reader will find the exercises described in the chapter on Massage of the Pelvic Organs. MED/C/AVAZ TREA 7TMEMZ. 281 MEDICINAL TREATMENT. The Medicinal Treatment of uterine displacements is still an unsettled question. Notwithstanding the claims of some physicians that the properly selected remedy is all- sufficient, and mechanical treatment worse than useless, the writer's general experience is to the contrary, and he does not believe that any remedy alone can be relied upon to reduce a uterine displacement of long duration, if it exists to a marked degree. Mechanical treatment — i. e. the reduction of a displace- ment, and the retention of the uterus in an approximately normal position by some instrument — is often brought into disgrace by its improper use. The pessary must be as carefully chosen and accurately fitted as a remedy would be selected or a splint applied to a broken bone. Not only this, but the patient must also absolutely obey the directions of her physician. It is the misuse and abuse of these instruments which have so often cast dis- credit upon them. - It must not be inferred that medicines are of no value: it is merely the question of being sufficient in themselves without further aid. Not only are they important to build the patient up to her best possible physical condition, but they often have a specific effect on the pelvic organs. There is an inherent force in the organism, which is always striving to cure or prevent the encroachment of disease. This force, aided by proper medicines, may effect a permanent cure in minor degrees of recent displacement, . and often the suffering in severe and inveterate cases can be relieved; in the latter, however, the symptoms are almost sure to return if the cause be not removed. The best results will be obtained by both medicinal and me- chanical measures. The Prognosis, as to ultimate cure, will be most favora- ! See chapter on Minor Surgical Gynecology. 282 DISPLACEMEAVTS OF THE SEXUAL OA'GAAVS. ble in the following classes of cases, according to the order given: — I. Displacements from traumatism, as a fall or lifting, when reduced immediately. 2. Displacements immediately following parturition, if they are recognized and properly treated soon after de- livery. 3. Recent displacements in women usually strong, but for the time being in poor health; the pelvic organs in an atonic condition, but the perineum intact. A generous diet, and pregnancy, are most likely to result in cure. Marked cases of uterine displacements, excepting in- version, which have lasted for a number of years, are sel- dom permanently cured, though the patients may suffer no inconvenience if mechanical treatment be employed. An important rule in the treatment of any uterine dis- placement is absolute rest in bed during the menstrual th periodº * Before giving the therapeutics for displacements of the uterus, the writer desires to make a suggestion regarding the relative value of symptoms in prescribing for these malpositions. He believes the most valuable symptoms for the selection of a remedy are those independent of the mal- position. The latter, in itself, is not a disease characterized by organic tissue changes, and many of the most prominent symptoms are the result of purely mechanical conditions, such as pressure on the nerves, traction on the ligaments, and congestion secondary to interference with the cir- culation. These symptoms, dependent upon mechanical conditions alone, resemble one another very closely, so much so that one or two remedies would cover, them in nearly all cases; or it might be said that these symptoms, secondary to the displacement, are covered by a very large number of remedies. In either case the prescriber is led astray. No one remedy will cure all diseases, nor can the PROGAVOS/S OF MEDICZAWAZ TREATMENT: 283 physician cure many diseases where there are so many remedies equally indicated that the right one cannot be selected. It is the remote or constitutional symptoms which will enable him to decide. When a surgeon is called to set a broken leg or reduce a dislocated wrist, he does not make careful note of all the symptoms, make his prescription, and then set the leg or reduce the wrist. He will reverse the order of procedure, and prescribe by the symptoms after he has restored the parts to their proper position. Why should not the same procedure apply to dislocation of the uterus? I cannot but believe that one cause of failure in treating these cases by remedies is that the symptoms the patients complain of most, i.e. those dependent on the displacement, as bearing down in the pelvis, sacral pain, interference with the blad- der functions, etc., are made the most prominent and im- portant symptoms in selecting a remedy, to the neglect of constitutional symptoms and the peculiarities df the patient, or other remote symptoms, which would guide the prescriber to the proper remedy. It may not be out of place in this chapter to classify the cases according to the benefit derived from remedies, or, in other words, to give the prognosis of the action of rem- edies for changes in the position of the uterus. So far as his experience goes, the writer would make the following divisions : — A. Remedies are of great value for displacements from traumatism when reduced immediately. B. They do excellent service for comparatively recent displacements in unmarried continent women in poor gen- eral health, and to a slightly less degree in married nulli- paras in a similar state of health. * C. Good results are often obtained in displacements following parturition, if they are recognized and properly treated soon after delivery. D. Some cases are occasionally relieved, but seldom 284 DISPLACEMEAZS OF THE SEXUAL ORGAA.S. cured, by remedies alone, when the displacements are of long standing or complicated by lesions of the pelvic fascia and muscles. Mechanical treatment may relieve, but it hardly ever cures. This last clause brings us face to face with the question, Do remedies restore the uterus to its normal position ? The writer fully believes they are capable of doing so in many of the cases of minor displacements and sagging of that organ. In chronic cases he has better results with medicinal, combined with mechanical treatment, than with either method alone. He has seen some marked cases of retroversion and prolapsus of the second degree appar- ently entirely relieved by medicines without any other treatment, though these have been exceptional instances. While the suffering of the patients has disappeared, he has not yet in any one of them found the uterus restored to its normal position, though it seemed higher in the pelvis than when the examination and diagnosis were first made. Under such circumstances, can the patient be considered cured P There are few physicians that have not seen women having displacement to a marked degree, even complete procidentia, who experienced no inconvenience, and felt perfectly well. Vedeler found forty per cent of the retro- flexions examined by him gave rise to no symptoms what- ever, even when the flexion was present to the highest degree. If such a large per cent of retroflexions ex- amined show no symptoms, surely there must be a very large per cent among women who do not see a physician because they feel well. In other words, if an estimate of the proportion of retroflexions causing suffering can be made with Vedeler's observations as a basis, the majority of women having retroflexion of the uterus are not in- convenienced by it. On general principles, if a patient recovers from all her subjective symptoms she is con- sidered cured. In a similar manner we speak of a patient * THERAPEUTICS OF DISPLACEMEAV7S. 285 being cured when she has recovered from an attack of pleurisy, even though extensive adhesions may be left behind. She is practically and symptomatically cured, though she is not in an anatomical sense. The conditions in displacements of the uterus are pe- culiar; in the writer's experience, the women who do not suffer from them are the exceptions to the rule. Any dislocation, be it of a limb, kidney, or a uterus, is a de- parture from the normal condition, and not in accordance with the laws of health, and the writer must admit that a cure of the symptoms without restoration of the uterus to its proper position is not, accurate/y speaking, a cure of the patient, though she may be practically a well woman. THERAPEUTICS, Aletris farinosa. It must be used in appreciable doses. It has been well termed the china of the uterine organs (china, he- lonias), and is a useful remedy for uterine displacements in debil- itated, chlorotic women, who have their menses too early and profusely, with labor-like pains (caul., viburn. Op.). * Arctium lappa" merits a careful trial. The writer has recently used it empirically in the first and second dilutions for many cases of retroversions, flexion, and descent of the uterus, with as good results as with any other one remedy. While there have been fail- ures, he has met with considerable success in relieving symptoms, and but little success in changing the position of the uterus, though such cases are reported. The best results have been obtained in young unmarried women suffering from retroversion, and com- plaining of anorexia, prostration of the muscular system, pain in the Sacrum and thighs, especially the right side, and Soreness in the pelvis. Abnormal discharges from the vagina do not appear to be necessary in prescribing this remedy. * Dr. H. H. Reed gave arctium lappa 2 (burdock), with excellent results, to a patient suffering from procidentia. He had intended to operate on the vagina and perineum, but the position of the uterus improved so much, there seemed to be no need of it. Compare article by Dr. S. A. Jones, Hahne- mannian Monthly, September, 1882. 286 DISPLACEMENTS OF THE SEXUAL ORGANS. | Belladonna. A valuable remedy, highly recommended by Drs. C. Dunham,” Matheson,” and others. It is especially appli- cable to cases of recent displacement, with active congestion of the uterus and surrounding structures, especially the right ovary (apis); back aches as if broken in small of back. The urine is dark, scanty, with frequent tenesmus of the bladder, and slight strangury. The menses are too early, and too profuse (amm. carb., calc. carb., nux' vom.), or offensive, thick, decomposed dark red 6/ood. The pelvic pains are burning (ars.), throbbing, or lanci- nating (conium). Zhere is great pressing dozemzeyard in the geneta/s, as if everything would ſa// out, worse when sitting bent over or when walking, better by sitting erect or standing. (Lil. tig., natr. mur., nux vom., plat., podo., puls., sepia.) Sepia, nux vom., and puls. have very similar symptoms, differing by the following con- Comitant symptoms. Sepia, – aggravated by sitting up, more so by standing, and most of all by walking; relieved by lying down. Nux vom., - Constipation, but little leucorrhoea. Puls., - worse from heat, better in open air; pressure on the bladder, with fre- quent copious micturition without strangury; copious, thick leu- corrhoea. Symptoms point to hydraemic rather than hyperaemic condition (C. Dunham). On examination, the vagina is hot and dry, the right ovary tumefied and sensitive, and sometimes pulsa- tions are felt in the congested organs. Calcarea carb. (Calc. phos., Calc. iod.). Scrofulous diathe- sis: menses too early, too long, and too profuse; milky leucor- rhoea, acid reaction, with itching and burning; easy perspiration, profuse in the morning; much sweat about the labia; aching in the vagina, and stinging in the cervix uteri. Conium. /ndurations of the uterus; of ovaries; of breasts; lancinating pains in the pelvic organs (bell.); soreness and swelling of the breasts, before the menses; stinging pain in cervix uteri. Dr. Leadam” recommends conium in course, with platina when there is great prolapsus, or procidentia with induration (aurum). Ferrum iod. This was Dr. H. C. Preston’s “favorite remedy, 1 Lectures on Materia Medica, Vol. I. p. 262, 1878. * On some of the Diseases of Women, p. 40, 1876. * Leadam’s Diseases of Women, p. 285, 1874. * British Journal of Homoeopathy, Vol. XXV. p. 497. THEA'A PE (VT/CS OF DASA LA CAEA/E/WTS. 287 in the first decimal trituration, for uterine displacements, including both retroversion and prolapsus ; atony and passive congestion of the uterus ; diurnal enuresis. Scrofulous and chlorotic women with fiery red faces. Helonias. Should be given low. Sensation of soreness and weight in the pelvis; prolapsus uteri and erosion of the cervix. Leucorrhoea dark, offensive, and constant, may be serous, with profuse flooding ; flowing on lifting, or the least exertion. Patient anaemic, and face Sallow. Menses too frequent and profuse ; flow passive, dark, coagulated, and offensive. The vagina is in an irritable condition; the labia hot, red, swollen, itching, and some- times aphthous. Murex purp." Is very similar to sepia, and deserves further investigation. The patient has a sensation of “uterine conscious- ness”; aching, drawing, or burning pains in the loins, hips, and around the pelvis; pains and tenderness in the anterior part of the thighs, worse on lying down ; feeling of general prostration, and sinking, “all-gone" sensation in the stomach. There is very marked increase of sexual instinct (platina); the menses are de- layed. After flowing a few days the menses cease, and after twelve hours reappear (Sepia, kreosote). Nux vomica is an important remedy for the treatment of various uterine displacements. Passive congestion of the pelvic veins; pressure towards the genitals, especially in the morning; menses too early and too profuse (alum., ambr., amm, carb., Öe/Z., calc. carb.); flow dark; during menses, morning nausea with chil- liness and attacks of faintness; constipation ; general muscular debility. Dr. Leadam recommends that it should be followed by sulphur when used for congestion of the uterus. Platina. Increased sexual instinct. With prolapsus, there is menorrhagia; flow too early, too profuse and too long, with much bearing down; pains in the small of the back, extending to the groins; great sensitiveness of the genital organs; painful sensitive- ness, and constant pressure in mons veneris and genital organs. 1 C. Dunham, Lectures on Materia Medica, Vol. II. p. 158, 1878; and American Homoeopathic Review, pp. 306 and 399, 1864. 288 DISPLACEMENTS OF THE SEXUAL ORGAAVS. Podophyllum. Prolapsus uteri, after overlifting or parturi- tion, with aching and bearing-down pains; pain in the uterus and ovaries, especially the right. | Secale" is especially applicable to displacements following par- turition. Its characteristic action on the uterus, such as prolonged bearing down, forcing pain in the hypogastrium, urging toward the genitals, and atonic uterine hemorrhage of dark or very fetid blood, indicate it. A fresh preparation, in a low attenuation, should be persistently used, taking care not to produce drug Symptoms. Where secale fails, ustilago should be borne in mind. | Sepia. Dr. Dunham styled this the remedy par excellence for prolapsus. “The simultaneous irritability of the bladder and the presence of leucorrhoea, together with the hot flushes and the sympathetic affections of remote organs, serve especially to indicate it.” The pain in the uterus, with severe bearing down and strong pressure in the pelvic organs, is very characteristic. The vagina is hot, dry, and painful to the touch. There may be excoriating, yellow, or milky leucorrhoea before the menses. The sensation of sinking or “goneness” in the epigastrium is a leading symptom. The bearing down is relieved by lying down, returns on sitting up, is worse on standing, and is particularly aggravated by walking. There is marked venous congestion of the pelvic organs. This remedy is valuable, but has been very much overestimated for the treatment of displacements. It is so often prescribed as a matter of routine practice, that many physicians have expected too much, and been disappointed sometimes in the results. Stannum” has often proved very serviceable ; leucorrhoea of yellow, white, or transparent mucus, with great debility; prolapse of the vagina or uterus, with bearing down in the hypogastric region; the monses are too early, profuse, and preceded by melancholia. Sulphur is an invaluable remedy for all forms of uterine dis- placement, and must be persistently used in cases of inflamma- tion and venous congestion of the pelvic organs. The menses I See Allgemeine Hom. Zeitung, Vol. XXIV. No. 2, p. 153, cases reported by Dr. Kaltenbach. 2 Recommended by Dr. Henriques, British Journal of Homoeopathy, p. 477, 1850. AºA2AMAE DAES ATO/P D/SA/LA CEMEAV7 S. 289 are too late, too profuse, and of too short duration ; the blood thick, dark, and excoriating; and during the menses there is pres- sure in the pit of the stomach, burning in the vagina, and after the flow profuse yellowish excoriating leucorrhoea. The general symp- toms are important, such as heat on top of the head, with Cold feet; burning of the soles of the feet, and cramps in the calves of the legs and soles of the feet at night. The following remedies can also be consulted: Aconite, aesculus hip., argentum, armica, arsenicum, aurum, canth., caul., Cimicifuga, crotalus, kali bi., lach, liz. tig., merc., nux mos., puls., testi/ago. Aless important remedies are: Agaricus musc., ammon. mur., ars., china, graphites, nat. mur., nitric ac., rhus tox,” Soda chlora- tum zinc. The following classification may serve as a guide in the selection of a remedy. It is hardly necessary to say that a remedy is not limited to only one condition, but that its sphere of action may extend to several, according to the symptoms of the case. Anteversion.”— Bell, calc. carb., canth., cannabis Sat., dig., gels., graph., hyosc, kali carb, lycop., nuºc vom., sepia, Sulph., terebin- thina.” - A'etrozersion. — Bell, bryonia, Cauloph., Cimicif., collinsonia, helonias, hepar, merc. viv., nux vom., puls., Sabina, Secale, Senecio, sepia, sulph., veratr. vir. A'etroversion * beginning with trouble in the rectum, such as rectal paralysis, chronic constipation, and hemorrhoids. AEsc. hip., aloes, alumina, calc. carb., collinsonia 2-x, ham., nux vom., podo. 1 Rückert's Klinische Erfahrungen, Supplement, p. 634. * Dr. H. H. Reed writes me: “In a case of retroversion in a nullipara, I prescribed rhus, from the general symptoms, to prepare the patient for a pessary; and in about three months, when I went to fit one, the displace- ment had disappeared.” * Dr. Tritschler reports some remarkable cases of posterior and anterior displacements of the uterus with hypertrophy and induration, others with sterility, which were cured by the chloride of gold 3 x. (See Hahnemannian Monthly, 1877, and Homoeopathic Recorder, p. 102, May 15, 1877, quoted from the Allgemeine Hom. Zeitung, Vol. XCIV. Nos. 17, 18, and 19.) * I have found this remedy very useful to relieve extremely severe attacks of dysuria, and constant tenesmus of the bladder, and passage of a small amount of very bloody urine, in a long-standing case of anteversion. It did not cure the latter, but it would relieve the tenesmus, etc., like magic. U I9 29O D/SPLACEMEAVTS OF THE SEXUAL ORGAAWS. Lateroversion" (from traumatic causes) — Arnica, bell, hyperi- cum, rhus tox. These remedies are excellent for any displace- ment from traumatism. Prolapsus uteri.”— These remedies are also useful for retrover- sion. AEsc. hip., aloes, arctium lappa, bell, calc. carb., ferr. iod, helonias, lil. tig., murex purp., muz vom., podo., rhus, stannum, sepia. - Arolapsus * with atony of the rectal walls and constipation. (Compare retroversion with constipation and hemorrhoids.) . Alu- mina, bell., lycopodium, nux vom., natr. mur., opium, plumbum, Sulph., zinc. Prolapsus” or retroversion with too frequent and profuse menses. — Ars., bell, calc., carb., canth., china, erigeron, ferrum, ham, kre- Osote, magnesia carb., nux vom., phos. ac., Sabina, Secale, Sulph., trillium, zinc. Aºrolapsus * apparently due to subinvolution, or chronic metritis. — Bell, carbo veg., conium, kreosote, murex purp., nux wom., secale. For Peritoneal Inflammation * following the reposition of a dis- placed uterus with adhesions.—Bell, bry, hypericum, rhus tox. If sciatica follows, colocynth. * - Prolapsus of the Vagina.”— Arnica, kreosote (?), merc., nux vom., Secale. Prolapsus of the Vagina," if caused by frequent births and hard work, arnica ; if from severe and long-continued coughing, with straining at stool, nux vom. ; if from relaxation of ligaments or muscles, or general weakness in consequence of chlorosis, leu- corrhoea, excessive venery, Onanism, etc., phos., puls., merc., China, ferrum. * See note 3 on previous page. * Records of Homoeopathic Literature, 1875, p. 174. * Leadam, Diseases of Women, p. 285, 1874. 4 Compare Ludlam, Diseases of Women, 1881. * Leadam, op. cit., p. 297. 6 Dr. Cl. Müller, Hom. Vierteljahrschrift, p. 452, 1860. EAVDOME TRITIS. 29I CHAPTER XVI. END OMETRITIS. TNNDOMETRITIS, or inflammation of the lining of the uterine cavity, may be acute or chronic, and affect the cervix, body, or the entire endometrium, in either form. Forme. Etiology. Symptoms and Diagnosis. Acute endometritis (catarrhal). (Fibrinous.) (Haemor- rhagic.) Differential diagnosis. Chronic endometritis (cervical). Traumatism, such as im- proper use of the uterine sound, tents, intra-uterine pessary, contact with irri- tating chemicals, abuse of coitus; effects of cold, espe- cially during menstruation, with suppression of the flow; inflammation of the vagina extending upward, particu- larly if gonorrhoeal ; im- proper evacuation of retained menses from imperforate hymen; acute eruptive dis- eases, such as measles, Scarlatina, Small-pox, etc.; retrocession of eruption in these diseases. This is sometimes the con- tinuance of the acute form, and may be produced by the same causes. When the acute form passes into the The symptoms are not severe unless from parturition or evacuation of re- tained menstrual flow. There is a Sense of weight, dragging, and pain in the pelvis. The latter may also be present in the back and thighs, and accompanied by frequent and painful micturition. After a few days there is a leucorrhoeal discharge, which may be sufficiently irritating to excite vaginitis and produce excoriations on the external genitals. The uterus is somewhat enlarged, the cervix swollen and sensitive, the os open and the margins red; the canal is filled with a plug of albuminous and very tenacious mucus. The mobility of the uterus, the absence of inflammation in the Sur- rounding tissues, and the lack of marked constitutional symptoms, will distinguish it from other diseases. The only symptom which may bring the patient to the physician is leucor- rhoea. There is a sense of bearing down or pelvic pain, worse on exercise, and menstrual disorders not infre- 292 AAWDOMAE 7TP/27/S. Forme. Etiology. Symptoms and Diagnosis. chronic, there is often pres- quently develop. Symptoms of anae- ent a scrofulous diathesis, an mia are often present. enfeebled condition from any Physical examination shows the cer. of the causes producing anae- vix is enlarged, and a little sensitive. mia, or imperfect circulation | There is usually more or less erosion from mode of dress, disease, about the os; the lips of the cervix may etc. The more marked ex- have a rough, raw appearance, i. e. citing causes of this disease granular degeneration, and, in addi- are laceration of the cervix, jtion, swollen follicles and chalk-like polypi in the cervix, obstruc- || concretions are seen, giving a rasp- tion to escape of menstrual | berry appearance to the cervix. When fluid, subinvolution, preven- ; this is the condition, ectropium is tion of conception, or the in- present, and there is almost invariably duction of abortion. laceration of the cervix. Sometimes the cervix has a normal appearance, and there is nothing but the excessive amount of tenacious cervical mucus to mark the presence of the disease, which affects the glands of the cervix in particular. In the chronic form, the cervix suffers most, forming cervical endometritis or endocervicitis. Corporeal. Same as above and pres- || The cervix and cavity of the uterus : ence of tumors in the uterine may be simultaneously or separately cavity or encroaching on it. affected. In corporeal endometritis, (Fibrous.) the leucorrhoea is less tenacious and viscid than when it comes from the cervix, and is sometimes tinged with (Hyperplastic, blood. Menorrhagia is not uncommon. or polypoid.) The endometrium bleeds easily, and is abnormally sensitive to touch with the sound. Sterility is often present. These symptoms distinguish corporeal from cervical endometritis, as the others are common to both. The only complications are those resulting from exten- sion of the inflammation to the neighboring structures. Specific endometritis may extend to the peritoneum through the Fallopian tubes with serious results. En- dometritis from septic puerperal causes, or after the evac- uation of retained menses, may be of a dangerous, or even JCA2 UCORRA/CEA. 293 fatal character; otherwise, the prognosis is favorable in acute cases. The chronic form is one of the most com- mon of the gynecological diseases, and at the same time one of the most difficult to cure, especially when asso- ciated with ovaritis." As a general rule, the more the Nabothian glands are involved, the more obstinate is the disease. - The pathology of endometritis is very like inflammation of mucous membrane elsewhere, plus the inflammation of the utricular and Nabothian glands, and the increased secretion in consequence. The causes of this disease are very similar to those producing catarrhal inflammation in other portions of the body, and the same general prin- ciples of treatment apply to both; but how far those remedies particularly adapted to the one will cure the other is not known. LEUCORREIOEA. It may not be out of place here to call special attention to this symptom of catarrhal inflammation of the lining membrane of the genital tract. When it occurs as a symptom of vulvitis or vaginitis, the reader is referred to Chapter VIII. From a practical point of view, leucorrhoea may be divided into two classes, physiological and pathological. The former is of slight amount, short duration, and is more often found in women having a scrofulous taint; for example, some women have a slight leucorrhoea during cold weather, the mild forms of leucorrhoea in pregnancy, a small amount of leucorrhoea immediately before and just after the menses which entirely ceases during the interval. In the last instance, it may be that the leucorrhoea is due ,” An excellent study of the relation of endometritis to ovarian disease, by Dr. Mary Putnam Jacobi, will be found in the American Journal of Ob- stetrics, p. 352, April, 1886. Compare also her Studies in Endometritis, in American Journal of Obstetrics, 1885. 294 AºAVOOME TRZZTW.S. to a vicarious action of the mucous membrane, and the Sudden suppression of the discharge by astringent injec- tions might result in inflammation of the pelvic structures, which would not be the case were it checked more gradu- ally by milder treatment. The leucorrhoea during cold weather is often cured by wearing closed flannel drawers, and using a chair in a warm room, instead of the cold, open privy. The great characteristic between physiologi- cal and pathological leucorrhoea is, that the former is tran- sient, the latter constant, but subject to variations; the former requires very little treatment, the latter may tax the powers of the most astute physician. Though the etiology is that of the disease producing the discharge, such as endometritis, there are three great causes of leucorrhoea, which must be remembered for the successful treatment of this affection. I. Scrofulous dyscra- l Here dity sia associated tº . º. - e e * } Too frequent parturition or prolonged lactation. with anaemia or J Anything producing anaemia. chlorosis - Retarded portal } Diseases of the heart or liver. circulation Chronic constipation. 2. Congestion Growths in the uterus. of the pel- - Displacement of the uterus. vic organs Subinvolution. Local irritation - Ovaritis. º tº a 0 \ Incomplete or excessive coition. Masturbation. Acute exanthemata. * Ascarides, especially in little girls. \. 3. Specific } Gonorrhoea. Syphilis. Three forms of leucorrhoea are usually described, vul- var, vaginal, and uterine. The first is sebaceous or sero- purulent; seldom profuse. The second has an alkaline reaction, usually of milky character, and contains an abun- dance of pavement epithelium undergoing fatty degener- ation. The third has often, but not always, an alkaline A.A., UCORRAIOE.A. 295 reaction; the discharge from the cervix is thick and gelat- inous, from the uterus thinner and more like mucus. The last two forms are often found together. Leucorrhoea from specific causes usually flows from both urethra and vagina, has an acid reaction, and is character- ized by its thick, yellow, or purulent appearance. A dis- charge of this kind which can be stripped from the urethra is good evidence of gonorrhoea, especially if it contains gonococci." A very offensive watery discharge, sometimes contain- ing blood, is one of the earliest symptoms of malignant disease, and calls for a careful examination. Whatever the form of leucorrhoea, the principles of treatment are the same. The axe must be applied to the root of the tree; the cause must be carefully investigated and removed. The treatment must be aimed at the source of the disease. If anaemic, the patient must be built up by generous diet, outdoor air and exercise, as she is able to bear it, sea bathing or a sponge bath with Salt water and vigorous friction, as well as the use of proper medi- cine; if the uterus is displaced, it must be replaced; if the ovaries are inflamed, they must receive attention. It is hardly necessary to recapitulate each particular cause, the treatment of which will be found in its appropriate chapter. The importance of a generous diet cannot be over- estimated. The loss of albumen from the system is a constant drain, and tends to increase the anaemia. Nature tries to offset it by arresting the menstrual flow; but the waste in the system needs replenishing, not by the pickled limes, olives, chalk, and slate-pencils of school-girls, nor the highly seasoned food of their mothers, but by plenty of lean beef, mutton, milk, and eggs, – in short, a plain non-stimulating diet. Where the digestion is weak, and meat cannot be borne, the author has successfully used * See page 3oo. 296 - AºAVDOMA 7TP/7/.S. beef juice, prepared in the following manner. Take a juicy steak, preferably the round; cut off the fat; broil it quickly over hot coals, merely enough to sear the surfaces without cooking the meat inside. Cut a few gashes in it, and press out the juice with a lemon-squeezer, or, far better, a meat-press. This can be seasoned, and taken clear or mixed with bread crumbs. In this way a patient can easily take the juice of two or three pounds of steak a day, and derive much more benefit from it than from that popular delusion, beef tea, which is stimulating, but con- tains Scarcely any nourishment. The local and medical treatment is the same as for endometritis, of which it is a symptom. - The Treatment of Acute Endometritis consists in remov- ing the exciting cause so far as possible, enjoining perfect sexual and physical rest, and the use of copious hot-water vaginal douches night and morning. No local treatment is necessary. The Treatment of Chronic Endometritis is a different matter, and may baffle the physician's skill to cure it per- manently, particularly if the body of the uterus is affected. Vaginal douches should be employed twice daily, to which a little impure carbolic acid, calendula, eucalyptus, hydras- tis, or glycerine can be added. If hot vaginal douches have already been properly used for some time without benefit, then discontinue them and only employ a vagi- nal douche for cleansing purposes. Hot-water douches are often used to advantage, but are also abused as rou- tine treatment, and may do harm. Carbolic acid is to be used for offensive leucorrhoea with pruritus; calendula, for bloody leucorrhoea; eucalyptus, for bad-smelling leucor- rhoea, such as is common with cancer of the uterus; hydrastis, for copious yellow leucorrhoea, which may be either bland or excoriating. Boro-glyceride may be used for bloody, offensive leucorrhoea with pruritus. If the cervical canal is very small, or the external os is TREA TMAAV7" OA' EAWDOMAE 7TP/ZY.S. 297 a little contracted so that the cervical secretions are some- what pent up, it is absolutely necessary to dilate the canal or incise the cervix sufficiently to allow them a free exit. Before a local application can be made with any degree of efficiency, the plug of mucus in the cervical canal must be removed, which is not always an easy matter, as the mucus is so tenacious. . It can be done with a uterine pis- ton syringe having a short piece of rubber tubing on the nozzle, which is introduced well into the external os. The plug of mucus is sucked in by drawing the piston quickly out; or a small, narrow piece of dry sponge can be intro- duced in the canal, and rotated with the dressing forceps so as to entangle and bring out the thick mucus; but it is of no use to try it with cotton." Sometimes a stream of water from a syringe will cleanse the canal most effectually. FIG. I 18, MARTIN's CURETTE MODIFIED FROM ROUX. Recently I have spooned out the canal with Martin's curette, and found it very effectual. After the diseased mucous membrane has been thor- oughly cleansed by one of these methods, an application can be made of impure carbolic acid, eucalyptus, Church- FIG. I.19. SouTHwick’s CERVICAL SYRINGE. ill's tincture of iodine, iodized phenol, or thick extract of pinus canadensis.” The cervix syringe of the author will 1 The local use of the peroxide of hydrogen (twelve volumes) has been recommended for this purpose, but the author cannot speak very favorably of it from a limited trial, except when the discharge is purulent. The prep- aration is very unstable, and soon deteriorates. * For the indications for the use of these applications, see page 37. 298 EAVDOMETR/7/.S. be found very useful for this, but it must never be inserted in the canal beyond the angle of the tube. Pyrogallic acid is a favorite application of most German gynecolo- gists, especially for erosion of the cervix accompanying endocervicitis. It is commonly employed by pouring half an ounce into the speculum, and allowing it to bathe the cervix thoroughly for five minutes. The speculum is then depressed, the fluid runs out into a small basin, and a small tampon is sometimes inserted into the vagina. In obsti- nate cases of endocervicitis, with a profuse glairy discharge like the white of egg, the application of a fifty per cent aqueous solution of chromic acid to the cervical canal at intervals of a week may become necessary. It is an heroic measure, however, and should be reserved only for very obstinate cases. Gelatine or cocoa-butter pencils of io- copMAN & SHURTLEFF. His FIG. I2O. SouTHWICK's OINTMENT INJECTOR FOR PATIENTS TO USE WITH CERATES FOR Hom(E TREATMENT. doform, tannin, hydrastis, etc., are favorites with some; or the same substances, including calendula, eucalyptus, and boracic acid, may be used as a cerate or mixed with glycerine." Dr. Conrad Wesselhoeft mentions the following appli- cations. Merc. cor. I : 4,OOO aqueous solution, for metritis and endometritis; red, swollen cervix, everted os; mucous leucorrhoea and great tenderness. Atropia Sulph. I : 4,OOO aqueous solution, for a red, dry, painful cervix and everted os. An occasional application of a solution of nitrate of silver (five grains to the ounce) is sometimes necessary on account of its stimulating properties; but its use should be restricted, as severe and almost incurable ovaritis has resulted from its use." * See page 37. 7 RAEA 7TMAE/V7" OA” AAVDOMAE ZTA’/ ZY.S. 299' The distended follicles must be opened, and if they are seriously involved it is often necessary to remove them with a curette." Sponge tents are also used for this purpose, and exercise a decided alterative effect on the tissues. The use of injections into the uterine cavity should never be attempted unless the canal is patulous. It is a question with the writer, how far local applications to the endometrium of the body of the uterus will result in permanent benefit to the patient. This membrane is constantly undergoing degeneration and repair from the muscular structures beneath. These must be put in a condition to produce a healthy lining to the cavity, and this can be best accomplished by constitutional treatment. Excellent authorities, however, recommend the use of the compound tincture of iodine or iodized phenol; and others believe in thorough irrigation of the cavity with a double- current uterine catheter, or the application of iodoform in pencils or powder. Dr. Gehrung” has invented an ingeni- FIG. I.21. GEHRUNG’s BLOWER. ous instrument for blowing powder into the uterine cavity or vagina. Should severe menorrhagia be a prominent Symptom, it probably depends on the presence of polypi or a fungoid degeneration of the endometrium. In these * The writer has noticed that a very large proportion of cases of leucor- rhoea were associated with laceration of the cervix, and promptly cured by operating on the latter. When the lacerated surfaces and cervical canal are both filled with distended follicles and nodules, Schroeder's method of ex- cision of the cervical membrane can be combined with Emmet's operation. For a description of this operation, see Schroeder, Krankheiten der weib. Geschlechtsorgane, 1881, p. 135. * American Journal of Obstetrics, p. 1233, December, 1886. 3OO AºAVDOMETRIZYS. cases the thorough use of the dull wire curette, followed by the local application of iodine, will control the memor- rhagia. Equal parts of oleate of zinc (made from Castile soap) and iodoform is a good application for fetid leu- corrhoea, with erosions of the cervix or vagina. It is exceedingly difficult to cure chronic endometritis with- out perfect rest during the menstrual period, and abso- lute sexual abstinence. In leucorrhoea depending on a gonorrhoeal vaginitis or endometritis," Fritsch 4 warmly recommends a solution of equal parts of chloride of zinc and water. Twenty grams (one table-spoonful) of this solution is added to a litre of water (one quart+), and used for a vaginal injection at a temperature of 30° R. (99.5° F.), and continued if necessary through menstruation. The leucorrhoea generally ceases after ten injections, but returns if the cervix, endometrium, and tubes are involved. In this case the uterine cavity is cauterized with a stronger solution of chloride of zinc, and an iodoform pencil introduced. We are often at a loss to determine positively whether a patient is suffering from gonorrhoea or not. In some cases the patient will not admit it; in other cases, it will not do even to suggest the idea to her mind; in still other cases, particularly those of long standing, we are asked whether the discharge is due to gonorrhoea, and if it be infectious. The following method of procedure will en- able the physician to decide the questions; for if the gonococci be found with certainty within epithelial cells, as described below, the proof of gonorrhoeal infection is positive, as well as the danger of infection. The author desires to state that this view is called in question by a few investigators.” The latter, however, as a rule, refer 1 See page 136. * Dr. H. Fritsch, Die Behandlung der gonorrhoischen Vaginitis und En- dometritis, Centralblatt für Gynākologie, No. 30, p. 477, 1887. * Dr. J. M. Baldy, Gonorrhoeal Diseases of the Uterine Appendages, Trans- actions of the American Gynecological Society, p. 402, 1889. I)/A GAVO.S./S OF GO/WOR/8A/CEA. 3O I merely to the presence of gonococci independent of their relation to epithelial cells. Press a minute drop of the dis- charge tightly between two cover glasses. This makes a very thin transparent layer, which can be readily stained. Care must be taken that a very thin layer is obtained: a common mistake for beginners is to get it too thick. Hold a cover glass in a pair of forceps with the smeared side upwards. Pass it in this position three times through the flame of a spirit lamp, as you count three in a Space of five seconds. Next drop the cover glass prepared side down on a strong watery solution of methyline blue or gentian violet, so that the cover glass floats on the surface. Methyline blue stains blue; gentian violet, violet, or what often appears as a red color rather than violet to the observer. Allow the cover glass to float on the solution not less than five minutes, and more time is occasionally neces- sary. Wash it well in clear water, dry the edges with blotting paper, and place on a glass slide as usual in mounting preparations. A No. 3 ocular and a good Hº, oil immersion, objective in a strong light, will clearly show if gonococci be present. They are characterized by two minute points, which apparently touch each other, similar to the two dots of a colon placed close together. This has also been described as giving them a dumb-bell appearance. They are also grouped together in colonies. We must only attach importance to those gonococci which always appear in pairs, as above described, when they are within epithelial cells. I am well aware that the clinical importance of the “Gonococcus Neisser’’’ has been called in question; * but in spite of the opin- ions of some former observers, I believe the specific prop- 1 Neisser, Centralblatt für die med. Wissenschaften, No. 17, p. 497, 1879. * See Von Zeissl, Wiener Klinik, Heft 11, 12, Wien, 1886, and Wendt, Centralblatt für Bacteriologie und Parasitenkunde, No. 3, p.409, 1888; also Steinberg, Medical News, 1883. 3O2 - AAWDOME TRITIS. erty of the gonococci, and the diagnosis of gonorrhoea by them, is now beyond question." Gram's methcq of Coloring * is believed by some to be superior to the one described above, but is more complicated. In recent cases, a single preparation is quite sufficient, and will Swarm with these micro-organisms. I have found them numerous a year and a half after infection. As a rule, it is best to make a number of examinations in cases of long standing, if no gonococci be found, before stating positively that none are present, as they become less numerous in cases of long standing. So long as gonococci are present, the discharge contain- 1ng them is infectious, though clinical experience shows that a discharge which has lasted for many months is much less virulent than when it is quite recent. The urethra of one individual after a time may tolerate a chronic discharge from one person which would certainly infect another one. In some cases of long standing, it is sometimes difficult to distinguish with certainty the gonococci in colonies, and in the shape of double points in and out of the epithelial cells, from other micro-organisms or albuminoid bodies, especially as there are five different types of false gonococci. Under such circumstances, after washing the cover glass before placing it under the microscope, dip the slide for a mo- ment in a weak solution of acetic acid (dilute acetic acid five minims, distilled water five drams and a half), and again wash the cover glass in water. As the acetic acid solution decolorizes other organisms more rapidly than the gonococci, the latter will remain a distinct blue.” Gonorrhoea has a terrible and often lasting effect in women, and is never to be lightly considered.* The dis- * Roux, Baumgarten's Jahresbericht, No. 2, p. 90, 1888. * Gram, Fortschritte der Medicin, No. 2, p. 186, 1884. 3 Medical Record, Nov. 23, 1889. * Compare Die Tripperansteckung bein weiblichen Geschlechte, by Dr. M. Sånger, Leipzig, 1890. A French translation of Sänger's excellent mon- ograph will be found in the Annales de Gynécologie, p 130, February, 1890 COAZ) PLO.MATA A CUM/AVATA. 3O3 ease is quite apt to extend from the endometrium to the Fallopian tubes, causing salpingitis, sterility, and nearly always death should the tube Sac and its poisonous puru- lent contents be discharged into the peritoneum. - Gonorrhoeal salpingitis is a serious disease, which will make a woman an invalid. It is seldom cured except by an operation, and subjects the woman to constant danger of life from rupture of the sac, besides a dangerous surgi- cal operation to remove it. - This fact should be more appreciated by physicians when called upon to treat cases of gonorrhoea, who seri- ously, if not criminally, fail in their duty if they do not on every occasion emphasize the vital danger of infecting a woman. Prevention is of the utmost importance, and were the danger of infection sufficiently impressed on those suffering from the disease, there would be a marked dimi- nution of invalid women, and of sudden death from acute and apparently unexplainable attacks of peritonitis, really due to rupture of a Fallopian tube distended by gonor- rhoeal salpingitis. It is important to remember that, after gonorrhoea, patches or single groups of pointed, long, fig-like warts appear, called condylomata acuminata. These grow very quickly, and the discovery of them about the vulva, vagina, or cervix uteri is very good evidence of a preced- ing gonorrhoea. They are to be carefully distinguished from flat condyloma, which are very different. These latter appear like thin, flat warts, with a moist surface, t on the vulva or about the anus, and after a time undergo ulceration. They constitute one of the chief manifesta- tions of syphilis, and are very contagious. The pointed condyloma are not contagious, and can be removed by ordinary operative treatment, a ten per cent pyrogallic ointment, or an ointment consisting of one part resorcin and two parts of simple cerate. Flat condyloma should be treated in the same way as syphilis. 3O4. AºAVOOA/A2 TRZZY.S. THERAPEUTICS. In prescribing for leucorrhoea, the character of the dis- charge is generally less important than the general symp- toms, and those arising from the physical condition of the patient. The symptoms attending the menstrual flow, and of the ovaries, are of no little value in selecting the remedy. || Antimonium tart. Many physicians consider this one of the most important remedies for chronic corporeal cervicitis; * the cervix is much enlarged, with a superficial erosion about the os. (Aurum, carbo an., sepia.) It is an excellent remedy both for the inflammation of the endometrium, and for the body of the cervix. - | Arsenicum. Chronic endometritis of the body of the uterus, particularly if menorrhagia is a marked symptom.” It is also use- ful for endocervicitis, if the patient is weak, the discharge thin, and the pelvic pains of a burning character; leucorrhoea profuse, yel- low, thick (hydrastis, kali bi.), corroding (kali carb.); pressive, burning, lancinating pains in the ovary, more often the right, ex- tending into the thigh, which feels numb and lame, worse from motion or bending over. White leucorrhoea, acute attack from taking cold, or debility of exhausting disease, cancer, kidney, cardiac, or pulmonary disease. II Belladonna is an invaluable remedy in acute endometritis either of the body or cervix of the uterus ; also, if the inflammation has extended beyond the endometrium, so as to involve the mus- cular tissue. The cervix is very sensitive, swollen, and reddened: the mucous membrane about the OS is of a bright Scarlet hue, and there may be superficial excoriations; there is much heat, dryness, throbbing pain, and bearing down, in the pelvic organs. Bryonia. If the endometritis follows imperfect development or retrocession of some skin eruption, and there are also other symptoms belonging to this remedy, it deserves a trial, though 1 Dr. Ludlam, New England Medical Gazette, November, 1877; and Dr. Gourbeyre, Clinique, July, 1881. - 2 Hahnemannian Materia Medica, Part I. p. 18 (Arsenic). 7A/AEA'A PAE UT/CS OF EAVDO.)/A2 7TP/T/S. 3O5 the author has not met with reports of cases verifying this indication. - Il Calc. carb. Compare also calc, phos. It is especially use- ful for scrofulous patients, and is indicated more by the general than the local symptoms, when strumous disease, especially of the cervical glands, is present; perspires on the least exertion, par- ticularly about the head; very hungry in the morning, acidity of the stomach; feet feel cold and damp; menses too early and too profuse; leucorrhoea before the menses; milky leucorrhaea (coni., lyc., fºuls., sepia, Sulph. ac.), at times profuse, with itching and burning. Dr. Ludlam thinks this remedy is not indicated in cer- vical endometritis, unless the inflammation extends up beyond the internal os uteri. Leucorrhoea in children (caulophyllum, cannab. Sat., sepia) and before puberty. Cimicifuga. This remedy is warmly praised by Dr. D. Dyce . Brown,” in a very able article on the Treatment of Endocervicitis. The general symptoms are of great importance. Zhe patient is nervous, neuralgic, and hyperasthetic, but not so hysterical as the ignatia patient; the uterus is engorged ; the cervix eroded and hypertrophied ; examination shows a marked sensitiveness of the pelvic organs, especially the ovaries, and the left rather more than the right, not from pain but from the general hyperaesthesia; head- ache in the vertex, forehead, over the eyes, or in the eyes; the pain is dull, pressive, and heavy in the eyes, and there is the same heavy pressure, with a drawing sensation, in the fundus of the eye- ball ; the pupils dilated. Croton tig.” In delicate strumous patients with local itching from the discharges, thoracic rheumatic pains as a possible reflex Condition, exhaustion. Graphites. Profuse leucorrhaea of very thin white mucus, with weakness in the back; leucorrhoea occurs in gushes day or night; abdomen distended; menses delayed, scanty and pale. Dr. Jahr concurred with Dr. Wahle in recommending it for the cauliflower, wart-shaped excrescences on the neck of the uterus. The latter * Transactions of International Homoeopathic Congress, London, p. 244, I881. * * * Dr. J. Heber Smith. 2O 306 AºAVOOME 7/8/7/S. also prescribed it for induration and congestion of the cervix; painful tubercles on the sides of the cervix ; great weight and lan- cinating pains in the lower part of the abdomen and uterus. These point to graphites as a valuable remedy for laceration of the cervix with follicular disease. Guaco. Dr. Eduardo Fornias,” in his lecture on “exotic drugs,” states that guaco taken in appreciable doses produces a copious, corrosive, putrid leucorrhoea, which is very debilitating. A lady, who had never suffered from these symptoms before taking the drug, reports that she sometimes “felt as if fire were running out of her parts, and that the inside of her thighs was materially tanned, and her clothing always stained yellow ; she complained also of a terrible itching and Smarting, especially at night.” Helonias. Zeucorrhaea with general debility ; melancholia with a sensation of weight, Soreness, and dragging in the uterus. It may be accompanied by intense pruritus, heat, and swelling, with exfoliation of the epidermis. Hepar. Scrofulous subjects; profuse catarrhal discharge, with streaks of blood in it; erosions about the os uteri, which are sen- sitive to touch, bleed easily, sting and burn, and have an odor of old cheese. | Hydrastis. Zenacious, thick, ropy, yellow leucorrhaea; severe erosion of the cervix; constipation, with hemorrhoids and dyspep- sia, with a faint or sinking sensation at the stomach. Kali bichromicum.” Leucorrhoea yellow, ropy. (Hydrastis.) Pain and weakness across small of back, and dull heavy pains in hypogastrium. Leucorrhoea that can be drawn out in long strings, yellow, ropy, stiffening the linen. Leucorrhoea and tendency to prolapsus uteri, worse in hot weather. Soreness and rawness in vagina. | Kali sulph. Has proved an excellent remedy for chronic gonorrhoeal infection, purulent leucorrhoea, aching in pelvis, and rheumatic pains in the knees. Kreosote.” Yellow /eucorrhaea with great debility (carbo an.). * Homoeopathic Journal of Obstetrics, May, 1886, p. 231. * Dr. L. L. Danforth. * Mrs. — For ten years she suffered from a frequent and copious leu- ºcorrhoeal discharge, staining the linen yellow, and stiffening it; worse between 7THEA’AAA, UTYCS OF EAVDOMAE 7TP/7/.S. 3O7 White leucorrhoea having the odor of green corn; soreness, smart- ing, and burning between the labia and thighs, with burning, biting pain; violent itching of the vagina and labia; external genitals sometimes swollen, hot, hard, and Sore. Menstrual flow intermittent, usually copious, accompanied by difficult hearing, with roaring and humming in the head. Cervix tumefied with burning, sensitiveness to touch, or coitus and offen- sive discharges." Dragging in back relieved by motion (sepia aggravated). | Lycopodium is highly recommended by Dr. Leadam. Pa- tient looks pale and sallow ; complains of pressive or full head- aches; sleeps badly, and is always chilly; feels full after eating; “bloating ” or distention of the abdomen from accumulation of gas ; constipation with hard stools; red sediment in the urine. There seems to be a general sluggishness of the muscular, venous, and digestive systems, preventing the normal peristaltic action of the intestines; there are dryness and burning in the vagina, darting pains in the uterine region ; coition is painful. The leucorrhoea may be like milk (calc. Carb., coni, kreos., puls., sepia, sulph. ac.), bloody, or corroding. || Mercurius. The solubilis is preferred by Dr. Matheson 4 for superficial erosion of the os uteri. Dr. Hughes * states that merc. cor. is his favorite remedy, if the eroded portion appears deeply excavated, and the cervix is swollen and indurated. Dr. the menses; vulva a little irritated, but there was no other trace of disease. Kreosote cured her. — DR, LANDRY, Bull, de la Soc. Méd. Hom. de Aºrance, Vol. XII. No. 5. Miss , ast. 25, brunette. Amenorrhoea for six months, from chill, when the menses returned; cannot lie on either side; constant dull pain in the region of both ovaries, and inability to bear pressure there; urine color- less in the morning; brownish yellow acrid leucorrhoea. She was given kreosote 20 x. before each meal. In two days the pains were less, the leu- corrhoea became diminished, less acrid, and she could lie on the left side for a short time. She then received kreosote 4 x. once a day; the morning urine now became of a normal color. In fourteen days she could lie on both sides, the leucorrhoea was quite gone, also the pains in the ovaries, and she re- mained well.—DR, PRALL, Allgemeine Hom. Zeitung, Vol. XCII. No. 11. 1 Farrington. * Dr. Matheson, Four Lectures on the Diseases of Women. * Dr. R. Hughes, Manual of Therapeutics, Vol. II. p. 300. : © : . º : : º ; 308 AºAVDOMAE 7TRZZY.S. Ludlam * recommends merc. iod. for endocervicitis in scrofulous Subjects, with erosion of the os, and enlargement of the nabothian glands. It is especially valuable in cases of gonorrhoeal or syph- ilitic origin, and severe erosions of an unhealthy type; profuse greenish, yellow, or purulent leucorrhaea, worse at night; Smarting, corroding, itching, and inflammation of the vagina. It is a superior remedy in hypertrophy of the uterus, or chronic metritis. When the leucorrhoea is yellow, thick, nabothian glands and follicles in- volved, Dr. Conrad Wesselhoeft recommends merc. viv. 2 x. inter- nally, one grain twice or at most three times a day. | Nitric acid. This was a favorite remedy of Dr. Jahr " for flat, superficial erosions on the cervix (thuja, sepia), resembling ulcerated aphtha: ; erosions resulting from syphilis, discharging dirty yellow pus; excrescences on the os uteri. Dr. Leadam recommends its persistent use in alternation with sulphur at long intervals. | Phosphorus ought to be a good remedy, as it has caused endometritis,” but there are very few reports of its use. The menses are too early and too scanty, or there may be frequent and profuse metrorrhagia, acrid excoriating leucorrhoea. | Pulsatilla is one of the best remedies for leucorrhaea with delayed or scanty menses; the leucorrhaea is thick, creamy, or milky (calc. carb., coni., sepia, Sulph. ac), with swollen vulva, painless; acrid, thin, burning (alumina, ars., coni., kreosote, merc., phos.); pressive pain toward the uterus, with morning nausea; involuntary micturition at night; frequent, profuse flow of urine ; dyspepsia. Rhus tox. has been recommended for erosions of the cervix, having a raspberry appearance, probably due to distention of the follicles.4 | Sepia." Enlargement of the uterus, probably from venous engorgement; prolapsus, with much bearing dozen , great dryness 1 British Journal of Homoeopathy, 1884, p. 302. * Forty Years’ Practice, p. 179; Diseases of Females, p. 246. * Hausmann, Berl. Bitr. z. Geburt. u. Gyn., Bd. I. p. 265. 4 U. S. Medical and Surgical Journal, July, 1874. 5 Girl, aet. 5. Pale, emaciated, no appetite, and strength rapidly decreas- ing. For fifteen months has had an unceasing and terribly exhausting leu- corrhoea. The discharge was sometimes thick, and of a yellowish green ; tº § : : : : THERAPE O/T/CS OF EAWDOME 7TRZZY.S. 309 . of vulva and vagina, which are painful to the touch ; leucorrhaea yellow, or like milk, excoriating (alumina, ars, kreosote) at the climacteric, and especially before the menses ; flat, superficial ero- sions about the Os; tendency to mucous catarrh everywhere ; con- stipation and piles ; a pale, Sallow complexion, pimples or skin eruptions on the face and genitals; much general itching of the skin. It is very serviceable in chronic inflammation of the uterus and induration or hypertrophy of the cervix (aurum, carbo am.). Dr. Dyce Brown uses the twelfth centesimal with great confi- dence. | Silicea. Scrofulous diathesis; profuse, thin, acrid, corrosive (ars., kreosote, merc., puls.), or purulent leucorrhoea; constipation, weakness, and sense of great debility; sensitiveness to cold air. The characteristic headache and nervous symptoms of silicea are important in prescribing this remedy. Strychnia sulph. 3 x. One-grain tablets twice a day. Much vesical, reflex tenesmus." | Sulphur. It is a valuable remedy for the so called chronic metritis, and seems to reduce the venous engorgement by stimu- lating the portal circulation. This remedy is indicated by the general rather than the local symptoms. The leucorrhoea is pro- fuse, yellowish, and corrosive, burning in the vagina; the patient is melancholic, irritable, and peevish, complains of great mental Confusion, vertigo, weight on the vertex, rush of blood to the head ; appetite is gone, or excessive, fulness and pressure in the stomach after eating; constipation, or early morning diarrhoea; copious and frequent urination at night; numb sensations in hands and feet; burning of the soles of the feet at night. Thuja was recommended by Dr. Hartmann for indurations and readily bleeding excrescences about the os and cervix uteri; but Dr. Jahr " has never seen the least benefit from it, and speaks highly of graphites and kreosote, suggested by Dr. Wahle of Rome color, sometimes thin, and always very profuse; running through the night- dress, sheet, and down into the mattress on which she lay at night. Sepia, 4 x., a few pellets every third night, for four weeks, completely cured her.— DR. CHARLEs SUMNER, AV. V. State 7% ans., p. 314, 1871. 1 Dr. Conrad Wesselhoeft. * Forty Years' Practice, p. 179. 3 IO AºAVDOMAE 7/2/7/.S. for the same condition. Superficial aphthous erosions about the Os, and on the cervix uteri. Aeſt-sided ovaritis, worse at each menstrual period. Dr. Jahr' states that he has found the following remedies efficacious for catarrhal leucorrhoea: — Puls., sepia, Sulph., calc., cocc., graph., lyc., silicea. Dr. Farrington mentions, among other remedies, ammonium mur., strained feeling in groin forcing patient to zwalk bent over, crumbling stool, leucorrhoea after every urination. Dr. Clotar Müller” recommended especially calc., china, merc., nat. mur., phos., puls., Sabina, and sepia. He also wrote the following digest, to which some additions have been made : — Aleucorrhaea purely in consequence of chlorosis, without any gran- ulations or excoriations. – Calc. carb., China, ferrum, nat. mur., phos., puls., sepia. Aleucorrhaea with marked irritation, erosions, granulations, etc.— Ant. tart., arg. nit., bell., Calendula, hydrastis, iodine, merc., Sabina, thuja. A.eucorrhaea zeith cachectic appearance, and organic disease of the zuterus and neighboring organs. – Carbo veg., ars., kreosote, merc., graph., Sulph. - Aleucorrhaea zwith digestive disturbances. – Nux vom., phos., puls. ; if also hysterical and nervous, cocc., calc. carb., Coffea, lycopodium. Aleucorrhaea zwith sexual excitement, lustful crawling in the genitals. – Plat., china. Aleucorrhaea with indifference or azersion to coitus. – Causticum, Inat. Inhur. Zeucorrhoea of slimy, white, or yellowish mucus. – Calc. carb., natrum, puls. Aleucorrhaea more purulent. — China, merc., nit. ac., nux vom. Aleucorrhaea thin and watery. — Alum., ars., graph., ferrum, iodine, Sabina. 1 Forty Years’ Practice, p. 179. 2 Hom. Vierteljahrschrift, p. 448, 1860. A&AE/MAZAD/AES A'O/º LAZ. UCOAEAEA/CEA. 3 II A.eucorrhaea thick and fluid. — Ars, mez., natr., sepia, zinc. Zeucorrhaea excoriating, biting. — Alum., ars., carbo veg., he- lonias, iodine, kreosote, merc., nit. ac., phos., puls., sepia, silic., Sulph. Zeucorrhaea offensive. — Carbo veg., kreosote, nit. ac., Sabina. Aleucorrhaea, bloody slime, or like meat-juice. — Calc. carb., cocc. 2 x., China, kreosote, lycop., nit. ac. Aleucorrhaea white and milky. — Calc. carb., ferrum, lycop., nat. mur., puls., Sabina, silic, zinc. Aleucorrhaea greenish. — Carbo veg., kreosote, merc., Sabina, Sulph. Zeucorrhaea yellowish. — Ars., kali sulph., lycop., sepia. Aleucorrhaea before the menses. – Calc. carb., phos., graph., carbo veg, China, Sepia, puls. - Aleucorrhaea after the menses. – Puls., alum., graph., silicea, ruta, Calc. Carb. ſ Aleucorrhaea instead of the menses. – (Alumina,) ars, alb., china, cocculus, nux mosch., phos., (ruta grav.,) Senecin, sepia, silicea. The following list of remedies may be consulted for further study : — - Alumina, ammon. Carb.," arg, nit., aurum, bovista,” calendula, Cannabis Sat,” carbo animalis and veg., cauloph., Ceanothus am.,” * Mrs. B–, aet. 46. Constant feeling of weight in the epigastrium, worse after food, especially meat; no relish for food. Menses every fort- night, profuse, black, coagulated; profuse milky leucorrhoea, with itching of the vulva, and backache, especially before and after the menses; urine red- dish, and flow often interrupted. Ammon. carb. 4 x. cured in about two weeks. – DR. R. M. THEOBALD, Hahnemannian Monthly, p. 332, February, 1872. - * A sense of enlargement and fulness in the head, in an obstinate case of leucorrhoea, led Dr. Teste to give bovista with success. – British Journal of Aomoropathy, p. 292, 1877. Af * This is said to cure infantile leucorrhoea with the greatest certainty. — American Observer, p. 539, November, 1872. * Constant and severe pain in the left hypochondrium of more than two years’ duration; also pain under the left ribs, with yellow leucorrhoea; menses once in two weeks. Ceanothus amer. 6.x. prescribed. The pain ceased in two days, and the leucorrhoea soon after. —DR. J. C. BURNETT, Homalo- Žathic World, p. 14, Jan. 1, 1880. - 3I 2 AºAVDOME TRIZY.S. cham., cicuta, conium, ferrum, gels., ham., hepar sulph., hydroco- tyle,' ignatia, iodine, ipecac,” kali carb., lach, lil. tig., mag. mur., nux vom., phytolacca, platina, puls., Sabina, Secale,” tarantula," Xanthoxylon. | Highly recommended by Dr. Andouit for severe erosions, with profuse leucorrhoea.— Allgemeine Hom. Zeitung, also British Journal of Homatopathy, p. 587, 1859. * Dr. Imbert Goubeyre has given it a limited trial, and thinks it has a positive effect.— British Journal of Homaeopathy, p. 21, 1870. 8 Mrs. Leucorrhoea in gushes every four or five days; very severe bearing-down, dragging-out feeling in the lower abdomen; cannot promptly start the flow of urine, must always wait a few minutes. She has always had rheumatism. Secale 3 x, dil. promptly cured her. —DR. J. C. BURNETT, British Journal of Homatopathy, p. 87, 1877. * Dr. Nunez, North American Journal of Homoeopathy, Vol. XX, pp. 456 and 486. FROSION, ETC, OF THE CERVIX UTERZ. 313 CHAPTER XVII. EROSION AND LACERATION OF THE CERVIX UTERI. N connection with endometritis, it may not be out of place to describe these lesions, which so often ac- company it, and are of so much practical importance. This has seemed all the more necessary, as so many prac- titioners are not aware of the relation of erosion of the cervix, laceration of it, endometritis, and leucorrhoea to one another. Many do not make a distinction between erosion and ulceration. A genuine ulcer of the cervix is Scarcely ever seen, except in malignant disease ; and the “ulcer on the womb,” which strikes terror to the heart of the patient, and makes the case too often a profitable one to the doctor, is merely an abrasion of epithelium, more or less severe. Its real name is erosion. This may be so Severe as to have a red, angry appearance, with tufts of villi on the surface, feeling rough or slightly granular to the touch; the follicles are enlarged, and in some places have dried up, leaving chalk-like or cheesy granules on the surface. *- It may be laid down as a rule, with few exceptions, that, . where severe erosion is present, there is also a laceration of the cervir as the primary cause. The erosion may tempo- rarily heal, but is almost sure to return if the laceration be not properly closed by an operation. Some of the effects . of laceration are shown in the following diagrams, which also serve to explain why it is not always easy to make a diagnosis. 3.14 EROSIOM, ETC. OF THE CERV/X UTER/. º d Fig. 122. Diagram of uterus. The line of laceration, e.g., which may be uni- or bi-lateral; w, v, vaginal walls; A, diagram of cervix, as seen with a Sims speculum. Fig. 123. In this diagram, the lacerated surfaces, e.g., have flattened out against the vaginal walls, v, v'; they are eroded, and the follicles enlarged. B, speculum view of the cervix, the shading representing the area of laceration. Compare Figs. 122, 126. When a laceration of the cervix takes place, the uterus is enlarged, heavy, and sinks down in the pelvis so as to AACE/PA 7TWOAV O/ THE CERVIX U TERZ, 3 I5 És & FIG. 124. Section of uterus showing laceration of the cervical canal extending to the line lA. C, speculum view of cervix with large irregular os uteri. Compare Figs. 122, 123. FIG. 125. The same as Fig. 124. Compare C, showing the cervical hyperplasia, and rolling out of the cervical mucous membrane, the dotted line representing the normal contour. drag somewhat on the ligaments by which it is suspended. As the cervix is torn and its outer surface divided, the 3 I6 EROSIOM, ETC. OF THE CER VIX UTERI. tension from above is unequally distributed, and the lips gape a little, like a split celery stalk. The posterior lip may catch on the sacral wall, and the more the heavy uterus sinks in the pelvis, the more the lacerated sur- faces and the cervical canal are flattened out against the posterior vaginal wall. The blood-vessels in the cer- vix may be somewhat constricted in consequence; there are congestion and hypertrophy of the cervical lips, and involution of the entire uterus is retarded. . The capil- laries are engorged, and serum poured forth. The epithe- lial layer is softened and cast off, aided by the friction against the vagina. The follicles are also involved, their excretory ducts occluded, and the secretion collecting in the interior distends them with a peculiar pearly lus- tre. They may burst, and discharge the contents; or the latter may dry up, leaving a whitish, cheesy residue, looking like a particle of chalky concretion just beneath the surface. It is evident that, so long as the lacerated surfaces are continually irritated by constant friction against the vagina, no permanent cure will take place. The red, raw, angry- looking surface may be healed temporarily by treatment, but the same condition is almost always reproduced by the same causes. Nature attempts to cure it by uniting the wound; and in consequence we find plugs of hardened or so called cicatricial (?) tissue in the angles, which are the source of a large amount of direct or reflex irritation. The latter may be in the form of various neuralgias in different parts of the body, without unusual pelvic symptoms point- ing to local trouble. Leucorrhoea is frequently present. On examination, the angles of the laceration are sensitive, the erosion has a soft velvety feeling, the follicles feel like bird-shot beneath the surface, and often cicatricial bands extend to the areolar tissue. Localized cellulitis near the angles, and subinvolution, are often present. Besides sore aching pains in the pelvis, there are the symptoms arising LACEA’A 7/0/W OF THA. CAEA’ſº UTE/e/. 317 from various complications, and not infrequently reflex neuralgia. The reason why so many cases of laceration of the cer- vix are mistaken for erosions, or so called ulcerations, is that most practitioners use a tubular or bivalve speculum; this distends the vaginal vault, and stretches the cervical lips apart so that the eroded surfaces appear to lie in nearly the same plane, and bear a chose resemblance to FIG. 126. Bilateral laceration of the cervix, hypertrophy of the anterior lip, and erosion as it appears in the speculum. Taken from nature. The black ring is the vagina. a granulating ulcer. (See Fig. 123, B, and compare with Fig. 126.) The Sims speculum is the only one giving a view of the cervix without disturbing the relation of the parts. The presence of a laceration, if it is not felt by the examining finger, can be readily ascertained by hooking two uterine tenacula into the lips of the cervix, and bring- ing them together, when the eroded surfaces will roll into 3 I 8 EROSIOM, E Z C. OF THE CEA V/X UTERZ. partial apposition, and the line of laceration appear on the Outer margin of the cervix. The treatment of erosions of the cervix is often tedious, as they are sometimes slow in healing; but they should be cured if possible before deciding on an operation, except in severe cases. After an erosion has healed and the swelling diminished, the cervix will have a very differ- ent appearance and the necessity for an operation may be avoided. Local treatment should be employed two or three times a week. The cervix must be cleansed first with absorbent Cotton, and the plug of mucus in the cer- vical canal ought to be removed with the Roux curette. Any swollen follicles having a purplish or dark pearly lustre, or containing white cheesy deposits of inspissated mucus, and which feel to the examining finger like small shot beneath the surface, must be opened. No pain will be caused. The application will vary somewhat with the local conditions. If the uterus is not much engorged, the erosion does not bleed with the least touch, and there is considerable leucorrhoea, the dry treatment applied in the following manner is efficient. Fill one of Davidson's pow- der blowers with equal parts of hydrastin, Sanguinaria, and myrrh, and blow on powder enough to cover the erosion with it, then rub a dry wool tampon in the same mixture, and apply it to the cervix, and beneath it, in such a way as to support the uterus. This tampon should be removed within thirty-six hours. Calendula cerate is good when the erosion bleeds very easily, but I have usually been obliged to resort to some other application to complete the cure. Boracic acid and plantago cerate is excellent, especially if the erosion looks a little aphthous, or if the leucorrhoea is offensive or excoriat- ing. If the cervix is much swollen and congested, and the patient complains of dragging pains, puncturing the cervix so as to withdraw three or four teaspoonfuls of blood will give much temporary relief to the patient, but it must not DZAGAVOSIS AAWD SEQUELA. 319 be done if the patient be anaemic, and not oftener than once in two weeks. The application of equal parts of boroglyceride and glycerine on wool tampons is very helpful for such erosions with congestion of the uterus. Crude pyrogallic acid is the favorite German application, and is often very efficient. Although these various medi- caments may have been faithfully employed, it will some- times happen that the erosion does not heal beyond a certain point. It is just here that an operation should be performed in many cases. Yet there are some in- stances in which the local and general improvement have been so marked, that we have reason to hope an operation could be avoided if the stubborn erosion would only heal. It is in such cases that I can recommend the local use of the nitrate of silver, merely touching the erosion with a solution of five grains to the ounce. This should be considered always as a last resort. The application of nitrate of silver has done an incalculable amount of mis- chief, which has never been fully appreciated. One very noticeable effect is pain in one or both ovaries, which is very difficult to cure. The erosion may heal all right, but if the cervix be severely lacerated, the erosion will very often return. In treating any case of erosion it is of the utmost importance to prohibit all sexual excitement. (See page 298.) The Sequela of cervical lacerations are sometimes seri- ous, though not in every case. It has been truly said, that there is scarcely any portion of the body where com- paratively slight lesions may produce So much suffering as in the pelvic organs. Perhaps the most important of the results of laceration of the cervix is the increased sus- ceptibility to epithelioma of the cervix, from the con- tinued irritation of the raw granular surfaces. The latter has been so marked, that distinguished specialists with an unusually large experience have mistaken it for epithe- lioma. This is a very important reason for Operating on 320 EROSIO/W, ETC. OF THE CERVIX UTERI. all lacerations of the cervix with erosions, and especially on all women, even if there is no erosion, in whose family there have been cases of cancer. - - Besides the local symptoms already described, there are hysterical manifestations, neuralgias, Subinvolution, menstrual derangements, anaemia, and even a partial loss of mental power. The only remedy is an operation which will remove the plugs of hardened (cicatricial) tissue, and restore the cervix as nearly as possible to its original con- dition. Not every case needs it, nor does the necessity for an operation depend entirely upon the extent of the lesion. A small laceration, with a large amount of hardened tissue in the angle, often gives rise to more severe symptoms than deep lacerations with less cicatricial (?) tissue, The necessity for an operation depends upon the symp- toms remaining after the cellulitis has subsided, and the endo-cervicitis healed so far as possible, except in cases where there is a family history of malignant disease. In the latter instance, the operation should always be per- formed to remove any possible focus of irritation for the development of epithelioma. If there are troublesome symptoms remaining, such as pain, leucorrhoea, headaches, neuralgia, menorrhagia, etc., after a careful selection of remedies, combined with local treatment, an operation is advisable, more especially if the patient dates the trouble from some particular con- finement. Two questions come up for consideration in connection with this operation: first, whether it entails sterility; and, secondly, if not, the possibility of recurrence in a subse- quent pregnancy. Much has been written, and statistics collected, to decide the question if possible. So far, there is reason to believe it favors rather than prevents child- bearing, more especially in those cases where a deep cervical laceration destroys the normal resistance of the inferior segment of the uterus, and the latter expands with TRAEA 7TMAEAVT FO/P LA CE/PA 7TWO/W. 32 I the growing ovum, allowing it to escape prematurely. It is not unlikely that an expert operator might succeed in , constructing a very narrow cervical canal which would materially diminish the chances of conception. During normal labor, the cervix should not be meddled with by stretching. it in any way. This is a common cause of laceration, though the lesion is unavoidable in many cases. Careful observers believe that the slight cicatricial tis- sue in the line of union is absorbed within six months afterward, and does not cause rigidity of the cervix. This is probably an instance of the alterative effect which com- monly follows the operation, as an enlarged uterus not infrequently becomes smaller, apparently as the result. It sometimes happens that a careful examination of the cervix three months after labor does not show any lacera- tion of importance, yet in another examination a year or two afterwards there may be all the appearance of an ex- tensive tear in the cervix and its sequelae. The writer has observed such cases where there had been no childbirth in the interval. He is of the opinion that in such cases there has been an abortion or much congestion of the pelvic organs, and irritation of the cervix in consequence . of increased secretion ; then endocervicitis follows, the tissue of the cervix hypertrophies, and is engorged with blood. The whole uterus is enlarged and sensitive. The swollen, large, eroded cervix gapes apart, as seen in the speculum, having all the appearance of a severe laceration. Similar cases are sometimes seen in young unmarried women, and with appropriate treatment are almost sure to be cured without an operation. Should a laceration be discovered during the lying-in period, it might heal spontaneously in exceptional cases if kept cleansed by vaginal douches of warm calendulated water; but closure by suture should not be attempted till after the period of involution has passed, i. e. not earlier than three months after labor. If the lesion has existed 2 I 322 EROSIOM, ETC. OF THE CERVIX UTERI. for some time, and is complicated by pelvic cellulitis, endocervicitis, granular degeneration of the cervix, etc., careful preparatory treatment is essential to success. It is important that the congestion and erosion of the Červix be reduced as much as possible; and all local inflamma- tion and Soreness about the cervix must have disappeared before it is advisable to operate on the laceration, i. e. perform trachelorrhaphy, or hystero-trachelorrhaphia, as it has been more properly termed. The preparatory treat- ment is therefore the same as for endometritis and inflam- mation of the pelvic cellular tissue and peritoneum, to which the reader is referred. There is very little risk to life; in over three thousand cases, ten deaths occurred, and these when the operation was less understood than at the present time. The per- centage of failures to secure union is larger in hospital than in private practice," which seems to show that it is for the advantage of the patient to have the operation performed at home, or in a private house, rather than in a hospital. . HYSTERO-TRACHELORRHAPHIA, OR THE OPERATION FOR THE CURE OF A LACERATED CERVIX UTERI (EMMET'S OPERATION). In some cases where women object to ether, or the pres- ence of renal or cardiac disease counter-indicates it, this operation can be performed with or without a six per cent solution of cocaine, as the cervix is not composed of very Sensitive tissue. The cocaine can be applied freely before the operation, with a camel's-hair pencil, and at intervals of five or ten minutes during it if necessary. Freshening the surfaces will not be felt, but the insertion of the needles is often painful. As a rule, it is better to give ether. About half an hour before the operation, the patient should undress, put on a vest, night-gown, and stockings, 1 Dr B H. Wells, American Journal of Obstetrics, June, 1884. OPAEAEA 7TWOZV A'O/º LA CAERA 7TWOAV. 323 and then take a vaginal douche of six quarts of hot (I 12°) mercurialized (I : 4OOO) water while lying on her back. This not only cleanses the vagina, but also diminishes the amount of blood in the veins and capillaries, and thus lessens oozing. The rectum should be emptied by an enema. While this is being done, the room where the operation will take place is prepared in the following manner. Place a table (a kitchen-table answers the purpose) about two by four feet in a good light, with the foot of it towards the window and raised a couple of inches on a piece of plank or a couple of bricks; cover it with a pair of folded blan- kets, a water-proof over them at the foot, and put a pillow at the head. Near the latter place a slop-pail, and a small stand with two washbowls and pitchers of hot and cold water for washing sponges. The latter are first cleansed in one bowl of carbolized (three per cent) water, and rinsed in the second bowl of water carbolized in the same way, taking care to squeeze them quite dry before they are passed to the second assistant. If the operator prefers, a solution of corrosive sublimate or the bin-iodide of mer- cury (I : 40OO) can be substituted for the solution of car- bolic acid. Another small stand is placed near the foot, and to the right of the operating table. The instruments to be used are put for a few minutes in a five per cent solution of carbolic acid, wiped dry, and laid on a clean towel which covers the small table. It is well to have them grouped together for convenience, i. e. tenacula in one group, scis- sors in another, and those used in applying the sutures in a third group, etc. The operation about to be described is that of its origi- nator, and the method universally employed in New York. It is more difficult, and requires more time, than the method of placing the patient in the exaggerated lithot- omy position, freshening with the knife, and using curved needles with silk sutures. I have tried both, and prefer 324 EROSION, ETC. OF THE CERVIX UTERI. the former method. The chief objections to the latter are, liability to excite pelvic inflammation by dragging on ad- hesions or sites of previous cellulitis, weakening of the uterine ligaments, and a remote possibility of causing haematocele by the tearing away of an adhesion, or rup- ture of varicose veins 1 in the broad ligaments; its advan- tages are the ease and rapidity with which the operation can be performed. It is a good plan to explain to each assistant, if inexpe- rienced, the details of what is expected of him, names of instruments, etc. This advice may seem superfluous; but the rapidity and success of an operation depend largely upon the detail of preparations, and the knowledge as well as experience of the assistants. Much of the time occupied by an operation is often spent by the operator having to do his own sponging, waiting for instruments, etc., instead of having everything at hand the instant it may be required. There should be six assistants, (although it is possible to get along with half that number,) arranged in the follow- ing manner: — * The first one administers ether. The second stands to the right of the table, and, bending over the patient, sponges; he has also charge of the te- naculum to steady the uterus in the left hand, and uses the counter-pressure hook and wire scissors. He must always watch the field of operation, passing Soiled sponges over his shoulder, and picking up fresh ones from a towel laid over the patient at his right. The third assistant sits at the right of the operator, watching him closely, and anticipating him in the choice of instruments by holding the proper one where it can be seized at once, receiving in return the one previously used. The fourth assistant holds the speculum, and raises the 1 Dr Emmet records a very serious case of haematocele caused by trac- tion on the cervix, in his Principles and Practice of Gynecology, p. 227, 1884. OPERA 7TWO/W FOA' LACEACA 7TWOAZ. 325 upper labium with the left hand. It is of great importance to keep the speculum in the precise position given by the operator. - The fifth assistant thoroughly washes the sponges with- out removing them from the holders, and places them with the handles toward the operator on the upper thigh of the patient; or, better, hands them to the second assistant. The sixth assistant does errands about the room, and helps wash and hand the sponges. The following instruments will be found necessary: — FIG. 127. I broad, short, and flat Sims's speculum. ( FIG. I.28. 1 Emmet's tenaculum. C I Sims's tenaculum. FIG. 129. CODMAN & SHURTLEFF, BOSTON. FIG. 130. I heavy tenaculum of solid steel, short hook and heavy shank. 326 EROSIO/W, ETC. OA. THE CERVIX UTERZ. 1 long mouse-toothed forceps. codMAN & shue'rlºff, BOSTON. FIG. 131. I pair straight sharp-pointed scissors, slightly curved on the flat (Dawson's). E -- - - II.Cº-ess - E - - --Cº. * = } E É - FIG. I32. I pair Emmet's cervix scissors, curved for the right hand. ſº- -> CODMAN & SHURTLEFF, BosTON. FIG. I.33. I counter-pressure hook. 1 Sims's needle forceps. 6 Emmet's needles, latest pattern, sizes varying from 3 in. to 1 + in. long, threaded by passing the ends of a piece of fine braided and waxed silk ligature, sixteen inches long, through the eye of the needle, in opposite directions. The needle and ends of the silk are twisted a little, to prevent the loop, which is about six inches long, from slipping out. A neat way to prevent tangling of the threads is to baste them coarsely through a strip of chamois-skin. 12 pure annealed silver wires (No. 27), twelve inches long, with half an inch of one end of each bent at a sharp right angle, to hook in and bend close down on the silk loop. - – = ------, - … = E-------> *E== ---E-->==E=E. Tº->= Eºs - T --------- rºmº-WFFRETRY. FIG. 135. I Sims’s shield. I pair of wire Scissors. =fºssTºšŠē g=º F.G.OTTO-SON S. J.Y. FIG. 137. 6 solid sponge-holders, in which are firmly fastened as many very small, fine, aseptic sponges; and an equal number of sponges in the clean carbolized water. It is better to etherize the patient in an adjoining room, bring her in, and place her on the table in Sims's position. A towel is folded from before backwards, over each thigh and buttock. The speculum is inserted so as properly to expose the cervix, and given to the assistant to hold. The cervix is now seized in the median line, with the solid tenaculum, on the anterior lip (at K, Fig. 138), and drawn a little forward, so as to put the tissues somewhat on the stretch, and obtain a better view of the torn surfaces; the posterior lip is seized with a second tenaculum, and 328 EROS/O.V., ETC. of 7//E CE/ey/A. J.7E/º/, the two lips are brought together to ascertain the amount of denudation necessary to obtain a symmetrical cervix. The solid tenaculum is then given to the second assist- ant, who holds it in, and thus steadies the uterus with his left hand while he sponges with his right. The operator Fig. 138. Diagram of a bi-lateral laceration of the cervix, with the anterior (A) and posterior (B) lips drawn apart, the shape of the denuded strips with the sutures inserted in the upper one; K K, undenuded strip left to form the cervical canal; F F, angle of laceration, and divergence of the lips; G, denuded strip; e e, first suture in- serted at the angle; d d, second suture; c. c and * *, also sutures; H, cervical canal. now takes up a bit of tissue on the lower side at a point corresponding and opposite to G, Fig. 138, with Emmet's fine tenaculum, or, if the tissues are soft and friable, with the long mouse-toothed forceps in his left hand, and de- nudes with the scissors (Dawson's) a thin continuous strip up to the angle F, which is met by a corresponding strip on the posterior lip. The sharp curved scissors are often useful in denuding the angle. Here the dissected strips must not be pulled hard while the scissors are cut- ting behind them, on account of stretching and removing much more than is necessary. OPERATIO/V FOR LA CERA 7TWOAV. 329 All enlarged follicles must be entirely removed, as well as hardened pieces of tissue at the angle. The latter, or supposed cicatrices, are seldom as large as peas, and the operator should not feel it necessary to excise a large sec- tion on account of “the cicatrix.” The area of denudation, which is shown in Fig. I 38, ought not to extend far out on the external mucous membrane of the cervix; and a strip about three sixteenths of an inch wide (KK) must be left FIG. 139. Diagram of the cervix after the lips are drawn together and the wires twisted. Letters same as in Fig. 138. for the cervical canal, a little larger at the outer ends so as to avoid too small an external os after union and shrinking of the tissues. A similar strip is then removed in like manner from the upper side of the cervix. It is impor. tant to bear in mind that the strips on the anterior and posterior lips are corresponding halves, and must be sym- metrical, the anterior with the posterior portion, in order to obtain good union. - If the laceration is on one side, only that side is denuded. The question of uni- or bi-lateral laceration is easily settled by passing a sound in the uterus, and holding it in the median line, and the extent of laceration on one or both 33O EAEOS/OM, ETC. OF THE CER VI.Y. UTERZ. sides of the sound at once makes the diagnosis. Some allowance must be made when lateral displacement is present. - There is little use in waiting and sponging for bleeding to cease. If there is some point which bleeds freely, it can be seized with artery forceps (Péan's) till the wires are in, ready for twisting. The best way is to proceed at Once to insert the sutures, beginning at the angles, and, if the laceration be bilateral, put in the suture first on one side, then on the other; for if all the wires are inserted on one side first, there is less room to put in the others on the opposite side. For this reason, unilateral tears are more difficult to suture than laceration of both sides of the cervix. The first suture is at a level, or a trifle above the denuded angle. When this is tightened or drawn upon, it rarely fails to control the bleeding. The third assistant bends the silver wire close down upon the loop attached to the needle (three fourths inch to an inch long), puts the needle in the needle forceps, and hands it to the operator. It is inserted about a quarter of an inch from the margin of the wound, and passed straight through nearly to the centre of the undenuded strip for the cervical canal. As the point is seen to emerge on the surface, the second, assist- ant presses on the cervix at that place with the counter- pressure hook, and the needle is pulled through with the needle forceps. It is again inserted, and made to emerge at corresponding points on the other lip. The loop and wire are then held taut in the hands, and the wire is made to pass through by a quick to-and-fro motion. One end of the wire is bent over and twisted a little around the other end, and slipped up within two inches of the cervix, while the free end is caught by the fingers of the nurse, if on the upper side; if the lower, it is passed beneath the lower edge of the speculum. Each suture is inserted in this way, with a space of OPERATION FOR LACERATION. 33 I three sixteenths of an inch between them; three on a side are usually sufficient; a little puckering of the edges can be remedied by superficial silk sutures. The object of passing the needle through each lip sep- arately is to secure greater accuracy of adaptation. A common mistake is to pass the needle near the denuded surface; the result is, when the suture is tightened, it puckers the surfaces together like the running-string in a bag, and there is only external union, leaving a dilated cervical canal in which the secretions collect, and the patient derives little if any benefit from the operation. The same objections apply to the curved needle, which necessarily passes in a curved direction, and drawing on the suture tends to force and pucker the tissues round a common centre more than when the straight needle is used in the above manner. The difficulty in introducing the first sutures at the ex- treme upper margin of the angles arises from lack of space to use the needle and its holder. This can be obviated by passing two needles, one through each lip, from the cervi- cal canal out to the surface, where it can be easily seized. One loop is passed through the other, the latter is drawn out through the lip, carrying the former loop with it, which now extends through both lips; a silver wire is then easily bent down in it, and drawn through as before. After the wires are all in place, the lips of the cervix are gently separated, and all coagula or bits of fibrine carefully sponged away. The sutures are fastened in the following manner. Both ends of the wire at the angle are seized by the twister, about two inches from the cervix, and the long free end cut off by the second assistant. Holding the wires by the twister, the operator kinks them down together immediately over the proposed line of union by the tenaculum, slips the shield over them close to the cervix, bends the wire down sharply over the shield, and twists till the twist of 332 EROSIO/V, ETC. OF THE CERV/X OWZTEAe/. the two wires meets at the edge of the wound, and removes the shield. A fine tenaculum is now slipped beneath the wire loop, and draws it out slightly where it enters the cervix on either lip; this diminishes the tension and dan- ger of cutting out at these points. The twisted end is bent close down on the cervix at right angles to the wound, and cut off, leaving an end half an inch long which will not prick into adjacent tissues. If the latter are blanched about the wire, it is too tight, and must be loosened by untwisting. Each suture is fastened in this way; the margin of the wound being held by tenacula, if necessary, to secure per- fect adaptation, or prevent rolling in of the margins. Finally, the sound is passed, to be sure that the cervical canal is pervious, the uterus placed in anteversion, retained if necessary by a small tampon smeared with vaseline, and the patient put to bed. She should be kept as absolutely quiet as possible for forty-eight hours, so as to secure primary union. On no account must she rise or sit up in bed for the first few days. The urine or faeces can be passed in a bed-pan. Night and morning, as well as after each micturition, a vaginal douche should be given of two quarts of warm water and one table-spoonful of the non- alcholic extract of calendula; some surgeons prefer hy- drastis to the calendula. The night and morning douches can be dispensed with after the fourth day, if there be no discharge. It is not uncommon to have very slight oozing for the first twenty-four hours, and on the third or fourth day a reddish discharge may appear for a short time, similar to the menses. This need cause no alarm, and very seldom interferes with union. There is scarcely ever any pain or rise of temperature (above 99°) after the operation ; indeed, it may be said, there are few if any operations known which so often give as much relief with as little pain and risk as trachelor- rhaphy. The great risk in properly prepared cases is \ OPERATION FOR LACERA Troy. 333 wounding the circular artery by cutting too deeply in the angles. The best remedy for this is to pass a deep suture above the angle, and twist it up. If the laceration was deep, and required seven or eight sutures, they should remain ten days ; otherwise, they can be removed on the eighth day. For this purpose the pa- tient is again placed in Sims's position, the speculum in- serted, the cervix brought a little forward, and steadied by a tenaculum inserted in the posterior surface of the pos- terior lip. The wire twist is gently raised with the forceps till the shining loop is seen, which is cut with the wire scissors near its insertion in the cervix; it is then with- drawn across the line of union so as not to drag the surfaces apart. Great care must be taken not to cut off the twist, which makes it very difficult to find and extract the loop. It is important to remember the number of sutures on a side, as it is easy to overlook one." On more than one occasion have I known excellent surgeons to be censured for the oversight. After the wires are removed, the patient is again put to bed, and the suture canals soon close. On the fourteenth day she can sit up, and in three weeks from the day of the operation go about the house if she has done well. Sexual intercourse must be absolutely prohibited for two months, and if the physician fears his directions will not be fol- lowed, it is well to leave a suture in the cervix; tell the patient, without comment, that it is necessary to leave a sharp wire there for a couple of months, which will do her no harm. The best time for operating is a week after the menstrual flow. While it is easy to perform with proper instruments, and union almost invariably follows, the best results are only obtained by careful attention to detail, a thorough knowledge, and some experience with the operation. Never try to trim a hypertrophied cervix down to nor- 1 See coil sutures, p. IOS. 334 EROSIO/W, ETC. OF THE CERVIX UTERI. mal dimensions in freshening, as the cervix will undergo a kind of involution, as well as the fundus, if enlarged after the operation. Do not promise the patient immediate relief, though some may be experienced, after the opera- tion. The best results will be seen six months afterward. The small cicatrix of complete union between well adjusted surfaces almost always disappears in six months, and will not cause rigidity of the cervix in a future labor. Unless the canal is made abnormally narrow, the operation does not cause sterility. If three years have elapsed between the operation and the next labor, laceration of the cervix is no more likely to take place again than at a first labor with the same conditions present. I have modified my method of operating on some cases in the following manner. The position of the patient, as- sistants, and instruments are the same, with the exception of Hagedorn's needle forceps, his strong cervix needles, and the No. 3 catgut hardened by chromic acid or juniper oil. (See page I I I.) The cervix is freshened in the usual manner; the raw surfaces carefully cleansed with hot water, every particle of blood-clot being sponged away. The anterior and pos- terior lips of the cervix are brought in contact, so that the freshened surfaces meet each other accurately. Both lips are then seized on their outer surfaces, near the external os, between the short points of a pair of gynecological bullet forceps. * Beginning at the upper angle of the laceration, the Ha- gedorn cervix needle is thrust deeply through the cervix, which is sewn with a continuous catgut suture, the stitches being taken near together; when one side is sewn, the needle is at once carried, without cutting the catgut, to the upper angle of the opposite side if the laceration be bilateral, which is sewn in the same way, i.e. one continu- ous piece of catgut is used for both sides. The bullet forceps are then removed, and an ordinary OPAZ /('A 7TMOA' A'O/ø LA CERA 7TWOAV. 335 silkworm-gut suture inserted at the same place, So as to hold the lips in contact should the catgut loosen pre- maturely. The catgut must not be touched with water or a wet Sponge. - After the sutures are all in, the cervix is carefully dried, and powdered with a little iodoform. A strip of iodoform gauze is packed loosely in the vagina. The patient is put to bed, and the urine is drawn with a catheter once in six hours. If there is no bad odor or discharge from the vagina, no vaginal douche is used, and perfect quiet en- joined. A little discharge and some odor are not uncom- mon about the fifth or sixth day after the operation. The gauze is then removed from the vagina, and a small carbolized douche with a little calendula is administered. The use of douches from the beginning is not advisable when catgut sutures are used, as the water softens the sutures; nor must these sutures be drawn tight when put in, &ut only snug enough just to hold the parts in contact with as little traction as possible. The advantages of this method are increased rapidity of operating on account of time saved in not twisting wires or tying knots, only one suture being removed, and a sav- ing of pain to the patient, besides equally good results. The author does not claim this modification of this operation as his own, though he has not known of or seen others operating in this way. 336 A CO/7 E ME Z R/T/S. CHAPTER XVIII. ACUTE METRITIS. HIS term is used to designate acute inflammation of the uterus from various causes. By far the most common is inflammation of the uterus after delivery, which is generally associated with septicaemia. Acute metritis in virgins is a very rare disease. This form will not be considered here, as it belongs to obstetrics, rather than gynecology. Acute metritis is liable to become chronic; but, with proper care and treatment, the acute symptoms subside within a week, and the others soon after, except in cases of great severity. The causes of this affection are: chill during the menses, with sudden suppression of the flow; traumatism from the use of the sound, curette, tents, intra-uterine pessaries and medications; production of abortion and surgical opera- tions on the uterus ; excessive venery and gonorrhoea. The constitutional disturbance will vary with the severity of the attack, and the extent to which structures adjoining the uterus are involved. A chill may mark its commence- ment, especially in septicaemic cases; following this there is a rise in temperature, with much local pain, sensitiveness, and sometimes throbbing in the uterine region, bearing down, not infrequently tenesmus of rectum and bladder, and nausea and vomiting when the peritoneum is affected. On vaginal examination, the cervix is found congested, with heat, dryness, and so much tenderness to pressure that the uterus generally cannot be mapped out by a bimanual examination. THERAPAE UT/CS. 337 The diagnosis of acute inflammation of the uterus is easy; but whether it is limited to that organ alone, it is sometimes impossible to decide. In severe cases the peri- toneum is generally involved. The pathological changes consist in congestion, enlargement, and a little softening of the uterus. Abscesses seldom, if ever, form within its walls, unless the inflammation is the result of septic infec- tion. The Treatment consists in perfect quiet in bed, a nour- ishing fluid diet, such as milk, eggs, soups, and gruels. In the very beginning of the attack, a copious hot-water vaginal douche is excellent to control the inflammation. Suppositories of belladonna may be used in the vagina, but no tampons. A hot bran or moist hot hop-bag on the hypogastrium will be sometimes of some service. In cases of septic infection, the hot douche should consist of a I : 40OO solution of corrosive sublimate. The indications for the following remedies are so well known, it is not considered necessary to repeat them in detail. The reader is also referred to the chapters on Chronic Metritis and Pelvic Cellulitis and Peritonitis. THERAPEUTICS. Acom., arn., ars., BELL., bry., canth., China, Crocus, gels., merc. cor, nuºc vom.,’ phos., puls, rhus tox,” verałr. vir. * Hartmann praises this remedy highly for metritis after labor, especially when coffea has been drunk to excess. – Therapie, vol. i. p. 496. * Dr. Hoyne says rhus tox. can be relied on for metritis following confine- ment with typhoid symptoms. – Clinic Therapeutics, vol. i. p. 131. 22 3- 338 CHA’O/V/C MAZ, TRZZYS. CHAPTER XIX. CHRONIC METRITIS.1 Synonymes: Areolar Hyperplasia, Parenchymatous Metritis, Sub- involution, Congestive Hypertrophy of the Uterus. HE name “Chronic Metritis” is chosen as being the One in more common use, though it does not always correspond to the exact pathological changes in the uterus. The disease consists essentially in an increased develop- ment of connective tissue, accompanied by passive conges- tion, with hypertrophy of the uterus. It is not necessarily associated with, nor does it follow, the usual course of inflammation. Sub-involution,” i. e. failure of the uterus to undergo complete involution after parturition, may be regarded as one of the first stages of chronic metritis. It is usually called a cause; but, practically, it is impossible to tell just when sub-involution merges into chronic me- * For a detailed description of the pathology of this disease, and the views of different authors, the reader is referred to an exhaustive article on Sub- involution and Chronic Metritis, by Dr. Mary Putnam Jacobi, in the Ameri- can Journal of Obstetrics, p. 802, 1885. * Super-involution, or atrophy of the uterus after parturition, the opposite condition to sub-involution, is comparatively rare, and seldom susceptible to treatment, unless the ovaries are in good condition. The uterus is small, perhaps an inch and a half deep, and the prominent symptom is amenorrhoea. Post-partum hemorrhage and protracted lactation, especially in scrofulous subjects, seem to be the most important predisposing causes. The treatment consists in restoring the patient to her best physical health, by nutritious food, exercise, fresh air, etc. The galvanic stem pessary has been thought useful as a local stimulant. The Faradic current is also well spoken of, in preference to the galvanic. S PMA 7'OM.S. 339 tritis, and ceases to be sub-involution. Chronic metritis is generally associated with endometritis, which frequently antedates it; and, like endometritis, may be confined to either the body or cervix uteri, the latter being the more common form. Although chronic metritis is seldom found in nulliparae, and in the great majority of cases begins with sub-involu- tion, the latter is not the only form of the disease. A uterus may undergo complete involution, and in conse- quence of some predisposing cause, as a scrofulous dia- thesis, debility, or too frequent parturition, chronic metritis may develop afterward from one of the following exciting causes: chronic congestion of the uterus from obstruc- tion to the portal circulation, uterine displacement, neo- plasms, the practice of incomplete sexual intercourse, intentional or otherwise; also, the exciting causes of sub-involution, laceration of the cervix, puerperal pelvic inflammation, getting up too soon after delivery, or co- ition before the sexual organs have undergone complete involution. - The Symptoms vary in different cases, and can hardly be separated from those of the complications which are usually present, such as laceration of the cervix, endome- tritis, etc. --- In most cases there are backache and bearing down Sensations in the pelvis, worse on walking; vesical te- nesmus, and painful or difficult defecation from pres- sure on the bladder or rectum; dyspareunia; leucor- rhoea; dysmenorrhoea; headache; and, not infrequently, dyspepsia. On bimanual examination, the uterus is found en- larged, and often, though not always, sensitive. It sags down in the pelvis, so that the cervix often rests on the pelvic floor, while the fundus tips in some abnormal direction. The sound shows an abnormal depth of the cavity. Where the disease is limited to the cervix, 34O CHROM/C METR/T/S. however, both the cavity and fundus are of the normal depth. The diagnosis of sub-involution is made by the menor- rhagia following parturition, and the increased size and depth of the uterus. The Prognosis in hyperplasia, affecting the body of the uterus, is unfavorable as regards perfect and permanent cure, but the patient can be relieved of her symptoms to such an extent that she will suffer little, if any, except as the result of some imprudence, when they will return. In hyperplasia of the cervix, the prognosis is favorable, as the complications are fewer and less serious. The Treatment of this disease must be persistent, and continuous for months if necessary. No permanent bene- fit will be derived from occasional prescriptions or appli- cations. As it is so often associated with the puerperal State, it may not be out of place to call attention to its management. The patient should have plenty of pure fresh air, and be fed freely as she can bear it, instead of dieted on thin gruel, toast tea, and other non-nutritious del- icacies so popular in the lying-in room. Sleep is essen- tial. It is a good plan to take the child into another room, so that the mother can rest undisturbed. From the begin- ning, the child can nurse at midnight, and not again till four in the morning. This interval can be soon lengthened gradually, and the mother have six or eight hours' sleep without the baby's remonstrance. It is of paramount importance for the physician to be absolutely sure of firm and permanent contractions of the uterus before leaving the patient. A binder properly applied, so as to support the relaxed abdominal walls for the first three days after delivery, is a comfort to the mother; but a very tight bandage, particularly if there is a pad under it, is very injurious. Besides a careful watch for any inflammatory symptoms, the obstetrician should not allow the patient to sit up before the fundus uteri has TA’A. A 7TMAZAVT. - 34. I receded to the pelvic brim," and should emphatically forbid any sexual intercourse during the three months following delivery. - - It is of great importance to ascertain and remove all causes of the disease, or complications which tend to keep. it up, such as endometritis, vaginitis, laceration of the cer- vix, or displacement of the uterus. Neglect to do this is the reason why so many women fail to receive any benefit from treatment. Not infrequently there is a fungoid or polypoid degen- eration of the endometrium, characterized by profuse men- orrhagia; unless internal remedies relieve, it will be neces- sary to use the blunt wire curette to remove the minute growths. - Any displacement must be corrected, so that the circu- lation will be free and unimpeded. The clothing ought to be loose about the waist, and the skirts suspended from the shoulders. If an abdominal bandage can be smoothly fitted, so as to take off the weight of the intestines from the pelvic organs, it will add much to the comfort of the patient. - Perfect sexual rest is necessary. The patient should keep her bed during the menstrual periods, and take a limited amount of exercise in the open air every day. Housework, going up and down stairs, using a sewing- machine, and long walks, must be prohibited. A plain nutritious diet is advisable to maintain the patient's health and strength. The mineral waters of Kreuznach, Ger- many, have a considerable reputation in the treatment of this disease. Local depletion by puncture or scarification of the cer- vix, so as to allow about a table-spoonful of blood to escape, will temporarily relieve the patient; but it is diffi- 1 This is readily ascertained by the hand on the hypogastrium. It varies from eight to fourteen days after delivery. See “Rest after Delivery,” by Dr. Garrigues, American Journal of Obstetrics, October, 1880, p. 861. 342 CHA’O/V/C A/A2 7TR/ZZ.S. cult to see how any permanent good will result. Too much importance cannot be attached to the systematic use of copious hot-water vaginal douches, which may be combined with hot sitz-baths.” Great benefit” is sometimes derived from a mild gal- vanic current, applied every second or third day, for three, or even four months, if necessary; the negative pole being placed on or within the uterus, and the positive over the hypogastrium. I have so far used a current of eight to twelve milliamperes for this purpose. Many physicians prefer the compound tincture of iodine for an application to the cervical canal or uterine cavity, according to the site of the hyperplasia. Other good authorities speak highly of the use of iodized phenol twice a week. When the latter is used for the first time, it is well to tell the patient that a bloody discharge will prob- ably follow, and that it is no cause for alarm. A mixture of glycerine and iodine, applied on tampons, has often a beneficial effect. Powerful caustics, such as chemically pure nitric acid, the acid nitrate of mercury, the solid nitrate of silver, etc., are apt to do far more harm than good, and should never be employed. In marked cer- vical hyperplasia, amputation by removal of wedge-shaped pieces from the anterior and posterior lips by Marckwald's method,” has often a decided alterative action, and is fol- lowed by diminution in the size of the uterus. When chronic metritis is associated with laceration of the cervix, an operation on the latter will materially reduce the size of the uterus by its alterative effect.* Any successful treat- ment must be persistent and long continued. Too much must not be expected from the remedy selected, without allowing sufficient time for it to act. Some cases are very 1 See chapter on Minor Surgical Gynecology, pp. 47 and 228. 2 See chapter on Electricity in Gynecology. 8 Archiv für Gynākologie, Bd. VIII. p. 48. 4 Compare chapter on Laceration of the Cervix, p. 313. THEA’APA. (WT/CS. 343 difficult to relieve, while in others the favorable effect of the remedy is very soon apparent. THERAPEUTICS. Actea racemosa.” Uterus engorged and sensitive, menses recur too often ; patient nervous, wakeful, and Complains of pain through the pelvis, and backache, relieved by lying down. Arsenicum. The iodide is preferred by some. It is adapted to both acute and chronic cases; burning, throbbing, lancinating pains in the uterus; similar pains extending from the abdomen, or ovaries, more especially the right, into the uterus, vagina, or thighs, which feel numb or lame, worse from motion or sitting bent over; leucorrhoea profuse, thick, yellowish (hydrastis, kali bi.), corrosive (alumina, kali carb., kreosote, merc., puls.); great restlessness, prostration, thirst, but worse from drinking cold water; aggravation of symptoms about midnight, if the symptoms are of a typhoid type ; threatened putrefaction or gangrene (secale cor., lach.). Aurum. Chronic cases of long standing. The uterus Sags low down in the pelvis, and is indurated ; suicidal melancholia, scrofulous, syphilitic, or mercurialized subjects. Dr. E. C. Price" finds aur. mur. nat. 2 x* (chloride of gold), next to ars. iod., the best remedy for cervical enlargement. (Carbo anima/is, sepia.) | Belladona." Acute cases. Arterial congestion of the ute- rus (sabina, lil. tig.); on vaginal examination there is marked pulsation in the pelvic organs, a sensation of heat, and great sensi- 1 Dr. B. F. Betts. * He also speaks well of ferr. iod. for the chronic form, with tenesmus of the rectum and bladder, with bearing down. — American Homaeopathic Ob- server, p. II.4, March, 1881. * Dr. Tritschler very warmly praises the chloride of gold 3.x. for indura- tions or hypertrophy of the uterus, and quotes a number of interesting cases, associated with extreme displacement of the uterus, generally posterior, also with sterility, cured by this remedy. He states the effect cannot be seen be- fore four weeks, and that many women notice a remarkable increase in the appetite during the use of gold. (Compare Hahnemannian Monthly, 1877, also Homoeopathic Recorder, p. 102, May 15, 1877, quoted from the Allge- meine Hom. Zeitung, Bd. XCIV. Nos. 17, 18, 19.) * This remedy is very highly commended for acute metritis by Dr. Mathe- son. Compare his four lectures on the Diseases of Women, Metritis. 344 CA//('OAV/C. A/F 7/8/T/S. tiveness; there is much bearing down, backache, throbbing head- ache, face flushed, and even delirium ; the lochia feels hot to the patient; menorrhagia, with profuse, hot, red flow ; menses too early (amm. Carb., Calc. Carb., nux vom.). Calc. carb. or iodide. Strumous diathesis, chronic cases, sub-involution ; menses too early, too long, and too profuse (aloe, ambr., amm. Carb., bell, brom., cyclamen, coccus cac., nux zom.); milky leucorrhaea (coni., lyc., puls., sepia, Sulph. ac.); profuse per- spiration from the least exertion, chiefly about the head; feet feel cold and damp ; acidity of the stomach. The patient feels worse during and after coition. Iodine is mentioned by Hempel” on clinical evidence; indura- tion and swelling of uterus and ovaries (coni.); metrorrhagia, worse after every stool; acrid, corrosive leucorrhoea, worse at time of menses; the breasts dwindle away, and become flabby; local or general emaciation. In a case where there was intense pain in the region of the uterus, the abdomen very sensitive with continual urging to urinate, heat and dryness of the vagina, and suppression of the lochia, iodine removed the pain at once, restored the lochial discharge, and freed the patient from danger. Hering states that this drug should not be given during the lying-in period, except in high potencies. - : Lilium tigrinum. Recommended by Dr. Hughes, where there is arterial congestion of the uterus (Sabina, bell.); much gen- eral nervous irritability; local pain and sensitiveness, with tendency to diarrhoea; there is also continuous pressure on the bladder; constant desire to urinate during the day, with Scanty discharge, followed by burning and smarting in the urethra; marked “bear- ing-down” sensation in the pelvis; sharp pains in the ovarian region. | Mercurius. The solubilis is preferred by Dr. Matheson for superficial erosion of the os uteri. Dr. Hughes prefers merc. cor. if the eroded portion appears deeply excavated and the cervix is swollen and indurated. Dr. Ludlam recommends the merc. iod. for endocervicitis in scrofulous subjects and erosion of the OS. It 1 Comprehensive System of Materia Medica and Therapeutics, 1st ed., p. 548. THE /*A PAE (V7./C.S. 345 is particularly indicated by profuse greenish, yellow, or purulent leucorrhoea, worse at night; smarting, corroding, itching, and in- flammation of the vagina; sensation of deeply seated soreness in the uterus, with dragging sensations; easy perspiration ; very sensi- tive to draughts of air, chilliness, and general aggravation of the symptoms at night. Pulsatilla. Sensation of weight in the abdomen and lumbar region, especially during menses; menses suppressed from wetting the feet, or delayed ; leucorrhoea thick, like cream or milk, pain- less, acrid, thin, burning, with swollen vulva (ars.); patient suffers from dyspepsia, has a tendency to diarrhoea, and feels much better in the open air. - | Sabina. Arterial congestion of the uterus (bell., lil. tig.); hemorrhage, rectal or vesical irritation, or both at the same time. Aemorrhage from the uterus, in paroxysms, worse from motion ; blood dark (crocus, cyclamen, Kali mit.) and clotted (amm. carb., cycla., ign., plat.), from loss of ſome in the uterus (caul.), after abortion or parturition, with pain in back extending to pubis: menses too profuse, too early, and last too long (bell, Calc. Carb., kali carb., nux wom.). Metritis after parturition, or abortion at about the third month ; sexual desire almost insatiable. It is es- pecially suitable to what might be termed sub-acute metritis. II Secale is the great remedy for sub-involution, both for the ordinary cases characterized by an atonic condition of the uterus, and the severe ones where gangrene threatens (ars., Zach., rhus), with a general adynamic condition of the system ; uterine hem- orrhage, worse from the least motion (erig., sabina); discharge black, fluid, and very fetid. After an abortion the uterus does not contract; thin, black, offensive discharge (usfilago); suppressed Zochia, followed by metritis (acon., bell.); extreme debility, prostra- tion, and restlessness (ars.). The lower dilutions of a fresh prepa- ration are more often used for sub-involution. || Sepia. Venous congestion of the uterus and pelvic tissues (murex purpurea); prolapsus uteri; pain in the uterus, and such severe bearing down that the patient feels as if she must cross the limbs to prevent protrusion of the parts; leucorrhaea yelloze, milky (calc. carb., coni., lyc., puls., Sulph, ac.), excoriating (alum., ars, kreos., merc.), worse before the menses. Dr. Leadam states that 346 CA/RO/V/C A/E TRAT/S. Sepia is suitable to the chronic, indurated condition of the uterus, its cervix and os, whether benign or malignant (aurum, carbo an.). The general symptoms of the patient indicating this remedy are to be borne in mind. | Sulphur. An excellent authority recommends the use of this remedy intercurrently in different dilutions, during the treat- ment of chronic cases, no matter what other medicines are given. Should the well known general symptoms of sulphur be present in addition to the local ones, this would be all the more important; Żmenses too late, too profuse, but of foo short duration, blood thick, dark, Sour-smelling, and excoriating; profuse, yellowish, corrosive leucorrhoea ; burning in the vagina, and itching of the genitals. Ustilago maidis.” Metritis and ovarian irritation, when there is acute pain, especially in the left ovary, with swelling; menses too soon and too profuse ; hemorrhage with clots, bearing down as if everything would come through. A fresh preparation is Important. The following remedies may be consulted for further information: — Sub-inzolution. — China, Calcarea phosphorica, caulophyllum, crocus, helonias, ipecac, mercurius, iodatum, natrum muriaticum,” rhus toxicodendron, trillium. Chronic metritis. – Baryta Carbonica, carbo vegetabilis or ani- malis, cocculus, collinsonia, colocynth, conium, ferrum, gelsemium, hepar sulphur, hyoscyamus, ignatia, iris, Éa/, iodatum, kali bi- chromicum, Åreosote, lachesis, lycopodium, magnesia muriatica,” mercurius iodatum, murex purpurea,” nux vomica, phosphorus, phytolacca, platina, pulsatilla, Sodae chlor,” veratrum album." 1 Raue, Record of Hom. Lit., 1873, p. 36. 2 Dr. H. H. Read writes me that “Natr. mur. did wonders in a case of sub-involution following puerperal inflammation, probably traumatic.” I prescribed it from the symptom, “Dreams of robbers in the house.” 8 Dr. Hughes speaks favorably of it in venous congestion of the uterus where the liver is at fault, Dr. Jahr also used it with success. 4 If the symptoms are similar to those of sepia and the menses are free, while with sepia the flow is rather scanty. 5 Dr. Cooper, Brit. Jour. of Hom., No. 126. 6 Mrs. — Been sick three months before coming under my care, great ZCHEA’AAA. UTICS. 347 weakness; face pale; eyes sunken, with dull expression; extremities cool. She complained of violent uterine pains, with a feeling of heaviness, which was attended by stitching pains, particularly on the posterior wall of the uterus. She could not rise because of the pain; entire loss of appetite; slimy diarrhoeic stools; constantly cold, especially the extremities. Physical examination showed the volume of the uterus increased, hard and sensitive to the touch, congestion of the neck of the uterus, and the least touch of it made her scream. Bell., nux. vom., and bry. did little good. Veratr. alb. 6. cured her in two weeks.-DR, SENTIN, in Hoyne's Clinical Therapeutics, Vol. I. p. 322. . - 348 BEAV/GAW GROWTHS OF THE UTER U.S. CHAPTER XX. BENIGN GROWTHS OF THE UTERUS. Myoma, Fibro-Myoma (Fibroid Tumors, Leiomyoma), Fibro-cystic Tumors, Fibrous Polypi, Fungoid Endometritis, Glandular Polypi, Cellular Polypi (the last three are varieties of Adenoma). TH ESE growths are considered in one chapter because their subjective symptoms are similar, differing only in degree, according to the size and situation of the tumor, and the same general principles of treatment apply to all. The myoma, or fibro-myoma, also known as a fibroid tumor, may be single or multiple, the size of a pea, or large enough to distend fully the abdominal cavity, and usually has a distinct capsule, especially if it be of long duration. It is most common near the fundus uteri, on the posterior wall, and is seldom found in the cervix. The surface is smooth, as a rule, rarely a little irregular. The stony hardness of a circumscribed mass within or in con- nection with the uterus is characteristic of a uterine myoma. Microscopically, it consists of hypertrophied connective and muscular tissue, and the degree of hardness depends largely on the density of the muscular elements. Though generally very hard, myomas are sometimes found which have a moderate amount of elasticity, and are therefore called soft or oadematous myomas (Lawson Tait). In myxo-myoma of Virchow the muscular fibres are not as compact, are separated by a jelly-like substance, or cellular bodies which grow rapidly by proliferation of the cellular elements, and the tumor is composed almost entirely of muscular elements. The soft myomas grow more rapidly 1 Die Krankhaften Geschwälste, Band III, Hálfte 1, p 192. MYOMAS OF THE UTERU.S. 349 than the hard, occur in younger women (Virchow), and may become myxosarcomatous. They are often observed to vary in size, being larger just before the menstrual periods, and continue to grow after the climacteric. Dr. Arthur Johnstone * believes that these soft myomas have their origin in the glandular structure, or, as he terms it, the adenoid tissue of the endometrium. Endometritis is generally induced by the presence of a myoma tumor, especially if it be of the sub-mucous vari- ety. In examining numerous preparations, Dr. Wyder * found glandular endometritis accompanying interstitial and sub-serous myomas. This glandular endometritis was more marked in proportion to the thickness of the muscu- lar wall between the tumor and the uterine cavity. The thinner the wall, as in sub-mucous myomas, the greater the growth of connective tissue (interstitial endometritis). The glandular endometritis shows no predisposition to ma- lignant degeneration of the mucous membrane, and in the pure form Dr. Wyder believes it does not cause bleeding. Bleeding is in consequence of the development of con- nective tissue and blood-vessels (endometritis fungosa); or if one portion grows very much faster than another, it may compress the veins, forming large sinuses, cause the blood to stagnate or back up in them, and thus produce hemorrhage. Apart from the inflammatory disorders of the pelvic tissues, and anomalies of menstruation, this affection is one of the more common, if not the most frequent, of the diseases peculiar to women. Myomas are also found in various parts of the body, less often in the male than female. They are almost unknown before or at puberty, but from this time gradually increase in frequency, and in the majority of cases develop between thirty and forty 1 Annals of Gynecology, October, 1888. 2 Wyder, Die Mucosa Uteri bei Myomen. Archiv für Gynākologie, Bd. XXIX., Hft. I. 35O BAEAV/G/W GROW THS OF THE UTER U.S. years of age. Their growth is very slow, usually ceasing after the climacteric, and life is endangered only in conse- quence of mechanical pressure or profuse menorrhagia. When small, and situated beneath the peritoneal invest- ment of the uterus, there are seldom any symptoms, and the patient may never be aware of their presence, unless they are discovered immediately after labor, when the ute- rus is so easily felt through the relaxed abdominal walls. The negro race is peculiarly liable to their development, much more so than the white. It seems to be true, also, that of the large pelvic tumors, myomas predominate in the African, and ovarian tumors in the white races. The relation of the etiology of myomas to single, fruit- ful, and sterile women has been carefully studied, and nearly all observers find that they are much more com- mon in married than single women." Gusserow * collected the records of nine hundred and fifty-nine women affected with these growths. Six hundred and seventy-two were married, and two hundred and eighty-seven unmarried. Of the married ones four hundred and sixty-four had borne children, and the remainder were sterile. He be- lieved, from the recorded experience of physicians, that the sterility was a result rather than a cause of the develop- ment of the tumor. Both Schroeder” and Winckel 4 agree with him in this opinion. - In five hundred and fifty-five women having uterine myomas, Winckel found one hundred and forty (24.2 per cent) were childless and single; four hundred and fifteen were married (75.8 per cent), and of these one hundred and thirty-four (24.3 per cent) were sterile. According to the population of Saxony, the proportion of middle- 1 The statistics of Routh show that this is true of women in England. — Schmidt's Şahrbücher, Vol. CXXIX. p. 236, 1866. 2 Die Neubildungen des Uterus, Chap. III. ; Deutsche Chirurgie, 1885. 8 Krankheiten der weibl. Geschlectsorgane, p. 2 Io, 1881. 4 Winckel, Diseases of Women, American ed., p. 409, 1887. M POMA.S. OA' ZTA/A2 O'TEAE O/S. 35 I aged married women to single women was as 9 to 7.3, and the prevalence of myomas among the unmarried to that among the married as 3 to 9; in other words, tumors of this nature occur nearly twice as often among the married as in the unmarried. Leopold found in four hundred cases that 81 per cent of the tumors were in married women, 19 per cent in the unmarried, and the proportion was a little larger for sterile married women than for the unmarried. Gusserow and Schroeder believe that sexual gratification rather favors the development of uterine myomas. While these opinions concerning the etiology of uterine myomas have obtained general acceptance, there are some physicians who differ from them. In a very carefully written essay, based on great experience and the personal study of over two hundred cases, Dr. Emmet' thinks those women who have not had children, i. e. the unmarried and sterile classed together, are more liable to myomas than those who have borne children. According to him, the fruitful are more liable than either the unmarried or sterile considered separately, while the last two classes are nearly equal in liability before thirty years of age. He believes their development is held in check by marriage, even though conception does not take place; also, that “be- tween the ages of thirty and forty the unmarried woman is fully twice as subject to large myomas as the sterile or fruitful,” and that sterile women are more subject to small myomas than either unmarried or fruitful women; he is also of the opinion that sexual gratification diminishes the liability to myomas. The complications and symptoms are those arising from pressure of the tumor on the neighboring structures, and increased determination of blood to the uterus. They vary somewhat, according to the situation of the tumors, which, for convenience of description are divided into, - * Principles and Practice of Gynecology, p. 548, 1884. 352 BEAV/G/W GROWTHS OF 7 HE UTER U.S. Sub-peritoneal myomas, when situated beneath the peri- toneal covering of the uterus (25 per cent)." Interstitial myomas, when situated in the parenchyma of the uterus (65 per cent)." Sub-mucous myomas, when situated beneath the endo- metrium, and projecting into the uterine cavity (IO per cent)." These forms mix with one another in great variety, though one type usually predominates. If a sub-mucous myoma projects far enough to have a distinct pedicle, it is then termed a fibroid polypus. It is probable that many myomas begin as interstitial tumors near the endometrium or peritoneal surfaces. As their size increases, they tend to grow in the direction of the least resistance, and, with the help of muscular contraction of the uterine parenchyma, become eventually sub-serous or sub-mucous myomas. The Symptoms are most pronounced, and constantly produced, by sub-mucous myomas and fibrous polypi; less frequently by interstitial ; and are often few or entirely ab- sent in the sub-peritoneal variety. Profuse menorrhagia or metrorrhagia is one of the most constant symptoms; and in the interval between the flowing there is a watery or leu- corrhoeal discharge of bloody serum from the uterus. This is a loss of lymphatic fluid which may weaken the patient nearly as much as hemorrhage. The flowing first appears as an increase of the monthly flow, and gradually becomes excessive with later periods, instead of a sudden and pro- fuse hemorrhage, as in carcinoma. There is alsº more or less weight and bearing down in the pelvis, pelvic pain, irritability of rectum and bladder, and pain along the course of the crural nerves, all of which result from press- ure. Pelvic pain and pain in the limbs, like sciatica, are especially common with myomas, developing posteriorly on the uterus and low down in the pelvis. Dysmenorrhoea 1 Winckel, Diseases of Women, Am. ed., p. 408, 1887. PHPSICAL EXAMINATIOM OF MYOMA.S. 353 is sometimes present, and is sometimes one of the earliest manifestations, together with pain in the intermenstrual period. Though these symptoms may be marked, the diagnosis of uterine myomas cannot be made without The Physical Examination.— Large myomas, extending into the abdominal cavity above the brim of the pelvis, are readily diagnosed in the great majority of cases by ab- dominal palpation. They are more often sub-peritoneal than sub-mucous, uniformly hard, and may be situated at the centre or on one side of the abdomen. The surface is generally, irregular, from the presence of one or more Smaller myomas, all of which form a single mass, held together by a framework of connective tissue; or, less frequently, the surface is smooth when a single tumor is present. Like all myomas, they develop slowly. Sometimes the myoma may project far enough from the uterus to have a short thick pedicle; but the uterus will always move with the tumor, as shown by the introduction of the sound within the uterine cavity, and motion given to the tumor will be communicated to the sound. While the presence of a large myoma can almost always be ascertained by the means just indicated, it is well to fol- low the method of examination given below for a small myoma, which is sometimes difficult to detect with abso- lute certainty. The best time to make an examination is very soon after the monthly has ceased, though this is by no means neces- sary or advisable if the flowing is almost continuous. The tissues are then more relaxed, the cervical canal open, and * the cervix soft, allowing a certain amount of dilatation with the finger as the uterus is crowded down upon it by the external hand. The tumor, therefore, can be felt bet- ter at this time. In all cases it is a good rule to have the patient in a position in which she can be examined to the best advan- tage. Although a fair idea of her condition may be ob- * 23 354 AAEAV/G/W GROWTHIS OF 7. HE O/ZTER OS. tained while she lies on her back on a firm mattress or Sofa, it is much better to place her on a table or gyneco- logical chair. All constricting bands about the waist, and Corsets, must be removed, and the thighs flexed on the abdomen to relax the muscles as much as possible. In all doubtful cases, ether anaesthesia will be of great as- sistance in making a thorough examination. A hot (I IO*) mercurial douche (I : 4OOO) before and after the latter is also advisable. - It is hardly necessary to state that the bimanual method of examining must be an invariable rule, and the cultiva- tion of a gentle touch without prying and prodding about in the pelvis is very desirable. The cervix quite commonly is found displaced. If the tumor be large, extending above the pelvic brim, the cer- vix is often drawn up, and sometimes out of reach, though the uterine cavity may not have much more than a normal depth. When the tumor is in the anterior or posterior wall of the uterus, that organ is displaced in the corre- sponding direction, particularly if it be of the sub-peri- toneal variety. This and the relation of the growth to the uterus are readily ascertained by careful bimanual pal- pation. In exceptional cases, when the myoma is sub- mucous, less often if it lies in the posterior uterine wall, the cervix is low down in the pelvis. The stony hardness of the tumor, which is seldom sensitive to pressure, its slow development, associated as a rule with menorrhagia in a woman about forty years old, are very characteristic symp- toms of a uterine fibroid. It is not always as easy to distinguish the class of myo- mas to which it belongs. The sub-peritoneal may be felt like a hard lump attached to the uterus, sometimes having a sort of ring or constriction at that place; while the intra- mural (interstitial) feels more like a hard bunch bulging out from that organ, with a perfectly smooth sloping sur- face and no constriction around the base of the tumor, and DIAGAOSIS OF MYOMAS. 355 an increased depth of the uterine cavity. A rectal exam- ination will often be of great service when the tumor is in the posterior part of the pelvic cavity. If the myoma be sub-mucous, the fundus is more symmetrically enlarged than in either of the preceding varieties. Sometimes the tumor is readily felt presenting at the external os; or by crowding the finger firmly up in the cervical canal, and pressing down on the uterus externally, it is distinguished near the internal os. - - It is always desirable to ascertain, approximately at least, the extent of the attachment of a sub-mucous myoma to the uterus. The first step in making this estimate is to find the depth of the uterine cavity, which is generally the distance from the external os to the upper border of the base of the tumor. A whalebone probe, the best instru- ment for this purpose, is passed up to the fundus uteri, taking care that it will go no farther by introducing it once or twice in a little different direction, as the point is lia- ble to catch in some fold of tissue; the forefinger is then placed on the probe, close to the cervix, and the instrument is withdrawn. Making a little allowance for the curve of the probe over the tumor, the instrument is laid on a piece of paper, on which are marked the points corre- sponding to the tip of the probe and the external os. It is then reintroduced along the opposite surface till it reaches the tumor, the finger placed on the probe next to the cervix, and again withdrawn. It is marked along the same line on the paper, and the distance between the two points corresponding to the tip of the probe gives a fair idea of the thickness of the base of the tumor; while the freedom with which the instrument will move laterally over the growth shows the breadth of its attachment. When the base of the tumor extends low down in the uterus, it often encroaches on the upper part of the cer- vical canal, making it difficult to introduce any instrument, and giving rise to the impression that there is a stricture 356 BENIGN GROWTHS OF THE UTERU.S. of the internal os; but the hard margin of the growth will dispel any such illusion. Having faithfully tried the means of diagnosis just de- scribed, and in the order given, – i.e. abdominal palpation, careful bimanual examination both vaginal and rectal, and the whalebone probe, — the physician may be still in doubt whether the myoma projects into the uterine cavity suffi- ciently to warrant operative interference through the vagi- nal orifice, when the tumor cannot be felt presenting in the cervical canal. Under these circumstances, it is necessary to dilate the cervix with tents," or a steel dilator; 1 press the uterus down from above, steady it below with volsellum forceps fixed in the cervix, and make a thorough digital examination of the uterine cavity, noting the attachment and projection of the myoma, the thickness of the endo- metrium over it, as well as pulsating arteries, if any, in the latter, which would be divided by incising the capsule. On introducing the finger, what seemed to be a large myoma may prove to be a polypus, which is readily removed. Considerable hemorrhage may follow so much manip- ulation; but irrigation with hot water, the application of iodine, and the vaginal plug will control it. The patient must be put to bed, and kept perfectly quiet till all sore- ness has subsided. It is hardly necessary to add, that, when there is con- siderable pelvic inflammation present with a myoma, the former must be cured before it is safe to attempt any operation or examination which the patient cannot read- ily endure without ether. The following table may be of assistance in diagnosing the variety of uterine myoma.” 1 See chapter on Minor Surgical Gynecology, pp. 63 and 69. * See also “The Differential Diagnosis of the Various Forms of Fibroid Tumors of the Uterus,” by Alfred Meadows, M.D., F.R.C.P., British Medical Journal, Vol. II. p. 716, 1883. . D/A GAVO.S./S OF MYOMA.S. 357 In Suð-mucous Myomas. Interstițial Myomas, Sub-ſeritoneal Mºyomas. The hemorrhage from the There is some hem-| There may be slight uterus is quite profuse, the more so in proportion to the projection of the tumor into the uterine cavity. Pain is slight. If there is a hard, firm, well defined tumor, uniform and symmetrical in shape, which has been slowly grow- ing for three years or longer, it is probably a fibrous poly- pus, or sub-mucous myoma. The uterine cavity is en- larged, filled, and distended by the tumor, which is felt by the finger after dilatation of the cervix. Its attach- ments can also be ascer- tained by the whalebone probe. The sub-mucous growths have more cellular, and less muscle tissue; they grow more rapidly than the other forms. orrhage, but, as a rule, not so much as in sub- mucous myomas. Pain is more severe than in the former case.] The growth, in about half the cases, is on the posterior wall of the uterus, which is not symmetrically devel- oped, but bulges a lit- tle on one side at the site of the tumor The uterine cavity is deeper, and more or less tortuous from the bulging of the tu- mor into the cavity. There is a larger proportion of muscle tissue, and the tumor grows more slowly. hemorrhage, but more often none, especially if the tumor is pedun- culated. Pain is often a very marked, though not an invariable symptom. Marked asymmetry between uterus and tumor. If there are several developing un- der the peritoneum, the uterus has a knobby outline. If the tumor be pedunculated, it is movable in proportion to the length of the pedicle, unless there are adhesions. The uterine cavity seldom has a greater depth than three inch- es, and is not propor- tionate to the size of the tumor unless the latter drags the uterus high up, and so length- ens the cavity. The muscle tissue is most marked in the sub-peritoneal. The tumor develops slow- ly, and is hard, having almost a cartilaginous feeling. 1 Hewitt, Diseases of Women, Vol. II. p. 2$5. 358 BAEAV/G/W GROWTHS OF THE O/TER U.S. DIFFERENTIAL DIAGNoSIs of MyomAs FROM PREGNANCY, EXUDATION IN CELLULAR TISSUE, HAEMATOCELE, AND COLLECTION OF FAECES. In all these, the history of the case, its duration, and present symptoms, are directly opposite to those common to uterine fibroids. Pregnancy. Myoma. “Tumor ’’ of short duration. “Tumor ’’ elastic to touch. Amenorrhoea. Usual symptoms of pregnancy. Of long duration. Tumor very hard. Uterine hemorrhage. Symptoms of pregnancy wanting. Cellulitic Exudation. Myozzza. History of pelvic inflammation. Exudation sensitive and immov- able. Exudation of short duration, and distinct from the uterus. No history of pelvic inflammation. Tumor not sensitive, and movable. Tumor of long duration, and in- timately connected with the uterus. Aſamatocele. Myoma. Formation rapid, and attended by symptoms of collapse. Fluctuation and immobility of tu- IſlOr. Formation slow, without symptoms of collapse. No fluctuation, and tumor mov- able. Collection of Faeces. Myoma. It is left-sided. Short duration. Can be indented by the finger. Does not move with the uterus. Symptoms of intestinal obstruc- tion. Functions of uterus not affected. Not limited to any side. Long duration. Cannot be indented. Moves with the uterus. No symptoms of intestinal obstruc- tion. Marked disturbance of the uterine functions. I)/ET FOR MYOMA.S. 359 DIFFERENTIAL DIAGNOSIS OF MYOMAS FROM Uterine Flexions. Cancer. Ozvarian Tumors. The sound enters the uterine cavity in the cen- tre of the supposed tu- mor. If a myoma is present, the sound pass- es by it into the uterine cavity, which does not correspond to the centre of the tumor, but lies in a different direction. Cancer of the fun- dus uteri is very rare. Its progress is much more rapid than a myoma. The dis- charges from the ute- rus are extremely of. fensive. Pain in the pelvis, and fixation of the uterus, are quite constant symp- tomS. Are seldom connected with the uterus. There is a wave of fluctuation on palpation, and their development is uni- lateral, and more rapid than myomas. Puncture with a fine needle of the aspirator draws off a fluid showing the characteristic granular cells. Where an ovarian tumor is firmly attached to the uterus, differentiation is often impos- sible, especially if the tumor be solid. The Prognosis for myomas is fortunately favorable, so far as life is concerned. Very few women die in conse- quence, though they may be bedridden for a long time. After the menopause, the tumor often gradually diminishes to a remarkable degree, undergoing a change similar to in- volution of the puerperal uterus, and ceases to be a source of danger, though its presence may be annoying. Myo- mas scarcely ever threaten life, except from the loss of blood occasioned by them. The Diet is important, and should be so regulated as to nourish the system in spite of the constant drain. Milk, eggs, beef juice, or raw meat extracts, mutton chop, etc., are important articles of food. Great success in the treat- ment of uterine myomata has been claimed by Dr. Salis- bury's method." It consists essentially in drinking a pint of hot water very slowly an hour or two before meals, and half an hour before retiring. The object of this is to cleanse the stomach before eating and sleeping. The 1 See article by Dr. Ephraim Cutter, American Journal of Obstetrics, Vol. X. p. 562. 360 PAE/V/GAW GROWTHS OF ZAZE O/TERCWS. muscle pulp of steak, cut from the centre of the round, . is broiled, seasoned to taste, and made an exclusive article of diet. All the connective tissue is removed by chopping the beef without stirring it. The fibrous tissue is driven down on the board, while the muscle pulp is occasionally Scraped off the surface with a spoon during the chopping, and prepared for eating as above. This treatment must be rigidly adhered to for one to three years to be successful. It has received much commendation from good authorities, such as Drs. Grailly Hewitt and Marion Sims, while others have never seen any benefit result from it. Indeed so little confidence is placed in it that it is scarcely mentioned in recent gynecological literature. The theory that it avoids so far as possible the eating of elements forming the tumor is wholly false. It merely gives a wholesome article of food, and in this way may nourish the patient. Some physicians believe they have seen benefit from wearing an earth poultice, or from the application of myro-petroleum to the abdomen, over the tumor, for a number of consecu- tive months. The Treatment of myomas of the uterus is too often un- satisfactory. Except where life is in actual danger, or the tumor easy of access, as in sub-mucous myomas and fibrous polypi, it is the better plan to adopt a palliative course, rather than surgical interference, in the hope that the patient will tide over the menopause. It is of great importance to correct a retroversion or prolapse of the uterus, as this favors congestion, and a much more rapid growth of the tumor. Uterine hemorrhage is the symptom which is the most dan- gerous to the patient, the most difficult and most important to control. This can be accomplished in many cases by a carefully selected remedy, the hot-water douche, curetting the uterine cavity, and the local application of the tincture of iodine or the perchloride of iron to the uterine cavity, the vaginal plug, thorough dilatation of the cervix with laminaria TREATMEAVT OF MPOMA.S. 361 tents, or a combination of these measures. On the least ap- pearance of blood, the patient should lie down with the hips raised a little, and remain in that position till the flow ceases. In the interval between the periods, moderate exercise in the open air, sun-baths, and bathing followed by vigorous friction of the skin, are excellent to maintain the general health. There should be no constriction of the waist, or pressure on the abdominal organs by the clothing, as it interferes with free venous circulation, and thus promotes hemorrhage. The tendency to constipation can be obvi- ated by regulating the diet; and an occasional collection of faeces removed by enemas, given to the patient, if neces- sary, in the knee-chest position. The mineral waters of Kreutznach, in Rhenish Prussia, are quite celebrated for the treatment of uterine myomata." - Electrolysis” has had its advocates from time to time, but has not been generally accepted as a reliable method of treatment for all cases. * The hypodermic injection of ergot” has been much used to check the hemorrhage, and is said to be very useful in 1 In an excellent article on “Carlsbad, its Springs, their Physiological Action and Indications,” Dr. Th. Kafka states that fibroid tumors often dis- appear as an apparent result of taking the water. — Monthly Hom. Review, p. 274, May 1, 1885. - * See chapter on Electricity in Gynecology. * Hildebrandt, American Journal of Obstetrics, November, 1872; and Byford, Transactions of the American Gynecological Society, Vol. I. p. 168. E. Evetzky collected the records of 223 fibroid tumors treated by the hypodermic injection of ergot. In 42 cases the tumors were absorbed. In 9 cases the tumors were expelled. - : In 71 cases the tumors diminished in size, and the symptoms were relieved. . In 51 cases no impression was made in size or density, but the symptoms improved. In 49 cases no benefit. I case died in consequence.— Mew York Medical Journal, p. 231, March, 1882. Though the results may appear favorable, the author must assert that ergot often fails to benefit patients suffering from fibroid tumors. 362 BEAVIGAW GROWTHS OF THE vTERUS. Some cases, particularly for those tumors projecting well into the uterine cavity after the cervical canal has been and is kept dilated. Dr. Winckel joins many physicians in commending this drug, but warns the profession against its use in large doses, especially in anaemic patients. The use of ergot has also been combined with incision of the cap- sule, in hopes that the tumor might become pedunculated, and more accessible for removal. This, however, is often impracticable in interstitial myomata. Next to ergot, Dr. Winckel” recommends hydrastis can- adensis in twenty-five-drop doses of the fluid extract three or four times a day; and if gastric disorder ensue, to use thirty-seven and a half grains of the dry extract in pill form instead of the fluid extract. These may be considered large doses. Fellner believed it caused uterine contractions, and increased the blood pressure. Schatz,” who introduced the remedy, thinks it causes contraction of the capillary vessels instead of the uterus, and differs from ergot in this respect. Both Wilcox * and Jermans” have found it very useful for uterine hemorrhage from other causes than the presence of myomata. Falk has made a careful study of the use of hydrastis Canadensis for uterine hemorrhage, and believes the active ingredient is hydrastinin. He uses a ten per cent aqueous solution, and injects hypodermati- cally half a dram to one dram twice a week in the inter- menstrual period, and every day if necessary at the time of the hemorrhage. He reports twenty-eight cases in which hydrastinin was employed with varying success. In some instances it arrested hemorrhages after ergotin had failed.” 1 Diseases of Women, Am. ed., p. 427, 1887. 2 Ibid., p. 428. 8 Centralblatt für Gynākologie, No. 46, 1883. 4 New York Medical Journal, p. 199, February 19, 1887. 5 Centralblatt für Gynākologie, No. 35, 1887. * Hydrastinin bei Gebärmutterblutungen, Archiv für Gynākologie, Heft II. p. 308, 1890. - SUAEG/CAZ TREATMEAVZ. 363 In my recent visit to Hamburg Dr. Prochownik assured me that he found the fluid extract of cotton root an almost infallible remedy for the hemorrhage due to myomas, and had employed it in many cases with complete success. General Considerations for Surgical Treatment. —While it is true that women seldom die in consequence of the myoma, it is also true that the various forms of local and internal treatment are sometimes inefficient, and dangerous symptoms may arise which require surgical interference to save life. Hemorrhage is almost always the complication which requires even desperate measures, and the help of the surgeon must not be delayed till after the vitality of the patient has been sapped by loss of blood. This uterine hemorrhage has no correspondence with the size of the tumor. It is not uncommon to find large tumors without hemorrhage of any significance, and frequently small tu- mors no larger than a chestnut may cause an alarming loss of blood. It is evident that operative measures must differ accord- ing to the size and situation of the tumor, and will also be influenced by the condition of the patient. The various operations will also differ in their mortality, and so far as practicable the safest method deserves the preference. The pedunculated sub-mucous myoma is often removed so easily, and with so little danger, it is better to remove it at once, even if the patient has no threatening symptoms. The same symptoms in other forms of myoma might not furnish any indications whatever. The age of the patient is also to be considered. It sometimes happens, though rarely, that the myoma does not develop till after the menopause, and then an operation is likely to become necessary, if the tumor grows rapidly, even if there be no bleeding. As a rule, the myoma ceases to grow after the menopause, and then undergoes a form of involution simi- lar to that following confinement. It usually shrinks some- what, and may even disappear if the tumor be small. 364 BEAV/GAV GPOWTHS OF THE UTEA’ U.S. If, therefore, a myoma is not found till about the age of forty-two or after, it is often possible to control the hem- orrhage till after the climacteric, and then the patient is usually out of danger; while the same conditions in a younger woman — about thirty-five years of age — might render an operation necessary, particularly if the tumor were growing rapidly, or causing profuse bleeding. Hem- orrhage is always a serious symptom, and should never be allowed to approach the danger line, as indicated by the conditions mentioned below, which furnish contra-indica- tions to operating Other things being equal, the average chances for recovery after surgical interference are rather better for women under forty than for those who are over that age. The following may be considered indications for surgi- cal interference: — I. Sub-mucous myomas projecting into the cervical canal, and dilating it. 2. Severe, persistent hemorrhage, not to be controlled by other treatment. 3. Extreme size of the myoma, especially if due to cystic degeneration. 4. Rapid growth, particularly in young women. 5. Serious invalidism and inability to earn a living. This may force a poor woman to an operation which a wealthy woman occasionally might avoid. 6. Disease of the tumor itself, such as suppuration or malignant degeneration. 7. Pregnancy sometimes causes extremely rapid growth, or the tumor may be so situated as to demand removal in preference to the Caesarian section. 8. Pressure symptoms, from the presence of the tumor in the small pelvis, or from interference with the circula- tion or other functions of the body. A very movable and hard myoma may sometimes cause ascites, which can only be cured by the removal of the growth. cowTRA-LVD/CATIONS TO OPERATING. 365 º There are, however, certain conditions in which the danger of an operation is So great as to contra-indicate interference, even though the case may seem very urgent. Extreme pallor of the skin and mucous membranes, with a drawn or haggard expression of countenance denotes a degree of prostration unfavorable to recovery. This is particularly true of Suppurating fibroids, and the operator will do well to be very cautious about operating on such patients without first improving their health. A more im- portant contra-indication to operating is degeneration of the heart muscle. This may take place rapidly, and at an early period. It may be brown atrophy, fatty degeneration, or anaemia, and the muscle have a light brown or milk-and-coffea appear- ance. The first symptom of increasing degeneration is a fine, easily compressible pulse of 90—IOO, readily excited by slight causes to I2O-I40, with panting respiration or desire for air, and anxiety. The appetite is diminished, the patient restless and sleepless. Over the right ventricle, and especially over the right auricle, there is a peculiar &ruit, not depending on any valvular disease, but on imper- fect filling of the right heart with blood. Any laparotomy under these circumstances becomes an operation of ex- ceeding gravity." Fat anaemic persons, with relaxed, soft muscles are not good subjects for an operation, but anae- mic women with strong, firm muscles will often bear it. A long narcosis is especially prejudicial to the former of the last two classes. A good condition of strength, a healthy, strong heart, and healthy kidneys, are very important for the success of severe operations. The surgical treatment of these tumors may be divided as follows in order of preference, according to the probable rate of mortality and the selection of the operation by the indications as given below: enucleation, vaginal hysterectomy, castra- tion, myomotomy. 1 Leopold, Archiv für Gynākologie, p. 19, Bd. XXXVIII. Heft I, 1890. 366 AAEAV/G/W GA2O WZTHS OA’ ZAZAZ UZZA' O.S. Buucleation is often employed after opening the ab- dominal wall. The tumor is peeled out of the uterus, the sides of the cavity firmly united by catgut ligatures, and the whole dropped back into the abdominal cavity, like the pedicle of an ordinary tumor. This operation does not imply either removal or mutilation of the uterus. Enucleation, as used here, refers more particularly to the removal of sub-mucous myomas." Whenever such a tumor presents in the vagina or in the cervical canal, or if in using the Sound to ascertain its attachments the tumor is found to have become pedunculated, it should be re- moved without delay, before the patient becomes exhausted or anaemic from loss of blood. There is scarcely any dan- ger from this operation, and there will be no hemorrhage from the severed pedicle. It can be accomplished by the écraseur, or persistent traction and the use of scissors or Thomas's spoon saw.” If the cervix is not dilated suffi- ciently, use laminaria tents, and if necessary there need be no hesitation in dividing the cervix laterally. If the tumor is not then readily accessible for the division of its capsule and enucleation of the myoma or the use of the ecraseur, it is better to postpone the operation in hopes that by the use of ergot the tumor will descend and be more easily removed. Careful antiseptic precautions are of the utmost importance. After the operation, insert a strip of iodoform gauze in the wound and vagina. This will serve the double purpose of drainage and a good dressing. It must be remembered that small fibroids may remain in the uterus after enucleation of the principal one, and that consequently a few months or years after it may become necessary to remove a second myoma which has developed and been forced down into the ute- rine cavity. Vaginal enucleation of a myoma in the uterine 1 See Enucleation of Fibroid Tumors, Doran, Gynecological Operations, p. 307, 1887. * Emmet, Principles and Practice of Gynecology, p. 566, 1884. § SUPA' U/8A TIAWG M VOA/A.S. 367 cavity should not be attempted if the tumor is larger than a child's head. The same sized tumor can be removed, however, if it is in the vagina, or springs from the cervix uteri. When the tumor is in the uterine cavity, Baker Brown introduced the operation of incising the cervical canal and the os internum, as well as the capsule of the myoma when practicable. This aids the spontaneous enucleation of the tumor by the uterine contractions, especially under the effect of ergot, and in some cases relieves the hemorrhage when the tumor is well down in the os internum. It has the disadvantage that an incision of the capsule may cause degeneration and suppuration of the tumor, with the dan- ger of septic infection. Myomas have a very limited blood and nerve supply, and readily suppurate from slight trau- matism or interference with the circulation in the capsule. The interior of the tumor has practically no blood-vessels. The existence of a central nutritive artery has been as- serted," but Roesger was unable to find it in a careful examination of a number of specimens.” Suppurating Myomas demand immediate removal, except in some cases where the suppuration has been caused by the negative galvano puncture, when removal by laparot- omy may be postponed if the discharge of pus is slight. Such cases may recover without an operation by following the ordinary treatment for suppuration under other circum- stances. When suppuration of a myoma occurs spontane- ously, the tumor is almost always of the sub-mucous variety. If the strength of the patient permits, there should be no delay in removing the decaying mass, which is usually most pronounced on the lower portion of the periphery of the growth. A strong Simon curette is an excellent in- strument for the purpose. If the entire tumor can be 1 Lawson Tait, The Lancet, No. 8, p. 21, 1883. 2 Ueber Bau und Entstehung des Myoma Uteri, Zeitschrift für Geburts- hillfe und Gynākologie, Bd. XVIII. Heft I, p. 139, 1890. 368 BEAV/GAW GROWTHS OF THE UTERU.S. easily removed, it should be done; but if not, or if the patient is very weak, it is better merely to remove rapidly the sloughing portions, irrigate thoroughly with perman- ganate of potash, make the operation as short as possible, and repeat it at intervals of a week or ten days till the entire mass is removed. I Great caution is necessary in operating on these cases when the pulse is rapid and weak, and the skin and mu- cous membranes appear pale and bloodless. It is a ques- tion in such cases whether it is not better to employ antiseptic injections, curette only sloughing portions easily reached without taxing the patient, and endeavor to nour- ish the system rather than, when the vitality is so low, to submit her to what would be otherwise a simple opera- tion. Suppuration of a myoma increases the danger of its removal. Vaginal Hysterectomy is an operation in which it is some- times difficult to say whether or not castration is preferable. Leopold prefers total extirpation of the uterus by the vagina under the following circumstances: — - 1. If all other treatment has been tried in vain, and health and life are threatened from hemorrhage, pain, pressure symptoms, inflammatory or degenerative changes in a single or multiple myoma, not larger than an infant's head. 2. If after careful examination the ovaries are inflamed on one or both sides, and too firmly adherent to perform castration. 3. When the patient is so weak as to make laparotomy questionable. Vaginal extirpation of the uterus is a thorough opera- tion. Only a small opening is made in the abdominal cavity, which provides good drainage; the intestines are not cooled; the strength of the heart is not taxed as much as in a laparotomy; it does not last much longer than castration, and is shorter than a myomotomy; finally, it CAST/PA 7/O/V FOR M POMA.S. 369 avoids the possibility of ventral hernia. It is therefore preferable to a laparotomy for anaemic women when a thorough operation is necessary. It has, however, the ab- solute requirement, that the tumor must not be larger than a baby's head; and the larger the growth, the more diffi- cult is the operation. Castration, i. e. removal of the ovaries, is worthy of careful consideration for anaemic women when the tumor is as large as an infant's head, and the necessity for an operation depends chiefly on the hemorrhage and rapid- ity of growth. - The operation should not be performed when the hem- orrhages do not correspond to the menstrual period, or if they are not aggravated at that time, if the menopause has arrived, or if the myoma is of the Oedematous variety. It is better adapted to small and rapidly growing tumors ac- Companied by profuse hemorrhages, than to large myomas. In the latter the ovaries sometimes are found, and removed only with great difficulty. When castration is impracticable, or if myomotomy ap- pear too formidable an operation, it may be well to con- sider the proposal of Rydygier' simply to ligate the internal spermatic arteries, the uterine artery, and the round ligament, and then close the abdomen. He reports a case successfully treated in this way. The operation of castration dates from 1872, when Pro- fessor Hegar,” in Germany, and Dr. Battey,” of Georgia, advocated removal of the ovaries for the relief of various affections, among them being uterine myomas accompanied by profuse hemorrhage. As this is one of the conservative surgical measures, it has found much favor. Dr. Wiedow” has collected the records of one hundred and forty-nine 1 Wiener Klin. Wochenschrift, No. 10, 1889. - * Compare Hegar and Kaltenbach, Operative Gynākologie, p. 334, 1881, for a careful history and description of the operation. * American Journal of Obstetrics, January, 1880. * Archiv für Gynākologie, Bd. XXV. 24 37O BAE/W/G/V GA’O WZTHS OA’ 7TAZAZ (WZTEA’OWS. operations of castration for uterine myomas. Fifteen of them ended fatally. In seventy-six cases the final results were as follows: — Atrophy of the tumors and menopause . . . 54 cases. Occurrence of the menopause only . . . . 7 “ Atrophy of tumors only . . . . . . . . 2 “ Diminution of bleeding and atrophy . . . . 6 “ Menopause for three months followed by ex- pulsion of the tumor . . . . . . . . I case. Irregular, slight hemorrhages . . . . . . 2 cases. Irregular, severe hemorrhages . . . . . . I case. Immediate good results followed by severe bleeding and growth of the tumors . . . 3 cases. Mortality of the one hundred and forty-nine operations. . . . . . . . . . . . Io per cent. More recently Dr. Wiedow' has reported sixty-six cases from Professor Hegar's clinic, with five deaths, – a mor- tality of 7.6 per cent. Four of these deaths occurred with the first twenty-four operations. For the sake of greater accuracy for remote results only those cases are mentioned which have been under observation three or more years after castration. These numbered thirty-seven, – Menopause immediately after the operation . . . 21 Menopause with occasional bloody discharges . . 15 Flow ceased for six months, and then regular weak periods . . . . . . . . . . . . . . I Twenty-four out of thirty-three large myomas entirely disappeared; eight tumors underwent marked diminu- tion, and only one showed no decrease. In view of these excellent results, extirpation of the myoma is reserved at that clinic for pedunculated sub-serous or sub-mucous tumors, fibro-cystic tumors, and those of extremely large size. 1 Centralblatt für Gynākologie, No. 7, 1890. C.A.STRA T/O/V Aº O/C A/ POMA.S. 37 I Some cases continue to have the same pains and other symptoms due to uterine myomas after the operation as before. Dr. Gusserow believes castration “leads with great certainty to an arrest of hemorrhage, provided the uterine tumors are not too large, and not in a condition of cystic degeneration ”; besides, it is a much safer opera- tion than extirpation of the tumor. Dr. Leopold and others praise the operation, and report good results. Dr. Homans of Boston has found that the bleeding may con- tinue just as severe after castration; and Dr. Winckel 4 still considers this operation sub judice for unoperative myomas with a mortality of fifteen per cent, and a fail- ure for the desired result in twenty per cent of the cases . which recover. This is, however, much more unfavorable than the reports of other operators. Prochownik” has had better results. He reports twenty- two cases of castration without a death. Twelve of these were for myomas, and in these the results were remark- able. The tumors diminished in size; pain and bleeding ceased. All of these growths would have otherwise re- quired supra-vaginal amputation, or enucleation from the uterine walls or pelvic connective tissue. It is interesting to note that the results of castration for neuroses compli- Cating sexual disorders were not so good when healthy ovaries were removed. Dr. Taitº advocates removal of the Fallopian tubes with the ovaries, and has met with remarkable success. His unusually low rate of mortality must be largely attributed to his remarkable skill as a surgeon. Unfortunately, it will not always arrest the hemorrhage, nor can the ovaries always be found. * Diseases of Women, Am. ed., p. 437, 1887. - - * Beiträge zur Kastrationsfraga, Archiv für Gynākologie, Bd. XXIX. Heft 2. * The Modern Treatment of Uterine Myomata, British Medical Journal, Vol. II. p. 287, 1885. In fifty-eight consecutive cases, all recovered from the operation. In the fifty cases reported in this article, all were very much relieved or cured by the operation excepting one, who was afterwards cured by removal of the tumor. 372 BEAV/G/V G/&O WTHS OF THE UTERU.S. Myomotomy, or the removal of sub-peritoneal myomas by abdominal section, is a formidable operation. The in- dications for it must necessarily overlap those for castra- tion. They are, briefly, myomas larger than an infant's head, growing rapidly, especially if before the menopause, degeneration of the myoma and the threatening of life by otherwise uncontrollable hemorrhage, pain, or pressure. Myomotomy is more particularly indicated if castration is impracticable, the tumor very large, pedunculated sub- peritoneal, or fibro-cystic. As this is one of the most serious operations known to surgery, the risk should be duly considered, and the chances for probable recovery be based on the average mortality of many operators rather than on the exceptional low rate of some distin- guished and remarkably skilful individual." Myomotomy has been performed with much success by many operators, more especially Schroeder,” Martin,” Leo- pold, Sänger, Fritsch, Bantock,” Thomas Keith,” and Law- son Tait. Martin is the originator of an excellent method for the intra-peritoneal treatment of the pedicle, and has obtained excellent results with it. Bantock may be said to represent the advocates for extra-peritoneal treatment. Both these methods are fully described in the references 1 Dr. H. R. Bigelow made an elaborate study of Gastrotomy for Uterine Myomata (fibroids), with statistical tables, in the American Journal of Ob- stetrics, 1883–84. - * For a study of his methods, see Myomotomy, by Prof. Karl Schroeder, British Medical Journal, Vol. II. p. 714, 1883; also Hofmeyer, Die Myo- motomie, 1884, reviewed by Dr. Wiener in the Centralblatt für Gynākologie, No. 11, 1886, and his later publication, Grundriss der Gynākologischen Operationen, p. 205, 1888. 3 Pathologie und Therapie der Frauenkrankheiten, p. 279, 1887. 4. A good description of Bantock's method of performing supra-vaginal hysterectomy can be found in Doran's Gynecological Operations, p. 287, 1887. Compare with this Hysterectomy for Myoma, by Greig Smith, Ab- dominal Surgery, p. 211, 1887. 5 Dr. Thomas Keith, who has had remarkable success with this operation, has abandoned it in favor of electrolysis, and now condemns myomotomy. See Contributions to the Surgical Treatment of Tumors of the Abdomen, Part I., 1885, and Part II., 1889. AM VOA/O TOM V. 373 to these names. Both Sänger" and Fritsch 4 have modi- fied the extra-peritoneal method, which is preferred by most operators as being more successful in their hands than Martin's method. The danger from this last opera- tion is from hemorrhage and Septic infection if the uterine cavity has been opened. The merit of the intra-peritoneal method is the rapidity and simplicity of the operation, the speedy convalescence, and in many cases the preservation of the uterus. It is best fitted for sub-peritoneal tumors with a small pedicle, or if the tumor can be enucleated with not more than a very small opening into the uterine cavity. If, on the other hand, the uterine cavity is freely opened, the tissue friable, soft, or cystic, and the patient physically weak, extra-peritoneal treatment of the pedicle deserves the preference. Fritsch unites the stump in the median line and stitches it in the abdominal wound, while Hegar allows the rubber ligature to remain, employs hysterectomy pins, and fastens the stump wholly extra-peritoneally. The scope of this work does not permit further discussion of the subject. The following list of operations on fibroid tumors by Dr. Leopold will give some idea of their mor- tality in comparison with one another: — 28 Enucleations, I death ; from sepsis . . . . . 35 Castrations, 4 deaths; from sepsis . . . . . 56 Myomotomies, 12 deaths; from sepsis 21 Vaginal hysterectomies, 3 deaths; from sepsis : The medical treatment is considered on page 378. FIBRO-CYSTIC TUMC).R.S. These are quite rare, and chiefly interesting for their close resemblance to ovarian tumors. It is quite probable that very many of those growths described as fibro-cystic * Zur Technik der Amputatio Uteri myomatosi supra-vaginalis (Intraperi- toneale Abkapselung, elastische Dauerligatur des Uterusstumpfes), Central- blatt für Gynākologie, No. 44, p. 718, 1886. * Sechzig Fälle von Laparomyotomie mit epikritischen Bemerkungen über die Methoden dieser Operation, Volkmann's Sammlung, No. 339. 374 BEAVIGN GROWTHS OF THE UTERU.S. tumors of the ovary really originated from muscular fibres in or near the uterus, and not from the ovary. True cysts of the uterus are extremely rare, and all fibro-cystic growths are the result of a cystic transformation in myo- mas, which may take place in various ways, but chiefly from separation between muscular fibres, the collection of serum, or rapidly proliferating cellular elements, in the space thus formed, and the fusion of many cavities into one. This is most common in sub-peritoneal varieties, and less frequent in the interstitial ones. - Their symptoms are the same as those accompanying myomas of the same size, excepting that hemorrhage is not so common with the fibro-cystic tumor. The differential diagnosis is extremely difficult, and often impossible. The most distinctive feature is a localized obscure sensation of fluctuation without the hardness of a myoma. If an aspirator be used, a variable amount of fluid is drawn off, which leaves solid portions of the tumor in the abdomen; this fluid coagulates spontaneously, and closely resembles the liquor sanguinis; under the micro- scope," it shows a few epithelial cells, oil globules, and fibre cells, characteristic of the structure in which the cyst originated. The granular ovarian cell, or Drysdale's cor- puscles, peculiar to ovarian tumors, are not present. The microscopic appearance of the fluid is the best guide in cases of doubtful diagnosis. Emptying the cyst by trocar or aspirator has not been attended with much success as a method of treatment. As an almost invariable rule, they must be treated in the same way as uterine myomas. They develop earlier in life than ordinary myomas, grow rapidly, and call for immediate removal if the strength of the patient will warrant such a formidable operation. UTERINE POLYPI. Uterine Polypi (adenoma) are divided into three classes: cellular, glandular, and that known as fungoid endometri- 1 Atlee, Ovarian Tumors, p. 263. OTER/AVE POL WP/. 375 tis. The first is the most frequent, and it is covered with mucous membrane, which gives to it the common name of mucous polypus. It is generally situated near the internal os, and seventy per cent of the cases occur between fifty and seventy years of age. Its texture is soft and vascular, like a nasal polypus. - The glandular polypus consists in a hypertrophy of the cervical follicles or Nabothian glands, and is commonly associated with laceration of the cervix. The various en- larged follicles are united to one another, so that the polypus may resemble an hydatiform mole. Fungoid (polypoid) endometritis" has been mentioned in a previous chapter, but further consideration of it is necessary. It may be merely a hypertrophy of the mem- brane lining the uterine cavity, with moderate dilatation of the utricular glands, and affect the entire membrane; or it may occur in localized spongy patches, like soft, flat, wart- like excrescences, which are attached by a broad base to the walls of the uterine cavity. In more rare cases, the utricular glands of the uterus participate more actively in the new formation, leading to diffuse glandular develop- ment in the mucous membrane. This is known as diffuse adenoma of the uterus. Polypi are liable to develop from any condition causing a passive congestion of the lining membrane of the uterine cavity, and especially from chronic endometritis. They vary in size from a pea to a hen's egg; and all three forms have symptoms common to one another and to uterine myomas, such as uterine hemorrhage, watery dis- charges from the uterus, leucorrhoea, pelvic pain, etc. Pain, however, is generally absent in pediculated polypi, which lie in the external os or protrude from it. It is often a matter of surprise that so much trouble can come from such a small growth. The presence of a polypus no larger than a pea may excite profuse menorrhagia, leu- * Olshausen, Archiv für Gynākologie, Bd. VIII. p. 97. 376 AAEA'ZGAV G/&O WZTA/S OAT THAZ UTE/e U.S. corrhoea, etc., which only cease when the growth is re- moved. One of these little tumors has been known to act like a little ball valve in the cervical canal, causing both dysmenorrhoea and sterility. The Diagnosis is easy when the growth can be seen or felt presenting in the external os uteri; but when it lies within the uterine cavity, it is a difficult matter, and the presence of a polypus can only be ascertained by dilating the cervical canal, and exploring the uterine cavity with the finger. - Prognosis. – The proneness of all forms of uterine polypi to recur after removal, and the enfeeblement of the system due to the hemorrhage, leucorrhoea, and pain caused by these growths, have led some observers to be- lieve them to be of a malignant character. This applies more especially to endometritis fungosa with diffuse de- velopment of the utricular glands. Indeed, specimens of this growth removed by the curette have been examined by expert microscopists, and pronounced without hesita- tion to be malignant, which the subsequent history of the case proved to be an incorrect diagnosis. Adenoma and carcinoma are sometimes found in the same specimen, which Ziegler terms adeno-carcinoma. This has led some writers quite recently to believe that an adenoma may develop into a carcinoma. At all events, adenoma may be considered as on the boundary line be- tween benign and malignant disease," which can be deter- mined only by the subsequent history of the case, as the microscope does not give us sufficient light on the sub- ject.” While circumscribed pediculated polypi may recur frequently, they are not at all likely to assume a malignant character. The same cannot be said, however, concerning the endometritis fungosa, i. e. general or local hyperplasia of the mucous membrane of the uterine cavity, involving 1 Winckel, Diseases of Women, p. 358, 1887. * Gusserow, New Growths of the Uterus, p. 350, 1887. 7 RAEA TMAZZWZT OA' A' O/L PP/. 377 the utricular glands as described above. The frequency of recurrence, the extent of the disease, and the depth it penetrates into the uterine wall, indicate malignancy in proportion to the prominence of these symptoms; while Dr. Goodell 4 adds an important clinical observation, that “malignant diseases of the endometrium are usually found in old maids and in sterile women, while malignant diseases of the cervix almost always occur in women who have borne children.” - The Treatment is obvious. When one of these little growths is seen in the cervical canal, seize the pedicle with dressing forceps, and twist it off. In rare instances it may be so large that an écraseur must be used. Nearly all the small intra-uterine polypi can be crushed down and removed by the dull wire curette, which will do no harm; and if a small polypus be suspected, this curette had better be used instead of dilating the canal. If both this and Roux's curette fail, the cervix must be dilated, and the noose of an écraseur passed over the pedicle of the tumor to remove it. This latter operation is subject to the same risks as the removal of a sub-mucous fibroid, and is not to be performed without due consideration. It is a cardinal rule that all manipulations of any kind in the pel- vis must be carefully avoided when there are any symp- toms of pelvic inflammation. These growths do not cease to develop after the climacteric, and are liable to return after removal. Only a short time ago the writer removed a glandular polypus from an old lady who said she was Seventy-two years old. *- In endometritis fungosa, the cervix must be dilated, un- less it is sufficiently relaxed from the frequent hemorrha- ges and all the diseased tissue be thoroughly removed with Roux's curette. The uterine cavity should then be injected with iodine or the undiluted perchloride of iron, taking great care that the cervical canal is sufficiently patu- * Goodell, Lessons in Gynecology, p. 316, 1887. 378 BEAV/GM GROWTHS OF THE UTERU.S. lous to allow a free escape of the fluid injected. In cases of frequent recurrence, when the above treatment has failed, fuming nitric acid, or the solid nitrate of silver, has been used. This very severe treatment should not be employed until all other remedies have failed, except removal of the uterus. The latter is best done by the operation known as vaginal hysterectomy," and is indicated if, in spite of all other measures, the growth becomes of a malignant char- acter, and nests of epithelial cells and atypical formations are observed under the microscope, The Medical Treatment of uterine myomas, fibro-cystic tumors, and uterine polypi is considered under one head- ing, as the same remedies apply to any one of them, if in- dicated by the symptoms. Unfortunately, it is doubtful whether any remedies have any power of directly causing the tumor to be absorbed, or expelled from the uterus. The growth and the attending hemorrhage are sometimes checked or arrested, so that the patient passes safely through the climacteric, and suffers little inconvenience afterward. Cases are reported where the tumors dimin- ished in size under treatment; but as many of these are at the menopause, it is a question to which the result was due. Even if there be no perceptible improvement in the actual size of the tumor, if the pain and hemorrhage can be suffi- ciently controlled by remedies till after the climacteric, it is a far better course to pursue than to submit the patient to a dangerous operation. Consult also the chapter on Menorrhagia and Metrorrhagia. THERAPEUTICS. Belladonna. Plethoric patients. Much bearing down in the pelvis (lil. tig., natr. mur., plat., sepia). Menses too early and too profuse ; bright red blood; or thick, decomposed, dark red 1 Compare A. Martin, Frauenkrankheiten, 1887; Greig Smith, Abdomi- inal Surgery, p. 185, 1887; and Münchmeyer's report of Leopold's operations at the Dresden Clinic, Archiv für Gynākologie Bd. XCIII. Heft 3, 1889. THERAPEUTICS. 379 blood. The blood feels hot to the parts; throbbing and sensitive- ness to the touch in the pelvic organs. || Calcarea iodide." Patients having a strumous diathesis. Menses too early, too long, and too profuse; milky leucorrhoea, with itching and burning; acidity of the stomach; profuse per- spiration in the morning (quiniae sulph., nitric ac., phos., rhus tox.) and on slight exertion. It must be prepared fresh, and kept in a blue glass bottle, out of the light. The writer has had two cases in which calcarea carb., 3 x. trit., seemed to diminish the size of the tumor to a marked degree. One was about the size of a cocoanut, in the left side of the pelvis, and seemed to partake of the characteristics of both a myoma and ovarian tumor, though the symptoms pointed to the former rather than the latter. The sec- ond one was a distinct sub-peritoneal myoma, about the size of a man's fist, on the anterior wall of the uterus. In less than two years the growth had so decreased in size it could hardly be found by the most careful bimanual examination. It is by no means claimed that calcarea is the sovereign remedy for myomata. Only, it seems one of the most promising ones, if its use is persisted in long enough ; but there are very many cases in which it will be of no service. China. Is excellent for the prostration accompanying the loss of blood; also for uterine hemorrhage of dark blood and clots, fainting, and muscular twitching. 1 The indications for this remedy in the treatment of uterine myomas are not well understood. It secms to be more often effectual in causing a gradual diminution of the tumor than any other remedy, and in doses too small to act on the theory of calcification of the growth and interference with its nutrition. It is significant that the most celebrated mineral waters for the cure of fibroids contain a large amount of lime salts. Good results have been reported from the third decimal trituration. It has also been recom- mended in the shape of ten grains to a pint of water, a teaspoonful to be taken after each meal, gradually increasing to a table-spoonful. This may act very similar to the chloride of calcium in possibly causing a calcareous degeneration in the tumor; but as it has been found that the coats of the arteries are also likely to undergo the same degeneration, the remedy may become a dangerous one. It seems quite probable that it can influence the nutrition or development of these tumors in a certain number of cases, without being given in sufficient quantity to produce the degeneration alluded to. & 38o AEAVIGAW GROWTH.S OF THE UTER U.S. | Ferrum. Anaemia from loss of blood; stinging headache and ringing in the ears before the menses; flow too profuse, pas- sive and dark, accompanied by labor-like pains in the abdomen, and a glowing, red face. - Platina. Menses too early, and too profuse; flow dark and clotted, with much bearing down and pinching pains in the abdo- men; nymphomania; painful sensitiveness, and constant pressure in the hypogastric region; the body feels cold, excepting the face. Sabina. Menses too early, too profuse, and last too long; hemorrhage from the uterus in paroxysms; worse from motion ; blood dark and clotted, and sometimes offensive; with pain from back to pubis. || Secale. This should be freshly prepared, and will be found to act best in the tincture, or lower dilutions. Menses too pro- fuse, and last too long; uterine hemorrhage, worse from least mo- tion ; discharge thin and black; black, lumpy, or brown fluid, and very fetid; pains in the uterus of an expulsive character. | Trilline. Metrorrhagia, especially at the climacteric, flow returns every two weeks. It may be active or passive, and is ac- companied by pain in the back, and cold limbs. Dr. Ludlam speaks highly of this remedy for the hemorrhages resulting from myomas, and thinks it most useful in those cases where the muscular fibres of the uterus have been decidedly developed by pregnancy or otherwise. The following remedies may be consulted for further reference: — Ars., aurum," carb. veg., cinnamon, conium, crocus, cyclamen, gossypium,” erigeron, hamamelis, iodine, lach., lycop., mag. mur., mercurius Sol., nitric ac., phos., sepia, silicea, Sulph., thuja, usfilago, vinca major.” 1 Dr. Schwabe considers this the chief remedy, especially the aur. mur. natr., to promote resorption. Like other remedies, it must be used persever- ingly. — Lehrbuch der Hom. Therapie, 3d ed., Vol. II. p. 992. * Dr. Garrigues recommends the cotton root for the treatment of the hemorrhage. — Medical Record, Vol. II. p. 554, 1885. * Recommended by Dr. Meadows for the hemorrhage of fibroid tumors.- Zancet, July 12, 1873. MALIGMAAT DISEASE OF SEXUAL ORGAA's. 381 CHAPTER XXI. MALIGNANT DISEASE OF THE SEXUAL ORGANS, Y the term “malignant disease” is meant a neoplasm which returns after extirpation, and tends with more or less rapidity to a fatal termination. Extensive de- struction of tissue characterizes them all. They may be classified as follows: — Sarcoma, or recurrent fibroid. Non-cancerous. | * > Corroding ulcer. Malignant º - “º s - º ºhs. Epithelioma, papilloma, or cauli- | flower excrescences. U Cancer." Scirrhous or hard. Medullary, encephaloid, or soft. Colloid. - The question of local or constitutional origin of the disease will not be discussed here, nor the details of its pathology, as both lie outside the scope of this work, and can be found in more voluminous treatises. Malignant disease of the sexual organs presents the same character- istics, and is subject to the same pathological changes, as in any other part of the body. Women are much more subject to it than men, the married more than the single, and the uterus more than any other locality. Unfortunately, most of these cases are not seen by the physician till the disease has made marked progress. 1 The comparative freedom of the Jewish race from cancer is quite re- markable. Why this should be, the author is unable to explain any more than he can the liability of the negress to fibroid rather than ovarian tumors. 382 MALIGAWAAVT DISEASE OF SEXUAL ORGAAVS. Subjective symptoms are almost always wanting in the earlier stages; and the patient does not apply for relief till there has been a hemorrhage from Some comparatively slight cause, such as coition. This has been preceded usually by an acrid, profuse, and very offensive watery discharge, sometimes tinged with blood. The latter is one of the earliest symptoms, and calls for a very careful examination of the patient, especially if there have been unusual losses of blood. - Sarcoma grows much more slowly than cancer, but its fatal termination is equally sure. Its symptoms are very similar to those of myomas, and sometimes the macro- scopical appearances are so much alike that only a micro- scopic examination will reveal the true character of the growth. Many authorities speak of a hard sarcoma as a recurrent fibroid. Myomata (fibroid tumors) very rarely become the seat of sarcomatous degeneration. This dis- ease is almost invariably situated at or near the fundus, and does not tend to infiltrate the lymphatics and neigh- boring structures as does carcinoma. It does not always occur in the shape of a well defined tumor simulating a myoma, but quite as often as a diffuse infiltration of the mucous membrane, forming soft granular masses, or knotty villous projections growing toward the uterine cavity and down to the internal os. If it originates in the muscle of the uterus, it may be seen in the shape of scattered nod- ules, which penetrate the veins, and which are carried to adjacent organs or even to remote parts of the system. The chief points in making a differential diagnosis from a myoma are given in the table at the end of the description of carcinoma (p. 388). Corroding Ulcer is a very rare affection, and, in the great majority of cases, occurs toward the close of the climac- teric. It is found extending from the cervix to the vagina, and is probably a form of epithelioma, though its progress appears to be slower. As it develops, a vesico- or recto- AºA-Z TA/A2 LZOAZA. 383 vaginal fistula may form, and all the subjective signs of cancerous infection of the system be present. Cancer. – Epithelioma is by far the most common form, while the others are very rare, scirrhus especially so. Epithelial cancer is almost invariably an affection of the cervix uteri, from which it may spread up into the body of the uterus, or down on the vagina. Medullary cancer almost always attacks the uterine cavity above the cervix, and may leave the latter untouched. FIG. 140. EARLY STAGE of AN EPITHELIoMA As IT APPEARs IN THE Speculum. Figure 140 is an illustration of the early stage of a cauli- flower growth (epithelioma) on the cervix of a pregnant uterus. The patient was wholly unaware of it, and the ex- crescence was discovered accidentally. Figure 141 is an illustration of a scirrhus of the cervix of a woman fifty-three years old, who desired relief from a troublesome leucorrhoea. This growth progressed with extreme rapidity. The hard nodular condition of the cer- vix, and the early extension of the disease to the para- metrium, with fixation of the uterus, are characteristic of scirrhous cancer of the uterus. In both these cuts the 384 MALIGMAA/7 DyszASE of sexvAz orgays. difficulty of photographing color makes the illustrations appear indistinct, which is improved by viewing it at a little distance. Fig. 141. SciRRHous CANcer of THE CERVIx, witH commencing Ulceration. The Etiology of this dread disease is not well under- stood, though there are some well known predisposing causes. Like all forms of malignant disease, cancer de- velops most frequently at or near the climacteric. Hered- ity and frequent parturition play an important part. The black race is less subject to it than the white. Of late years great importance has been attached to laceration of the cervix as a predisposing cause. It is not difficult to see how the constant irritation from the friction of the abraded surfaces would tend to develop local disease, espe- cially in those having hereditary tendencies. The writer believes it should be an invariable rule to close every abraded laceration of the cervix in cases where there is any hereditary taint. Symptoms. – There are none characteristic of the in- ception of this disease. Considerable progress is often made before the patient notices any thing unusual. The A. P/7 HAZZZO.1/A1. 385 earliest symptom in most cases is a watery, excoriating vaginal discharge, which is occasionally bloody, and in a short time becomes offensive. The hemorrhage soon in- creases, and is easily caused by coition or the careless use ºum º --> * Sºd Mºšº º º Rºss ºtº §), ºf FIG. I.42. EPITHELIoMA of THE CERVIx UTERI. of the vaginal douche. There is also a varying amount of pelvic pain on moving about. By this time there is a cauliflower-like growth projecting into the vagina from the cervix, and extending up a little into the uterus. Na- ture apparently tries to prevent systemic infection by oc- clusion of the lymphatics, which become engorged, and the throwing out of an exudation in the cellular tissue, i.e. cellulitis, in which the uterus is more or less fixed at 25 386 MALIGMAMT DISEASE OF SEXUAL ORGAA.S. an early stage of the disease. As molecular death of the tissues advances, there is increased hemorrhage from ex- Coriation or sloughing of the blood-vessels, and a dark, grumous, or gruel-like vaginal discharge, of an extremely offensive odor. The sallow cancerous cachexia is devel- oped, and Septic symptoms gradually appear later, as the patient fails in strength and becomes exhausted by hem- orrhage and by pain. The latter is not complained of, as a rule, till the disease is well advanced, with a large amount of exudation surrounding the uterus. Death generally takes place in sixteen or eighteen months from the begin- ning of the disease, except where life may be prolonged by treatment. The Diagnosis is not difficult if the disease has made any advance." Besides the foregoing symptoms, the fria- ble cauliflower-like growth attached to the cervix, its bleeding on the slightest touch, and the fixation of the uterus, are quite enough for a diagnosis. Whenever ma- lignant disease is suspected, the vaginal examination must be conducted with the greatest care, lest the delicate and friable walls of the blood-vessels be injured, and profuse hemorrhage result. By gently passing the finger well back along the recto-vaginal wall, the cervix can be felt, and the surface of the growth touched without injury. Persistent flowing at the climacteric is always a sus- picious symptom of myoma or carcinoma. If it occurs after the menopause has apparently taken place, it is a very strong indication of cancer, and the practitioner should never allow such a discharge of blood or bloody leucor- rhoea to continue without making a careful examination, under ether, if necessary, and using the spoon curette to ascertain if there is any soft place in the uterine cavity from which he is able to remove bits of broken down tissue. Such a condition almost always means a diagnosis of cancer, usually of the medullary form, and should be 1. See Cancer of the ovary. D/FFE/CE/VZYA/L DIA GAVOS/S. 387 confirmed by the microscope. It must be remembered that the cervix may appear healthy, and the body of the uterus may not be much enlarged or sensitive, and yet the cavity of that organ be filled with the product of cancer degeneration. The patient may also appear quite well, and it is easy to make a mistake in diagnosis if the above directions are not carefully observed. Epithelioma is the only growth having a rough, friable surface; excepting the stony hardness of scirrhus, all others are softer, and do not have the crumbling sensa- tion to the touch of epithelioma. - The odor left on the examining hand is extremely offensive, and difficult to remove. The writer has found Platt's chlorides, full strength, (which is immediately washed off.), very useful for this purpose. An excellent authority recommends a solution of thymol, prepared in the following way. Heat three drams of alcohol, and dis- solve fifteen grains of thymol in it; then add half an ounce of glycerine and thirty-four ounces of water. The Diagnosis of Cancer at an Early Period, before any marked symptoms, growth, or ulceration have appeared, is exceedingly difficult, a problem in most cases which only time can solve. Laceration and hyperplasia of the cervix, with hypertrophy of connective and fibrous tis- sues, produce a sclerosis very closely resembling cancer- ous infiltration. A dark red, or yellowish red nodule, which bleeds very easily and projects on the cervix, is always of a suspicious character. Their differences are contrasted in the following table, which will serve also for the diagnosis of probable cancer in an early stage of development. - 388 MALIGMAAWT DISEASE OF SEXUAL ORGAAVS. \ Benign Sclerosis. Does not change in a few months. Uniform throughout the cer- vix. The fissured lobes of the cer- vix are smooth, or a little rough from the enlarged Nabothian glands. The erosion about the os, if present, is of a bright red color. If granulations appear about the os, they grow slowly. The hardened tissue is ex- panded by a sponge tent. Is not liable a few months after its discovery to be fol- lowed by watery or bloody discharges. - Section of a minute piece un- der the microscope shows an excess of connective and fibrous tissue. © Malignant Sclerosis. Begins to change in a short time. Cervical sclerosis lasting twelve months without changing is almost certainly benign. One part of cervix hard, the rest of a normal consistency. One lobe larger than the oth- ers, with a nodulated surface, or there is a dark red nodule which bleeds very easily. The mucous membrane on the summit of the nodules may be a little eroded, and has a violet or livid blue color. Granulations exuberant, and grow rapidly. Is not expanded by a sponge tent.1 Is soon followed by offensive watery or bloody discharges. Sections show nests of round or epithelial cells in stroma of connective tissue. Cancer of the External Genitals does not differ from its general characteristics in other parts of the body. It usu- ally takes the form of the corroding ulcer extending from the vagina, or of an epithelioma. - All forms of malignant disease end fatally, and with similar symptoms, but differ widely in their duration. The following table may be useful in distinguishing them from uterine fibroids, and from one another. 1 Spiegelberg's test. See page 63. A)/FFERE/VT/A/, /)/A G/WOS/S. 389 Uterine Myomas. Sarcoma. Corroding Ulcer. Cancer. Comparatively com- | Very rare. Very rare. Epithelioma com- IITOIſle mon; other forms very rare. Grows slowly. Slowly, but more rapid- Slowly. Most rapidly of all. ly than myomas. Very hard. A little softer than a | No tumor, but | Soft and friable, ex- myoma. loss of substance |cepting the scirrhus, from the begin- which is very hard. ning. Most common on Scarcely ever seen ex- | Is on the cervix | Is almost invari- the posterior wall, but cept at or near the fundus and vaginal walls. |ably in the cervix, not limited to any part of the uterus. On di- lating cervix, the tu- mor is found hard and firm. He m or rh a ge marked, and predom- inates over the watery discharges. Lymphatics are not invaded. Uterus movable if not prevented by ad- hesions, or size of tu- II].Or. Does not recur after removal. uteri. On dilating cer- vix, the tumor is found rounded, and a little soft, more often small, soft, and granular. There is hemorrhage, but watery discharges like washings of meat predom- inate. They do not be- come offensive so early in this disease as in cancer. Invasion of the lym- phatics does not occur till quite late in the disease. Uterus movable except in the last stage. © Recurs. Hemorrhage is a marked symp- tom. Invasion is very late, and no infiltra- tion in the neigh- boring tissues. Uterus movable except in the very last stage. Recurs. and scarcely ever found primarily in the fundus uteri. Very offensive ichorous, watery, or grumous discharges, and hemorrhage more or less profuse. Invasion is very early. Uterus is fixed and immovable early in the disease. Recurs. As the encephaloid and colloid varieties of cancer attack the ovaries, and scarcely ever the uterus, the reader is re- ferred to the chapter on ovarian tumors for a description of them. The Treatment may be radical or palliative; the former when all the diseased tissue can be safely removed, the latter when surgical interference is impracticable. If the patient is strong enough for an operation, it should be performed without delay. Many distinguished surgeons think the axillary glands should be removed in every case of mammary cancer 390 MA L/GAWAAVT D/SEA.S.E OF SEXUAL ORGAAVS. \ which is operated on; otherwise, the operation fails in its object, and the cancer is sure to return in the axilla at an early period. Should experience prove that the neigh- boring lymphatic glands must always be removed to in- sure a new lease of life to the patient, it will greatly limit operating for uterine cancer, as here the lymphatics are involved at a very early stage, and all of them cannot be removed. At present, experience shows that early removal of all the diseased tissue prolongs life, while, if it is only partially performed, the remainder of the cancerous tissue grows much more rapidly than if left alone. Even in the latter case an operation has been thought beneficial by some, as there would be less sloughing of the diseased mass, and less danger of septicaemia and hemorrhage. Experienced operators, however, hesitate to interfere with the intention of performing an incomplete operation. After the re- moval of a malignant growth, the patient should not fail to report every month or two for a careful examination, and if the least nodule is found indicating a return, it should be removed at once. The practical questions for a physician are, whether the operation is feasible, and likely to benefit the patient, i. e. the limit to radical treatment; and, secondly, what op- eration to select. It may be laid down as a rule, that, where there is invasion of the tissues outside of the uterus. or vagina, or secondary deposits elsewhere, an operation should never be undertaken. It is needless to add, that the patient's health must be fairly good, as there is often profuse hemorrhage during the operation. For sarcoma especially, and also cancer of the body of the uterus, which cannot be removed with certainty by other means, extirpation of the uterus offers the most hope, though it is attended by a high rate of mortality." 1 For a history and description of the methods of hysterectomy up to 1881, the reader is referred to essays by Dr. J. Mikulicz, in the Wien. Med. VAG/AWA/C HYSTERECTOM V. 39 I Freund's method of operating by opening the abdominal cavity, and ligating the lower portions of the broad liga- ments through the vagina, is exceedingly difficult to per- form, and much more dangerous" than extirpation of the uterus through the vagina without opening the abdominal wall.” It is essential for the uterus to have a certain amount of mobility for the performance of the latter Wochenschrift, November 20, 27, December 25, 1880, and January 1, 8, 22, February 5, 12, 19, 26, 1881. 1 B. S. Schultze, Ueber Totalextirpation des carcinomatósen Uterus, Deutsche Med. Zeitung, 1886, Nos. 2–4. * Hegar and Kaltenbach, Operative Gynākologie, 1886. See also Cyclo- paedia of Obstetrics and Gynecology, Vol. VII. pp. 17, 22. Dr Hofmeyer states that in Schroeder's Clinic at Berlin there have been twenty-four cases of total vaginal extirpation of the uterus without a single death, and expresses his opinion that in malignant diseases of the uterus removal of the entire organ is more correct than amputation of the body only. — American Journal of Obstetrics, p. 1042, October, 1886. Dr. Leopold of Dresden has removed the cancerous uterus per vaginam thirty-eight times, with only two deaths. – American Journal of Obstetrics, p. 918, September, 1886. - Since then he has reported forty-eight cases of total extirpation of the uterus for carcinoma, procidentia, and severe neuroses, with only three fatal cases, two of which were from sepsis. This gives him the low mortality of 6.2 per cent for this operation; 69.2 per cent have remained free from a return for from one to three and a quarter years. The earlier the operation is per- formed, the longer the period before the return of the disease. —LEOPOLD, 48 Totalextirpationen des Uterus wegen Carcinom, Totalprolaps, und schwerer AWeurosen, Archiv fir Gymäkologie, Bd. XXX. Hft. 3. In a later report Dr. Leopold reports eighty cases of total vaginal extir- pation of the uterus for carcinoma, with a mortality of 5 per cent. 64.5 per cent of these cases had remained free from recurrence for more than two years. Seventy-one out of the eighty report one or more pregnancy. In fourteen of the cases there was marked infiltration of the parametrium; yet there are only three in which the cancer has returned, showing that an infil- tration is not a positive contra-indication to the operation. Carcinoma of the body of the uterus recurred in one third of the cases; of the neck of the uterus in 40 per cent, and of the cervix in 20 per cent. — Archiv für Gynā- Æologie, Bd. XCIII. Hft. 3, 1889. Leopold's method is to dissect from below upward, gradually drawing the uterus down without retroverting it, and ligating with an ordinary aneurism needle in advance of each incision. Richelot's clamps, so much used by some operators, are not employed by him, as he does not feel sure that hemorrhage will not occur after they are removed. 392 MAZZCAWAAV7' D/SAEASE OF SEXUAL ORGAAVS. operation. Extension of the disease far on the vagina, or into the tissues surrounding the uterus, infiltrations in the parametrium, and firm fixation of the uterus contra-indi- cate any attempt to perform hysterectomy. The operation of vaginal extirpation of the uterus has been ably discussed by Drs. Martin and Jackson; * the former reporting three hundred and eleven cases, with a mortality of only 15. I per cent. This is less than the mortality of amputation of the cancerous breast, which was 15.6 per cent in seven hundred and seventy-eight cases re- ported by Küster. Dr. Jackson, who opposes this opera- tion, truly says that the mortality of a series of cases operated on by expert Surgeons is not a correct indication of the mortality among those under the care of less experi- enced operators. Dr. Post” compiled the statistics of three hundred and forty-one cases in which the mortality was 27 per cent. Dr. A. P. Palmer” has reported a list of sixty- six cases in which twenty-three died within a week, a mor- tality of 34.8 per cent. These are the results of thirty-three operators, many of whom performed the operation for the first and only time, and in some of the cases the operation was performed as a last resort, so that this mortality repre- sents the other extreme to Dr. Martin's report. Schauta 4 warmly recommends vaginal extirpation of the uterus for cancer, and well says that the success of the operation lies largely in the hands of the general prac- titioner, as many cases are not brought to the operator till late in the progress of the disease. The earlier the 1 Transactions of the Ninth International Medical Congress, Gynecologi- cal Section, 1887. A good report of this, with the papers of Drs. Jackson and Martin, a translation of Martin's method of vaginal extirpation of the uterus from his Handbuch der Frauenkrankheiten, 1887, and other interest- ing information concerning cancer of the uterus, will be found in the Annals of Gynecology, November, 1887. 2 Dr. Sarah E. Post, Americal. Journal of the Medical Sciences, January, 1885. * New York Medical Journal, July 9 and 16, 1887. 4 Centralblatt für Gynākologie, p. 71, No. 5, 1888. VAG/AWA L H PSTEAEECTOMP. 393 operation is performed, the more likely is the patient to recover from it, and the longer the period before the dis- ease returns. Every dark red or yellowish nodule which bleeds very easily, and projects from an erosion on the cervix, should be excised. When the diagnosis of a sus- picious nodule is in doubt, a little cocaine can be injected into the cervix uteri, and a small piece be excised pain- lessly for microscopic examination. Dr. Tannen, of Bres- lau, has written an excellent report of 103 total extirpations of the uterus for cancer by Professor Fritsch." In the first 60 cases there were 7 deaths (I 1.6 %), in the last 43 cases there were only 3 deaths (6.9 %); 57.0 % were well I year after the operation; 47.O %, 2 years; 48.7%, 3 years; 45.0%, 4 years; and 36.0%, 5 years after the operation. Fritsch's method differs somewhat from that of Martin, and is similar to that described by Greig Smith.” Dr. John Bryne * gives a very interesting report of 367 cases of uterine cancer treated by him with the galvano- cautery, which he considers superior to all other treatment. In 59 cases, in which the disease was limited to the vaginal portion of the uterus, the average period of exemption was eight years and seven months; 16 cases could not be traced ; 2 died; 3 others had recurrence in two years; and 2 were too recent operations to be included. Prognosis. – As to recurrence of the disease, the bal- ance of testimony from the most experienced operators points to vaginal extirpation of the uterus at an early stage as the operation followed by the longest immunity from the disease.* If the disease is well advanced, the pel- vic lymphatics will be affected and the operation useless. 1 Archiv für Gynākologie, Bd. XXIX. Heft 3; also Bd. XXXVII. Heft 3, p. 420, 1890, which contains comparative statistics and accounts of different methods. - * Abdominal Surgery, Vaginal Hysterectomy, p. 185, 1887. * Transactions of the American Gynecological Society, p. 79, 1889. 4 Centralblatt für Gynākologie, p. 71, No. 5, 1888. 394 MAL/GAWAAV7' D/SEASE OF SEXUAL ORGAAVS. It follows that the prognosis must depend to a great extent on the general practitioner who makes an examina- tion, and a correct diagnosis at an early stage of the dis- ease. If the patient has no return of the disease at the end of a year from the operation, it is possible that the cancer will not recur; if she remains free from it for two years, it may be stated in general terms that the chances of non-recurrence are nearly even ; and if she remains free for four years, the disease is not likely to return. The methods of Sims,’ Schroeder,” and Baker,” aided by the thermo-cautery if necessary, are the most efficient, if the patient will not submit to total extirpation of the uterus, which is by far the best operation when practicable for any form of malignant disease of the uterus. Pal/iative Treatment consists in relieving pain, control- ling hemorrhage, and neutralizing the offensive odor. When remedies fail in the former, opium in some form must be used. An application of chloral hydrate, one dram to an ounce of glycerine, or stronger if necessary, is warmly praised for this purpose. Iodoform in powder has disinfecting and slight narcotic properties; or, both iodoform and chloral hydrate may be combined in the form of a vaginal suppository containing ten grains of each. Eucalyptus is a very superior application, either in cerate or liquid form, mixed in the douche to destroy the odor, and to a limited extent allay the pain. Terebine has been recommended for the relief of hemorrhage, pain, and odor in advanced stages of cancer of the cervix. The vagina is first disinfected, and then pure terebine mixed with an equal amount of olive oil is applied on a tampon to the diseased surface. When these will serve the purpose 1 The Treatment of Epithelioma of the Cervix Uteri. American Journal of Obstetrics, Vol. XII. No. 3, July, 1879. 2 Krankheiten der weibl. Geschlechtsorgane, 1881, p. 288. Compare ed. of 1887. 8 American Journal of Obstetrics, April, 1882, and February, 1886, p. 184. PALLIATIVE TREATMENT: . 395 of allaying the pain, opium should not be employed, as the latter causes more or less derangement of the system. At the New York cancer hospital * vaginal hysterec- tomy is not often performed, and the palliative treatment is as follows. Removal as far as possible of all sloughing, or cancerous tissue, with Simon's spoon curette, with frequent digital examinations during the operation, to estimate the amount of tissue requiring removal, and to avoid injury to the peritoneum or bladder. If there be much bleeding, the Paquelin thermo-cautery at a red heat is freely used. Should the bleeding continue, a tampon is placed in the vagina and allowed to remain thirty-six hours. Applications of bromine, chromic acid, or bichromate of potash in solution are made once or twice a week for the after treatment, preference being given to a twenty per cent alcoholic solution of bromine. Care must be taken to smear the mucous membrane of the vagina with vaseline, or it will be burned by the application. The offensive discharges due to molecular death and destruction of tissue do not appear till there is ulcera- tion. A solution of half of one per cent of creolin, or as strong as two per cent, either warm or hot, is used to irri- gate the vagina several times a day if necessary. The antiseptic properties of creolin are not nearly as good as it has been maintained, but there is no danger in using it compared with the bichloride of mercury. Its milky appearance and odor, similar to carbolic acid, prevent those mistakes which are liable to occur with transparent Solutions. It is an excellent deodorizer, has considerable anaesthetic properties, and is somewhat ha-mostatic. The pruritis vulvae, caused by the ichorous discharges, is usually relieved by the free use of resorcine (3ij) and glycerine (3j). A solution of chloride of zinc has been recom- mended by various eminent writers for many years, but 1 Cleveland, Transactions of the American Gynecological Society, p. 462, 1889. 396 MALIGMAAWT DISEASE OF SEXUAL ORGAAWS. the uncertainty of the dose, the inability to obtain the exact effect desired, and the difficulty of fixation or limit- ing its action to a particular spot or depth of tissue, have made it an impracticable agent for most cases. It acts merely as a caustic, and has no specific action in itself on malignant disease. The following preparation has some advantages over the ordinary solution of chloride of zinc, and is in considerable favor with Dr. William Tod Helmuth as a preparation of the kind for epithelioma: — B& Zinci chloridi. Hydrastis submuriatis. Unguent. Stramonii, aa 3j. M. ft. ung. - This is applied to the affected surface after the removal of the cancerous tissue as directed above. It is a good plan for the patient to keep a saturated solution of alum at hand to use as an injection in case of unexpected hemorrhage. The application of Churchill's tincture of iodine to the entire surface of the cancer seems to check the progress of the disease to a limited extent, and also to control the loss of blood. Bleeding spots may be touched with diluted perchloride of iron, or the dry sub-sulphate of iron can be locally applied. It is well to bear this in mind in case of unexpected and severe hemorrhage from a vaginal examination. Fritsch highly recommends packing the vagina with a strip of iodoform gauze for carcinoma of the uterus. The iodoform is combined with an equal amount of tan- nin on account of its astringent effect, and for the purpose of disguising the odor of the iodoform. This is also used for a dressing after the palliative surgical treatment. Here the raw surface is covered with iodoform and tannin in powder, and the gauze packed against it. He contends 1 Volkmann's Sammlung, No. 288. THAEFA PAE UTICS. 397 that the carcinomatous odor is entirely controlled by this treatment. - - The offensive odor can also be corrected by douches of from two to five per cent solutions of carbolic acid, creosote, permanganate of potash, eucalyptus, or thymol, I : 1,000 sol. The nozzle of the syringe must be intro- duced and the water injected very carefully lest hemor- rhage be caused. The tip can be shielded by a piece of rubber tubing drawn over it, with holes in the sides, and projecting about an inch from the end. The Diet must be generous, and the system well nour- ished, so as to counteract as long as possible the poisonous influence of the cancer. - The Medical Treatment has but little encouragement to offer, except as it can relieve pain, and check the progress of the disease, or systemic infection. The physician has yet to discover the remedy which has any decided curative effect on cancer. s THERAPEUTICS. | Arsenicum has been the favorite remedy for cancer, some physicians preferring Fowler's solution, but more the iodide of arsenic. It corresponds best to the later stages of the disease, when the cachexia begins to develop. Great exhaustion; rest- lessness; much thirst ; hemorrhage with lancinating burning pains in pelvis; acrid, watery, corrosive leucorrhoea, sometimes offensive. Calcarea carb. This would seem a possible remedy for cancer, judging by the two cases cured by it in the shape of powdered oyster-shells, which were reported by Dr. Peter Hood in the “Lancet” for 1868. His observations were authenticated by Mr. Spencer Wells. Graphites was recommended by Wahle, but has not met the expectations of some other physicians. It seems best adapted to epithelioma; menses only once in six weeks, the flow being black, clotted, and offensive ; constipation. 398 MALIGMA NT DISEASE OF SEXUAL ORGAA/S. | Creosote.” Epithelioma, much burning and pain in the pelvis. The discharges are acrid, excoriating, and offensive; pruritus vulvae; external os open. Coition painful, accompanied by burning, and followed by a bloody discharge. Menses too early, too profuse, and protracted; flow dark, lumpy, and offensive. Lachesis is more useful at the climacteric period. Dr. Ludlam mentions it for a tendency to passive hemorrhages, alternating with a profuse discharge of blood, sharp lancinating pains in the pelvis. Nitric acid. Epithelioma of the cervix. Irregular men- struation, with intercurrent, profuse, brown, offensive discharges. Hemorrhoids, with burning, sticking pains in the rectum. Baehr states that this drug is only suitable as an intercurrent remedy at the commencement of the disease, and is of no use when ichorous dissolution has commenced. * Tarentula. Dr. Nuñez recommends it for cancerous ulcer of the os, induration of the neck and fundus of the uterus, or chronic vaginitis with granulations. It would therefore seem to be especially useful for corroding ulcer. The following remedies have been recommended for cancer, and are worthy of study: — Alveoloz,” argentum met., aurum, carbo an:, carbo veg, cedron, conium, cundurango (?), euphorbia heterodoxa,” iodine, juglans cin., ham.," hydrocot. asiat,” hydrastis, kali Sulph. (epithelioma), 1 See Rückert's Klinische Erfahrungen, Vol. II. p. 353. e * The fresh juice of the plant is applied locally. See paper by Dr. I. A. Velloso, British Journal of Hom., p. 201, 1884. Dr. J. B. Hunter employed it some for epithelioma of the uterus, but without marked curative effect. It is caustic in its action. - 3 Dr. J. T. Kent comments on this remedy as follows: “Burning along the course of any nerve, burning along the spine, burning in the stomach, emaci- ation with burning in the deep parts. Burning, stinging pains of cancer when nothing else will help. After arsenicum has refused to help, though its symptoms seem to be present, this medicine will make the patient sleep as if he had taken morphine. It has acted as a perfect euthanasia in cancer deaths.” . . . . " ; , , 4 These remedies are more useful to control the loss of blood than for any specific influence on the disease. - * Ruddock, Text-book Prac. Med, and Surg., p. 453. N 7 HERAPE UTYC.S. 399 kali cyanatum" (cyanate of potash), lapis alba,” phytolacca, platina,” Sabina,” sang.” (to prevent return after excision), Secale,” sepia, silicea, thuja” (epithelioma).” * Hom. Recorder, p. Io, Jan. I 5, 1888. * Dr. V. Grauvogl states that five cases of uterine cancer, pronounced to be such and incurable by old-school physicians, were completely and perma- nently cured by this remedy. It must be used before the tissues break down. He has never seen any benefit from it in open cancer. — Allgemeine Aom. Zeitzeng, June 15, 1874. * See note 4, page 398. * Ruddock, Text-book Prac, Med, and Surg., p. 453. * Dr. Schwabe found thuja very beneficial in a case of cancroid, though recovery did not take place. — Lehrbuch der hom. Therapie, 3d ed., 1882, Vol. II, p. 995. 4OO PEZ V/C CELLULITIS AAWD PERITO/WITIS. \ CHAPTER XXII. PELVIC CELLULITIS (PARAMETRITIS 1), PELVIC PERITO- NITIS (PERIMETRITIS), AND PELVIC ABSCESS. HE first two of these diseases are the most common of those peculiar to women, and there are few affec- tions which have given rise to so much dispute, – the ad- vocates of one almost ignoring the existence of the other. Unfortunately, morbid anatomy has not been able to settle definitely the disputed question, as there are comparatively few opportunities for necropsies in the various stages of either disease, and the false membranes of pelvic peritonitis sometimes so closely resemble the peritoneum as to cause error in determining the origin of the disease by its post mortem appearance. Theoretically, they are separate and distinct from each other; but from the practical clinical standpoint of the practitioner, the writer believes these affections generally coexist, though the one may largely predominate over the other; just as, in pneumonia, the lung symptoms are the most prominent, though in all marked cases the pleura 1 Dr. W. A. Freund has given a very thorough description of chronic atrophic parametritis in his Gynākologische Klinik, Vol. I. p. 203, published by Trübner in Strasburg. A review of it will be found in the Centralblatt für Gynākologie, p. 447, 1886. It is characterized by chronic inflammation of the fascia, and aponeurosis of the fatless connective tissue, with subsequent con- traction, as in cirrhosis of the liver; uterine displacements, etc. follow. Pessaries are useless in this disease, so far as a cure is concerned. The author can add no treatment for it differing from that given for pelvic cellu- litis. The action of morphia in causing atrophy of the female genital organs, especially of the ovaries, suggests a possible remedy for it. An interesting report of such a case, by Dr. Levinstein, can be found in the Centralblatt für Gynākologie, No. 40, p. 633, Oct. 1, 1887. PEL WIC CELLUL/7/S. 4OI is more or less involved. A no less distinguished writer than Dr. Emmet declares himself unable to distinguish between them, and employs the term “cellulitis" as the most common pelvic inflammation of the non-puerperal state, reserving “pelvic peritonitis,” not for a distinct and separate lesion, but for a much graver complication of the cellulitis. This is directly contrary to the views of Drs. Schroeder, and Thomas, and of nearly all gynecologists, the last condition applying to what the latter would call pelvic peritonitis in the great majority of cases. These subjects will be treated, therefore, not as abso- lutely distinct from each other, but as coexisting to a certain extent, the one or the other predominating sufficiently to warrant the corresponding name, while in rare cases both may be present to an alarming extent, and seriously threaten or destroy the life of the patient. PELVIC CELLULITIS. Pelvic Cellulitis, or parametritis, as Professor Virchow | styled it in contra-distinction to perimetritis for pelvic peritonitis, means a local or general inflammation of the areolar tissue of the pelvis, without including periproctitis, psoas, or iliac abscess. It is often associated with the puerperal state, and is excited by exposure to cold, traumatism, and rarely extension of inflammation from neighboring structures. A similar condition is seen in the cellulitis appearing early in the development of malignant disease of the ute- rus, and fixing that organ. The great majority of cases follow abortion, or labor at full term, and, according to Professor Schroeder, are due to septic infection. The writer has seen a number of cases diagnosed as uncompli- cated puerperal fever, without a suspicion that an extensive cellulitis was present. As causes of traumatism may be cited coition too soon after confinement (a physician neglects his whole duty 26 4O2 PEL WIC CELLULATIS. if he fails to warn his patients against sexual intercourse before three months after delivery); surgical operations, especially on the cervix; ill-fitting pessaries; and harsh applications or examinations when the uterus or neighbor- ing tissues are unduly sensitive. It is most likely to follow surgical operations when the patient is in an enfeebled condition, when chronic cellulitis is already present, and from septic infection. In very exceptional cases, all the cellular tissue about the uterus is involved in the inflammation; but as a rule it is limited to one side of the uterus, or a broad ligament, and most often in the left side of the pelvis. Not infre- quently the exudation extends up and out of the pelvis, so that it can be palpated externally, especially in puerpe- ral cases. Pelvic congestion would be a more accurate name for many cases called pelvic cellulitis. There is, however, no distinct history of inflammation, but bearing down, drag- ging sensations, pain in the pelvis, a Sensation of Soreness, and the uterus is enlarged and heavy. The Clinical History of pelvic cellulitis comprises three stages: Congestion, exudation, and resolution, or, less often, suppuration. In nearly all cases there are marked symp- toms in the beginning of the disease, which is ushered in with a chill followed by fever, and a variable amount of pain in proportion to the extent to which the peritoneum is involved. g On examination, the vagina is hot and sensitive, particu- larly at some spot, and an expert may be able to distin- guish a localized puffiness or Oedematous condition of the tissues. This stage is succeeded in a few hours by the stage of exudation or effusion at the site of the inflamma- tion. The symptoms of fever continue, the temperature being a little higher toward evening; dysuria and menor- rhagia or metrorrhagia are not uncommon. A thin leucorrhoeal discharge from the uterus may give rise to CZ/AV/CA/C H/S 7 OAQ P. 4O3 the diagnosis of endometritis; but this is secondary to the cellulitis, and any application to the endometrium might be followed by a fatal increase of the inflammation. There is more or less pelvic pain from the pressure of the exuda- tion on the nerves, and the drawn-up adducted position of the thigh is characteristic. Not infrequently, the patient limps on the side corresponding to the exudation. In- duration in the inflamed areolar tissue progresses in proportion to the amount of the effusion in it of the liquor sanguinis. It is apparent, therefore, that while the tumor thus formed will vary in location, size, and consistence, it will have a peculiar feature, that of immobility, - an important fact in differential diagnosis. The tumor is most often found near the angle of a lacerated cervix, or in the left broad ligament; from here it may extend up and out of the true pelvis, so as to be easily felt externally. This is especially true of puerperal cellulitis. On examination, its consistence will be found to vary at different periods of the second stage. In the beginning, only a diffuse resistance is felt, without sharply defined borders. In exceptional cases, the uterus may rest in a bed of cellulitic exudation; here, the pelvic peritonitis is an important complication, and, as a rule, the predominant disease. In a short time, the exudation grows harder, with well defined borders, till it seems as if molten lead had been run into the tissues and hardened in them. While it is quite sensitive in the beginning in pro- portion to the extent of inflammation of the peritoneum accompanying the cellulitis, it gradually diminishes till it can be freely handled without causing much pain. In the third stage of absorption, the former symptoms of fever and local inflammation gradually subside; the tumor slowly diminishes in size and sensitiveness, but becomes harder. The absorption of large exudations is usually accompanied by a variable amount of hectic fever. In some cases the tumor remains stationary for an indefinite period. 4O4. PEZ VVC CEZ/. UZZZYS. Fortunately, most cases undergo absorption, and few suppuration. If the latter takes place, the symptoms of fever and inflammation do not subside, the tumor remains Soft and very sensitive; the temperature increases, being higher at night than in the morning. Chills may attend the formation of pus, but do not always. The further consideration of suppuration will be found under the head of Pelvic Abscess, at the close of this chapter. It is not to be supposed that all cases of cellulitis have marked symptoms, and run a perfectly typical course, as described above. There are some exceptions to the rule. A woman does not seem to do well for some weeks after confinement. She suffers no acute pain, but has a Sense of Soreness, loss of appetite, some fever, is weak and listless, and a careful examination often reveals extensive cellulitis. The Diagnosis is easy in nearly all cases when the exudation is large; but if very small, it is more difficult. Though the symptoms may point to the disease, an examination is necessary for a positive diagnosis, and to determine the extent of the affection. The patient must occupy the dorsal position, with all the clothing loosened, and the thighs drawn up to relax the abdominal muscles. The physician then carefully palpates with the palmar surfaces of the fingers over the hypogastric region and sides of the pelvis, to ascertain if the exudation has ex- tended up out of the true pelvis. He next thoroughly anoints the forefinger, and gently and slowly introduces it along the posterior wall of the vagina, taking note at the same time of the heat and dryness of the canal. The cul-de-sac of Douglas is examined with a very gentle touch, also the region around the cervix, and, finally, the broad ligaments, with the careful help of the other hand outside over the corresponding regions. If there is not much sensitiveness, considerable pressure of the opposed fingers may be necessary to distinguish and ac- PA’OG/WO.S./S. 4O5 curately map out a small exudation. A rectal examina- tion will often disclose an exudation in the utero-sacral ligaments which would otherwise escape notice. In regard to a differential diagnosis between an exuda- tion in the cellular tissue and one in the peritoneum, it is said that the uterus is immovable, and often connected with the cellulitic tumor, but is much more free and mov- able in peritonitis; in cellulitis the exudation is lower in the pelvis than in pelvic peritonitis. The character of the cellulitic tumor has been described above. When it is very large, it crowds the uterus one side, or out of place, and may press hard enough upon some nerve to cause severe neuralgic pain in the pelvis or leg. With the stage of absorption, the uterus not only resumes its former position, but with the continued con- traction of the tissues is also permanently drawn out of place. Lateral version or flexion is the most common form of displacement from this cause; i.e. cellulitis in one of the broad ligaments. Sterility sometimes follows from destruction of the Graafian follicles or ovaries by suppura- tive action or atrophy; also from adhesions binding the Fallopian tubes down, and rendering them, impervious. Uterine displacement and sterility are far more frequently the result of peritonic complications. Secondary to these may be mentioned salpingitis, amenorrhoea, menorrhagia, and dysmenorrhoea. The Prognosis depends largely on the violence of the symptoms and the extent of the exudation. Life is seldom in danger. A small abscess may form, break, and heal up in a few days, or the effused mass become absorbed in a fortnight; but this is exceedingly rare, and no amount of skill will always predict the time of recovery. When the tumor is sharply defined and not very sensitive, the prospect of complete cure is very good if the patient be willing to follow her instructions for a sufficient length of time. It is better to qualify the prognosis to her, and 4O6 AEZ V/C. PER/TO AWAT/S, state that if she recovers in six weeks she will do well, though sometimes such cases get well sooner. The general principles of local treatment are so similar to those of pelvic peritonitis that they will be considered together. The reader is therefore referred to the following Section, both for treatment and the differential diagnosis (pp. 416, 419). PELVIC PERITONITIS. Pelvic Peritomitis (Perimetritis) is very common in the non-puerperal state, and less frequently seen after delivery than cellulitis, which is rarely independent of delivery or traumatism. In other words, the pelvic in- flammation, often called cellulitis, is really of peritoneal origin. It is a local peritonitis; and bearing this in mind will aid in studying the etiology and pathology, as well as the treatment. The causes of pelvic peritonitis may be classified as follows: — ſ Pelvic cellulitis. Extension of in- ; Endometritis flammation. iº - Ovaritis. ſ Products of catarrhal or purulent inflammation (gonorrhoea) from the Fallopian tubes. Hemorrhage into peritoneal cavity. Rupture of cysts. Extra-uterine pregnancy. U Intra-uterine injections. Parturition or abortion. ! Surgical operations. | Blows or falls. | Excessive venery. Sudden suppression of the menstrual flow. Uterine displacement. Ovarian or sub-peritoneal tumors. The presence of malignant or tubercular disease. Escape of fluids into the peri-- toneal cavity. Traumatism. . A.TIO/LOGY. — PA THO/OO. V. 4O7 The relation of most of these causes to pelvic peritonitis is too evident to need further explanation. The effect of gonorrhoea extending Successively from the vagina, uterine cavity, and through the Fallopian tubes to the peritoneum, is seen among immoral women, who are especially subject to this form of peritonitis. Some phy- sicians believe that a woman who has had gonorrhoea. cannot conceive. The condition of the system, and the retrogressive changes following delivery, powerfully pre- dispose the patient to either peritonitis or cellulitis from slight causes, and make her susceptible to septic infection. The importance of the lymphatic system in connection with these diseases has not received sufficient attention. When the lymphatics become clogged, as in malignant disease, tuberculosis, or septic infection, inflammation in the surrounding tissue seems pretty sure to follow. The irritation caused by the presence of a tumor results in the adhesions which are so common. Surgical operations, even of the most trivial character, or any mechanical interference with the uterus, by a sound, pes- sary, etc., must never be attempted when there is either gem- . eral or local painful sensitiveness of the pelvic organs, and pelvic abscess (the ovaries excepted). Furthermore, ſhe pre- cautions taken in operations on other parts of the body should be observed more rigid/y, if possible, in those involving the generative system. The pathological appearances may be summed up in thickening of the peritoneum and adhesions to the uterus, ovaries, intestines, omentum, etc., varying from fine deli- cate threads to firm bands or sheets of tissue, encapsuling Serous or purulent exudations. Like its neighbor, pelvic cellulitis, pelvic peritonitis may develop insidiously or with marked symptoms, which is the rule; may run an acute or chronic course; and, for conve- nience of description, is divided into three similar stages, — congestion, effusion, and resolution or suppuration. 408 PEL WIC PEAC/TOM/TVS. The Clinical History of acute pelvic peritonitis during the first stage is very characteristic. The patient has a feeling of chilliness, though it is sometimes absent; then follows increase of pulse and temperature, tenderness over the hypogastrium, and pain, which may be intense. There may even be tympanitic distention of the abdomen, and vomiting. The peculiar anxious, drawn expression of the face is an important Symptom. Though these are the more common phenomena.mark- ing the commencement of this disease, there are two other forms, as in general peritonitis, where nearly all of them may be wanting. In one, the characteristic expression of the face is present; the patient passes into a weak or collapsed state within some hours, or two or three days, suffers no pain, and the pulse and temperature are not in proportion to each other or the serious condition of the patient, — i. e. the pulse goes up, while the tempera- ture remains near or below normal. Very few of these cases recover. The other form may be termed chronic, and invades the pelvis to a great extent, without other symptoms than a poor appetite, perhaps slight fever, painful coition, and some indefinite pain or soreness in the uterine region after unusual exercise. The chronic form results from the presence of malignant or tubercular dis- ease, gonorrhoeal infection, displacements of the uterus, and pelvic tumors. If the patient does not succumb to the acute form, it is much more likely to terminate in suppu- ration than if it develops more slowly and insidiously. Most of the symptoms of the first stage are continued into the second, that of effusion, which may consist of coagulable lymph on the surface of the membrane in mild cases, a collection of serum, or it may even be sero-puru- lent in severe forms of a septic origin. The effusion usually becomes encapsuled by adhesions and the forma- tion of false membranes, slowly shrinks, and hardens as the watery portion is absorbed. It may form a localized CLIMICAL HISTORY. 409 tumor at one side of the uterus, or settle in the cul-de-sac of Douglas, and rise up around the uterus; as it hardens, the entire vault of the vagina becomes hard, and feels as if plaster of Paris had been run into the pelvis and hardened there, and all about the uterus, which is fixed by it in severe cases. The disease has now become chronic; the fever, temperature, and extreme sensitiveness abate, but the patient complains of a variable amount of pelvic pain, aggravated by walking and unusual exercise; dysuria is common when the utero-sacral ligaments are involved, and the symptoms are often worse at the men- strual periods. - Excepting by the previous history of the case, it is generally impossible to distinguish between pelvic cel- lulitis and pelvic peritonitis in the second stage after the acute symptoms have subsided. The fact that cellulitis in this stage, independent of traumatism and parturition, has scarcely ever been found at an autopsy by any observer, and that the cases diagnosed as cellulitis have proved to be peritonitis, make it highly probable that cellulitis is not nearly so common as has been supposed. Besides, the long duration, and the susceptibility of ex- acerbations from exceedingly slight and apparently un- important causes, point to the sensitive peritoneum as the source of the disease. The peritoneal exudation is less likely to suppurate, is absorbed more rapidly, is higher in the pelvis, and, as a rule, allows more mobility to the uterus, than the cellulitic tumor. As the symptoms slowly disappear with the third stage, of resolution, the patient's general health improves in proportion; but for months she will have to guard against cold, traumatism in any form, etc., or the peri- - tonitis will reappear in all its former intensity, if not even greater. The Diagnosis of acute cases is very easy when the symptoms are marked, or in the second stage, with the 4IO PEL WIC PEA’ſ TOAVITY.S. pelvis filled with exudation, and the tissues surrounding the uterus very hard. It is remarkable, however, how many cases of small exudations are overlooked, particu- larly when situated in the utero-sacral ligaments or on the posterior upper surface of the broad ligaments, which are common sites of this disease. In the acute stage, with high fever and extreme local sensitiveness, the local examina- tion with finger or instruments had better be deferred, as no good and much harm may come from it. When the more severe symptoms have subsided, a careful exami- nation is necessary to confirm the diagnosis, and to adopt proper methods of treatment. In nearly all cases of disease it is well to have the patient in bed, where there are no obstacles to a thorough examination, and the physician can freely use his hands or stethoscope as he sees fit. Here, too, there must be no obstacles. The clothing should be freely loosened, the patient lie on her back, with the thighs moderately flexed on the abdomen. The bimanual method must be carefully employed; for gentleness, not force, and the power of concentrating the attention on the touch of the examining finger, are requisites for a skilful examiner. The ability to detect small adhesions which only partially fix the uterus, or effusions, will depend largely on these conditions. - Not only must the vaginal vault be systematically ex- plored, first the cul-de-sac of Douglas, then at the sides of the cervix, the anterior fornix of the vagina, and the broad ligaments, but also the utero-sacral ligaments, and the pos- terior and upper surface of the broad ligaments through the rectum. In some instances, when the patient cannot resist the impulse to contract the abdominal walls, or if the latter are very fat, it will be necessary to give ether; but this has the great disadvantage that spots of local inflammation or tenderness may remain undetected, as she is no longer sensitive to pain. D/AWA7E/PEAVT/A/, D/A GAVO.S./S. 4 II The exudation varies in size from a walnut to a large ..mass filling the pelvis. In the early stage, before adhe- sions or false membranes have formed to shut off the fluid from the peritoneal cavity, the effusion is not likely to be felt, as the fluid at once yields to the touch of the finger. Later, however, when it is encapsuled, and becomes some- what hard, it is easily detected. In the beginning it is exquisitely sensitive, and slowly grows less So, till it can be readily handled without causing much pain. Adhe- sions can sometimes be felt like fine strings extending from the uterus into the adjoining tissue, especially at the angle of a lacerated cervix. The immobility of the uterus is another indication that these are present. In rare instances the exudation may extend well up above the true pelvis into the abdominal cavity, and give rise to the suspicion of a fibroid or ovarian tumor with the presence of subacute peritonitis; but the history of the case, and the variations in the size of the tumor in the course of a few days, will distinguish it. It enlarges with increase of pain from slight causes, and diminishes rapidly, to a certain extent, as the serum is absorbed. DIFFERENTIAL DIAGNOSIS. Ae/zzc Perztozziężs. Ae/zyre Cel/zzlitzs. Pe/zyzz Abscess. Myoma or Ozarzazz Trezzor. Haematocele. Develops with se- vere pain, extreme sensitiveness, and symptoms similar to general perito- nitis. Occurs indepen- dent of the puer- peral state. Exudation im- movable, and very sensitive, unless Development not so violent; chill followed by fever, but no vom- iting; less pain and sensitiveness. Very rare, inde- pendent of the puerperal state or surgical opera- tions. Exudation im- movable, sensi- tive, but less so May result from either cel- lulitis or peri- tonitis. Immovable; not always sen- sitive. Development very slow, without symptoms of in- flammation. More common at or near the cli- macteric. Freely movable, and not sensitive. Develops sud- denly, with pain, symptoms of col- lapse, and inter- nal hemorrhage, and without rise of temperature. Immovable, and sensitiveness varies according 4. I2 PEL WIC PER/TOAVITIS. Pelznic Pelznic Pelzac Myoma or Aſaematocele Peritozzitts. Cellulitis. A&scess. Ozarian Tumor. - far advanced in than the preceding to its duration, chronic form. disease. or a soft yielding mass which can- not be grasped. Tumor formed Same as in peri- Tumor is low Tumor higher Tumor elastic by exudation very tonitis. down in the up in the pelvis: and fluctuating hard; gradually pelvis, and fluc- hard if a myoma, in the begin- shrinks tuateS. elastic if ovarian. ning; gradually Tumor extends up, from lowest point of the cul-de- sac of Douglas, uniformly around the uterus, like set plaster of Paris, or in utero-sacral lig- aments; less often, at the sides of the uterus. Frequent- ly the exudation is felt only in roof of the pelvis. Suppuration Tare. Uterus at first crowded to one side by the exuda- tion, and drawn back again and out of place as the lat- ter is absorbed. Adhesions are COII]]|T|OIł. Often worse at the men strual epochs. Tum or most often at sides of cervix, or in broad ligament; feels separate from the uterus, and as if attached to the walls of the pelvis; generally extends lower in the pel- vis, and more at the side, than the former. Suppura tion In Ore COIn In On. Uterus displaced as in peritonitis, but no adhesions unless complicated by peritonitis. Less movable than in former af- fection. Not aggravated by the menstrual epochs. Occupies the site of previous exudation in either cellulitis, peritonitis, or haematocele. U terus dis- placed. Tumor higher in pelvis, and, if myoma, attached to the uterus. Displacement of uterus not so marked. Menorrhagia is a prominent symp- tom of uterine my- Omata. shrinks and hardens. Tumor begins in lowest point of the cul-de-sac of Douglas, and extends up in the pelvis on an approximate lev- el, bagging out the cul-de-sac, or is encapsuled ex- ternal to the per- itoneum and ex- tends downward around the rec- tum. Uterus crowd- ed forward to- ward the pubis, instead of lateral displacement. The duration of pelvic peritonitis is variable; and, from the great tendency to relapses, it is likely to continue for an indefinite period without proper treatment. As sequelae may be mentioned displacement and fixa- tion of the uterus by adhesions, sterility, atrophy of the PE/L WIC A BSCE.S.S. 4 I 3 ovaries, occlusion of the Fallopian tubes, amenorrhoea, and dysmenorrhoea. - The Prognosis depends, of course, on the extent of the disease and the severity of the symptoms. Fortunately, few cases die; but complete recovery from this affection requires great care, patience, and faithfulness in treatment on the part of both the patient and her physician. In the acute stage, it is a good sign if the pulse and temperature diminish in proportion to each other, and if the pulse be- comes fuller, stronger, and less rapid as the pain subsides. It is a bad sign if the pulse becomes quicker and weaker as the pain ceases, and there is very little chance for life if the pain stops suddenly, the pulse flickers, and the features collapse. Death is at hand when the pulse and tempera- ture become disproportionate to each other and the extent of the disease; i. e. the temperature falls to or below normal, perhaps to 96°, the pulse growing rapid and weak, 140 to 150 or more per minute, even though the condi- tion of the patient may be good in other respects. PELVIC ABSCESS. The exudation of pelvic peritonitis or pelvic cellulitis sometimes undergoes suppuration instead of absorption. While these are far the most common causes of pelvic abscess, there are others, such as remains of an extra ute- rine pregnancy, haematocele, periproctitis, suppuration of an ovarian cyst, and caries of any of the pelvic bones. It follows pelvic cellulitis more often than pelvic perito- mitis, and is more common in the puerperal state than out of it. The syphilitic, scrofulous, and tuberculous diatheses are marked predisposing causes, as well as a general depression of the vital forces or physical vigor of a woman. Pelvic abscess is also more apt to follow when the exudation is of septic origin. If, under the above conditions, the fever continues moderately high, 4I4 PEZ V/C. A B.SCE.S.S. and the exudation remains exquisitely sensitive and does not harden, there is good reason to expect the formation of an abscess. Though it may develop insidiously, with scarcely any or no symptoms, the formation of pus is generally character- ized by chills, fever, profuse perspiration, prostration of the patient, throbbing pain in the pelvis, disturbances of micturition or defecation, or even neuralgic or sciatic pains in the limb from the pressure of the abscess on the surrounding structures; persistent pain or aching in the heel is sometimes observed in connection with a large pel- vic abscess. In rare instances the fever symptoms have subsided, and the pus has been retained for months or even years. Generally the hectic fever continues, the abscess increases in size, and breaks either into the vagina, rectum, bladder, or groin, and, least frequently of all, into the peritoneal cavity, which almost invariably causes a fatal attack of peritonitis. The Diagnosis is made by the history of the case and the presence of a fluctuating tumor in the pelvis, ascer- tained by bimanual examination through both the vagina and rectum. It should be remembered that the presence of peptone in the urine generally attends any extensive suppurative process;' and in cases of a swelling of a doubtful character in the pelvis, a careful examination of the patient's urine may decide the diagnosis. The Prognosis is favorable when the abscess has a free opening into the vagina and rectum, so that the cavity is thoroughly drained, if the fever and purulent discharge diminish, and also if the odor be not very offensive. The prognosis is unfavorable where there is a marked heredi- tary taint of tuberculosis or scrofula, and a feeble state of health, if the abscess be deep-seated, and opens into both bladder and rectum, or by a long sinus which does 1 Jaksch, Klinische Diagnostik, p. 275, 1889. AA’OGAWO.S./S AAWD TREA TMAEAVT. 4I 5 not permit a free discharge from the cavity, unless surgical interference can change these conditions. There are few diseases which test a patient's consti- tution and vigor more than the constant drain of a large abscess. It is of great importance, therefore, for her to eat the most nutritious food in abundance, — meat soups and all the meat she can digest, with milk, eggs, and fresh vegetables, aided if necessary by some malt liquor. Treatment. — Notwithstanding the assertions of eminent men to the contrary, the writer feels positive, from results in his own experience, that carefully selected remedies are very beneficial. The same principles of surgery for the treatment of abscesses in other portions of the body apply equally here. The collection of pus must be evacuated by as free an incision as is consistent with safety." Mr. Lawson Tait prefers to reach the abscess through the abdominal wall, and to use a drainage-tube afterwards. The more usual method of opening, however, is to expose the lowest point of the abscess with a Sims speculum, insert the needle of an aspirator, and, when pus is found, run a narrow-bladed bistoury along the needle as a guide. This opening is very cautiously enlarged enough to allow a free discharge of the pus, which is generally very offen- sive, and the cavity is thoroughly cleansed with a weak solu- tion of carbolic acid, or bichloride of mercury (I : 3OOO), without allowing the water to flow with any force from the syringe. A drainage-tube is then inserted, and a little iodoform or sublimate gauze packed in the vagina. Irrigation of the cavity with one of the above solutions will be necessary once or twice a day, or less often, according to the quality and quantity of the discharge. There are few places in the body where it is more haz- ardous to plunge a knife than here, so that it behooves a physician to guard against all possible mistakes and 1 P. F. Mundé, Report of Ten Cases, American Journal of Obstetrics, p. 113, February, 1886. 416 PEL WIC CELLULITIS, PERITO/VITIS, ETC. the wounding of large blood-vessels. If the abscess opens through a long sinus, and has become chronic, it will be necessary to dissect the sinus out, and make an opening which permits the free flow of pus, and the irrigation of the cavity of the abscess. When the abscess extends high up in the pelvis, and there is reason to believe it is intra- rather than extra- peritoneal, it is usually best treated by an abdominal in- cision, dissection out of the pyogenic membrane, so far as possible, and by drainage. The Treatment of pelvic cellulitis does not differ from that of pelvic peritonitis in the stage of effusion and induration. In the very commencement of the stage of congestion, with the initial chill, cellulitis can often be abated by the immediate and continuous use of the hot-water douche. The patient must be warmly blan- keted, with a hot-water bottle or heated bricks at her feet, and the injection should be continued till reaction is established, the fever subsides, and free perspiration has commenced. The hot-water spinal bag applied to the lumbo-dorsal region is worthy of trial, in the hope that it will contract the pelvic blood-vessels and diminish the congestion. 4. - This same treatment can be adopted for slight attacks of pelvic peritonitis, but in the acute stage of the severe forms there would be danger of aggravation. In both these diseases, especially the latter, absolute rest while acute symptoms are present cannot be over-estimated. The patient must be waited on like an infant, without the least voluntary motion of any kind on her part. In peritonitis, opium in some form is the sheet-anchor of the old school, both to allay pain and Secure additional quiet; but it has the disadvantage of causing consti- pation and faecal impaction, which interferes with free portal circulation, and in consequence materially hinders TREA 7TMAEAVT. 4I 7 recovery. The removal of a collection of faeces, if pres- ent, is one of the first things to be attended to by the practitioner. - As long as there are symptoms of local inflammation, rest is essential, particularly at the menstrual period. A hammock is one of the most comfortable things for the patient to lie in. Coition is a positive injury. The sewing-machine, and walking, riding, or any exercise which aggravates the pain, are to be positively forbidden, and high-heeled shoes in particular. Hot-water injec- tions" are invaluable so long as any exudation is present, to stimulate the pelvic circulation, and thus promote absorp- tion. The writer has obtained excellent results in some cases by medicating the last pint of the injection with glycerine, iodine, or hamamelis. In case the uterus is out of place, and drags on the ligaments, much good can be done by inserting every other day an antiseptic wool tampon, so as to raise that organ up, and thus remove a Source of irritation ; taking care, however, that the tampon does not press against the sensitive effusion and cause pain. This same tampon can be impregnated with iodine and glycerine, which is the best application the writer has so far used for these cases when of long duration. In the early stages, bella- donna cerate or extract is superior, and iodol or iodo- form has a more soothing effect than either. When there is much active inflammation, tampons cannot be endured, and the belladonna, iodoform, or any other cerate, can be applied with an ointment injector, or the medicament can be used in a suppository. Where there is much congestion, and but little inflammation, with a great deal of dragging on the uterine ligaments, Hofmann's pessary will give much relief, and is easier to wear than a hard rubber instrument. Like all soft rubber pessaries, it will absorb secretions, and requires constant attention, or it 1 See chapter on Minor Surgical Gynecology. 27 418 PEZWZC CELLUZZTIS, PER/TOM/T/S, ETC. will become very offensive. Some of these pessaries have a rubber cup attached to hold a cerate for application, but the writer finds it difficult to make much practical use of it. FIG. I.43. HoFMANN's PEssary. For the removal of an obstinate pelvic cellulitic mass the following prescription is efficacious: — * Bt Extr. belladonnac. Camphorae pulv. . . . . . . . . . aa 5i. Ungt. hydrarg. . . . . . . . . . . 3ss. Lanolin . tº e 3i. M. et S. Apply on Canton flannel to skin over the swelling.” In connection with these pessaries, a carefully fitted abdominal supporter will give great relief in taking off a certain amount of pressure from above. The diet must be the most nutritious possible, and so regulated as to secure a daily movement from the bowels. In cases of exudation in the utero-sacral ligaments and much irrita- tion at the neck of the bladder, Dr. Emmet has found it necessary to prolong the incision in the button-hole oper- ation for prolapse of the urethra, so as to free the fascia at the neck of the bladder, and thus relieve the constant inclination to urinate. The galvanic current has met with some favor in the treatment of these diseases, to promote the absorption 1 Dr. L. L. Danforth, Cinn. Lancet. THERAPEUTICS. 4 IQ of both exudations and adhesions. After the acute in- flammatory symptoms have subsided, careful massage of the pelvic organs” will prove very effectual in removing exudations and adhesions, besides doing much to prevent Subsequent uterine displacement from contraction at the site of the exudation after it has disappeared. THERAPEUTICS OF PELVIC CELLULITIS, PELVIC PERITONITIS, AND PELVIC ABSCESS. | Aconite.* A valuable remedy in the stage of congestion (veratr. vir.), especially when it results from cold; high fever; hot, dry skin; great thirst ; much anxiety and restlessness. Vomit- ing is sometimes present, and cutting pains in the abdomen. It should be given in the lower potencies, in severe cases (1 x. or 2 x.) as often as once in fifteen or twenty minutes, till the fever begins to subside and perspiration commences. It is most useful at the time when the hot-water douche is indicated. Dr. Jousset” recommends twenty to thirty drops of the mother tincture to be taken in twenty-four hours for very acute and severe cases of pelvic peritonitis. | Apis 3.x, trit. will sometimes abort suppuration. It is good for relapsing abscesses, and is one of the most useful remedies to stimulate the absorption of exudation. Apis is to effusion in the * * doubtful if there is such a great difference, therapeutically, in the coils of wire as some writers would lead us to be- lieve. He has nevertheless employed the various sizes 32 498 ELECTRICITY IN G PAECOLOGY. of wire in coils, though he is not yet convinced of their necessity. - The well known tendency of the negative pole to cause a blister has led many physicians to believe that the elec- trode must be covered with chamois leather, or some other material, to avoid blistering when the negative pole is used internally. This is a mistaken idea; it is the electricity, and not the electrode or its covering, that raises the blister, A4 7.7 FA2/E.S. # 499 and the only way to avoid it is to use an electrode which has surface enough to disperse harmlessly the electricity which would be concentrated on a small electrode and Cause a blister. The combined Faradic and galvanic cur- | ſ º {{ | § º º: º ºf Rºº? º | ſº º º º º # [. # | FIG. 155. FARADIC BATTERY witH THE ENGLEMANN Coils. rent has been recommended rather indefinitely, and is very little used. This may be considered a brief Summary of well known facts to be remembered, and introductory to the actual employment of electricity. 5OO Az ZAZ C7.R/C/7"Y ZAV G VAWA. CO/LOG P. First class instruments are necessary for the best result. A cabinet battery gives a more uniform and steady cur- rent than can be obtained from the small cells in portable batteries, and requires very little care. I am using the wall cabinet made by Waite and Bartlett, and have in it water and German silver wire rheostats, as well as the Faradic coils of different sizes of wire of the Englemann design, similar to Fig. I 53, only the cells are in the cellar. This º * CAVAQ'º. CWY,NAD. . . . º \ º- *!"| % % % % ſ'''' º A ºf ſºft''''/. AEA 7 AFA/74. O 24: G. Zºº, /327. / | | º tº FIG. 156. CHLoRIDE of SILVER FARADIC BATTERY, witH CoARSE AND FINE COILS. battery has given me much satisfaction. If used only for gynecological cases, the wire rheostat and interrupted gal- vanic are unnecessary, and add to the size and expense of the battery. As many physicians do not care to go to so much ex- pense, the next best substitute is a thirty cell portable galvanic battery (Fig 154) and a separate Faradic battery. The two should not be combined in any portable instru- ment. The best separate Faradic battery for gynecologi- cal use with which I am acquainted is the one made by Waite and Bartlett with the Englemann coils (Fig. I55). AA 77 ERAAE.S. 5OI The chloride of silver Faradic battery made by the J. A. Barrett Company (Fig. 156), is very convenient to carry when a mild current is desired. The chloride of silver galvanic batteries are models of lightness and compactness, especially those made by the A | ºf -- FIG. 157. CHLoRIDE OF SILVER GALvanic BATTERY. J. A. Barrett Company (Fig. I57), and as there is no fluid to Spill, they are very convenient for transportation. They have, however, a high internal resistance and low electro- motive force in comparison with a good acid battery which unfits them for gynecological work till this objection is °Vercome. It is claimed that the new chloride of silver (wet cell) battery made by the McIntosh Company (Fig. '58) has a considerable higher electromotive force than other chloride of silver batteries. It is rather heavy, and, like others of this class, is more expensive to buy and run than an acid battery of similar character. Another excellent battery is the No. 4 Waite and 502 A / EC7.R/C/TV /AW G VAWA. CO/LOG P. Bartlett, with a Du Bois Reymond coil. No battery in- ferior to these, or equally good-ones made by a reliable firm, should find a place in the office of any physician who expects to succeed with electricity in gynecology. If only one battery is purchased, buy the galvanic, as it is more generally useful than the Faradic. The time possibly may —A tº º * º º º D º * & . \ , ; c. : - .#E: E. FIG, 158. McINTosh CHLoRIDE OF SILVER BATTERY. COMBINED GALVANIC AND FARADIC BATTERY. come when storage batteries filled from street currents may be employed, or the current taken direct from an Edison incandescent circuit. An apparatus for the latter purpose has been designed by Massey, which is essentially a modification of Gärtner's rheostat. Bröse of Berlin announces that he has perfected such an instrument; but his claims are not sufficiently demon- strated at the time of writing to warrant recommendation. Indeed, the direct use of any circuit designed for electric ELECTRODES. 5O3 lighting by merely interposing resistance to weaken the current is too dangerous, and requires too much care in its use, for the writer to recommend it to any general prac- titioner. The milliampère meter is absolutely necessary to use properly the galvanic current. An instrument regis- tering two hundred and fifty milliampères will be sufficient, though a very limited number of physi- cians have employed five hundred or more milliampères. Quite a large variety of electrodes have been recommended, but a limited number will answer every purpose. The following list contains all the more important ones for gynecological purposes. A zinc plate or wire gauze (Fig. I 59) at least 4 × 5 inches EHº for a dispersing electrode on the abdomen. Fig. 59. Wise e g s - GAUZE ELECTRODE. A clean napkin of Turkish towelling is to be - wrapped over it when used. A clay electrode (Fig. 160); the author has not seen any equally good substitute when cur- rents are employed which exceed seventy-five milliampères, Fry's combination electrode for treating stenosis and dys- - - - - - º sº WTT. §º. =======--a ; : & % FIG. I60. GOELET’s CLAY ELECTRODE. menorrhoea (Fig. 161); a vaginal electrode (Fig. 162); a ball-tipped electrode, the ball having a diameter of three fourths of an inch ; a short intra-uterine electrode for the cervical canal (Fig. I63); a long intra-uterine platinum electrode which will reach to the fundus (Fig. I64). If only the cavity of the uterus is to receive the current, insulate the cervical portion of the electrode with a piece of thin 5O4 ELECTRICITY IN G VAWECOLOG V. rubber tubing drawn over it, or by melting a layer of shellac on it in the flame of a spirit lamp. A set of intra- uterine tips for use with the positive pole (Fig. 165); tips i i for the four electrodes should fit the same staff. A bi- polar vaginal electrode (Fig. I66); a bipolar intra-uterine electrode (Fig. 167). & A myoma (fibroid) spear (Fig. 168) or trocar (Fig. 169) for puncturing the tumor from the vagina will be neces- AE/LECTA’O/DA.S. 5O5 sary for physicians who propose to pursue Apostoli's methods in every detail. Many of the more important electrodes are combined to advantage in a case, as in Fig. 170. It is needless to remark that all the electrodes used in the vagina must be kept scrupulously clean. : . E sº- NH- tº E. s: º º n |- K. : É. ; I am accustomed to heat the metal electrode in a gas flame, and allow it to cool while I am arranging the battery and the patient. She should take a vaginal douche before coming to the office, and if an electrode is to be employed within the uterus, the cervix and vagina should be swabbed with a I : 2OOO solution of corrosive sublimate. The dis- 506 ELECTRICITY IN GPMEcoLogy. persing electrode on the hypogastrium must be thoroughly Saturated with quite warm salt and water, be evenly applied, and covered with a folded towel to keep the patient's clothing dry. This last is a matter of some importance, i ; |§ and is liable to be neglected. The clay electrode soon dries hard, and requires some soaking again to soften the clay. Adding twenty-five per cent of glycerine to the salt and water, and thoroughly working it in the clay, will do ATA IV. (VA’Aº OA. AEA 7TYAZ /ø P. 5 O7 much to keep it soft, as the glycerine will not evaporate. The operator should first be sure the battery is in good working order before trying it on a patient. No trouble is i likely to be experienced with a well connected modern cabinet battery, but the smaller batteries are often a trial to the owner. \ The following causes may aid to locate the source of 508 A. Z.A. CZZe/C/TP //V G VAVE.CO/LOG P. failure to obtain a proper current. Loose or broken con- nections in any part of the battery, either in the binding cords, wires, or imperfect cells. The trouble can be quickly located by testing different cords and each cell separately with the milliampère meter. Small amount of fluid in the cells. Weak bichromate and sulphuric acid solutions which have a dark brown blackish appearance and green edge are exhausted and worthless." A deposit of salts on the zincs also interferes with the action of a battery; this can be soaked off in hot water, and afterwards it is well to dip the Zincs for a moment in muriatic acid, and then immerse them again for a short time in quicksilver. This should be done at intervals of a couple of months, and will keep the zincs in good condition. The reason why a Faradic appa- ratus does not work, which is at once observed by the absence of the buzz, is often due to imperfect adjustment of the spring and armature by the screw designed for that purpose, or the spring may be bent down on the armature, and require bending back. All the connections must be screwed very tight in order to obtain the full working power of a battery. The same rule must be observed in the connections with the electrodes, especially when strong currents, are employed, as then the least jar or rattle would cause very painful shocks. When mild currents of electricity are used, they should 1 The following formulae are recommended for making battery fluid for portable batteries. Preference is given to the first one. Neither should be used till cool. Dissolve eight ounces of bichromate of soda in two quarts of hot water, in an earthen vessel. When cool, add to it slowly eight fluid ounces of com- mercial sulphuric acid, and then mix thoroughly in the solution one ounce of the best quality of bisulphate of mercury. Dissolve three ounces of bichromate of potash in fifty-four fluid ounces of hot water (a little less than three pints) in an earthen vessel; add an ounce and a half of nitrate of potash (saltpetre). After cooling, add slowly eight fluid ounces of commercial sulphuric acid, and mix thoroughly in this solution one ounce of the best quality of bisulphate of mercury. The latter salt is not absolutely necessary to either formula, but it improves the zincs, and the electricity is sharper. A COTE /AWAELA/l/.]/4 TWOAV. 509 be repeated every second or third day; if the galvanic current exceeds Seventy-five milliampères, once or twice a week is sufficient. - - The presence of any acute inflammation of the uterus or its appendages, or of the peritoneum or cellular tissue, generally contraindicates the use of electricity. An ex- ceedingly mild Faradic current can sometimes be used with benefit. It requires very great care, and is not to be rec- ommended to any one who has not had large experience. Acute /nflammations," and pelvic peritonitis in particular, generally contraindicate the use of electricity. Apostoli and his immediate followers recommend the fine Faradic coil current, calling it the current of high tension, and a vaginal bipolar electrode placed against the tender spot. Much gentleness must be observed, and no stronger cur- rent used than is easily endured by the patient; it must be continued till relief is experienced, which may be fifteen minutes or half an hour. When the case has sufficiently improved to introduce the bipolar electrode into the ute- rine cavity without causing much pain, the electricity is employed in this place instead of the vagina, if the uterus is the seat of the inflammation. The uterine bipolar elec- trode, however, is rather clumsy, and the operator should make no attempt to introduce this electrode till the ex- treme sensitiveness of the pelvic organs has subsided. The same rules governing the use of the sound apply to any intra-uterine electrode. 1 Those who wish more details for using electricity in the diseases of women, as well as some knowledge of the physical properties and physiological effects of the electric current, are referred to the following works, as well as to the references given under the heading of Myomas of the Uterus, page 516. Electricity in Diseases of Women, Massey, 1890. Gynecological Electro-Therapeutics, Bigelow, 1889. (This is essentially a compilation of Apostoli's writings.) Electro-Therapeutics, King, 1889. Practical Application of Electricity, Liebig and Rohé, 1890. (It contains quite full descriptions of apparatus and electric currents.) 5 IO ELECTRICITY AW G PAVECOLOGY. * Notwithstanding the opinion of such an authority as Apostoli, the writer would caution all but experts in trying the above procedure till further clinical experience has demonstrated the value of the recommendation. Adhesions. Apply a large negative galvanic pole in the vagina, and the large dispersing electrode to the hypogas- trium. Press the negative pole against the adhesion, mov- ing the electrode occasionally, and pass the current of fifteen to thirty milliampères, according to the sensitive- ness of the patient, for ten minutes. Actual pain must not be produced, nor strong currents used with the negative pole in the vagina, as these are liable to produce blisters which lead to excoriations, and may in turn cause adhe- sion of the walls of the vagina. - Amenorrhaea. In young women, when a direct applica- tion to the uterus is to be avoided, pass a moderately strong Faradic current for ten minutes between the hypo- gastrium and lower lumbar or sacral regions. When there is no objection to a uterine application, insert the nega- tive pole of the galvanic current in the uterine canal, and apply the positive pole to the hypogastrium. Use a cur- rent of ten to twenty milliampères for ten minutes. Cellulitis and Pelvic Peritomitis. Compare Acute In- flammations. The fine Faradic coil is employed for the relief of pain in the same manner, independently of acute inflammation This current may prove inferior to the galvanic for the relief of pelvic pain in general, which so often attends organic disease. It is a well known fact that the normal excitability of a nerve at the negative pole is increased, and the normal excitability at the positive pole is diminished. This is the reason why the positive pole is generally recommended for the relief of pain. The clini- cal fact is, however, that in very many instances pain is aggravated by the positive pole and cured by the negative pole. Various theories have been proposed to account CELLULITIS AAWD PEL WIC PEA-ITOM/T/S. 5 II for it, but the writer would suggest that it is quite in accord with simi/?a similibus curam tur. Waller and De Watteville are of the opinion that sedation follows the excitation of the negative pole, the current being discontinued, and vice zersa with the positive pole. Whatever the theory, the facts remain the same, and the writer knows no reason why the electric current cannot have a curative effect, in accordance with those principles governing the effects of drugs. After the acute symptoms of a pelvic inflammation have entirely subsided, and only an exudation or adhesions remain, use the galvanic negative pole in the vagina (see Adhesions), and the dispersing electrode on the hypogas- trium. Do not use a stronger current than can be easily borne by the patient, as a recurrence of the inflammation is easily excited. Galvano-puncture has been recommended as a more . rapid method of curing old exudations than the one just mentioned. The shield covering the spear is placed by the finger, without using the speculum, against the lowest and most projecting portion of the exudate, avoiding large blood-vessels, peritoneum, etc.; the spear is then thrust into the tissue, and connected with the negative pole. A small slough and exudation will appear in a few days at this place. One puncture may be sufficient, and half a dozen may be required. The patient must remain in bed for three days afterward, and can then go about. The vagina must be antiseptically cleansed before and after the puncture, and finally a small tampon of iodoform gauze should be inserted. Similar treatment is recommended for pelvic abscess, with a strong current (250 m. a.). I must, how- ever, emphatically dissent from such treatment of pelvic abscess, as it is in my opinion unscientific, and not in accord with the best principles of surgery. I must also warn my readers to be very chary how they employ 5 I2 A. LAZCT/P/CVTV /AW G PAVAECO/LOG V. galvano-puncture, both from the danger of exciting in- flammation and of septicaemia. - Displacements of the Uterus. Comparatively recent cases often derive considerable benefit from electricity, es- pecially when the uterus is large and heavy, and if there is considerable muscular relaxation of the parts. Flexions are treated either by the bipolar intra-uterine electrode, which is often impracticable, or by one Faradic pole, coarse or medium coil, in the uterus, and the other on the hypogas- trium. Should the Faradic current fail, insert the positive galvanic pole (platinum or gold electrode) in the uterine canal, place the negative electrode on the hypogastrium, and pass a current of twenty to fifty milliampères for five minutes; should the electrode stick a little to the canal, turn off the electricity to zero, then reverse the poles with the pole changer, and use the negative pole for a short time to loosen the intra-uterine electrode. The gal- vano-Faradic current has been recommended, but the writer has not yet tried it. In chronic cases of uterine displace- ment, with much relaxation of the ligaments, I have em- ployed a slowly interrupted galvanic current. Versions are treated in a similar manner. Adhesions must be broken as already described; if the vaginal walls are prolapsed or the uterus has descended, use the vaginal electrode con- nected with the negative galvanic pole and a current of fifteen to thirty milliampères; more than this is liable to blister the mucous membrane. The uterus must be kept in place all the time as well as possible. Massage can be combined with electrical treatment to excellent advantage. Dysmemorrhaea can be treated like amenorrhoea in young women or girls, when it is desirable to avoid direct local applications to the uterus. Spinal galvanization alone often gives very good results, especially when there are any signs of spinal irritation. For this purpose, use large electrodes well moistened with warm salt water; apply the DPSMEMORRACEA. 5 I 3 positive galvanic pole to the nape of the neck, and the negative galvanic electrode, mounted on a long stiff shaft to slide down the back beneath the clothing, to the lumbar region. Use a current of fifteen to fifty milliampères, gradually increasing the current till the limit is reached, and diminishing it in the same manner at the end of ten minutes, taking care to avoid shocks, or giving much pain to the patient. Should the above methods fail, or if there is no objection to local treatment, applications directly to the uterus will often cure the patient. If there is Stenosis of the uterine canal and the so called obstructive dysmenor- rhaea, insert the positive galvanic electrode in the uterine canal, selecting as large an electrode as will enter the canal with only a moderate amount of force. The indifferent or large electrode should be applied to the hypogastrium. Twenty milliampères for ten minutes is an average strength of current, though I have occasionally used forty milliam- pères for five minutes; such a current is likely to cause considerable pain, both at the time and afterwards, and should not be employed except for stubborn cases. Ten or fifteen milliampères is often all a patient can comforta- bly bear. If for any reason a mistake has been made, and an ordinary metallic electrode has been used, it will stick quite fast to the canal. Rather than hurt the patient by pulling the electrode out, diminish the current to zero, reverse the poles with the pole changer so that the positive pole in the uterus becomes the negative, then increase the current to thirty or forty milliampères for a few minutes to loosen the electrode, which can now be removed in the usual manner. If the patient suffers much pain after the treatment, she should rest some time before returning home, where she should go to bed and remain till the pain has ceased. If the pain is neuralgic, i. e. neuralgic dysmemorrhaea, use the negative pole in the same way as the positive is employed above. Though the current is not so painful, 33 5 I4 AE/LAECT/P/C/TV /AW G PAVE.CO/OG V. I would advise not more than ten to twenty milliampères two or three times a week for the first month. If the dysmenorrhoea is not then relieved, use a current of twenty to fifty milliampères to cauterize and destroy the mucous membrane, which may be hyperasthetic. Membramous dysmemorrhaea is to be treated like endometritis, using considerable care in increasing the current, as the endome- trium is sometimes quite sensitive. - Budocervicitis and Endometritis. The negative galvanic pole is applied to the cervical canal or uterine cavity ac- cording to the place affected, and the large dispersing positive galvanic pole to the hypogastrium. Pass a cur- rent of twenty or thirty milliampères for ten minutes three times a week. If the leucorrhoea is not improved after six treatments, increase the current to seventy-five mil- liampères twice a week, eight minutes each time; should the leucorrhoea still remain unimproved after four treat- ments, increase the current to two hundred or even two hundred and fifty milliampères for eight minutes, once a week; if there is no improvement after five treatments by the last mentioned current, discontinue the electricity. If any of these currents, and the milder it is the better, diminish the leucorrhoeal discharge, continue to use cur- rents of the same strength, but with longer intervals and shorter seances as improvement continues. While elec- tricity is very often of great service, it is to be remem- bered that leucorrhoea is in very many cases dependent on causes remote from the genital apparatus, and is not always a purely local disease. In such cases, electricity will often fail to do any good, or prove merely palliative in its effects. The same systemic causes which gave rise to the disease are likely to remain in spite of electrical treat- ment, and must be combated with carefully selected inter- nal medicine. Should the endocervicitis or endometritis be attended with a very copious leucorrhoea, or very pro- ME/WO/P/CAHA GAA A/VD MET/PO/8/8A/A G/A. 5 I5 fuse and too early menstruation, or by intermenstrual hem- orrhage, use the positive pole rather than the negative. Exudations. See Cellulitis. Fibro-cystic Tumors are not likely to be amenable to electrical treatment, and the author cannot recommend it. Dr. Gehrung has proposed puncturing the cyst with a trocar, and using electricity afterward. It may be that the contents of these cysts, like those of the ovary, offer too much resistance to the electricity for any curative effect to follow; however that may be, the author believes that the electrical treatment of these tumors is inefficient, and will prove quite inferior to well established surgical operations for the removal of such growths. Fibroid Tumors of the Užerus. See Myomas. Hemorrhages. See Menorrhagia, Metrorrhagia. Inflammation, Acute or Chronic. See Acute Inflamma- tion, Metritis, Sub-involution, and Cellulitis. Leucorrhaea. See Endometritis. Memorrhagia and Metrorrhagia. If the flowing is com- paratively recent, i. e. has appeared for only a couple of times, and the uterus is large, insert the negative pole of the Faradic current within the uterus, and connect the other pole with a large dispersing electrode on the hypogastrium. Use a medium or coarse coil, and swell the current, i. e. gradually increase and diminish the current once in two or three minutes. Continue a current that is comfortably en- dured by the patient for twenty minutes or half an hour, and repeat it every day. If this does not arrest the flow- ing after a few applications, or if it is of long standing and very persistent, resort to positive galvano-cauterization, as recommended for the hemorrhage depending on myomas. The Faradic current applied in the above manner is very effective, less painful to the patient than the positive pole of the galvanic current, involves no destruction of tissue, 5 I6 ELECTRICITY IN G PAEcozogy. and is preferable in beginning the treatment for the arrest of hemorrhage not dependent on the presence of a foreign growth, such as a myoma. I have used the primary Fara- dic current with marked success for persistent and profuse flowing in the third or fourth week after confinement, when ergot and other remedies had failed, by simply placing the negative pole over the hypogastrium, and the positive pole to the Sacral region, using large flat elec- trodes at both places and as strong a primary current as the patient could comfortably bear. Metritis. If hemorrhagic, the treatment is the same as for menorrhagia. Otherwise, the treatment is the same as for endometritis, using the negative galvanic pole within the uterus and at first a mild current of twelve milliam- pères. If the patient experiences no relief after a few treatments, use forty milliampères, and if necessary in- crease the current to one hundred and fifty milliampères, according to the sensitiveness of the patient. Severe pain is always to be avoided, and it is rarely necessary to exceed seventy-five milliampères. The treatment should be given two or three times a week, and be persevered with at least two months, if a cure is not obtained sooner. The electrical treatment can be combined advantageously with massage of the pelvic organs. Myomas of the Uterus." The electrical treatment of these tumors was in a large measure the introduction of the 1 The following references are only a few of the important contributions to the treatment of uterine myomas by electricity, but they are sufficient for the reader to obtain an excellent idea of the subject, from the standpoint of various writers: — s Sur un nouveau Traitement électrique des Tumeurs fibreuses de l’Utérus. Dr. Lucien Carlet, published by Octave Doin, Paris, 1884. He reports the treatment of ninety-four cases. An interesting article on Electricity in Gynecology, and a report of three fibroid tumors successfully treated by it, will be found in the Journal of the American Medical Association, July 17 and 27, 1886. See also Electrolysis A/ POMA.S. OAP 7 HAE O/TER OS. 5 I7 scientific application of electricity to the diseases of women. In few subjects of surgery or medicine during the last three years has there been so much heated discus- sion, and even invective. It is neither possible nor practi- cable to review here the history of it, and all the argu- ments pro and con. The hearty indorsement of it by such eminent men as Sir Spencer Wells, Thomas Keith, and other well known surgeons, commends the method to our careful consideration, not only for the treatment of operable uterine myomas, but for those cases that posi- tively refuse all operative interference. There is already some reaction from the electrical treatment of myomas, and many who have tried it have no faith in its efficacy, and have found it not entirely devoid of danger. It seldom causes entire disappearance of a tumor of any considerable size, but there is reason to believe that it often arrests or checks the hemorrhage from sub-mucous or interstitial myomas when the positive pole can be brought into actual contact with the source of the hem- of Uterine Fibroids, by Dr. Franklin H. Martin, in the same Journal, p. 78, Jan. I 5, 1887. - Dr. Englemann, Transactions of the American Gynecological Society, 1886. Valuable papers on the use of Electricity will be found in the Transactions of the same Society for 1887, 1888, and 1889. - S. Cholmogoroff, Zur Behandlung der Fibrome der Gebärmutter mit den constanten galvanischen Strom, in Zeitschrift für Geburtshilfe und Gynākologie, p. 187, 1889. Dr. Keith has reported 106 cases, some of which were treated with excel- lent success, in Electricity in the Treatment of Uterine Tumors, 1889. Dr. Apostoli reported 278 cases; 95% of these were treated with great benefit. See British Medical Journal, p. 699, Oct. 1, 1887; also, Nov. 19, 1887. He also read an instructive paper in reply to objections to his method of treatment at the Congress of the British Medical Association at Glasgow, Aug. 8, 1888. It will be found in the Annals of Gynecology, p. 1, Oct., 1888. Dr. Thomas Keith has written a hearty indorsement of Apostoli's method, and condemnation of hysterectomy without first using electricity, in the Brit- ish Medical Journal, June 8, 1889. Mr. Lawson Tait presents clearly his objections to this treatment of ute- rine myomata in various articles in the British Medical Journal for the past four years. 518 F/LECT/P/CVTV /AW G PAVE.CO/LOG V. orrhage, and thus it may serve to tide the patient over the menopause. - The haemostatic effect of the positive pole is due quite as much to its caustic effect as to electrolysis. How much a myoma may be affected in nutrition, apart from the direct local or polar effects, has yet to be demonstrated. The ex- periments of Gustav Klein,” of Stevenson,” and of Shaw,” would indicate the possibility of modifying nutrition by the interpolar current, as well as showing a decided local action on tissues within a radius of half an inch of the needle inserted into the myoma. Prominent among the objections to electrolysis are: — 1. Inefficiency. 2. Production of adhesions rendering myomotomy more difficult. 3. Production of cystic degeneration in tumors which otherwise would not require removal. In regard to the first, the experience of different indi- viduals does not concur. While it is not specific for all cases, there seems no reasonable doubt that benefit follows in a large enough proportion to warrant careful and patient use of electricity. The second objection is valid for some exceptional cases where too strong currents have been employed, producing peritonitis. The third objection is rather from a theoretical than a practical standpoint, and lacks actual proof or demon- stration. . The electrical treatment of uterine myoma is still on trial, and it is not yet possible to define accurately the limits to its use. In a general way, it may be said that 1 Wirkung des constanten Stromes auf Myome, Zeitschrift für Geburts. hillfe und Gynākologie, p. 174, Bd. XIX. Heft 1, 1890. * Transactions of the Obstetrical Society of London, Vol. XXX, p. 229, 1889. * Ibid., p. 243. MPOMAS OF THE UTERU.S. : IQ Soft and rapidly growing myomas (not the edematous variety, which can only be treated successfully by extirpa- tion) are most amenable to treatment by electricity, and remarkable results are sometimes obtained. Härd, stony myomas are slow to respond to it. Sub-mucous myomas are most readily cured; then the interstitial, which are forced often down into the uterine cavity, apparently by uterine contractions, and made accessible to safe opera- tive interference, or, if near the surface of the uterus, the myoma may become sub-peritoneal. - This last form, also called sub-serous, is least suscepti- ble of all the varieties of myomas to this treatment, and is also the least likely to endanger life. As the very large myomas are often sub-peritoneal, the chances for complete Success are not as good with very large myomas as with Small ones. * When a sub-mucous myoma or a fibroid polypus can be readily removed by ordinary surgical measures, it is far better to remove it than to try electricity. The galvanic punctures usually necessary in such tumors are prone to cause Suppuration and septicaemia, even with careful anti- Septic precautions, as these growths have a low vitality. No one should attempt the method without having a thor- oughly good battery, capable of generating a uniform cur- rent of at least one hundred and twenty-five milliampères, using a reliable milliampère meter. The best results we can expect are arrest of hemorrhage, which is more diffi- cult with sub-mucous and interstitial tumors than sub- peritoneal, relief of pain, some diminution of the tumor, and general improvement of nutrition ; the last is some- times manifested by a deposit of fat on the abdomen, which is liable to lead the operator to think there has been no diminution of the tumor, which may be actually much Smaller. This is practically a symptomatic cure of the patient, though the anatomical conditions may remain much the same. It is, however, enough to tide the case º 52O FLECTRICITY ZAV G WAVE.CO/LOG V. over the climacteric, when such tumors tend naturally to diminish, and the patient remains comparatively comforta- ble, without submitting to the serious risk, pain, and dis- comfort of a surgical operation. The electrical treatment of uterine myomas is not without some risk, particularly if galvano-puncture is employed, but the danger is very little in the hands of experienced operators. The method of treatment to be adopted depends on the presence of hemorrhage. When this is present, the positive galvanic pole of platinum or prepared steel is inserted in the uterine cavity. The better it can be applied to all parts of the endometrium, and moved about in the uterine cavity care- fully during the application, the more certain it is to arrest hemorrhage. Actual contact of the electrode with the site of the hemorrhage is almost essential in order to arrest it. This is why the Goelet improved Apostoli electrode with a series of graduated tips is a very useful intra-uterine electrode. Instead of the gas carbon tips of the Apostoli electrode, he has hydrogenized steel tips, which are not easily corroded by the positive pole, and for a time resist the action of acids. They are not very durable. The largest tip which will pass to the fundus uteri and fit snugly is first selected, and after the current has passed for three or five minutes a tip is chosen which will best fit the section of the uterine cavity just below the one not already subjected to the electric current. This is esti- mated by the gauge on the electrode. The same pro- cess is repeated for the next lowest portion of the cavity, till every part has been treated. This method requires the electrode to be kept perfectly quiet while using the current. I am using the gas carbon tips of the Apostoli electrode, and I have not yet found it necessary to change them much if a snug fit is first obtained. Small tips are often necessary for the first few treatments, after which the cavity readily admits larger electrodes. The large clay electrode, thoroughly softened and saturated in warm MPOMAS OF THE UTERUS. 52 I salt and water, is applied over the tumor externally, and a current of at least seventy-five milliampères is passed for ten minutes. This is a good strength to begin with for the first treatment, and can be increased if the patient can bear it to two hundred and fifty milliampères, though I very seldom use more than one hundred and seventy- five. This is enough, though stronger currents have been employed. Care must be taken that during the application all the battery connections are screwed very tight, that the patient be perfectly still, and the electrode be held very steady; the least jarring will cause painful shocks, and most women suffer considerable pain when the current exceeds one hundred milliampères. Two to three minutes must be taken to increase the current gradually to the desired strength, four or five to keep it there, and two minutes to return to zero. This swelling of the current can be made to advantage by the rheostat, and is to avoid painful shocks. Any abrasions or pimples on the skin make the application much more painful, and all such places must be carefully covered with gold-beater's skin or bits of adhesive plaster before applying the clay electrode. The writer believes the clay electrode is better than any of its numerous substitutes. It must be thor- oughly plastic, and be accurately adapted to the tumor. After the use of a strong current which causes much pain, the patient should go directly to bed, and remain there till the pain has subsided. Labor-like pains, and a serous or bloody vaginal discharge, are not uncommon for the first twenty-four hours after the application. The treatment can generally be repeated twice a week. While the author has found electricity a useful agent to arrest hemorrhage, it has not proved a specific, and he would suggest caution in promising patients relief from it. Many treatments are often required. If there is no hemorrhage to control, the negative pole is to be substituted for the positive, and the electricity administered with all the precautions used with { 522 Az ZAZCT/P/C/7 'P' / W G PAVE CO/COG V. the positive pole, and in the same manner. In tumors projecting into the cervical canal when enucleation by the usual surgical methods cannot be considered, also when the tumor projects prominently into the pelvis, galvano- puncture can be employed with advantage. This requires a needle or spear insulated to within half an inch of the point. This is attached to the negative galvanic pole, and, guarded by the forefinger in the vagina, is thrust a quarter or half an inch, never more, into the growth, and the current passed as usual. The direction of puncture must be always toward the centre of the tumor. The best place to puncture is through the cervical canal, if the growth is accessible; the next best place is in the median line posterior to the cervix; then on one side of the cervix, avoiding the artery. Punctures anterior to the cervix are not allowable, on account of the danger of wounding the bladder. The benefit of the galvanic punc- ture lies chiefly in arresting nutrition, the danger is in necrosis, suppuration, and Subsequent Septic infection, as thorough drainage is sometimes difficult to secure. (See suppurating myomas, p. 367.) Prevention of infection is of the utmost importance. The case must be managed with as much aseptic precaution as an abdominal section. The instruments, vagina, and cervical canal, especially if the puncture is made through it, must be made as thoroughly aseptic as possible by the well known sur- gical measures for that purpose, and a strip of iodoform gauze introduced into the vagina after the operation. The frequency of treatment, and the strength and duration of the current, are the same as first given for the treat- ment of hemorrhage, except that rather stronger currents are employed. Cocaine has been used to dull the pain of the puncture, but it is inferior to the first stage of ether anaesthesia, which is often necessary for using currents exceeding one hundred and fifty milliampères. A patient ought to be put to bed at once after galvanic puncture. AVOAV-DE VE LOPA/A2AWT. 523 and to remain there till all signs of inflammation have subsided. AVom-development. Unless the uterus is two thirds its normal size in the virgin, and the patient either has an occasional menstrual flow or periodical crises correspond- ing with what might be menstrual epochs, there is very little use in trying electricity. The uterus may increase some in size, yet a few months after the treatment has been discontinued the physician must not be surprised if he finds the uterus has diminished to its original dimen- sions. The galvanic stem pessary has been recommended for non-development of the uterus, but the writer is in- clined to believe that any benefit derived from it is quite as much due to the mechanical irritation excited by its presence, like any stem pessary, as to the trivial amount of electricity it can generate. The Faradic current with a medium or coarse coil can be tried, as in amenorrhoea, or a ball electrode can be introduced into the rectum oppo- site the cervix, or into the vagina, and the other electrode applied to the hypogastrium. This current should be con- tinued with only moderate strength for twenty minutes or half an hour, and be repeated every other day. Six months may be necessary to cure some obstinate cases which are just within the curable boundary, and no marked results should be anticipated in less than two months. The galvano-Faradic current has also been recommended for this condition, the negative pole of the galvanic cur- rent being attached to the electrode in the vagina, and the electrode on the hypogastrium to the positive pole of the Faradic current. Intra-uterine applications might have a more stimulating effect, but the non-development of the uterus together with the non-development of the vagina, which is not an uncommon accompaniment, renders the in- troduction of the electrode within the uterine canal both painful and difficult. 524 Az ZAZCZAC/C/TP //V G PAVE CO/COG P. Ovaritis. Ovarian Irritation. Relief is sometimes given by using a large ball electrode in the vagina connected with the positive galvanic pole, and the dispersing pole, as usual, on the hypogastrium, connected with the nega- tive galvanic pole. Should this fail to relieve, remember that the poles can often be reversed to good advantage, and the negative applied to the seat of pain. In either case, use a mild current, eight or ten milliampères, twenty minutes at a time every third day. Should this fail, use the bipolar electrode with the fine Faradic coil, as recom- mended by Apostoli for acute inflammation. Pelvic Pain. Use the same treatment given for ovaritis. Salpingitis. Negative galvano-puncture has been rec- ommended for the various forms of this disease. The author has not yet treated a case in this manner, and would urge his readers not to employ it till there is much more evidence of its value and superiority over other methods of treatment than we now possess. - Stenosis of Cervia: Uteri. Use positive galvano-cauteri- zation, as recommended for obstructive dysmenorrhoea. Sub-involution is treated very effectively by electricity. Introduce a bipolar electrode within the uterus, and use the coarse Faradic coil, or a slowly interrupted current, for fifteen minutes at a time every other day. If the uterus has become hard and firm, and remains very large, treat it like chronic metritis. Super-involution must be treated early if it is to be cured. The treatment is the same as for non-devel- opment. Vaginismus has been successfully treated by using a mild galvanic current, with the positive electrode in the vagina, and the negative over the hypogastrium. I N D E X. Abdominal supporters, how to make, 60. Areolar hyperplasia of the uterus, 338. Abscess of the labia, 132. Ascarides, treatment of, 97. therapeutics of, 134. Atresia of the genital canal, 152. of the pelvis, 4oo, 413. - of the perineum, 133. Acute metritis, 336. Battery fluid formulae, 508. Adeno-carcinoma, 376. Baycurn, a substitute for tannin, 45. Adenoma of the uterus, 348, 374. Belladonna, local application, 38. Adhesions and uterine displacement, 257. Bi-mannal examination, 15. Adhesions, electricity for, 510. Bladder, washing out the, 85. Affections of the climacteric period, 158. Bodily posture, influence of, 3. Albuminuria preceding the first menses, Boracic acid, local application of, 38. I61. Boroglyceride, indications for, 38. Alexander's operation, 26r. Bromide of potash, local use of, 39. Alum, application of, 37. Bromine, application of, 395. Amalgamation of battery zincs, 508. Amenorrhoea, 189. and dysmenorrhoea, 227. Calendula, local application of, 39. case cured by apis, 198. Cancer, diagnosis of, 386, 387. arnica, 198. differential diagnosis from uterine cocculus, 196. fibroids, 388, 389. euphrasia, 199. of the cervix, 383. manganum, 199. 4 Sponge tent test for, 63. nux moschata, 199. of the external genitals, 388. polygonum hydropiper, 199. of the ovary, 459. digest of remedies for, 200. of the uterus, 381, 383. electricity for, 123,510. •T chloride of zinc for, 395. general treatment of, 191, # contra-indications to operating, relation to education, 190. 392. therapeutics of, 194. cured by lapis alba, 399. Anomalies of the climacteric period, 158. diagnosis at an early period, 387. Anteflexion of the uterus, 264. * medullary, 383. Anteversion of the uterus, 264. - palliative treatment, 394. tenesmus in, cured by terebinthina, prognosis after treatment, 394. 289. schirrhous, 383. Aphthous inflammation of the vulva, 95. symptoms, 384. Application of liquids, 33. radical surgical treatment, 390. of ointments or cerates, 34. therapeutics of, 397. of pencils of gelatine or cocoa-butter, vaginal hysterectomy, 392. medicated, 35. Carbolic acid, local applications of, 39. of powder, 34. Case taking, 12. & 526 INDEX. Castration for uterine myomas, 369. Catalepsy, 168. Catgut, preparation of, for sutures, 111. Cauliflower growths, 383. Caustics, 45. Cellular polypus, 348. Cellulitic exudation, differential diagnosis from uterine fibroids, 358. Cerates, local application of, 34. Cervical canal, how to cleanse it with dry sponges, peroxide of hydrogen, Syringe, suction, 28. Cervix, dilatation, indications for, 64. dilatation of, with tents, 63. with instruments. 68. elongation of, in prolapsus, 268. erosions of, 298, 313. laceration of diagnosis, 317. indications for operating, 313. sequelae, 319. ulceration of, 313. Change of life, 158. Chloral hydrate, application of, 39. Chloride of zinc, application of, 45,395. Chlorosis, 161. therapeutics of, 164. Chorea at puberty or menstrual period, I67. therapeutics of, 173. Chromic acid, 39. Chronic metritis, 388. case cured by veratrum album, 346. Clay electrode, how to keep soft, 506. Cleansing the cervical canal, 28. Climacteric, ailments of the, 160. diet and hygiene at the, 160. period, anomalies of the, 184. therapeutics of the, 185. ulcers at the, cured by polygonum, 188. Coil suture, 127. Condylomata, 303. Consanguineous marriage, 8. Corroding ulcer, 382. Curette, use of the, 71. Cystitis, 83. differential diagnosis from pyelitis, 84. therapeutics, 88. Cyst of the vagina, 247. Cystocele, 246. Deaf-mutism, relation to consanguineous marriage, 8. Dermoid cysts, 461. Dilatation of the cervix, uteri by grad- uated sounds, 67. by tents, 63. rapid, by dilators (Goodell's method), 69. indications for, 64. Displacement of the ovaries, 277. of the uterus, 243. electricity for, 512. massage for, 488. Dress, relation to gynecology, 3. Drysdale's corpuscles, 462. Dysmenorrhoea, 221. cured by aconite, 230. ammonium carb., 231. apis, 238. borax, four cases, 232. ignatia, 239. nux vomica, two cases, 239. Sarsaparilla, 240. silicea, 235. silico-fluoride of calcium, 240. valerianate of zinc, 237. veratrum viride, 236. viburnum opulus, 236. differential diagnosis, 225. electricity for, 512. examination for, 226. forms of, 223. membranous and millefolium, 239. membranous, cured by hydrastics, 242. therapeutics of, 230. treatment of congestive, 227. membranous, 229. neuralgic, 226. obstructive, 228. ovarian, 227. Eczema of the vulva, 95. Education, relation to gynecology, 3. Elaterium, local use of, 40. Electricity, causes of current failure, 507. for acute inflammation, 509. adhesions, 51O. amenorrhoea, 510. cellulitis and pelvic peritoriitis, 5 Io. displacements of the uterus, 511. dysmenorrhoea, 512. endocervicitis, 514. endometritis, 514. exudations, 514. fibro-cystic tumors, 514. fibroid tumors of the uterus, 515. AAWD EX. Electricity for hemorrhage from the ute- rus, 515. leucorrhoea, 515. menorrhagia, 515. metrorrhagia, 206, 515. metritis, 516. - myomas of the uterus, 516. non-development of uterus, 522. ovaritis, 523. ovarian irritation, 523. pelvic pain, 523. Salpingitis, 523. stenosis cervix uteri, 524. Subinvolution, 524. vaginismus, 149, 524. in gynecology, contra-indications, 509. preparations for applying, 505. Endocervicitis, 291. electricity for, 515. Endometritis, 291. electricity for, 514. fibrinous, 224, 291. forms of, 291. polypoid, 375. therapeutics of, 3o4. Epilepsy, 167, 173. cured by bovista, 179. nitric acid, 179. Oenantha crocata, 177. therapeutics of, 173. Epithelioma of the cervix uteri, 383. Erosion of the cervix uteri, 298, 313. treatment, 318. Eucalyptus globulus, local use of, 40. Examination, bi-mannal, 15. of patients, Io. with the speculum, 24. Sims’s speculum, 30. Sound, 18. Extra-uterine pregnancy, 427. Faradic current, character of, 494. physiological action, 496, primary, 496. Fibrinous endometritis, 224. Fibro-cystic tumors, 373. electricity of, 515. Fibro-myoma of uterus, 348. Fibroid tumors of the uterus, 348. electricity for, 516. therapeutics of, 378. Fibrous polypus of the uterus, 348. Fig warts, 303. 527 Fissures at neck of bladder, 76. Fistulae, 155. Fluids, application of, 33. Flushing at the climacteric, 184. Foot bath, how to take, 227. Galvanic current, physiological action of, 494. polar effects of, 496. Galvano-puncture, 511. * Glandular polypus, 348. Glycerine, local use of, 40. Gonococci, tests for, 301. Gonorrhoea, 77, 3oo. Gonorrhoeal vaginitis, 3oo. Haematocele, differential diagnosis, 411. of the ovary, 445. pelvic, 425. extra-peritoneal, 431. intra-peritoneal, 428. Hamamelis, local use of, 41. Headache at menstrual periods, therapeu- tics of, 181. Hereditary disease and marriage, 8. Hot-water douche, indications for, 46. Hydrastis, local use of, 41. Hysteria, 167. case cured by bovista, 179. therapeutics of, 173. Hystero-epilepsy, 172. Hysterotrachelorrhaphy, 322. Infantile uterus, electricity for, 522. Inflammation of the uterus, 336, 338. of the vagina, 140. of the vulva, 132, 136. Inversion of the uterus, 271. Iodine, local use of, 41. Iodized phenol, local use of, 42. Iodoform, local use of, 42. Iron, local use of, 43. Itching of the vulva, 93. Jequirity, local use of, 43. Knee-chest position, 254. Labial abscess, 132. therapeutics of, 134. 528 JAWDEX. Laceration of the cervix, 313. operation for, 322. sequelae of, 319. Laceration of perineum, Io2. operations for, Io?, 118, 127. Leiomyoma of the uterus, 348. Leucorrhoea, 293. local treatment, 296. therapeutics of, 304. case cured by ammonium carb., 311. bovista, 311. ceanothus, 3II. kreosote, 307. Secale, 312. sepia, 308. Levator ani, movement to strengthen, 488. Malignant disease of the sexual organs, 38I. Marriage and hereditary disease, 8. in relation to uterine diseases, 5. of relatives, 8. relation of tumors to, 8. Massage of the pelvic organs, 481. contra-indications, 482. indications, 483. for acute inflammations, 484. adhesions, 483. chronic metritis, 483. exudations in the pelvis, 483. inflammatory products, 485. prolapsus uteri, 489. uterine displacements, 488. Matico, local use, 45. Membranous dysmenorrhoea, 229. cured by borax, 232. hydrastis, 242. electricity for, 513. & therapeutics of, 241. Menorrhagia, 202. electricity for, 515. local treatment of, 203. therapeutics of, 207. case cured by aconite, 212. bovista, 215. cyclamen, 216. hydrastis, 213. ustilago, 217. Menstrual periods, headaches attending, 18o. - Menstruation, painful, 22I. process of, 159. profuse, 202. Scanty, I99. Menstruation, vicarious, 218. Metritis, acute, 336. case cured by nux vomica, 337. rhus toxicodendron, 337. chronic, 338. - case cured by chloride of gold, 343. therapeutics of, 343. parenchymatous, 338. Metrorrhagia, 202. electricity for, 206, 515. membranous, case cured by cyclamen, 212. Morphine, producing atrophy of the sex- ual organs, 4oo. Myomas of the uterus, 348. castration, 369. considerations for surgical treatment, 363. cured by calcarea iodide, 379. diagnosis of forms of, 357. diet for, 359. differential diagnosis, 358. from pelvic inflammation, 411. electricity for, 516. myomotomy for, 371. physical examination of, 353. prognosis for, 359. suppuration of, 367. therapeutics of, 378. treatment of, 360. vaginal hysterectomy for, 368. Neuroma of the urethra, 73. Nitrate of silver, local application of, 43. Non-development, electricity of, 523. Nymphomania, 180. - case cured by Salix nigra, 180. Ointments, application of, 34. Opium, local use of, 44. Ovarian cysts, dermoid, 461. multilocular, 462. papillary, 462. Ovarian irritation, electricity for, 523. Ovarian haematoma, 445. Ovarian neuralgia, 440. therapeutics of, 442. in pregnancy cured by ignatia, 443. cured by xanthoxylon, 43. Ovarian tumors, 458. relation to marriage, 458. benign, 461. IVDEx. Ovarian tumors, malignant,459. two cases cured by apis, 472. one cured by auric chloride, 473. bovista, 473. two cured by bromide of potash, 473. one cured by calcaria carbonica, 476. two cured by colocynth, 478. one cured by graphites, 473. iodine water, 479. lycopodium, 479. cantharis and thuja, 480. clinical history, of, 469. differential diagnosis, 467, 468. examination of, 464. Ovaries, diseases of the, 444. examination of the, 444. imperfect development of the, 445. exanthematic cirrhosis of the, 446. displacement of the, 277. normal position of, 444. Ovariotomy, 470. Ovaritis, 445. acute, 446. case cured by ferrum phos., 455. graphites, 456. guiacum, 456. plumbum acet., 454. podophyllum, 454. and sterility, case cured by platina, 454. digest of remedies for, 456. electricity for, 524. local treatment of, 449. chronic, 447. prognosis of chronic, 448. therapeutics of, 451. Ovary, absence of, 445. cancer of, 459. causes of pain in the left, 446. inflammation of the, 446. third, 445. Painful menstruation, 221. therapeutics of, 230. Papillary ovarian tumor, 462. Parametritis, 4oo. chronic atrophic, 400. Parasites of the vulva, 97. Parenchymatous metritis, 338. Parovarian cysts, 463. Pediculus pubis, 97. Pelvic abscess, 400, 413. differential diagnosis, 411. electricity for, 511. 529 Pelvic abscess, surgical treatment, 415. Pelvic cellulitis, 4oo. clinical history of, 402. case cured by arsenicum, 420. diagnosis, and differential diagnosis, 4O4-4II. from pelvic peritonitis, 409, 411. electricity for, 510. local treatment, 416. therapeutics, 419. Pelvic congestion, 402. Pelvic floor, movement to strengthen, 488. Pelvic hazmatocele, 425. clinical history of, 429. Pelvic peritonitis, 400, 406. electricity for, 510. case cured by merc. Sol., 422, clinical history of, 408. diagnosis, 409. differential diagnosis from pelvic cel- lulitis, 4 II. pelvic abscess, myoma, or ovarian tumor, 4 II. - hamatocele, 41 I. etiology of, 406. local treatment, 416. prognosis, 413. surgical treatment, 407. therapeutics, 419. Pencils, gelatine or cocoa-butter, medi- cated, 35. Percussion of the spine, 487. Perimetritis, 4oo. Perineal fascia, injuries to, and their ef- fect, Ioa. Perineal laceration, Io2. Perineorrhaphy, clinical rule for, Io2. Emmet's method, 122. Tait's method, 127. with a rectocele, 118. without a rectocele, 107. Perineum, abscess of, 133. forms of laceration, Io;. as a support to the uterus, Iog. when to operate on a laceration of the, IoS. Perimetritis, 4oo. Pernitrate of mercury, application of, 45. Pessaries, anteversion, 56. fitting for posterior displacements, 52. galvanic stem, 67. introduction of, 54. moulding and fitting of, 55. retroversion, 52. rules for, 62. 34 53O : AAVOAZ X. Pessaries, soft rubber, removal of odor from, 55. stem, 59. use of, 59. vagino-abdominal, 57. Pinus canadensis, local application of, 44. Pinworms, treatment of, 97. Plantago and boracic acid, local use of, 44. Pollutions in females, 180. Polypoid endometritis, 375. Polypus of the urethra, 74. of the uterus, 348. cellular, 374. glandular, 375. therapeutics of, 378. Powder, local application of, 34. Pregnancy, differential diagnosis from uterine myomas, 359. extra-uterine, 427. Probe, how and when to use the ute- rine, 18. Procidentia uteri, 267. case cured by arctium lappa, 285. Prognosis for uterine displacements, 281. for uterine polypi, 376. Prolapse of the mucous membrane of the urethra, 76. ovaries, 277. Prolapsus uteri, 267, 268. massage for, 489. Prolapsus vagina, 246. Pruritus vulvae, 93. therapeutics of, 98. three cases cured by caladium, 98. case cured by hydrocotyle, Ioo. rhus tox., Ioo. two cases cured by sulphur, Ioo. caused by drinking coffee, Ioo. silico-fluoride of calcium, IoI. lapis albus, IoI. diet for, 94. electricity for, 96. ,etiology of, 93. local treatment of, 95. therapeutics of, 98. Puberty, 158. albuminuria just before, 161. hygiene of, 2. Puerperal state, care in the, 340. Pyelitis, differential diagnosis from cysti- tis, 84. Rapid dilation of the cervix, 69. Rectal applications, 36. Rectocele, 118. Retroflexion of the uterus, 248. treatment of, 253. with fixation, treatment of, 257. Retroversion of the uterus, 248. cases cured by chloride of gold, 289. cured by rhus tox, 289. treatment of, 253. - Rules for the use of stem pessaries, 67. tents, 67. - Salpingitis, 524. Sanguinaria, local use of, 44. Sarcoma, 382. of the ovary, 459. uteri, 390. Sexual fraud, effect of, 5. organs, displacement of, 243. Silk, how to coat it with carbolized wax, II 2. Silkworm gut, II2. Sims's position, 29. Sound, examination with, 18. differential diagnosis with the, 22. indications for using the, 18. how to replace the uterus with the, 20, 25I. A Speculum, examination with the, 24. introduction of the bivalve, 28. of the Ferguson or cylindrical, 26. of the Sims, 30. Spinal bags for ice or hot water, 49. Sponge tent, test for cancer of cervix (Spiegelberg), 383. Stem pessaries, 59. rules for use of, 67. Stenosis of cervix uteri, electricity for, 524. Sterility, case cured by platina, 454. and dysmenorrhoea, 226. relation of, to operation on lacerated cervix, 320. Sub-involution, 338. electricity for, 524. case cured by natr. mur., 346. Super-involution, 338, 524. Supporters. See Pessaries, 49. Tampons of absorbent cotton, 32. tow, wool, 32. how to make, 32. medication of, 33. Tannin, local application of, 45. IAWD EX. Tents, how to use them, 63. of corn stalks, laminaria, sponge, tu- pello, 64. rules for use of, 67. Therapeutics of albuminuria preceding puberty, 161. abscess of the labia, 135. amenorrhoea, 191. chlorosis, 164. chorea, 173. climacteric period, 185. cystitis, acute and chronic, 88. dysmemorrhoea, 230. endometritis, 304. epilepsy, I 73. fibroid tumors of the uterus, 378. hemorrhage from the uterus, 207. hysteria, I73. leucorrhoea, 304. menorrhagia and metrorrhagia, 207. menstrual headache, 181. toothache, 184. menstruation, painful, 230. vicarious, 219. metritis, chronic and acute, 343. myomas of the uterus, 378. ovarian neuralgia, 442. ovaritis, 451. polypi of the uterus, 378. pruritus vulvae, 98. urethral diseases, 79. uterine displacements, 285. vaginismus, I51. vaginitis, I44. vicarious menstruation, 219. vulvitis, I44. Toothache at menstrual periods, 184. Trachelorraphy, 322. Trance, 168. Trichiasis, 94. l Tumors of the ovaries and broad liga- ments, 458. relations to marriage, 8. Ulceration of the cervix uteri, 298,313. Urethra, diseases of the, 73. Urethritis, 77, 79. Uterine disease and marriage, 7. Uterine displacements, 243. digest of remedies for, 289. effect of pregnancy on, 261. fixed by adhesions, treatment of, 257, 259. massage for, 488. 53 I Uterine displacements, mechanical treat- ment of, 49. operations for, 260. prognosis for, 281. shortening the round ligaments for, 26o, 261. therapeutics of, 285, 284. value of medical treatment, 280. Uterine fibroids, 348. medical treatment of, 378. Uterine flexions, differential diagnosis from uterine fibroids, 265. Uterine hemorrhage, 202. Uterine polypi, 374. medical treatment of, 378. prognosis of, 376. Uterus, anteflexion of, 264. anteversion of, 264. congestive hypertrophy of, 338. curetting the, 71. displacement with fixation, treatment of, 257. hemorrhage from, treatment of, 204. hypertrophy of case cured by chloride of gold, 289. inversion of, 272. diagnosis, 273. prognosis, 274. treatment by amputation, 277. elastic pressure, 276. immediate reposition, 274. lateral flexion of, 267. normal position of, 244. outlining the, 15. prolapse of, 268. retroflexion of the, 248. retroversion of the, 248. Vagina, atresia of, I 52. cyst of, 247. prolapse of the, 246. Vaginitis, 14o. case cured by coccus cocti, 147. Sulphur, 147. local treatment of, 142. therapeutics of, 144. Vaginismus, case cured by cuprum, 152. Farradic current for, 149. galvanic current for, 524. therapeutics of, 151. Vascular growths of the urethra, 73. Ventral fixation of the uterus, 262. Vicarious menstruation, 218. case cured by belladonna, 220. 532 AAWDAX. Vicarious menstruation, case cured by digitalis, 220. lycopodium, 229. two cases cured by pulsatilla, 219, 22O. -- - case cured by Senecio, 220. therapeutics of, 219. Wulva, abscess of, 132. aphthat of, 95. eczema of, 95. itching of the, 93. Vulva, itching of the, therapeutics of, 98. parasites of the, 97. trichiasis of the, 94. Vulvitis, local treatment of, 136. therapeutics of, 144. Warts on vulva, 303. Zinc, poisoning by the cyanuret of, 237. Zinc oleate, local use of, 45. Y | 9015 02076'3%;" *...*... .º.º. ºº º %RSITY OF MIchi ||||||||||| Filmed by Preservation 1990 --> * †, , , , , d º º - ::::::::::: * > ..." . " : º . is . . . . sº º * º,...; "º.; ; : #. º sº §ºgº.º.º. 㺠sº ..:*::::::::----- º Šºš. gº. ºxºs •, ºr, Kº-º-º: gººgºgº Bºrº : ºn-gº- - fº §: ś ºrigºrº *::::::::::::::sº sº *-****** *::::::ºss-ºw - - - - - - - - - - -- –, ∞： • №ººººººººº -- ' ！ º， ，，es sººs ºss» sºººººººººººš！«■■■■■■■>.■■>*<<<< ∞.• №ssae，§§§§§-s s'- sº, ſºſ, （） rºº ºf *:: * : * * * * ºr ºf * ， , …: '. … rºº." ...tº; … º, ºr Žºrž . . . . . 22*.*.*.*.*.*. .*.*.x, ºr ºz. . xº！