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 3 1822 01222 6213 
 
 
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 V-.

 
 CLINICAL NOTES 
 
 OH 
 
 UTERINE SURGERY. 
 
 WITH SPECIAL REFERENCE TO THE 
 
 MANAGEMENT OF THE STERILE CONDITION. 
 
 By J. MARION SIMS, A.B., M.D. 
 
 LATE SURGEON TO THE WOMAN'S HOSPITAL, NEW YOKE, 
 
 Fellow of the New York Academy of Medicine ; of the New York Pathological Society ; of th« 
 New York Historical Society ; of the New York State Medical Society ; of the Royal Medical 
 and Chirurgical Society, London; of the London Medical Society ; of the Pathological 
 Society ; Hon. Fellow of the Obstetrical Society, London ; Honorary Member of the 
 • German Society of Physicians and Naturalists, Paris ; Hon. Fellow of the Im- 
 perial Academy of Medicine of Belgium ; Knight of the Legion d'Honneur, &c. 
 
 NEW YORK: 
 WILLIAM WOOD & CO., 27 GREAT JONES ST.
 
 Trow's 
 
 Printing and Bookbinding Co., 
 
 205-213 East 1 2th St., 
 
 NEW YORK.
 
 TO 
 
 SIR JOSEPH F. OLLIFFE, M.D., 
 
 (UNIV. PARIS), 
 
 , FELLOW OP TflE ROYAL COLLEGE OP PHYSICIANS (LOND.) ; PHYSICIAN TO HER MAJESTY'S E1IBA891 
 AT PAKIS ; OFFICER OP Till! LEGION OP HONOUR, ETC. ETC. 
 
 My Dear Sir Joseph, 
 
 When I came to Europe, now more than three years ago, I had 
 no idea of remaining here permanently. But I found in you a 
 warm and generous friend, whose wise counsels and noble liberality 
 elevated me at once into a most favorable position. It was princi- 
 pally through your influence that I was able to reach the highest 
 circles of practice. Without you my sojourn here would have been 
 temporary and fruitless. 
 
 Let me assure you, my dear Sir Joseph, that it is not only to 
 you, as a learned and accomplished Physician, whose great talents 
 and attainments have placed him so deservedly in the foremost ranks 
 of his Profession ; but it is also to you as a true man of noble 
 impulses and generous nature; it is to you as a Friend, when I most 
 needed a cheering comforting word, that I now come with this 
 Volume, and beg you to accept it simply as a token of Gratitude 
 for the many acts of kindness and friendship which you have so 
 lavishly bestowed upon me. 
 
 J. MARION SIMS.
 
 PREFACE. 
 
 In 1862, I voluntarily left my own country, on account of its 
 political troubles. Our unfortunate civil war continued much 
 longer than any of us, North or South, anticipated. In 
 consequence of this my residence abroad was prolonged far 
 beyond my original intention. I therefore had time to look 
 over my note-books, and to cull such facts as illustrate the 
 method of treating Uterine Disease at the Woman's Hospital. 
 These facts are strung together in the form of these " Notes." 
 
 Having an innate horror of writing, I have not tried to make 
 a book ; on the contrary, I have simply related in detail my 
 various operations, and given the history of cases in which 
 circumstances led me to adopt a modified procedure, or for 
 which I have devised new forms of instruments. 
 
 A clinical report of this sort very naturally divides itself into 
 groups of cases which may be made illustrative of the principles 
 of practice. 
 
 In my own country my contributions have generally been 
 received with kindness ; and although I have reason to hope 
 that they will have a friendly reception here, still, as I make no 
 literary pretensions, it is with the greatest diffidence that I 
 appear as an author on this side of the Atlantic. 
 
 As its title indicates, this collection of " Clinical Notes" lays 
 no claim whatever to the character of a systematic work. It is 
 simply a voice fron the Woman's Hospital, which, in all
 
 v j PREFACE. 
 
 probability, would never have been heard if I had remained at 
 home. I wish most sincerely that I could have produced some- 
 thing more worthy of the position so long held by me in that 
 noble Charity ; for to this I owe all that I know practically of 
 the subjects herein treated. 
 
 In looking over this volume, it would seem that I owe an 
 apology to, and must claim the indulgence of, my brethren for 
 three things: — 
 
 1st. A clinical review of personal experience, taken from 
 note-books, as this has been, must almost of necessity be written 
 in the first person. 
 
 2nd. It may be necessary to excuse to my senior readers the 
 minuteness of detail in which I have sometimes indulged ; but, 
 at the same time, I must plead the necessity of such minuteness 
 for the guidance of my younger brethren, for whom principally 
 these pages were penned. 
 
 3rd. The illustrations are not all as good as I would have bad 
 them. Most of them are mere diagrams made by myself. For 
 any inaccuracies I alone am responsible ; for any artistic value 
 that they may possess, the credit is wholly due to Leveille, 
 Lackerbauer, and Yien, of Paris ; and to Mr. Orrin Smith, of 
 London. 
 
 A word of explanation on another point. It will be seen 
 that I have not touched upon the accidents of parturition, such 
 asfistuke of the bladder, rectum, and vagina, lacerated perineum, 
 &c. It is only just to myself to say that I have ignored these 
 for the present, because I hope, if time and circumstances 
 permit, to prepare, at no distant day, a fully illustrated mono- 
 graph on these subjects. To have done them ample justice here 
 would have interfered, in some sort, with the plan, and aug- 
 mented very considerably the size of this volume.
 
 PREFACE. y jj 
 
 In conclusion I beg leave to say that I am under special 
 obligations to Dr. Tbos. D. Pratt for timely aid ; and I take tbi? 
 occasion to return my sincere thanks to my friend, Mr. Ernest 
 Hart, for useful suggestions and valuable assistance rendered as 
 these pages were passing through the press. 
 
 London : 1, Bolton Row, May Faib, 
 1st January, 1860.
 
 CONTENTS 
 
 Introduction, , , , . 1 
 
 On the Method of Uterine Examination, 5 
 
 SECTION L 
 
 Conception occurs only during Menstrual Life, .... 27 
 
 Early Pregnancy, 29 
 
 Conception without Menstruation, ....... 30 
 
 Errors in Diagnosis, 32 
 
 False Quickening, 34 
 
 SECTION II. 
 
 Menstruation should be such as to snow a Healthy Condition of 
 
 the Uterine Cavity, 
 
 Scanty Menstruation, 
 
 Profuse Menstruation, 
 
 Menorrhagia from Granular Erosion, 
 
 from Fibrous Engorgement of the Cervix, 
 
 from Fungoid Granulations, 
 Sponge Tents, now to make and introduce, 
 
 Sea Tangle Tent, 
 
 Menorrhagia from Polypus, .... 
 Use of Glycerine in Uterine Surgery, 
 Diagnosis of Polypous Tumours, 
 
 The Ecraseur, 
 
 Intka-Uterine Polypi, 
 
 Polypi of the Fundus and Posterior Wall, 
 The Operation for the Removal of Polypi, 
 Fibroid Tumours, 
 
 37 
 39 
 41 
 43 
 44 
 4G 
 47-C5 
 6G 
 67 
 71 
 72 
 76 
 82 
 86 
 90 
 94
 
 CONTENTS. 
 
 Uterine Probes, 104 
 
 Menorrhagia from Inversion of the Uterus, .... 123 
 
 Painful Menstruation, 138 
 
 Incision of the Os and Cervix, • 153 
 
 SECTION III. 
 
 The Os and Cervix Uteri should be sufficiently open, not only to 
 permit the Free Exit of the Menstrual Flow, but also to 
 
 admit the Ingress of the Spermatozoa, 175 
 
 Normal Conditions and Relations of the Uterus, . . . 175 
 
 Anomalies, 178 
 
 Os Tinoe — abnormal, 181 
 
 SECTION IV. 
 
 The Cervix Uteri should be of Proper Size, Form, and Density, . 197 
 
 Hypertrophic or Defective Development of Cervix Uteri, . 200 
 
 Method of Amputation, 201 
 
 Proper Form of the Cervix, 213 
 
 Illustrations of the Conical Cervix, 216 
 
 Induration of the Cervix, 222 
 
 SECTION V. 
 
 The Uterus should be in a Normal Position, i. e. 
 verted nor perroverted to any great degree 
 Position and Relations of the Pelvic Organs, 
 Uterine Displacements, 
 Anteversion, 
 Retroversion, 
 Pessaries, 
 Procidentia Uteri, 
 
 NEITHER ANTE- 
 
 226 
 227 
 229 
 232 
 249 
 26-1 
 287 
 
 SECTION VI. 
 
 The Vagina must be capable of Receiving and Retaining the Sper- 
 matic Fluid, . 313 
 
 Imperforate Hymen, . .315 
 
 Vaginismus, 317 
 
 Atresia Vaginje 326 
 
 Absentia Vaginae, 340 
 
 Short Vagina, 342 
 
 Non-retaining Vagina 345
 
 CONTENTS. 
 
 X] 
 
 SECTION VII. 
 
 For Conception, Semen with Living Spermatozoa should be deposited 
 in the Vagina at the proper time, 
 Nature and Properties of Semen, 
 Spermatozoa, .... 
 Artificial Fertilization, 
 Period for Conception, 
 
 349 
 351 
 352 
 364 
 371 
 
 SECTION VIII. 
 
 The Secretions of the Cervix and Vagina should not poison or kill 
 
 the Spermatozoa, 377 
 
 The Vaginal Secretions, 379 
 
 Vaginitis, 379 
 
 Leucorriicea, 383 
 
 Vaginal Injection, 385 
 
 Endo-Cervicitis, 391 
 
 Cervical Mucus, 393 
 
 Intra-Uterine Abscess, ........ 396 
 
 Endo-Metritis, 397
 
 UTERINE SURGERY. 
 
 INTRODUCTION. 
 
 I i»o not propose to write a complete monograph on Ute- 
 rine Surgery, or on the treatment of sterility, but simply 
 to interweave the two, while taking a glance at such 
 surgical difficulties as seem ordinarily to interfere with 
 conception. To make a work of this sort complete would 
 be to write a book on all the diseases of women, and on 
 some of those of the opposite sex. But this is not my 
 object, and I shall confine myself to the consideration of 
 such cases as ordinarily come under the observation of 
 the practitioner. 
 
 An inquiry into the conditions favourable to concep- 
 tion would almost necessarily involve a consideration of 
 those opposed to it ; and this would lead very naturally 
 to the investigation of the best means of overcoming 
 such obstacles. This is the order in which I propose to 
 consider the subject ; but it is not the one by which my 
 experience was gained. It came by a very different pro- 
 cess. 
 
 In the course of treating the diseases of women, I, like 
 others similarly engaged, found many cases of sterility 
 accidentally cured simply by curing some uterine affec- 
 tion. After a while I discovered that they were as 
 various and as varying as the diseases upon which they 
 depended. Then, by a classification of all diseases of the
 
 2 UTERINE SURGERY. 
 
 uterus just as they were encountered, I found sterility to 
 be incident to many of them. These naturally arranged 
 themselves into two classes ; viz., — 1st. Those who had 
 never conceived ; and — 2nd. Those who had ; but who 
 for some reason had ceased to do so for a time, say five 
 years, or more. The first I called " Natural Sterility ; " 
 the second, " Acquired Sterility." 
 
 In looking over my note-books for a series of years, I 
 was surprised to see how nearly equal these two classes 
 were. Sometimes one and then the other would predo- 
 minate ; but they were so evenly balanced, that from 3 
 to 6 per cent, would cover the variation either way. 
 
 I mean that this is so, taking all cases of uterine dis- 
 ease as they are promiscuously presented. If we consider 
 the cases of those only who come to consult us merely 
 on the subject of sterility, without reference to disease 
 or actual suffering, the first class will, of course, greatly 
 predominate. But it is by a study of all, that we de- 
 duce the principles that are to guide our judgment in 
 individual cases. It is by this that we are able to specify 
 the conditions most opposed to conception ; and, at the 
 same time, those most favorable to it. 
 
 The trouble in one case may depend upon mere con- 
 traction of the os ; in another upon malformation of the 
 same — in another upon engorgement of the cervix — in 
 another upon elongation — in another upon hypertrophy 
 — in another upon simple induration — in another upon 
 curvature of the canal of the cervix — in another upon 
 polypus — in another upon a fibroid — in another upon 
 malposition of the uterus — in another upon some anato- 
 mical anomaly or malformation of the vagina — in ano- 
 ther upon vitiated secretions of the cervix — in another 
 upon those of the vagina, the one generally acting me- 
 chanically, the other chemically — in another upon the
 
 INTRODUCTION. 3 
 
 absence of spermatozoa ; while others may be compli- 
 cated with several of these anomalies all subjects of 
 study and investigation. 
 
 And when we come to analyze these various causes 
 and complications, they are resolved into one great gene- 
 ral principle, embracing all manner of obstructions to 
 the free passage of living spermatozoa into the cavity of 
 the womb. In all curable cases ovulation must be per- 
 fect, and the faulty link must be found in defective fruc- 
 tification, or else all our efforts are in vain. If the wo- 
 man has passed the period of ovulation, of course we 
 can do nothing for her. If the ovum never passes into 
 the fallopian tubes, a thing impossible to determine, it is 
 equally beyond remedy. We may safely assume a nor- 
 mal menstruation as a sign of normal ovulation. This 
 being our guide, we may hope, in the majority of cases, 
 to find some of the troubles above enumerated, many of 
 which are eventually curable. 
 
 It is self-evident that if we knew exactly all the 
 conditions of the uterus and its appendages absolutely 
 essential to fecundation, it would not be very difficult to 
 determine, in any given case, in what particular it dif- 
 fered from the proper standard. And, on the other 
 hand, if we knew exactly the conditions of the uterus 
 and appendages absolutely opposed to fecundation, it 
 would not be very difficult to determine at once the 
 chances of cure. 
 
 This is but another way of saying that here, as in 
 every other department of medicine, knowledge of both 
 normal action and abnormal condition is essential to safe 
 and sure methods of treatment. 
 
 A few years ago, the subject of conception was 
 wrapped in the profoundest mystery ; but now, thanks 
 to the labours of Martin Barry, of Bischoff, of Coste, of
 
 4 UTERINE SURGERY. 
 
 Pouchet, and other modern physiologists, its laws are 
 much better understood. 
 
 As usual, pathology is here behind its great pioneer, 
 physiology, and yet quite in advance of therapeutics ; 
 for until a comparatively recent period we had no 
 rational views on the treatment of the sterile condition ; 
 and almost all that is now known has emanated from 
 the Edinburgh school. Indeed, little or nothing has 
 been added to the labours of Mcintosh and of Simpson ; 
 and the English language presents us with but one com- 
 plete monograph on the subject, — that by Dr. A. K. 
 Gardner,* of New York. 
 
 Macintosh f discovered that most of his sterile pa- 
 tients had a contracted os and cervix ; and he con- 
 ceived the idea of dilating these by bougies, such as 
 were used ordinarily for stricture of the urethra. His 
 success was very remarkable, but none of his followers 
 were able to attain equally good results. Simpson, 
 seeing the uncertainty and even danger of dilatation, 
 had the happy thought of incising the os and cervix 
 to render their enlargement more thorough and more 
 permanent. The results have not been all that were 
 hoped for ; but enough has been done to show that 
 we are at last on the highway of improvement ; and 
 it seems to me that further advances must be made 
 as heretofore, by means almost purely surgical. 
 
 From any point of view this subject is one of great 
 importance ; for the perpetuation of names and families, 
 the descent of property, the happiness of individuals, 
 and occasionally the welfare of the State, and even 
 
 * " On the Causes and Curative Treatment of Sterility," by A. K. Gard* 
 ner, M.D., &c., New York. 1856. 
 t Macintosh's " Pathology and Practice of Physic."
 
 INTRODUCTION. 5 
 
 the permanence of dynasties and governments, may 
 depend upon it. 
 
 Without further preliminary remarks, let us then 
 inquire, " What are the conditions essential to Con- 
 ception ?", 
 
 1. — It occurs only during menstrual life. 
 
 2. — Menstruation should be such as to show a 
 
 healthy state of the uterine cavity. 
 3. — The os and cervix uteri should be sufficiently 
 open to permit the free exit of the menstrual 
 flow, and also to admit the ingress of the 
 spermatozoa. 
 4. — The cervix should be of proper form, shape, 
 
 size, and density. 
 5. — The uterus should be in a normal position, i.e., 
 neither ante-verted, nor retro-verted to any 
 great degree. 
 6. — The vagina should be capable of receiving and 
 
 of retaining the spermatic fluid. 
 7. — Semen, with living spermatozoa, should be 
 
 deposited in the vagina at the proper time. 
 8.- -The secretions of the cervix and vagina should 
 not poison or kill the spermatozoa. 
 I lay these down as postulates, embracing the 
 general principles or laws most favourable — indeed, 
 essential to fecundation ; and I propose to take them 
 up seriatim, and to show, from clinical experience, 
 wherein the sterile condition differs from the fecund, 
 and to point out, so far as we know, the surest methods 
 of relief. 
 
 But before entering upon this discussion, it will be 
 well, perhaps, to say something 
 
 On the Method of Uterine Examination. — Almost
 
 6 UTERINE SURGERY. 
 
 every physician accustomed to treat the diseases of 
 women has educated himself to some peculiar method 
 of examination. I propose here to give my own 
 plan. 
 
 Every thorough uterine investigation is naturally 
 divided into two stages, the first requiring the touch, 
 the second the sight ; the dorsal decubitus for the 
 one, the left lateral for the other. For the touch 
 alone, the patient may lie on a sofa or a bed ; but the 
 one is too low, and the other too soft and yielding, for 
 a speculum examination. I therefore prefer a common 
 table, two or three feet wide, and four or five feet long, 
 covered with a wadded quilt, or blankets folded. This 
 is a little more formidable, but it is better for both 
 physician and patient. Indeed, it is essential, if we 
 wish to make a very thorough examination. The table 
 being properly prepared, the patient is requested to 
 loosen all the fastenings of the dress and corsets, so 
 that there may be nothing to constrict the waist or to 
 compress the abdomen. While this is being done, the 
 physician should bathe his hands in warm water, and 
 wash them well. It may seem odd to insist upon this, 
 but I do most earnestly ; 1st, because it softens and 
 warms the hands ; 2nd, because it insures their clean, 
 ness ; and 3rd, because it assures our patient against 
 any dread of contamination by the touch, a thing by 
 no means to be despised. 
 
 All being ready, the patient is now requested to sit 
 on the edge of the table, and then to lie down on the 
 back, with -the head, but not the shoulders, supported 
 by a pillow, while the feet rest momentarily on a chair. 
 
 Many practitioners allow the feet to hang down, 
 each on a chair, but this is by no means the best plan 
 for either physician or patient, nor is it the most deli-
 
 INTRODUCTION. f 
 
 cate. As soon as the patient is laid comfortably back 
 on the table, the surgeon will raise her feet from the 
 chair, upon which he is now to sit down, and place 
 them on the edge of the table, with the heels separated 
 some ten ov twelve inches, while the knees are a little 
 wider apart. This flexure of the thighs and legs in- 
 sures the relaxation of the abdominal walls. Some 
 patients will at first, in spite of our entreaties, place 
 the soles of the feet together, and let the knees fall 
 widely apart, while others will unconsciously hold the 
 knees closely together, and brace the feet firmly out- 
 wards, each condition being equally opposed to an easy 
 exploration of the vagina. 
 
 The patient once on the back, with the extremities 
 properly flexed and fixed, must be assured that there 
 is to be neither pain nor exposure of person ; this last 
 being more dreaded than the most intense suffering. 
 
 Everything being ready, let the left index finger be 
 well lubricated, not with sweet oil, which is often 
 gummy and sticky, nor with grease, which is often 
 rancid, but with warm water and Castile or other fine 
 soap, which is a cleaner, cheaper, and better lubricant 
 than any other. Pass the finger into the vagina — do it 
 gently — if otherwise, we may jar the nervous system, 
 and produce involuntary spasmodic action of the abdo- 
 minal muscles. The patient may become agitated and 
 alarmed, and we may perhaps be compelled to pro- 
 crastinate a very minute examination to some future 
 *time. As the finger passes, let it ascertain if there is 
 anything abnormal about the ostium vaginae. Is it 
 contracted, rigid? Is the hymen present or absent? 
 Is it irritable or tender? Then as to the vagina : Does 
 it dip down towards the coccyx ? Does it run more in 
 the direction of the axis of the pelvis ? Is it of normal
 
 g UTERINE SURGERY. 
 
 temperature? Is it short? Is it deep? Is it nar- 
 row ? Is it capacious ? Does it contain any foreign 
 body ? If so, is it something inorganic, previously in- 
 troduced? Or, is it something organic, growing on 
 the walls of the vagina, on the os tincse, or does it come 
 from the cavity of the uterus ? Is it benign or malig- 
 nant? Then what of the womb? Is the os open or 
 closed, large or small ? Is the cervix too long, too 
 pointed, too small, too large ? Is it indurated or 
 ulcerated ? Is the body of the organ in its proper 
 position? Is it ante-verted, retro-verted, or flexed in 
 any direction ? Is it larger or smaller than natural ? 
 Is it of proper form ? Is it indurated ? Is it fixed or 
 movable ? Is there any complication, ovarian or fibroid ? 
 
 All of these conditions are ascertainable by the touch 
 alone. We need no speculum to tell us of the volume, 
 position, and relations of the uterus and its appendages. 
 
 But I should not omit to say that the mere touch 
 by the vagina is not alone sufficient. 
 
 It is necessary to make pressure with the right hand 
 on the abdomen in the hypogastric region at the same 
 time that the left index is carried into the vagina. The 
 two hands then act conjointly in ascertaining the con- 
 dition and relations of the uterus. 
 
 Is it in its normal position? Then the os uteri 
 will rest on the end of the left index finger, while the 
 fundus will be distinctly felt by the other hand, in a line 
 drawn from the os, in the direction of the umbilicus. 
 
 Is it ante-verted ? Then the os will be very far back 
 towards the hollow of the sacrum, while the fundus will 
 be felt by the index just behind the symphysis pubis, 
 pressing down upon and perhaps parallel with the 
 anterior wall of the vagina. 
 
 But I repeat that the touch by the vagina is not
 
 INTRODUCTION. 
 
 9 
 
 enough to determine this point positively, and it is 
 essentia] always to make pressure at the same time 
 with the other hand, just above the pubes. It will 
 
 Fig. i. 
 
 then be very easy to measure the size and shape of the 
 body of the womb, for it will be held firmly between 
 the fingers of the two hands, and its outline and irre- 
 gularities will be ascertained with as much nicety as if 
 it were outside of the body. Thus isolated, we deter- 
 mine its condition as easily as we would that of a pear 
 wrapped up in a common towel or napkin. 
 
 The retro-uterine region, represented here as being 
 occupied by a small tumour, is quite as easily explored 
 by the touch alone. To do this, pass the left index 
 finger to the posterior cul de sac, hook it up behind 
 the cervix uteri, raise this upwards, draw it forwards, 
 and at the same time press the outer hand in the 
 direction of the point of the left index. 
 
 In a thin subject, where there is nothing abnormal,
 
 10 
 
 UTERINE SURGERY. 
 
 the external finders and the internal one can "be 
 brought very near together behind the cervix, with- 
 out pain to the patient or inconvenience to the 
 operator; and if there is anything abnormal, this 
 manipulation is sure to detect it. 
 
 We may now and then be obliged to pass the finger 
 into the rectum to clear up some doubtful point ; but 
 this is rarely necessary. 
 
 By this method, versions, flexions, fibroid offshoots, 
 and other irregularities, are readily detected ; and if 
 at any time there is a doubt about the direction or 
 depth of the uterine cavity, the sound will at once 
 clear it up. 
 
 Having ascertained all these points by the touch, 
 we are ready for the second stage of the examination — 
 viz., that by the speculum. As before said, for the 
 digital examination, the dorsal decubitus is preferable ; 
 but for the speculum, the left lateral semi-prone position 
 is the best. 
 
 In 1845 I first used my speculum for vesico- vaginal 
 fistula operations, placing the patient on the knees. I 
 rarely resort to this method now, but as it may some- 
 times be necessary in a complicated case of vesico-vaginal 
 fistula, or in some forms of malignant disease, I shall 
 here quote the following from my first paper on this 
 subject, published in the American Journal of Medical 
 Sciences, January, 1852. 
 
 "In order to obtain a correct view of the vaginal 
 canal, I place the patient on a table, about two and a 
 half by four feet, on her knees, with the nates ele- 
 vated and the head and shoulders depressed. The 
 kuees must be separated some six or eight inches, 
 the thighs at about right angles with the table, 
 and the clothing all thoroughly loosened, so that
 
 INTRODUCTION. 
 
 11 
 
 there shall be no compres- 
 sion of the abdominal pa- 
 rietes. An assistant on each 
 side lays a hand in the fold 
 between ,the glutei muscles 
 and the thigh, the ends of 
 the fingers extending quite 
 to the labia majora ; then by 
 simultaneously pulling the 
 nates upwards and outwards, 
 the os externum opens, the 
 pelvic and abdominal viscera 
 all gravitate towards the epi- 
 gastric region, the atmosphere 
 enters the vagina, and by 
 its pressure, soon stretches 
 this canal out to its utmost 
 limits, affording an easy view 
 of the os tincae, fistula, <fcc, 
 To facilitate the exhibition 
 of the parts, the assistant 
 on the right side of the 
 patient introduces into the 
 vagina the lever speculum, 
 represented in fig. 2, and 
 
 then, by lifting the perineum, stretching the sphincter, 
 and raising up the recto-vaginal septum (fig. 3), it is 
 as easy to view the whole vaginal canal as it is to 
 examine the fauces, by turning a mouth widely open to 
 a strong lio-ht. 
 
 "This method of exhibiting the parts is not only 
 useful in these cases, but in all affections of the os 
 and cervix uteri requiring ocular inspection. 
 
 " The most painful organic diseases, such as corroding 
 
 Fig. 2.
 
 12 
 
 UTERINE SURGERY. 
 
 ulcer, carcinoma, &c, may be thus exposed without 
 inflicting the least pain, while any local treatment may 
 be instituted without danger of injuring the healthy 
 
 Fig. 3. 
 
 structures. By this method also a proper estimate) 
 anatomically, can be had of the shape and capacity of 
 the vagina ; for where there is no organic change, 
 no contraction, and no rigidity of it from sloughs, 
 ulcers, or cicatrices, and where the uterus is movable, 
 this canal immediately swells out to an enormous 
 extent." 
 
 Thus I wrote in 1852 ; and I have introduced %s. 
 2 and 3, copied from the American Journal of Medical 
 Sciences of that date, merely for the purpose of con- 
 trasting my past and present methods of vaginal 
 exploration.
 
 INTRODUCTION. 
 
 13 
 
 Many persons who have never witnessed {he use of 
 my speculum, doubt the correctness of my explanation 
 of its rationale as given above. But let such experi- 
 ment for themselves, and give us a rationale more in 
 accordance with the laws of natural philosophy, if they 
 have one. For a successful experiment certain con- 
 ditions are requisite. At the risk of being tedious, 
 I will reiterate them. Let the experimenter first 
 loosen all the strings and fastenings of the dress and 
 corsets, and then place the patient on a table on 
 her knees, and bend her body forwards till the head is 
 brought down to the plane of the table, where it may 
 rest in the two hands, its weight supported on the left 
 parietal bone, while the elbows are thrown widely out 
 from the sides. The knees are to be separated eight or 
 ten inches ; the thighs are to be at about right angles 
 
 with the table ; thus the plane of the table (ah), the 
 axis of the thighs (etc), and that of the body (cb), would 
 form a right-angled triangle, of which the thighs and 
 table would make the right angle, and the body the 
 hypothenuse. The patient must be taught to maintain 
 unflinchingly this position ; she must not pitch forwards 
 and make the pelvian angle (c) obtuse, nor draw the 
 knees up under the body, making it more acute ; she 
 must not arch the spine (cb) upwards, for this brings 
 into forcible action the abdominal muscles, which should
 
 14 UTERINE SURGERY. 
 
 be perfectly relaxed, with the spine rather curved down 
 wards, as we see it in sway-backed animals. With these 
 precautions fully impressed on her, she is to breathe 
 easily, and relax the muscles of the abdomen. In con- 
 sequence of this position quietly retained for a few 
 moments, the movable abdominal and pelvic viscera 
 necessarily gravitate towards the epigastrium. Now, if 
 the surgeon will get immediately behind his patient and 
 lay his hands on the nates, and push them gently 
 upwards and backwards, taking care that her position is 
 not changed, he will see the mouth of the vagina open, 
 and at the same moment hear the air rush into it with a 
 blowing or hissing sound ; and then if he will, with even 
 his finger, raise the perineum up towards the os coccygis, 
 he will see the vagina distended like an inflated bladder. 
 If, however, he will use my speculum instead of the fin- 
 ger, the cavity of the vagina will be more easily seen. 
 
 If he will now remove the instrument (or finger), 
 and allow the mouth of the vagina to close, and then 
 if he will let his tired patient fall over on her side, he 
 will have audible and unmistakable evidence of the 
 sudden escape of air from the vagina. In private prac- 
 tice, even with the patient on the side, this is such an 
 unpleasant occurrence, and so mortifying to a sensitive 
 person, that I generally keep a catheter by me, to be 
 placed momentarily in the vagina, that the air may 
 escape noiselessly. If we fail in the above experiment, 
 it will be because we have omitted some of the condi- 
 tions essential to success. 
 
 The object of this speculum (whether used with the 
 patient on the knees or on the side) is to elevate the 
 perineum and to partially support the posterior wall of 
 the vagina ; the pressure of the atmosphere with the 
 gravitation of the viscera does the rest. All other
 
 INTRODUCTION. JR 
 
 specula act directly on the walls of the vagina, which 
 they mechanical ly distend. This one, as a rule, touches 
 but a small portion of the posterior wall. 
 
 I was led to the invention of this speculum by a sin- 
 gular incident. As showing from what trifles important 
 results sometimes spring, I venture to record here the 
 circumstances. I feel the more justified in this because 
 my speculum is by some in England, and by a few on 
 the continent, called by the name of another man, who 
 had nothing to do with it, except to hand it to the instru- 
 ment-makers here to be copied, and who in their turn 
 have been the unconscious agents of doing me a great 
 wrong. In December, 1845, a lady was riding on a pony 
 in the suburbs of the city of Montgomery, Alabama, 
 where I then resided. It took fright and suddenly 
 jumped from under her — she fell, striking her pelvis 
 on the ground. I saw her soon afterwards ; her suffer- 
 ings were very severe. Besides the contusions from the 
 fall, she complained of rectal and vesical tenesmus. On 
 examination, I found a complete retroversion of the 
 uterus. I had been taught by lectures and books that 
 the best method of reducing a recent luxation of this 
 organ was to place the patient on the knees, and then 
 act on the uterus through the rectum and vagina. This 
 lady, covered with a sheet, was so placed across her bed. 
 I then introduced a finger into the vagina, but effected 
 nothing by it. Not wishing to pass the finger into the 
 rectum, which is always disagreeable, and to be avoided 
 if possible, I introduced the middle and index fingers 
 together into the vagina, and while I was making efforts 
 to replace the uterus, all at once it happened that I 
 could not touch the uterus, nor even the walls of the 
 vagina, and my fingers were swept around in the pelvis 
 without touching or being touched by anything except
 
 IQ UTERINE SURGERY. 
 
 just where they were grasped by the mouth of the 
 vagina. While I was wondering what could be the 
 cause of this anomaly, my patient said she was relieved 
 from the symptoms of which she was complaining so 
 seriously but a few moments before. As she was re- 
 lieved, although T did not understand how it was done, 
 my duties to her were of course at an end. She was 
 large and heavy ; letting her go, I requested her to lie 
 down. Being quite exhausted from pain and the unna- 
 tural position in which she had been placed, she threw 
 herself quickly down on her side, when the sudden 
 escape of air from the vagina gave a ready solution of 
 my dilemma, as well as of the rationale of the reduction 
 of the dislocated uterus, which was now found to be in 
 its normal position. And what was its rationale ? 
 When the patient was in the position described, there 
 being a natural tendency of the pelvic viscera to 
 gravitate towards the epigastric region, it would 
 require no great vis a tergo to produce the desired 
 result in a recent case of this kind. One finger, how- 
 ever, was not long enough to throw the organ up, nor 
 were the two ; but when they were both introduced, in 
 my varying manipulations and strenuous efforts, the 
 hand was accidentally turned with its palm downwards, 
 which thus brought the broad dorsal surface of the two 
 parallel fingers in contact with the vulvar commissure, 
 thereby elevating the perineum and expanding the 
 sphincter muscle, which allowed the air to rush into the 
 vagina under the palmar surface of the fingers, where, 
 by its mechanical pressure of fifteen pounds to the square 
 inch, this canal was suddenly dilated like a balloon, and 
 the uteius replaced by its pressure alone. Having at 
 this time a patient with a vesico- vaginal fistula, which I 
 could not understand, I placed her in the positiou above
 
 INTRODUCTION". \^ 
 
 described, and used the handle of a spoon, curved at 
 right angles, to open the vagina, elevate the perineum, 
 and allow the air to enter, which afforded me a complete 
 view, not only of the fistula, but of the whole vagina ; 
 whereupon this instrument (page 11, fig. 2) was a self- 
 suggested affair. 
 
 During my residence in Alabama, up to 1853, I had 
 no need of any better form of instrument, or any other 
 position for its application than that above described ; 
 but when I went to New York, a larger field of obser- 
 vation soon proved to me that it was essential to modify 
 both instrument and position, if they were to be used in 
 the every-day treatment of the ordinary affections of the 
 uterus ; for while a patient afflicted with such a terrible 
 infirmity a3 vesico- vaginal fistula is ready and willing 
 to be placed in any position, however fatiguing, a 
 moment's reflection will show that this kneeling posture 
 would be quite out of the question in the treatment of 
 the simple forms of uterine disease, as they occur in the 
 higher grades of life. 
 
 With this necessity before me, I went to work to 
 improve my speculum, and at the same time I discovered 
 that it could be used as efficiently with the patient on 
 the left side as on the knees. For nearly twenty years I 
 have used no other speculum, and whenever, in these 
 pages, I have occasion to speak of the speculum, let it be 
 remembered that I allude always and only to this one (fig. 
 5), with the patient necessarily on the left side. It is the 
 best speculum for any purpose, whether it be for the 
 application of the simplest dressing, or for the execution 
 of the most difficult operation. 
 
 I must of course make an exception in favour of the 
 conical ivory speculum, whenever it is necessary to apply 
 the hot iron, a thing rarely done in America. 
 
 2
 
 18 
 
 UTERINE SURGERY. 
 
 The speculum is univalve or duck-billed, as some 
 have called it. For the sake of convenience, two spe- 
 cula of unequal sizes are attached to the same handle, one 
 
 Fig. 5. 
 
 at each extremity. This handle may be slightly bent, 
 as seen in fig. 5, or it may be perfectly straight, as I for- 
 merly used it (fig. 2). The only object in the slight 
 curvature is to facilitate its leverage in prolonged opera- 
 tions. The assistant may become tired of holding on to 
 the distal end, and then it is a great relief to grasp the 
 shaft in the middle, where it is gently curved. The 
 object of having two blades or specula to one shaft is 
 merely to have them of different sizes so as to suit different 
 vaginas ; for there are no two vaginas exactly alike, 
 any more than there are two faces precisely alike.
 
 INTRODUCTION. 
 
 19 
 
 1 have one with a blade six inches long, another but 
 two inches, and another of the ordinary length, an inch 
 and three quarters wide. But these sizes are very rarely 
 needed. For ordinary purposes, two instruments, i.e. 
 four blades, are all that we need. 
 
 The smallest I call the virgin speculum ; for unhap- 
 pily we are sometimes compelled to use a speculum on 
 the unmarried, and then it is proper to have it of such a 
 suitable size as not to give pain, and not to injure the 
 hymen. Here one blade is a little less than three inches 
 long, the other a fraction over ; the first three-quarters 
 of an inch wide, the other seven-eighths. But the specu- 
 lum for ordinary use on the married has the smaller 
 blade about three and a half inches long, by about one 
 inch wide. This is the one that we need in nine cases 
 out of ten. 
 
 The other, or larger one, is about four inches long by 
 an inch and a quarter wide. This will be needed where 
 the vagina is very large. As said before, they are made 
 much wicrer ; but they are then apt to produce pain, 
 a thing always to be avoided. 
 
 In all vaginal examinations, it matters not for what 
 purpose, a speculum should never be used till we have 
 by the touch first and fully ascertained the condition of 
 the uterus and its appendages. 
 
 This injunction is particularly imperative, and for the 
 most obvious reasons. 1st, because the size of the spe- 
 culum should be always adapted to the capacity of the 
 vagina ; a small speculum in a large vagina is compa- 
 ratively useless ; on the contrary, a large speculum in 
 a small vagina is cruelly painful. 2nd, because it should 
 be passed in the direction of the axis of the vagina, 
 taking care not to strike it against the cervix uteri, par- 
 ticularly if this be the seat of granular erosion, of poly-
 
 20 UTERINE SURGERY. 
 
 pus, of cauliflower excrescence, or other hemorrhagic 
 disease, all of which should be previously ascertained by 
 the touch. 
 
 It has been objected to this speculum, that its use 
 requires the assistance of a third person. Apart from 
 its real value, there could be no stronger reason for 
 its universal adoption. I insist that a third person 
 should always be present on such occasions. Delicacy 
 and propriety require it, and public opinion ought to 
 demand it. I do not mean lay, but professional public 
 opinion. 
 
 I am sure that I never made a vaginal examination, 
 or used a speculum a dozen times in my life without the 
 presence of a third person. I have never had a patient 
 to object who was educated or sensible ; but the silliest 
 person would see the necessity of it when told that pro- 
 priety required it, even if an assistant were not neces- 
 sary. The few that have objected to the presence of 
 another person in the room at the time of a speculum 
 examination, have done so from the fear of personal 
 exposure. We are too apt to disregard this innate feel- 
 ing of delicacy when we have been much used to hos- 
 pital practice ; but we can never make a mistake if 
 we always cultivate the same gentleness and kindness 
 towards the poorest hospital patient that we would use 
 towards the highest princess. I repeat, then, that we 
 should never in our examinations allow any exposure of 
 person, not even in hospital practice. When the touch 
 is made, there can be none, of course, with the patient 
 on the back, and covered with a sheet. When the spe- 
 culum is used, we should see only the neck of the womb 
 and the canal of the vagina. 
 
 I have said that for a speculum examination there is 
 nothing better than a table covered with a quilt or
 
 INTRODUCTION. 
 
 21 
 
 blankets folded, and this is literally true ; but for the 
 consultation-room I have a chair which has served such 
 a good purpose that I introduce it here, that others may 
 profit by it. 
 
 Some twelve or fifteen years ago, Mr. James Holmes, 
 of Charleston, S.C., was driven to the necessity of invent- 
 ing what he called an " Invalid Chair. The patient 
 sitting in this chair (fig. 6), can with the greatest ease 
 
 and without an effort poise the body for any length of 
 time, at any angle between the erect and horizontal 
 postures. Mr. Holmes invented this chair especially 
 for a near relative of his, who suffered from prolonged 
 attacks of (I believe) gout or some other very painful 
 affection. It is much used in America, and was even 
 introduced on some lines of railway as a sleeping-chair. 
 I am thus minute, because I <!<> not wish to claim it as 
 mine. To adapt it to my own practice I had it made 
 24 inches wide instead of IS, and 30 inches high instead
 
 22 
 
 UTERINE SURGERY. 
 
 of 22. I have added legs or uprights, a, a, to support 
 the lower part of the chair when it is extended in the 
 form of an operating-table (fig. 7). There is also an 
 elastic cord, £, to pull these uprights back under the 
 chair when it is changed from a table to a mere chair 
 again. For all practical purposes it is really no better, 
 
 Pig. 1. 
 
 as before said, than a common table ; but any patient 
 would sit in the chair without nervous agitation, while 
 some become greatly alarmed at being requested to 
 mount a table. The patient once seated, is told that the 
 chair is only a couch, and she is requested to lean back 
 and extend it horizontally by her own weight, with 
 perhaps a little assistance from the nurse who stands at 
 the back of the chair. I am almost afraid to write 
 these little things, but I do it only for my younger 
 brethren, who may need to learn the importance of 
 educating their patients to feel that everything is being 
 done that delicacy and propriety require on an occasion 
 so trying to a sensitive nature. 
 
 When the patient lies back and the chair is extended 
 in the form of a table, it will be necessary to draw the
 
 INTRODUCTION. 
 
 23 
 
 person down to the lower edge of it, c <?, whether for 
 a digital or speculum examination. Afterwards the 
 patient moves again up on the centre or seat of the 
 chair, the uprights, «, «, are drawn back, and the chair 
 almost voluntarily assumes its proper form. 
 
 For a speculum examination the patient is to lie on 
 the left side. The thighs are to be flexed at about right 
 angles with the pelvis, the right being drawn up a little 
 more than the left. The left arm is thrown behind 
 across the back, and the chest rotated forwards, bringing 
 the sternum very nearly in contact with the table, while 
 the spine is fully extended, with the head resting on the 
 left parietal bone. The head must not be flexed on the 
 sternum nor the right shoulder elevated. Indeed, the 
 position must simulate that on the knees as much as 
 
 Fig. 8. 
 
 possible, and for this reason the patient is rolled over on 
 the front, making it a left lateral semiprone position. 
 The nurse or assistant standing at her back pulls up the
 
 u 
 
 24 UTERINE SURGERY. 
 
 right side of the nates with the left hand, when the 
 surgeon introduces the speculum, elevates the perineum, 
 aud gives the instrument into the right hand of the 
 assistant, who holds it firmly in the desired position. 
 
 The introduction of the speculum is a matter of 
 some importance. It is done under cover, with the 
 right index finger as a guide, as seen in fig. 8. The 
 object of this is to prevent the point of the instrument 
 from striking; against the cervix uteri. 
 The finger is not to be withdrawn till 
 we are sure that the end of the speculum 
 has passed beyond the cervix, or is well 
 ^ turned back towards the rectum. If 
 the patient breathes easily, the vagina 
 will be immediately distended by the 
 pressure of the atmosphere, so as to 
 bring the neck of the uterus, the pos- 
 terior cul-de-sac, and the whole of the 
 anterior wall of the vagina into view, 
 without the least traction, pressure, or 
 suffering. But if she is alarmed and 
 breathes hurriedly, or bears down, it 
 will be otherwise. If the uterus be 
 retroverted, the os tincaa is easily seen. 
 If it be in a normal position, there is no 
 trouble in getting a good view of it ; 
 but if it be completely anteverted, with 
 a narrow vagina, then it will be neces- 
 sary to hook a small tenaculum into the 
 anterior lip, and pull it gently forwards, 
 as shown in fig. 14, where the manner 
 of introducing the sponge-tent is illus- -^ 10 
 trated. The tenaculum is to be slightly 
 inserted into the mucous membrane. It gives no pai^
 
 INTRODUCTION. 25 
 
 and produces no bleeding, unless there is great engorge- 
 ment ; but even then it amounts to nothing. Another 
 plan of bringing the os tincse into view is to draw the 
 neck forwards by pressure in the anterior cul-de-sac 
 with this- instrument (fig. 10), which I call the uterine 
 depressor. 
 
 I have never known any one accustomed to this 
 method and these instruments who was willing to revert 
 to the old plan. 
 
 The consideration of other means of exploration, 
 such as the sound, tent, &c, I leave till we come to 
 speak of treatment.
 
 SECTION I. 
 
 CONCEPTION OCCURS ONLY DURING MENSTRUAL 
 
 LIFE.
 
 SECTION I. 
 
 CONCEPTION OCCURS ONLY DURING MENSTRUAL LIFE. 
 
 Tins is so self-evident, that it might be passed without 
 further notice. I do not know that conception has ever 
 occurred previously to the appearance of the menstrual 
 flow. Cases are recorded where it happened at a very 
 tender age ; but it was always preceded by the appear- 
 ance of the function that we are taught to look upon as 
 evidence of the fitness for conception. As an example, 
 I may cite the following, which is perfectly authentic. 
 
 Dr. Curtis, of Boston, examined into the particulars 
 of a case of early pregnancy that occurred in the poor- 
 house of that city, and reported " that the girl Elizabeth 
 Drayton became pregnant twenty-four days before she 
 was ten years old, and was delivered of a fine, full-grown 
 male child, weighing fully eight pounds, when she was 
 ten years eight months and seven days old. The reputed 
 father of the child is said to be about fifteen years of 
 age. The mother menstruated once or twice before 
 conception, was tolerably healthy during gestation, and 
 had rather a lingering but quite natural labour." * 
 
 Conception has occurred at an advanced period, and 
 even after a supposed change of life. 
 
 An instance of this sort fell under my observation 
 in the state of Alabama, in 1840, where an old negro 
 woman (said to be 58 or GO) became a mother, after 
 
 * Medical Times and Gazette, April, 1863, from the Boston Medical 
 Journal, February 19th, 1863.
 
 30 UTERINE SURGERY 
 
 having ceased to have children for more than twenty 
 years. 
 
 I regret exceedingly that I did not investigate this 
 case more minutely, but in my younger days I did not 
 feel much interest in the subject. But I now know of 
 two well-authenticated cases of parturition at the age 
 of fifty- two. 
 
 Many women conceive without menstruating, but 
 it is always during menstrual life. Most accoucheurs 
 have doubtless met with such cases. 
 
 I know a lady some 36 or 38 years old, who is the 
 mother of six children, three of whom were born (at 
 single births) without the least sign of intermediate 
 menstruation. She menstruated soon after marriage, 
 immediately conceived, was safely delivered at term, 
 and while nursing found herself pregnant again; she 
 then weaned her child, went the full term with the 
 second, was fortunately delivered ; and while suckling 
 it, became pregnant a third time. She thus bid fair 
 to have a large family very rapidly, but unfortunately, 
 after her third confinement, she got some uterine 
 disease that arrested her child-bearing for several 
 years. 
 
 Dr. Emmet and myself saw a case still more remark- 
 able than this in 1859. One of the patronesses of the 
 Woman's Hospital requested me to visit a poor woman, 
 a protegee of hers, who was supposed to have ovarian 
 dropsy, which had increased so rapidly that she appre- 
 hended an early fatal result. On visiting the patient, 
 she told me that the tumour began to grow not very 
 long after the birth of her last and eighth child, which 
 was now some twelve or thirteen months old. She was 
 still suckling it, and it seemed to be drawing her very 
 life out of her. She was in bed, greatly prostrated from
 
 CONCEPTION OCCURS ONLY DURING MENSTRUAL LIFE. 3 J 
 
 want of proper and sufficient nourishment, and from 
 the exhaustion of super-lactation, all of which had 
 been supposed to belong to the rapid growth of the 
 tumour. Laying my hands on the abdomen for pal- 
 pation, I instantly detected foetal movement. I asked 
 her if she suspected pregnancy ; she said no, nor had 
 she felt any quickening, although the movements of the 
 child were by no means feeble. The touch showed the 
 mouth of the womb dilated fully two inches, with the 
 head presenting. Labour set in the next day, and she 
 was happily delivered by Dr. Emmet of a fine vigorous 
 child. This was her ninth labour in fourteen or fifteen 
 years ; and she told Dr. Emmet, that during the whole 
 of her married life she had menstruated but three times ; 
 thus, notwithstanding the accepted views of the profes- 
 sion in regard to the relation of menstruation to concep- 
 tion, we find anomalies, which, however, are so rare that 
 they do not invalidate the rule. 
 
 It is a little curious that a woman should have had 
 eight pregnancies, and have gone the full term of the 
 ninth, without the least consciousness of a movement of 
 the foetus. 
 
 But there was evidently no malingering, for she was 
 immediately raised from the deepest despair to the 
 greatest joy, when her tumour was pronounced to be 
 a living child to be born in a few hours. I have seen 
 several cases of pregnancy where the mothers were 
 totally unconscious of any movement on the part of the 
 child. I allude to this as a subject of interest to the 
 profession at large ; for an error in diagnosis, whether 
 in failing to detect pregnancy when it exists, or in 
 asserting it where it does not exist, always injures us as 
 a body, and sometimes inflicts injury on the subjects of 
 our mistakes.
 
 32 UTER^E SURGERY. 
 
 A lady, married about twenty-three years, and child- 
 less, became irregular at forty-three. Her physicians 
 said it was incipient change of life, which, was doubtless 
 true. After a few months of irregularity, the menses 
 ceased entirely. With this change many women antici- 
 pate evil in some form or other. This poor sufferer 
 expected cancer, but instead of that her physicians 
 detected a pelvic tumour. She was plied with iodine 
 for a long time, and had flying blisters alternately over 
 the iliac regions ; but in spite of the most active means 
 the tumour continued to grow. Her case was considered 
 hopeless, and it was thought advisable for her to return 
 to the place of her nativity to die amongst her friends. 
 On her arrival in New York she patiently resigned her- 
 self to her fate, and made all arrangements for her 
 approaching dissolution. After waiting a month in 
 vain, some of her friends persuaded her to have other 
 medical advice, and I saw her. There was not the 
 slightest difficulty in detecting foetal movement and 
 foetal pulsation, and when I told her that in two weeks 
 she would need baby-clothes instead of a shroud, and a 
 cradle instead of a coffin, she could not believe it. 
 During the whole of her pregnancy she was not conscious 
 of any motion. 
 
 Here the mistake was fraught not only with damage 
 to the profession, but with loss to the husband, for, 
 engaged in a profitable business, he was compelled to 
 sell it off at a sacrifice, and to make a long journey to 
 New York, when he should have remained at home. I 
 have seen many similar mistakes, and that too since the 
 days of Dr. Kennedy's beautiful work on Obstetric 
 Auscultation. * We may be in doubt about any case up 
 
 * < 
 
 ' Observations on Obstetric Auscultation ; with Analysis of the
 
 CONCEPTION OCCURS ONLY DURING MENSTRUAL LIFE. 33 
 
 to the fifth month of pregnancy, but never after that ; 
 for then the beating of the foetal heart will infallibly 
 guide our judgment. Dr. Routh,* of the Samaritan 
 Hospital, has detected pregnancy as early as from the 
 sixth to the thirteenth week by means of his vagino- 
 scope, which, coming directly in contact with the cervix 
 uteri, gives an earlier indication of the placental souffle 
 than we could get by the stethoscope. 
 
 Mistakes sometimes occur in the hands of the best 
 men in the profession, and then it is the result wholly of 
 carelessness. For example, a lady, thirty-five years old, 
 the mother of several children, had a small fibroid 
 tumour on one side of the womb. Her physician, a most 
 accomplished diagnostician, watched the progress of this 
 tumour, which seemed to be stationary for a long time. 
 I should remark that from the time the tumour was 
 observed, the patient ceased to have children. And so 
 things went on for five or six years, when the abdomen 
 beo^an to enlarg-e, and as we sometimes see in ovarian 
 tumours, the menses ceased. The physician put her on 
 bromide of potassium internally, and tincture of iodine 
 externally. In spite of this the tumour continued to 
 enlarge, and her physician brought her from a neigh- 
 bouring city to me. I had only to lay my hands on the 
 abdomen to detect motion, and with the stethoscope the 
 fcetal heart was easily heard. Now, here the physician, 
 having his mind full of the fibroid growth from which he 
 had so long anticipated evil, never made any thorough 
 
 Evidences of Pregnancy ; and an Inquiry into the Proofs of the Life and 
 Death of the Foetus in Utero." By Evory Kennedy, M.D., &c. Dublin : 
 Hodges & Smith. 1833. 
 
 * " On Some of the Symptoms o r Early Pregnancy." By C. H. P. 
 Routh, M.D., &c. London : T. Richards. 1864. Pp. 21. 
 
 3
 
 3_j. UTERINE SURGERY. 
 
 investigation of the case after the abdomen began to 
 enlarge, and the patient, who was a most intelligent 
 woman, declared she had not for a moment suspected 
 pregnancy, and that she had not experienced the slightest 
 sensation of motion. 
 
 While on this subject, I may mention an opposite 
 class of cases in which we occasionally make grave 
 mistakes. A hysterical sterile woman, naturally anxious 
 for offspring, imagines herself pregnant, denies that 
 she menstruates, affects a quickening, seems to grow 
 larger and larger, till at last the fulness of time arrives ; 
 she goes to bed, and has some irregular colicky pains ; 
 but nothing more. This is a case of hysterical mono- 
 mania, for which no physician could be responsible ; but 
 if called to give an opinion, he should be careful not to 
 be misled by the artful misrepresentations of a " mind 
 diseased." Young women sometimes honestly imagine 
 themselves pregnant, and physicians, I am sorry to say, 
 are occasionally deluded into the support of their whim, 
 notwithstanding; the fact that menstruation returns regu- 
 lariy every twenty-eight days, and pursues its usual 
 course. 
 
 An example of this sort occurred at Baden-Baden a 
 few years ago, under the care of a very eminent physi- 
 cian, now dead, who allowed his patient to lie in bed for 
 nine months to prevent a miscarriage, when in fact she 
 menstruated regularly during the whole time. At the 
 end of the tenth month another physician was called in, 
 who said the lady had never been pregnant at all. 
 
 But while many women go through pregnancy with- 
 out feeling the slightest motion of the foetus, a very 
 opposite state of things is occasionally met with about 
 the time of change of life. A woman, forty years of age 
 or more, becomes irregular ; she thinks herself pregnant ;
 
 CONCEPTION OCCURS ONLY DURING MENSTRUAL LIEE. 35 
 
 by-and-by, she quickens ; she begins to make baby- 
 clothes ; she tells her intimate friends of her interesting 
 condition ; she gradually grows larger ; the time for 
 confinement arrives ; she is not quite as large as in her 
 former pregnancies ; nevertheless she cannot be deceived, 
 for the frequent regular movements of the foetus make it 
 impossible for her to be otherwise than pregnant. At 
 last she becomes alarmed at the procrastination of the 
 labour, and sends for her physician, who finds the abdo- 
 men large, but the enlargement is due to an immense 
 deposit of adipose tissue in its parietes. He passes his 
 finger into the vagina, and discovers the uterus in an 
 unimpregnated state ; indeed, it may be smaller than 
 usual, for the cervix may be found rather atrophied, and 
 the whole organ gradually undergoing the change that 
 we always see when change of life occurs. 
 
 I have seen several cases of this false quickening, 
 never in a woman under thirty-eight, nor over forty-eight. 
 They had all borne children, and all had a tendency 
 to embonpoint. They were all women of culture, refine- 
 ment, and of good common sense ; and so strong in 
 every case was the mental impression of the sense of 
 quickening, that it was impossible to convince them that 
 there was no pregnancy. Two of these ladies returned 
 to me several times in the course of a year, and insisted 
 that I must be mistaken. I now regret having dismissed 
 them so peremptorily, as I thereby lost the opportunity 
 of watching the progress and termination of this freak 
 of change of life.
 
 SECTION II. 
 
 MENSTRUATION SHOULD BE SUCH AS TO SHOW A 
 HEALTHY CONDITION OF THE UTERINE CAVITY,
 
 SECTION II. 
 
 MENSTRUATION SHOULD BE SUCH AS TO SHOW A HEALTHY 
 CONDITION OF THE UTERINE CAVITY. 
 
 Of Scanty Menstruation. — If asked what constitutes 
 normal menstruation, I should reply, a painless uncoagu- 
 lated flow, returning at intervals of about four weeks, 
 lasting three, four, five, or six days, and requiring the 
 use of not more than three, or, at the farthest, four 
 napkins in the twenty -four hours. It may vary from a 
 healthy standard in both quantity and quality. It may 
 be scanty or profuse, and painful or not, without regard 
 to quantity. If the flow falls short of three days' dura- 
 tion, it may be called scanty. If it continues longer 
 than six or seven days, it may be profuse, but not always 
 so. It may be very abundant, and last but two or three 
 days ; and, again, it may continue twelve or fifteen days, 
 and be very scanty, requiring not more than one napkin 
 in the twenty-four hours. The explanation of either of 
 these conditions will generally be found in some organic 
 deviation from a normal state. 
 
 Conception may take place, whether the menstrua- 
 tion be scanty or profuse. But either extreme is not 
 very favourable to it, not that the amount of blood lost 
 is per se an important matter, except as the index of an 
 organic condition, favourable or otherwise to the fulfil- 
 ment of this great law of nature. 
 
 According to modern views, the menstrual fluid is not 
 a secretion, but an exudation of blood from the lining 
 membrane of the cavity of the uterus, which acquires
 
 40 UTERINE SURGERY. 
 
 its peculiar qualities by admixture with the secretions 
 of the cervix and vagina as it passes outwards. 
 
 We often see menstruation so scanty, that it lasts but 
 a day, or a day and a half, one napkin having perhaps 
 sufficed for the whole time. Under such circumstances, 
 it has been supposed that there is defective ovulation ; 
 but this, of course, is mere hypothesis, for it may or may 
 not be so. It must be admitted, however, that menstrua- 
 tion is a sign of ovulation, the one taking place when 
 the other begins, and ceasing when it stops. With 
 ovulation, we see the uterus suddenly developed in size, 
 the fit receptacle of a new being. With change of life 
 we see it gradually returning to the diminutive propor- 
 tions that it had before puberty. 
 
 In habitually scanty menstruation, if the patient has 
 never borne children, we shall generally find the uterus 
 smaller than usual, with rather a long, pointed, indurated 
 cervix, and if so the os and cervical canal will necessarily 
 be small. On the contrary, if the patient has borne 
 children, the uterus may be larger than natural ; but 
 the history of the case will probably show that there 
 has been some puerperal trouble of an inflammatory 
 character, resulting in imperfect involution of the organ. 
 In either case I have not derived the benefit that I had 
 expected from surgical means, such as a cupping pump 
 to the cervix, suction and laceration of the lining mem- 
 brane of the uterine cavity, and the intra-uterine 
 galvanic pessary of Professor Simpson, which seems to 
 have produced very good results in his experienced 
 hands, and also in those of his pupil, Professor Priestly, 
 of King's College Hospital. 
 
 For the general management of this class of cases, I 
 must refer the student to our systematic works (Chur- 
 chill, West, Hewitt, «fcc, <fec), and at the same time he
 
 OF MENSTRUATION. 4] 
 
 should not neglect Faradization, as taught and practised 
 by Althaus,* of London, and Duchennef (de Boulogne), 
 of Paris. Nor should he fail to study the brief mono- 
 graph of Dr. Chapman,J on cold and heat in the treat- 
 ment of the functional diseases of women. 
 
 It is now pretty well understood that electricity 
 judiciously administered is especially valuable as an 
 emmenagogue in young women, where the menstrual 
 function has not yet been fully established, in conse- 
 quence of a torpid state of the vaso-motor nerves of 
 the ovaries and uterus ; and it has also proved successful 
 when the catamenia have been lost after labour, or in 
 consequence of cold shock or mental anxiety. 
 
 Of Profuse Menstruation. — The profuseness of 
 menstruation is to be judged of not so much by its 
 duration as by the quantity of blood and the effects of 
 its loss. Sometimes it will be very abundant from its 
 inception to its termination. Again, it may be violent 
 for thirty-six or forty-eight hours, and then moderate to 
 a normal standard. A very good way to judge of the 
 quantity lost is by the number of napkins needed 
 to protect the person and linen. A change of three 
 or four napkins in the twenty four hours is about a 
 proper number for normal menstruation. If seven or 
 eight be needed, the flow may be called profuse, and if 
 
 * " ATreatise on Medical Electricity, Theoretical and Practical." By J. 
 Althau?, M.D. London. 1859. Pp. 298. 
 
 t " De l'Electrisation Localisee et de son Application a la Pathologie et la 
 Therapeutique." Par M. le Docteur Duchenne (de Boulogne). Paris. 
 Second Edition. 1861. Pp. 89. 
 
 X " Functional Diseases of Women," &c. By John Chapman, M.D. 
 London : Trubner & Co. 18G3.
 
 42 UTERINE SURGERY. 
 
 a dozen or more, then it may be called a menorrha- 
 gia. 
 
 In the treatment of menorrhagia, we are by no 
 means to neglect general constitutional remedies. Some 
 bleed, but I never saw a case in which I thought this 
 practice justifiable. All prescribe revulsives, tonics, 
 chalybeates, mineral acids, ergot, &c, which treatment 
 is well enough as far as it goes, but does not always 
 strike at the root of the evil ; and often valuable time is 
 thus thrown away. I know very well that we may have 
 menorrhagia from mere debility, from super-lactation, 
 and from some temporary engorgement of the portal 
 circulation ; but such cases are not very common, and 
 not usually obstinate. If there is anything abnormal 
 in the quantity of blood lost at the menstrual epoch, 
 there is always a cause for it, and we shall generally 
 be able to find it out by directing our attention to the 
 seat and source of the trouble. If the nose bleeds, we 
 try to stop it by the most direct methods in our power. 
 If the hemorrhoidal vessels bleed persistently, we attack 
 them with the ecraseur, ligatures, nitric acid, persulphate 
 or perchloride of iron. Why, then, should we permit 
 the womb to lose an unnatural quantity of blood without 
 at once interrogating it on the subject ? I would not 
 ignore such general means as we all admit to be avail- 
 able, but I would never put off a uterine exploration in 
 any confirmed case of abnormal flow ; for where there is 
 an inveterate menorrhagia, there will always be some 
 organic cause for it. It may be due simply to granular 
 erosion ; to engorgement of the cervix ; to fungoid 
 granulations in the cervical canal, or in the uterine 
 cavity; to polypi of the os, the cervix, or the cavity; 
 to a fibroid tumour, intra-uterine or intra-mural ; to 
 inversion of the uterus, to haematocele ; or it may be
 
 OF MENSTRUATION". 43 
 
 a sign of some malignant degeneration, all giving rise to 
 hemorrhage, and each requiring its own peculiar and 
 appropriate management. 
 
 I propose to illustrate, from clinical experience, the 
 surgical treatment of menorrhagia as it may originate 
 from one or the other of these sources. And first, — 
 
 Of Menorrhagia from Granular Erosion. — One 
 example of this will suffice. Mrs. , aged twenty- 
 eight, of leuco-phlegmatic temperament, confined four 
 years and a half ago, never well since, was greatly 
 exhausted by lactatiou, and weaned her child at six 
 months, had very profuse menstruation, lasting eight 
 days, some leucorrhcea, pelvic pains, dysuria, &c. — could 
 not walk at all — had to be carried up and down-stairs — 
 was quite anaemic and exhausted, irritable, peevish, 
 hysterical, crying easily and at trifles — had had the 
 usual constitutional and tonic treatment from several 
 physicians without improvement — the uterus in proper 
 position was larger than natural — the edges of the os 
 were covered with luxuriant granular erosions, which 
 could be seen extending up the canal of the cervix. To 
 these granulations I applied chromic acid, which is with 
 me a favourite escharotic. It is more powerful than the 
 nitrate of silver, and ordinarily perfectly painless. It is 
 used thus : — Take a drachm of the salt, which is very 
 deliquescent, and add slowly a drachm of distilled water ; 
 the salt is instantly dissolved and ready for use. Dip a 
 small, pointed, solid glass rod in the solution, let it not 
 take up more than a drop or two, and then apply it to 
 the granulations and to them only. It produces no pain, 
 and may be carried into the canal of the cervix or even 
 further. In this case it was applied as far as the os 
 internum two or three times, at intervals of twelve or
 
 44 UTERINE SURGERY. 
 
 fifteen days. A nutritious diet, but no medicine was 
 ordered. In three months the granulations and the 
 menorrhagia were well, and in three months more 
 conception occurred, and resulted in the birth of a son, 
 after five years of suffering. 
 
 Menorrhagia from Fibrous Engorgement of the 
 
 Cervix. — Mrs. , aged thirty-one, married at twenty 
 
 — two children, youngest eight years old — never well 
 since last labour — menstruation formerly normal, but 
 for the last seven years and a half it recurs too early, and 
 lasts often ten days very profusely.. Five or six months 
 ago she had it for three months continuously. She is 
 quite exsanguious and exhausted ; has had some leucor- 
 rhcea for the last four or five years. I was consulted as 
 much for the removal of her sterility as for the relief of 
 the menorrhagia. She had taken chalybeates, mineral 
 waters, <fec, and had been treated locally with the nitrate 
 of silver for a very long time without material benefit. 
 The neck of the womb was the seat of fibrous engorge- 
 ment, with superficial granular erosion. It was consi- 
 derably hypertrophied and indurated. The organ was 
 in its normal position. The thickened indurated lips of 
 the os uteri were in consequence of their hypertrophy 
 in close apposition, the one against the other, thus 
 mechanically closing the os, although it was large enough 
 to admit a No. 8 bougie. To the granulations on the 
 engorged fibrous cervix I applied the chromic acid as 
 already described, which healed the granular surface in 
 two months, but did not in the least modify the hsemor- 
 rhagic tendency. A sponge tent showed that there was 
 nothing abnormal in the cavity of the uterus, and I then 
 determined to incise the os uteri. There were two 
 reasons for this :
 
 OF MENSTRUATION. 
 
 45 
 
 1st : The bilateral incision of the os uteri would 
 divide the indurated structure of the cervix through 
 its whole extent up to the os internum, which would 
 probably ameliorate the engorgement, and diminish the 
 haemorrhage. And 2nd : It would separate the com- 
 pressed lips of the os uteri sufficiently to permit the 
 spermatozoa to pass to the cavity of the uterus, thereby 
 rendering conception possible ; and upon this taking 
 place I hoped for a complete revolution in the nutritive 
 functions of the whole organ, and an ultimate perfect 
 cure. 
 
 Accordingly, the operation of incision of the os and 
 cervix bilaterally, was performed on the 1st of October, 
 1860. The parts healed before the next menstrual flow, 
 which I was delighted to find greatly reduced in quan- 
 tity; indeed, it was almost natural. In three months 
 
 Fig. 11. 
 
 she returned home with a normal menstruation. The 
 mouth of the womb presented a totally different appear- 
 ance from what it did when she first came under my 
 observation. For instance, when I first saw her it was 
 a simple little transverse slit (fig. 11), with the opposite 
 surfaces closely applied to each other; but when she
 
 46 
 
 UTERINE SURGERY. 
 
 left it presented an entirely different appearance : the 
 two opposite lips of the os uteri slightly gaping open (fig. 
 12), thus rendering it possible for the semen to get to the 
 
 Fig. 12. 
 
 fundus uteri. Nine months after this lady left my care 
 shg conceived, and I have since heard that she was 
 safely delivered of a fine vigorous child, after an acquired 
 sterility of about nine years. The result is most grati- 
 fying, inasmuch as a purely rational surgical treat- 
 ment effected the cure of both menorrhagia and ste- 
 rility. 
 
 Of Menorrhagia from Fungoid Granulations. — 
 When an old burn and other chronic ulcers refuse to 
 heal, we often find the suppurating surface to be ele- 
 vated above the level of the sound skin, and we call it 
 " proud flesh," " exuberant granulation," " fungus," or 
 " fungoid granulation." It is usually indolent or insensible 
 to the touch, except, perhaps, just at the cicatrizing edge 
 of the cuticle, and it often bleeds easily on being touched. 
 It is a condition of things very much like this that 
 we here designate " fungoid granulations," as sometimes 
 the source of menorrhagia. These may be in the canal
 
 OF MENSTRUATION. 
 
 47 
 
 of the cervix, or in the cavity of the uterus, or iu both 
 at the same time ; but it is more common to find them 
 in one or the other alone, and perhaps more frequently 
 in the former. Wherever located, they are often the 
 source of an increased flow, which may be remedied by 
 local treatment. To diagnose their presence, let us 
 suppose a case of menorrhagia for investigation. If the 
 touch proves that there is no polypus or other source of 
 it to be found in the vagina, then we must look to the 
 cavity of the uterus for it. If it be from a granular 
 engorged cervix, the speculum at once reveals the 
 cause. But if the os and cervix be in a healthy condition, 
 then it conies from some portion of the utero-cervical 
 canal. Formerly we were left in doubt about the 
 pathology of menorrhagia, but we now explore the 
 cavity of the unimpregnated uterus with the greatest 
 facility, and, no longer groping in the dark, we are able 
 to treat most cases of it understandingly, if not always 
 successfully. Compressed sponge is a very old surgical 
 appliance, but in uterine therapeutics it is of compara- 
 tively recent date, and I believe we owe its generaliza- 
 tion here to Dr. Simpson ; but my own countrymen, 
 Dr. J. P. Batchelder and Dr. W. C. Roberts, of New 
 York, have both written very ably on this subject. 
 Sponge tents are now to be had at most druggists ; 
 those that we see in the shops are large clumsy things, 
 thickly coated with wax, tallow, or suet. They are diffi- 
 cult to introduce, and often slip half out of the cervix 
 into the vagina, there exciting an unnecessary amount of 
 irritation. To be sure they are well made, I have them 
 manufactured under my own supervision. They are so 
 indispensable nowadays that I may be pardoned for a 
 little minutiae on the subject. City physicians can order 
 them from the druggist, but the country practitioner
 
 48 
 
 UTERINE SURGERY. 
 
 cannot always do so, and this is my apology for dwelling 
 on the subject. 
 
 The sponge should be of good quality, but not too 
 soft and yielding. Of course, it should be thoroughly 
 cleaned ; but not bleached, for the bleaching process 
 deprives it of all elasticity. It should be cut into slightly 
 tapering conical pieces, from one to two inches long, 
 some smaller and others much larger than the thumb. 
 A pointed wire or a slender awl should be passed through 
 the centre of the long axis of the sponge, which should 
 then be thoroughly saturated with a thick mucilage of 
 gum arabic. A small twine of cord is then to be closely 
 wrapped around the sponge as it is held stiff by the 
 wire, beginning at the smaller extremity and gradually 
 winding on to the larger ; then the wire may be with- 
 drawn, and the new-made tent laid aside to dry. If we 
 are in a hurry it may be dried in the sun or by a fire, 
 taking care not to injure the texture of the sponge by 
 too great a heat. 
 
 When it is thoroughly dry, the twine is to be 
 unwound, and the little circular elevations made by it 
 on the surface of the tent are to be rubbed down by 
 fine sand-paper. Without further preparation it is then 
 
 Fig. 13. 
 
 ready for use. These diagrams represent the tents about 
 the size and shape that I usually make them. I never 
 allow them to project more than an eighth of an inch 
 from the os uteri into the vagina. Being introduced
 
 OF MENSTRUATION. 
 
 49 
 
 without grease, except a little suet just on the point, 
 they seldom slip out of position. If, however, there is 
 a disposition on the part of the cervix to eject the tent, 
 a small pledget of lint or cotton laid on the cervix after 
 the tent is introduced, will effectually prevent this 
 accident. I have seen a great deal of suffering produced 
 by sponge tents, and with all due deference to the 
 dexterity of surgeons, I must insist that this is wholly 
 unnecessary. The commercial tents, as said before, are 
 too large, and being introduced without a speculum 
 always induce more or less pain. My plan is this : — The 
 
 Fig. 14 represents the speculum elevating the posterior wall of the vagina ; 
 the tenaculum fixing the uterus by being hooked into its anterior lip ; 
 and the forceps holding the tent, which is introduced up to the os 
 internum. 
 
 patient being on the left side, my speculum is introduced ; 
 the os uteri is pulled gently forwards by a delicate 
 tenaculum hooked into the anterior lip, which fixes the 
 uterus, while the tent held by the forceps is passed 
 
 4
 
 50 UTERINE SURGERY. 
 
 easily and gently into the cervix to the required depth, 
 without producing pain. I make it a point never to 
 introduce a tent that is larger than the canal that is to 
 receive it, and thus, if it be gently done, it is impossible 
 to give pain ; and why should we ever inflict one single 
 unnecessary pang? 
 
 If we have the selection of the time for the intro- 
 duction of the tent, let it be in the morning, say by or 
 before ten o'clock. We should explain to the 
 patient, — 
 
 1st : That it may possibly produce a little uneasiness, 
 which is usually very bearable. 
 
 2nd : That it will certainly produce a dirty, disagree- 
 able, bad smelling, watery discharge, from which the 
 person and clothing must be protected by napkins, to be 
 changed as often as necessary. And — 
 
 3rd : That it will be necessary to see her in six or 
 eight hours, to remove the tent, and probably to iutro 
 duce another, if the cervix be not already sufficiently 
 dilated by the first one, to permit the passage of the 
 index finger freely into the cavity of the uterus. 
 
 If the second tent be needed, it may be allowed to 
 remain till the next morning. The tent is valuable both 
 as a diagnostic and therapeutic agent, but is to be used 
 with caution. If the second tent fail to dilate the cervix 
 sufficiently, it is safer, as a general rule, not to persevere 
 further for the time, but to wait a few days, and then 
 resort to it again. I am thus cautious, because I have 
 seen metritis follow its injudicious use. The tents of 
 commerce have a loop of tape, three or four inches long, 
 fastened to the large or outer extremity, for their easy 
 removal. 
 
 I use nothing of this sort, because I always expect 
 to remove the tent myself.
 
 OF MENSTRUATION. 51 
 
 Its removal is a matter of some nicety. 
 
 Place the patient on the side as for its introduction ; 
 apply the speculum, and immediately we see the sponge 
 projecting from the cervix and dilated from the size of 
 b to that 'of a (fig. 15). It will be saturated with a 
 
 g^Mu, 
 
 Fig. 15. 
 
 foetid, serous, or sero-sanguinolent discharge, which 
 is to be carefully wiped away. After this fix a pair 
 of spring forceps firmly on the centre of the sponge, 
 for the purpose of removing it. Then let the patient 
 turn over on her back, with the forceps still fastened 
 to the sponge. Now pass the left index finger into 
 the vagina along the locked blades of the forceps, 
 till it comes in contact with the sponge. The sponge 
 is not to be suddenly or quickly withdrawn, but it 
 is to be pulled gently first to one side and then to the 
 other, taking care at the same time to support the 
 uterus with the index finger, which is to be gently 
 carried into the cervix by the side of the tent, first 
 on one side, then on the other, to free its meshes or 
 interstices from the cervical mucous membrane, which 
 interlocks, as it were, with the substance of the sponge. 
 When the sponge has been well loosened all round, 
 and is found to slip down a little, then we should 
 be ready to thrust the finger up into the cavity of the
 
 52 UTERINE SUROEIIY. 
 
 womb, as we pull it away. If the finger does not 
 pass at once and easily, it is better not to use much 
 force, but, as before stated, to wait for another oppor- 
 tunity. The removal of the sponge is always followed 
 by more or less flow of red blood, showing a laceration 
 of tissue. The finger may pass the os externum with 
 tolerable ease, and still not be able to pass the os 
 internum, and here it is better to procrastinate a com- 
 plete exploration than to use an uudue degree of force. 
 But if the second joint of the index passes the os 
 externum, the point of the finger is already in the cavity 
 of the uterus ; and then, while we press the finger 
 onwards and upwards we should make a counter- 
 pressure with the right hand just above the pubes, 
 grasping the fundus of the uterus through the parietes 
 of the abdomen, and forcing it down on the end of the 
 left index, as we would push a thimble down on it. 
 Were it not for this outward counter-pressure, the 
 uterus would necessarily be pushed upwards before the 
 index, and we should seldom reach the fundus. There 
 are good reasons for placing the patient on the side, 
 and using the speculum for inspecting the sponge before 
 its removal. 
 
 1st : It is satisfactory to know that it has remained 
 precisely where it was placed. 
 
 2nd : It is well to see what amount of uterine or 
 vaginal irritation it has produced. 
 
 3rd : As the sponge is saturated with a disagreeable 
 discharge, it is well to clean it and the vagina thoroughly 
 before the manipulations necessary for a complete 
 uterine exploration. 
 
 All this accomplished, it is a temptation to almost 
 any one to pull the sponge away while the patient lies 
 on the side, with everything so nicely prepared for it
 
 OF MENSTRUATION". 53 
 
 and seemingly inviting to it. But I must specially 
 warn the surgeon against this temptation. 1st: Because 
 if the sponge be removed under these circumstances, 
 with the vagina widely open, the air rushes into the 
 cavity of the uterus, and I am sure that in my early 
 experience I had the misfortune more than once to see 
 metritis follow this accident. 2nd: Because the finder 
 cannot be passed far enough into the uterine cavity 
 for a thorough exploration, unless the external counter- 
 pressure be made with the other hand, which is neither 
 easy nor effectual in any other position than the 
 dorsal. 
 
 Having often to recommend the use of sponge tents, 
 I shall necessarily be compelled to speak frequently of 
 them in these pages, and I only regret that they are so 
 disagreeable as remedies. I never use them if I can 
 possibly avoid it, and I never apply them without 
 apologizing to my patient for the very unpleasant effects 
 they produce. 
 
 He who gives us an efficient, pleasant, and cheap 
 substitute for sponge tents, will confer a great boon on 
 Surgery. T know of no competent substitute, or I would 
 be too willing to adopt it. Having said so much on this 
 subject, we may now return to " fungoid granulations," 
 as a source of menorrhagia. 
 
 To show not only the diagnostic value, but the won- 
 derful therapeutic powers of the tent in such conditions, 
 let me give a case. 
 
 Mrs. , of bilious nervous temperament, aged 
 
 thirty-five, as a girl had occasional nervous attacks, 
 and suffered from painful menstruation. She was 
 married at twenty — was sterile — had yellow fever in 
 1853 — and was compelled to leave the South, and go to 
 New York on account of her health. She had menor-
 
 54: UTERINE SURGERY 
 
 rhagia from the time of the yellow fever, in 1853, till I 
 saw her, four years afterwards. She was scarcely ever 
 clear of a show for more than a week or ten days out 
 of a month. It was not excessive on any one day, but 
 its prolonged continuance had exhausted her strength 
 and worn out her nervous system. She could not 
 undergo the least fatigue — would faint easily, even from 
 emotional causes ; had tinnitus aurium and palpitation ; 
 and blindness was such a troublesome symptom, that 
 she consulted an oculist, who told her that the condition 
 of her eyes was wholly due to the enfeebled state of 
 her general health. She had taken chalybeates, tonics, 
 ergot, and sea-bathing, without improvement, and at 
 last I saw her in September, 1857. I did not dally a 
 moment with such general constitutional treatment as 
 would be naturally suggested, but at once attacked the 
 offending organ. The vagina was excessively tender to 
 the touch from the ostium vasrinsB to the cervix uteri. 
 This was evidently the result of an ichorous sero- 
 sanguinolent discharge that was ever present when the 
 haemorrhage, properly speaking, ceased. The uterus 
 was retroverted — the posterior wall consequently 
 hypertrophied ; the os was very small ; the cervix 
 rather long and acuminated, — which anatomical pecu- 
 liarities explained her symptoms previously to mar- 
 riage and her subsequent sterility. From the history 
 of the case, and from the volume and general condition 
 of the uterus, I expected to find an intra-uterine 
 polypus. However, the sponge tent alone would 
 put all speculation at an end. I should have said 
 that the irritability of the vagina was so great that 
 I could only use the smallest or virgin-sized speculum ; 
 and I was obliged to resort to emollient vaginal injec- 
 tions and to glycerine applications, for a few days, to
 
 ON MENSTRUATION. 
 
 55 
 
 render any speculum examination at all bearable. This 
 done, a very small sponge tent, not more than an inch 
 long, was passed into the cervical canal. It was worn 
 without inconvenience for twenty-four hours. It was 
 barely large enough to open the os uteri from the size 
 of a* No. 3 to that of a No. 8 bougie. But this was 
 enough to permit me to look into the canal, where I 
 could plainly see the source of the mischief. Fig. 16 
 
 Fig. 16. 
 
 would represent the general outline and relative 
 position of the uterus before the sponge tent was used ; 
 while fig. 17 would show a vertical section of the organ 
 
 Fig. It. 
 
 after its removal, when I could easily see the vegeta- 
 tions on the posterior surface of the cervical canal, as 
 shown in the diagram. These could have been scraped 
 away with Recamier's curette ; but I was anxious to 
 open the canal more largely and further up, into the 
 cavity of the uterus, with a view of more easily apply- 
 ing the curette, and with the hope of clearing away
 
 5Q UTERINE SURGERY. 
 
 whatever there might be above the portion that was 
 visible. Accordingly, I introduced a tent two inches 
 long, and large enough to fill completely the already 
 partially-dilated cervix. Of course it passed over the 
 crop of fungoid granulations, pressing them firmly 
 down into the very surface from which they sprang. 
 I directed this lady to call again next day. Her 
 residence was not less than five miles distant from my 
 own. 
 
 On the succeeding day, when she was to have come 
 to me, a furious storm prevented her going out, and, 
 as she felt no inconvenience, except from the fetor of 
 the sponge-tent watery discharge, she determined to 
 remain at home. But on the next day the weather 
 continued in the same state, it being the time of the 
 equinox, and I did not see my patient for seventy- 
 two hours after the introduction of the tent. I need 
 not say how anxious I felt, for I greatly feared the 
 consequences of its prolonged retention. When I 
 came to examine the vagina, the stench from the 
 sponge was almost unbearable, and the patient 
 declared that it had kept her in a state of nausea for 
 more than twenty -four hours. 
 
 Its removal — by no means easy — was followed by a 
 sudden profuse gush of bright red blood. I was so 
 much alarmed that I did not dare to resort to the 
 curette lest I might acid to the irritation already set up 
 in the parts. But of this I satisfied myself that there 
 were no longer any vegetations in the cervix so far as 
 could be determined by the touch. I did not permit 
 this lady to return home for three or four days, but 
 detained her in New York till I was sure that she was 
 over the dangers, if any, of the prolonged retention 
 of the tent. No medicine was given, and nothing
 
 OF MENSTRUATION. 5f 
 
 more was done, but she was sent home to await the 
 return of menstruation. 
 
 This came in due time, and lasted three days, instead 
 of seventeen or eighteen as before, being natural in 
 appearance- and quantity. She was thus cured by the 
 sponge tent alone in three days, and subsequently 
 became a mother. 
 
 A sponge tent is to us a sort of necessary evil. We 
 cannot do without it. It is not to be denied that, 
 while it is powerful to do godtl, it may also be equally 
 powerful to do harm. From a very large experience 
 of sponge tents in uterine disease, lam now 'firmly 
 convinced that we ought never to apply them, under 
 any circumstances, in the consulting-room. 
 
 Whenever they are to be used, the patient should 
 make up her mind to remain in-doors, if not in her bed- 
 room, for some days, and this even when used only for 
 a day. In hospital practice I do not remember a single 
 mishap from them, simply because the patients did not 
 go out and expose themselves to the vicissitudes of the 
 weather. Whereas, after applying them in the consult- 
 ing-room, I formerly had several accidents from them 
 before I could be convinced of their noxious properties. 
 However, with ordinary care, the tent is as safe as any 
 remedy capable of doing good. And, since I have 
 adopted the plan of treating private patients as I do 
 hospital ones, by keeping them in-doors during the time 
 of sponge tenting, I have had no cause to complain of 
 this agent. This course was forced upon me by more 
 than one such case as the following : — 
 
 Mrs. , aged thirty-four, married twelve years, 
 
 the mother of three children, the youngest five years of 
 age, always had rather profuse menstruation, but since 
 her last labour it became very profuse, lasting ten 01
 
 53 UTERINE SURGERY. 
 
 twelve days, and requiring the use of six or eight nap- 
 kins a day, and sometimes many more. She also had 
 leucorrhcea. She was of plethoric habit, but began at 
 last to feel the effects of the unnatural loss of blood. 
 She had been treated locally and constitutionally 
 without improvement. 
 
 The uterus, somewhat anteverted, was much larger 
 than it should have been, and the os and cervix were 
 granular. I, like the physician who preceded me, 
 attempted first the cure of this condition. In the course 
 of three months my patient was better of the leucorrhcea 
 and granular erosion, but the menstrual flow was as 
 profuse as ever. I then determined to explore the 
 cavity of the uterus, expecting to find there a fibroid or 
 polypoid growth, as the body of the organ was evidently 
 larger than it should be. Accordingly, a small tent was 
 introduced, and she was directed to return the next 
 day. She did so, having suffered no inconvenience 
 from it. It was removed, and a longer and larger one 
 introduced, and she returned home in a stage, a distance 
 of about four miles. This was in January, and the 
 ground was deeply covered with snow. She came to 
 see me the next day, saying that she was chilly the 
 night before. She was then feverish, seemed to be 
 quite ill, and complained of pain in the hypogastrium, 
 nausea, &c. I removed the tent, but made no effort at 
 uterine exploration. She returned home, had metro- 
 peritonitis, was dangerously ill for many weeks, and, 
 fortunately, eventually recovered, but never again to 
 place herself under my care. Now, if I had visited this 
 lady at her own residence, and applied the same treat- 
 ment, I am very sure that she would not have had the 
 serious illness that was evidently produced by her 
 exposure in snow storms, two days in succession, while
 
 OF MENSTRUATION. 59 
 
 she rode each day, to and fro, a distance of at least 
 eight miles, besides the exposure of crossing the ferry to 
 Brooklyn in a boat heated to, perhaps 80 degrees, while 
 the temperature outside was not more than 20° F. 
 During this same winter ('58) I had two or three other 
 cases similarly unfortunate. I then resolved not to use 
 sponge tents again on riding or walking patients, and 
 since then I do not remember an accident from them — 
 and this is saying a great deal in favour of their 
 innocuousness. However, I use them now with greater 
 caution — for instance, when I knew less about them than 
 I do now, I invariably allowed a tent to remain twenty- 
 four hours ; on its removal a second was usually intro- 
 duced to be worn another twenty-four hours; sometimes 
 a third was introduced for another twenty-four hours ; but 
 generally, indeed almost always, I subjected the uterus 
 to this treatmen t for at least forty-eight hours. Whereas 
 now, as I have already described (page 50), the whole 
 process should not occupy more than from twelve to 
 twenty-four hours at any one time. 
 
 The power of the sponge tent to modify the uterine 
 surfaces with which it lies in contact is truly wonderful. 
 It dilates the neck of the womb ; it softens it by 
 pressure, and by a sort of serous depletion ; it reduces 
 the size, not only of the neck, but of the body of a 
 moderately hypertrophied uterus ; it destroys not only 
 fungoid granulations, but even large mucous polypi ; and 
 in one instance I saw a sponge tent destroy wholly 
 a fibrous polypus as large as a pigeon's egg. 
 
 This was accidental, but it demonstrated clearly what 
 the sponge can do by pressure and capillary drainage. 
 
 When introduced into the cervix, the tent soon 
 absorbs moisture, and expands. It may produce a 
 little pain, but it is of no moment, and ceases ordinarily
 
 GO UTERINE SURGERY. 
 
 when the dirty serous or sero-sanguinolent discharge 
 begins. The meshes of the sponge and the surface with 
 which they are in contact become, after some hours, 
 intimately incorporated. The sponge forces itself into 
 the very structure of the cervix, and the mucous mem- 
 brane of the cervix shoots out into the interstices of the 
 sponge, so that it is somewhat difficult to separate the 
 two if the tent has been worn for any length of time- 
 On its removal, there is necessarilv a laceration of the 
 tissue incorporated with it. This lacerated surface 
 generally heals smoothly over in a few days after, 
 obliterating every trace of the original indolent fungoid 
 growth that gave rise to the menorrhagia. Thus, it 
 seems to perform the duties of M. Recamier's curette in 
 a most efficient manner, but I do not pretend that it 
 would always supersede it. 
 
 The curette is simply the adjuvant of the tent, and 
 always to be preceded by it. But there are cases where 
 their relationship is changed, the sponge becoming the 
 adjuvant of the curette, and this is when the fungoid 
 granulations are at the fnudus uteri. Then the sponge 
 is to dilate the cervix for the more easy application of 
 the curette. 
 
 In cases of menorrhagia that resisted all other treat- 
 ment, Kecamier passed his curette into the uterine 
 cavity, and raked it out as thoroughly as possible. 
 This was before the days of sponge tents. But now we 
 first dilate the cervix, pass the finger into the cavity, 
 ascertain precisely the seat of the fungoid growth, pass 
 the curette by the side of the finger, and thus operate 
 more understand ingly. 
 
 Fig. 18 represents the curette that I use; the 
 handle is malleable and may be bent laterally, or 
 backwards, or forwards, in the direction of the dotted
 
 OF MENSTRUATION. 
 
 61 
 
 lines, #, h. Thus it can be used with 
 equal facility on any portion of the * 
 uterine cavity. I have lately had it \ 
 made with a bill and socket joint, ' 
 in the middle of the shaft, but the 
 simple instrument, as here delineated 
 answers quite as well. 
 
 To show the power of the sponge 
 to destroy mucous polypi, I will select 
 one, and only one, of many cases that 
 I might bring forward. 
 
 In November, 1862, I was con- 
 sulted by a lady in Paris, who was 
 seemingly a perfect specimen of health, 
 but she was sterile. Menstruation 
 had always been rather profuse, last- 
 ing eight or nine days. 
 
 The uterus was retro verted, but 
 what would seem contradictory, it was 
 also anteilected. Suffice it for the 
 present to say, that the cervical canal 
 was enlarged by a bilateral incision. 
 The operation was performed in De- 
 cember, 1862, with the assistance of Sir Joseph Olliffe. 
 
 The parts as usual healed before the next men- 
 struation, which, however, was not much influenced 
 by the operation, for it went its usual course of eight 
 or nine days. After it was over I was examining the 
 condition of the cervical canal, and to my surprise, I 
 saw the end of a mucous polypus or enlarged nabotkian 
 gland lying high up in the canal, as shown at a, in 
 fig. 19. I passed a sponge tent in the morning along 
 the canal of the cervix, above and beyond the seat of 
 the polypus. In the afternoon I removed the tent aud 
 
 m 
 
 ma 
 
 WAV is 
 
 ,;Vi ' ii'l 
 
 II 
 
 ft', 1 ' 
 W;WJ, 
 
 
 Fig. 18.
 
 62 
 
 UTERINE SURGERY. 
 
 introduced a longer and larger one, and allowed it to 
 remain till the next morning. On its removal there 
 was no trace of the polypus to be found. Menstruation 
 
 Fig. 19. 
 
 immediately became normal, and has continued so ever 
 
 since. 
 
 This power of the sponge tent to destroy polypoid 
 growths was accidentally discovered at the Woman's 
 Hospital in this way. In 1856 a young unmarried 
 woman entered the hospital with a menorrhagia that 
 had bled her quite into a dropsical condition. The 
 flow was almost continuous, but attended with no 
 great degree of pain ; she was perfectly anaemic from 
 loss of blood ; had general anasarca, and was of a waxy 
 hue. We did not suspect the true character of her 
 disease ; and Dr. Emmet and myself agreed to give her 
 a nutritious diet, with chalybeates ; and so she went on 
 bleeding for several days longer, and a sponge tent 
 was then introduced. The uterus did not seem to the 
 touch to be much enlarged, and it was only two inches 
 and a half to the fundus. The cervix was small, and 
 the os was correspondingly so. When the tent was 
 removed there presented one of the most perfect 
 specimens of fibroid polypi that I ever saw. The
 
 OF MENSTRUATION. 
 
 63 
 
 diagram (fig. 20) shows its attachment and rela- 
 tions. 
 
 It had given me much trouble, and was a nice case 
 for operation, which might have been performed at the 
 
 Fig. 20. 
 
 moment, but I was anxious to show it to the Con- 
 sulting Board of the Woman's Hospital, and concluded 
 to put off its removal till the next day, which was the 
 day for their regular meeting. Accordingly I intro- 
 duced a large sponge tent, expecting to remove it on 
 the following day, and complete the operation in the 
 presence of the Board. Singularly, they did not meet, 
 and the poor patient with the sponge tent was com- 
 pletely forgotten. I expected Dr. Emmet to remove 
 the tent, and he thought I had done it ; and the nurse, 
 who, by the by, never forgot a patient, supposed we 
 had left it intentionally. However, about a week 
 afterwards, the nurse begged to call my attention 
 to the young woman with the sponge tent, saving she 
 thought u it must be rotten by this time, as the other
 
 64 UTERINE SURGERY. 
 
 patients in the same ward with her coold not stand 
 the smell of it any longer." My mortification at such 
 neglect, added to the dread of serious results to the 
 poor patient, may well be imagined. However, she 
 was soon on the operating table, complaining of 
 nothing but the intolerable fetor of the sero-san- 
 guinolent discharge, which had been going on con- 
 stantly for a whole week. The sponge and the tissue 
 of the cervix seemed to be thoroughly amalgamated, 
 and it was necessary to push the point of the finger 
 up between the two, and gradually separate them all 
 round before making traction on the sponge with the 
 forceps. I never performed a more unpleasant opera- 
 tion than the removal of the sponge; the stench was 
 such as to make one of the nurses vomit. When the 
 tent was introduced a week before, the tumour was 
 accurately measured, its volume, density, and attach- 
 ment all definitely settled, and easily so. It was a dense, 
 firm, fibrous polypus, about the shape of the diagram on 
 page 63 — a little larger, and having attachment to the 
 fundus as there represented. My surprise may be 
 imagined when, on introducing the finger into the 
 cavity of the uterus, after the removal of the tent, there 
 was not a vestige of the tumour to be found. The 
 pressure and drainage by the sponge had eradicated it 
 entirely. The patient speedily recovered, and was soon 
 restored to a vigorous state of health. Notwithstand- 
 ing the happy result of this accident, and the valuable 
 principle thereby established, I would not recommend 
 it as a rule of practice in fibroid polypi. For the dan- 
 ger of metritis by the prolonged contact of such an 
 irritant, and the still greater danger of pyaemia from 
 the disintegration of tissue, would render it too hazard- 
 ous. However, ihe tent may always be trusted to
 
 OP MENSTRUATION. 
 
 65 
 
 destroy fungoid growths and small raucous, or nabo- 
 thian polypi, when they cannot be otherwise removed. 
 Dr. Emmet, surgeon to the Woman's Hospital, whose 
 experience with the sponge tent is very large, has the 
 greatest confidence in their safety as well as efficiency. 
 I have seen him repeat them day after day, and I have 
 often heard him say that he has succeeded in doing 
 more for general hypertrophy of the uterus by this 
 means in a week than could be accomplished by any 
 and all others in two or three months. 
 
 I have said a good deal about the disgusting dis- 
 charge produced by the sponge tent. While at Baden- 
 Baden in the summer of 1863, I had occasion to use a 
 tent, and apologized to my patient for its bad effects. 
 In her case I had been previously using glycerine dress- 
 ings to the womb. As the tent showed a little dispo- 
 sition to- slip down, I applied a pledget of cotton, 
 saturated with Price's glycerine, over the neck of the 
 uterus, simply because it was convenient to do so. 
 When I went to remove the sponge in the afternoon, 
 ray patient told me that the discharge had no bad 
 odour, and, on examination, I found the pledget of 
 cotton and tent, after removal, perfectly devoid of any 
 fetor. I have now often used this as a disinfectant 
 of the sponge, and find it infallible in its results. The 
 only objection to it is that it sometimes prevents the 
 sponge from expanding to its fullest extent. 
 
 I have used tents of the Laminaria digitata, and 
 think well of them, but they can never wholly replace 
 the sponge tent. There is much trouble in retaining 
 them properly in place. It is often necessary to prop 
 them up with a tampon, and even then they slip out. 
 Besides this, they require a much longer time to dilate 
 the cervix. However, they are a valuable addition to 
 
 5
 
 66 
 
 UTERINE SURGERY. 
 
 our surgical resources, and for them we are greatly in< 
 debted to the late Dr. Sloan,* of Ayr, Scotland. 
 
 Dr. Greenhalgh has improved the Sea Tangle tent 
 very much, and it happened in this way. He had 
 some trouble in getting a pair of forceps made specially 
 for their introduction, and the idea occurred to him to 
 perforate the lower end of the tent for the 
 insertion of a stylet, which answered a 
 good purpose. But he soon discovered 
 that the perforated part dilated more 
 easily and to a greater degree than the 
 rest of it. He then had the perforation 
 made through the whole length of the 
 tent, when he found that it acted more 
 rapidly and more efficiently than before. 
 The tents of commerce up to this time were 
 tied round with a thread at the 'lower end 
 to facilitate their removal. This interfered 
 with the dilatation, by preventing the ex- 
 pansion of the tubular perforation below. 
 He then had the thread fastened to one 
 side of the tent as shown in the diagram 
 (fig. 21). I agree entirely with Dr. Green- 
 halgh that the tent should not, as a rule, 
 exceed two inches in length. 
 
 Prepared after Dr. Greenhalgh's plan, 
 it is much softer when removed from the 
 uterus than the solid tent, and the perfora- 
 tion is found of be dilated in proportion to 
 the expansion of the solid part, thus serving as a drain 
 to facilitate the escape of any secretions from the cavity 
 
 U 
 
 Fig. 21. 
 
 * Glasgow Medical Journal, October, 1862.
 
 OF MENSTRUATION. 57 
 
 of the uterus. Notwithstanding all this, I regret to say 
 they do not fulfil all the indications of the sponge tent, 
 and cannot wholly replace it. 
 
 Of Menorrhagia from Polypus. — Having spoken 
 of menorrhagia as a sequence of granular erosion, of 
 cervical engorgement, and of fungoid granulations, we 
 now come to consider it as a concomitant of polypus. 
 Accoucheurs and pathologists have described polypi 
 as soft, hard, mucous, glandular, cellular, cystic, 
 fibrinous, fibro-cellular, nbro-cystic, and fibrous. These 
 several divisions are anatomically and pathologically 
 correct ; but as I am taking only a surgical view of the 
 subject, I prefer to classify them topographically, that 
 is, not according to their own structural elements, but 
 simply according to their point of origin, which, by the 
 bye, is the simplest method of arrangement. Thus, I 
 would say that uterine polypi are naturally divided into 
 three classes : — 
 
 1st. Those growing from or about the os tincae. 
 2nd. Those growing in the canal of the cervix. 
 3rd. Those growing in the cavity of the uterus. 
 
 The first may be fibro-cellular or mucous. 
 
 The second are almost always mucous. 
 
 The third are almost always fibrous. 
 
 I propose to give clinical illustrations of these sub- 
 divisions. 
 
 In the first class they may be large or small. If of 
 the fibro-cellular variety, they may attain an enormous 
 size. I have seen them almost as large as the foetal 
 head at term. If of the mucous variety, they seldom 
 grow larger than an English walnut, and are usually 
 somewhat flattened by pressure between the cervix and
 
 08 UTERINE SURGERY. 
 
 the opposite wall of the vagina. To the sight these 
 seem to be only a congeries of fibro-cellular tissue and 
 blood-vessels. Polypi growing from the os tincse are 
 generally attached to one lip of it. I am not able to 
 say upon which one they are most frequently found. 
 They often prevent conception, but not always, for 
 our medical literature contains numerous examples of 
 labour complicated with, or obstructed by, very large 
 polypi, which could hardly have grown during the 
 period of gestation. 
 
 Their removal is easy enough. They may be cut 
 off with scissors, or removed by the ecraseur. I 
 know that fatal hamorrha^e has followed the use of 
 scissors, but it was before the discovery of the styptic 
 properties of the perchloride of iron by Pravaz. This 
 was indeed a boon to surgery, and Deleau* has 
 rendered a great service in vulgarizing its use. 
 
 But, unfortunately, it is a remedy of uncertain 
 properties. It often contains free acid, and then it 
 irritates the mucous surface of the vagina. So uncer- 
 tain is this preparation in New York, that the 
 profession there have almost entirely abandoned its 
 use, substituting for it the solution of the persulphate 
 of iron (as made by Dr. Squibb, of New York), which 
 seems to be quite as efficient and is not so liable to 
 the same objections. In Paris I could not get the 
 persulphate of iron, and I was obliged to return to the 
 use of the perchloride as a styptic. Mr. Swann, 
 chemist, Hue Castiglione, procured for me specimens 
 of the perchloride which purported to be neutral, but 
 
 * " Traite Pratique sur les Applications du Perchlorure de Fer en 
 Medecine." Par M. T. Deleau, Docteur en Medecine, &c. Paris : Adrian 
 Delahaye. 1860.
 
 OF MENSTRUATION. 
 
 69 
 
 they produced very deleterious effects on the vaginal 
 epithelium, and at last lie got some of Deleau's, and its 
 effects were as desired, viz. styptic and unirritating. 
 
 We will suppose a polypus growing from the 
 posterior lip of the os tincae, with a pedicle half an 
 inch, more or less, in diameter (fig. 22). If it is to 
 
 Fig- 22. 
 
 be removed by scissors, first prepare the styptic by 
 mixing one part of the solution of the perchloride of 
 iron, with three or four of distilled water; then 
 saturate pledgets of lint in it, or, what is better, 
 take some fine cotton wool, wet it thoroughly in 
 plain water, squeeze all the water out, and then wet 
 it in the mixture, and squeeze it nearly dry. 
 
 When all is ready, place the patient in the semi- 
 prone position, apply the speculum, lay hold of the 
 tumour with forceps, or a vulsellum, draw it gently 
 forwards, and cut it off at one stroke with suitable
 
 70 UTERINE SURGERY. 
 
 scissors. Sponge the cut surface a moment, and quickly 
 apply the lint or cotton previously prepared, and 
 press it firmly in place with a sponge probang (fig. 
 23). The firm pressure of one or two sponge probangs 
 on the styptic lint or cotton almost instantly checks the 
 bleeding. Wait a little to be sure of this, and then 
 put a tampon of dry cotton over all, merely to secure 
 the dressing proper in situ. The patient is put to bed, 
 the recumbent position is enjoined for a day or 
 two, and the bladder may or may not be emptied 
 by the catheter. 
 
 On the next day the dry cotton is to be 
 removed, taking care not to disturb the iron 
 dressing in contact with the cut surface. This 
 adheres closely to it, and is not, as a general rule, 
 to be removed till it is loosened and thrown off 
 by the suppurating process, which takes two, 
 three, or even four days. 
 
 But, when the dry cotton is removed on the 
 day after the operation, its place is to be supplied 
 by a bit of cotton saturated with Price's glyce- 
 rine, which is to be renewed daily, till the cut 
 surface be healed. For this purpose take some 
 fine cotton, as much as can be easily held in the 
 hollow of the hand, immerse it in tepid water, 
 and squeeze it gently under the water till it 
 becomes perfectly wet ; then press all the water 
 Fig. 23. ou £ Q £ -^ ail j sa t ura te it with Price's glycerine. 
 
 To do this, lay the moistened cotton in the palm of the 
 left hand, spread it out circularly for an inch and a half 
 in diameter, more or less as may be needed, scooping it 
 out in the centre — then drop half a teaspoonful of 
 glycerine on it thus held, and rub it into the cotton with 
 the point of the finger, then pour on a little more gly-
 
 OF MENSTRUATION. 
 
 n 
 
 cerine, and rub it in, and so continue till the 
 cotton becomes saturated. When finished, the 
 cotton should feel soft and pulpy, sbould be about an 
 inch and a half in diameter, and about half an inch 
 thick. 
 
 This dressing is an expensive one, for it will hold 
 from one to three drachms of gtycerine ; but I do not 
 think there is any substitute for it, and its effects are 
 such that I consider it cheap in the end. 
 
 This glycerole cotton is thus applied daily till the 
 first dressing is removed, and then it may be conti- 
 nued for a fevv days longer, till the whole surface be 
 healed. 
 
 Glycerine is now fixed in professional estimation as a 
 most valuable addendum to the domain of surgery ; and 
 to the philosophic and practical mind of Demarquay* 
 are we indebted for a complete treatise on the subject, 
 setting forth its properties and qualities. Its use in 
 uterine surgery occurred to me some seven or eight years 
 ago, in this way : — To a case of granular engorgement I 
 wished to apply some caustic or other; but, whatever it 
 was, I could not at once find it. Being very much hur- 
 ried, I looked around for some substitute. And it 
 occurred to me to apply a bit of cotton wet with glyce- 
 rine, merely to protect the os uteri from contact with the 
 opposite surface of the vagina, which was also quite 
 granular. I fully intended to use the caustic on the next 
 day. But, when my patient returned, she saluted me 
 with, " Well ! doctor, what effect did you intend the 
 treatment of yesterday to produce?" Seeing that there 
 was evidentlv something out of the way, I was quite at 
 
 * " De la Glycerine," &c. Par M. Demarquay. Paris. 1863.
 
 72 UTERINE SURGERY. 
 
 a loss for a satisfactory reply ; and she continued, " Yon 
 ought to have told me all about it, for, when I got home, 
 my linen was so wet that I had to change it, and the water 
 streamed from me all night in such a way that I have 
 had to wear napkins to protect myself." This was all 
 news to me, and, on examination, I found the pledget of 
 cotton still wet, lying just as it was placed on the cervix 
 uteri, which, together with the vagina, had a clean, 
 healthy, and greatly improved appearance, compared 
 with what it had the day before. I applied another 
 similar dressing, to see if it would produce the same 
 effect. It did, and these dressings were repeated till the 
 case was entirely cured : since which time I have used 
 glycerine in this way in all my surgical operations on 
 the neck of the womb, and in other cases of organic 
 lesion. 
 
 The effect of glycerine thus used is very remarkable. 
 It has great affinity for water. A bit of cotton saturated 
 with glycerine, and exposed to the air, will retain mois- 
 ture for weeks. When applied to the neck of the womb 
 as above directed, it seems to set up a capillary drainage 
 by osmosis, producing a copious watery discharge, deplet- 
 ing the tissues with which it lies in contact, and giving 
 them a dry, clean, and healthy appearauce. When such 
 a dressing is applied to a pyogenic surface on the cervix 
 uteri, for a few hours, and then removed, the cut or sore 
 will be as clear of pus as if it were just washed and 
 wiped dry. 
 
 Much has been written on the diagnosis of polypous 
 tumours. I do not intend to open the subject here, 
 but I would only say that the Gordian knot is easily 
 cut, if my method of exploration be adopted ; for, 
 with the patient on the side (or knees, if necessary), 
 with my speculum everything is brought so plainly
 
 OF MENSTRUATION. 
 
 73 
 
 into view that there is no possibility of making a mis- 
 take. 
 
 Dr. Graily Hewitt and Dr. Greenhalgh have related 
 eases where physicians were in doubt, and had even mis- 
 taken a common polypus for carcinoma. I have seen 
 several cases of mucous polypi slightly protruding from 
 the cervix that had been treated for granular erosion by 
 repeated applications of nitrate of silver; and a few 
 years ago I saw a woman, forty-eight years of age, 
 greatly reduced by prolonged haemorrhages, who pre- 
 sented almost exactly the cachectic physiognomy of 
 carcinoma. She had none of the lancinating pains of 
 
 A,/r *Y. 
 
 Pig. 24. 
 
 cancer, but when the finger was passed into the vagina, 
 it found a knobby hard growth occupying the place of 
 the cervix, and the os could not be felt. 
 
 When the ordinary speculum was used, this growth
 
 n 
 
 UTERINE SURGERY. 
 
 Fig. 25. 
 
 filled up its area, and all was in doubt. But, by the use 
 
 of my speculum, which left 
 the whole vagina freely open 
 to inspection, we found a 
 polypus of mushroom shape 
 fitting almost like a cap over 
 the cervix uteri (fig. 24). 
 The pedicle was short, and 
 the tumour fitted so well the projecting portion of the 
 cervix, that it was scarcely movable. The removal of 
 
 the tumour with scissors exhibited an 
 os tincse perfectly free from all appear- 
 ance of malignant disease. A not un- 
 frequent form of polypus is repre- 
 sented by fig. 25. This was removed 
 from a lady who supposed it was the 
 wornb coming out, because it protru- 
 ded from the mouth of the vagina. 
 When I told her it was a fibro-cellular 
 polypus, she was greatly alarmed, be- 
 cause she had lost one of her servants 
 by an operation of some sort for poly- 
 pus. 
 
 All classifications are more or less 
 arbitrary. This polypus might by some 
 be classed in my second subdivision ; 
 but as it grew distinctly from the edge 
 of the os tinea?, although some of its 
 fibres took root in the cervical mucous 
 membrane, I have put it in the first 
 class. 
 \ = ^ / We often find small polypi in the 
 
 Fig. 26. canal of the cervix. They vary from
 
 OF MENSTRUATION. 
 
 75 
 
 the size of a grain of wheat to that of a small bean, 
 and are called nabothian polypi. (See fig. 19, page 
 62.) 
 
 They may be very effectually destroyed by the me- 
 chanical pressure of a sponge tent worn for twenty-four 
 hours, or they may be pulled off by forceps, or cut off 
 with scissors ; I prefer the latter. We often fail in the 
 extraction of small mucous or cystic polypi, for the 
 want of a suitable instrument. 
 
 Dr. McClintock uses a fenestrated forceps for these, 
 which answers admirably. A vulsellum is not suitable 
 here, because their tissue is so delicate that it is apt to 
 tear out. Fig. 26 represents Dr. McClinfcK-k's polypus 
 forceps. They compress the pedicle, while the little 
 polypus lies unhurt in the fenestral opening. But for 
 larger ones, such as fig. 25, Charriere has made for me 
 
 Fig. 27. 
 
 forceps of this sort (fig. 27), with which we seize the 
 pedicle of the poly}), when we wish either to tear it 
 away or cut it off with scissors. 
 
 But suppose, for some reason, we wish to remove a 
 polypus by torsion. To render this process perfectly 
 safe, it is necessary that the pedicle be long and slender,
 
 76 UTERINE SURGERY. 
 
 and that the tumour be easily rotated. This process has 
 been applied to the small nabothian polypi and also to 
 iutra-uterine fibrous polypi with slight attachments. 
 Laying hold of the polypus with a fenestrated forceps, if 
 of the first variety ; with a vulsellum, if of the second ; 
 we rotate gently from left to right, and so continue till 
 all resistance ceases, when we remove the severed 
 growth. I am no advocate for this plan, unless under 
 very exceptional circumstances. 
 
 There are but few polypi that cannot be safely 
 removed with scissors, yet we may have reasons for 
 not wishing to resort to them. The patient may be so 
 exhausted by repeated and prolonged haemorrhages, that 
 we cannot afford to risk the sudden loss of an additional 
 small quantity of blood; or from some theoretical grounds 
 we may prefer not to cut. For instance, in Paris, 
 surgeons often refuse to perform the simplest cutting 
 operation when there is much erysipelas about, asserting 
 that a clean cut is more apt to produce erysipelas, and even 
 pysemia, than the lacerated wound of the ecraseur. Be 
 this as it may, let us suppose that we have to deal with 
 a polypus too formidable for scissors or for torsion. Our 
 only resource then is the ecraseur, — and a very sure and 
 safe one is it : sure in its action and safe in its conse- 
 quences. Formerly a ligature was passed round the 
 pedicle of such tumours, and tightened from time to 
 time till the mass sloughed away; but that day has gone 
 by, never to return. 
 
 The removal of a polypus by ligation is really a 
 dangerous operation, resulting not unfrequently in 
 pysemia and death, which seldom indeed happens when 
 the ecraseur is used. 
 
 We owe this admirable instrument- to the inventive 
 genius of Chassaignac.
 
 OF MENSTRUATION. Y7 
 
 It has been used in almost every imaginable way, and 
 often most inappropriately ; for instance, for fistula in 
 ano, for the removal of simple steatomatous tumours, for 
 excision of the mamma, for lithotomy, and even for 
 amputation' of the thigh. But the time is coming, indeed 
 is even here, when the true surgeon will raise it to the 
 dignified position that it merits, by confining it to such 
 operations as are peculiarly its own. For the ablation 
 of diseased structure in erectile tissue it cannot be over- 
 estimated. In Chassaignac's ward in the Larriboisiere 
 Hospital I have seen cases where malignant disease of 
 the tongue called for the removal of that organ, whicli 
 was done safely by this admirable instrument, and the 
 patients remained well for a long time afterwards. In 
 the same wards I have seen more than one case in which 
 M. Chassaignac had removed the anus, and a large 
 portion of the rectum, for cancerous disease, an operation 
 that would have been utterly impossible by any other 
 means, and one of these patients had been well for more 
 than a year. 
 
 These are, fortunately, rare cases, but they prove the 
 value, efficiency, and safety, of the ecraseur under the 
 worst, possible conditions. But it is for the removal of 
 haemorrhoids and uterine polypi that this instrument 
 is to find its most common and appropriate field of 
 usefulness. 
 
 Many modifications have been made of Chassaignac's 
 chain ecraseur. M. Maisonneuve uses a stiff but malle- 
 able iron wire, to be pulled through the tissue. Dr. 
 Braxton Hicks makes a cord of several fine threads of 
 wire ; while others fix one end of the chain (Charriere 
 and Tieman). I have tried all these, and have no hesi- 
 tation in saying that none of them are in practice equal 
 to Chassaignac's original instrument, It generally cuts
 
 ^8 UTERINE SURGERY. 
 
 through neatly, without drawing out long shreds oi 
 tissue, leaving us uncertain when the tumour is entirely 
 severed, if it be hidden from view, as it must be some- 
 times. Every little click of Chassaignac's instrument 
 measures for us most accurately the distance over which 
 the chain passes, warning us to rest. The resistance we 
 encounter in tightening it shows us the density of tissue, 
 and is the index to move slower or faster. Whereas, 
 every turn of a screw, whether a quarter, half, or whole 
 revolution, leaves us in doubt whether it is too much or 
 too little — while it is a power unmeasured and unappre- 
 ciated by the sense of feeling. This is strongly proven 
 by the fact that I have never broken one of Chassaig- 
 nac's instruments, while I have broken two worked by a 
 screw. The same thing has occurred in the dexterous 
 hands of Dr Graily Hewitt and of Dr. McClintock. 
 
 McClintock, in speaking of the ecraseur for uterine 
 polypi, says, " I have generally felt it necessary to bring 
 the bulk of the tumour beyond the external genital 
 orifice; and this necessity it is that limits its range of 
 applicability.' 1 * The difficulty of placing the chain 
 around the pedicle of the tumour while in the vagina, 
 and the still greater one of applying it within the uterus, 
 has been heretofore the great barrier to its universal 
 adoption. But I hope this difficulty is now overcome. 
 I do not think the polypus should ever be drawn outside 
 for ecrasement, or that there should be any undue trac- 
 tion made on the uterus while the ecraseur is being 
 worked. My plan is this. The patient in proper posi- 
 tion, the speculum (fig. 5) is introduced, and we have a 
 complete view of everything in the vagina. If the 
 
 * "Clinical Memoirs," &c, p. 171.
 
 OF MENSTRUATION. 
 
 79 
 
 tumoar is in the vagina, there 
 will not be the least difficulty 
 in applying the chain of the 
 ecraseur ; but, to do this with 
 facility, it is necessary to prevent 
 the chain from folding on itself, as 
 we attempt to carry its loop 
 over and beyond the tumour. 
 This was to me a source of an- 
 noyance for a long time, but at 
 last I have succeeded in giving 
 the chain a rigid fixity that 
 makes it very easy to do this. 
 
 Where the polypus has de- 
 scended into the vagina, Maison- 
 neuve's wire, or Dr. Braxton 
 Hicks' cord of wire, answers very 
 well ; but where it is intra-uterine, 
 with a contracted cervix, we 
 ordinarily fail in their application, 
 just as we do with the chain of 
 Chassaiirnac. 
 
 I have added to Chassaignac's 
 instrument a porte-chaine, which 
 may be described as a pair of 
 dilating forceps with spring 
 blades, which render the chain 
 stiff, so that it may be passed 
 straight into the vagina, or into 
 the cavity of the uterus, as easily 
 as we would a sound or a sponge 
 probang. After which the chain 
 is expanded by the blades of this 
 porte cname. 
 
 f?i\ 

 
 80 
 
 UTERINE SURGERY. 
 
 Fig. 28 represents the ecraseur with the porte- 
 chaine ready for use. It is carried into the vagina or 
 into the cavity of the womb thus arranged; the thumb- 
 piece, b, is then pushed forward and fastened at the de- 
 
 FiG. 29. 
 
 ^ 
 
 Fig. 30. 
 
 sired point by the notched rack, which is seen passing 
 through the shaft of the instrument ; this movement 
 dilates the spring blades of the porte-chaine, and ex-
 
 OF MENSTRUATION. g| 
 
 pands the chain to the required extent. When the 
 chain is made to encircle the pedicle of the 
 tumour, the porte-chaine is drawn up into the shaft of 
 the instrument simply by elevating the thumb-piece, b, 
 and pulling* it back in a straight line for three or four 
 inches, while the instrument is pushed forward along 
 the chain just as if there had been no porte-chaine 
 present. The porte-chaine is not wholly removed 
 from the ecraseur ; it lies in it3 place in the shaft while 
 the operation is being finished.* 
 
 Fig. 29 represents the porte-chaine detached from 
 the ecraseur, for the purpose of showing its mecha- 
 nism. When the thumb-piece b is pushed forward, e 
 being a fixed point as shown in figs. 28 and 30, the 
 joints dd must of necessity be forced apart, and this 
 it is that dilates the blades c c, which, holding the 
 chain securely in its grooves f f, g g, carries it out 
 to the required degree, as represented in fig. 30. 
 
 Fig. 30 shows the angles or joints, d d, projecting 
 through slots in the sides of the shaft. The only 
 thing necessary to insure the perfect working of the 
 apparatus is to see that the pivot e, as shown in all 
 three of the cuts, is quite at the extreme end of the 
 groove, at the top of the instrument. If by chance 
 it should not be, then the joints, d d, will not have 
 room to expand and project out of the sides of the 
 instrument through the slots made for this purpose. 
 
 The chain is worked by a hidden rack in the handle, 
 g (fig. 28). When the button, a, is pushed towards d, 
 
 * The mechanism of this instrument has been greatly simplified since I 
 presented it to the Obstetrical Society in December, 1864, and published an 
 account of it in the Lancet. For this improvement I am indebted to Mr. J. 
 Mayer, instrument-maker, 51 Great Portland Street. 
 
 6
 
 82 
 
 UTERINE SURGERY. 
 
 the teeth of the rack are caught by the notches in 
 the sides of the two long shafts that run from/" through 
 the whole length of the instrument ; when it is moved 
 towards 6?, then its teeth are elevated out of these notches, 
 and the chain and porte-chaine can be freely pushed up 
 and down the shaft like the piston-rod of a syringe. 
 This part of its mechanism is exactly the same as that of 
 Chassaignac's instrument, except that it is simplified, 
 hidden from view, and not in the way of the operator. 
 
 Let me illustrate the principle of its application by 
 a clinical observation. In February, 18(33, Dr. Morpain, 
 of Paris, invited me to operate on a patient of his, who 
 had a polypus as large as a goose's egg projecting partly 
 from the cavity of the uterus. 
 
 Fig. 31 represents its position, relations, and attach- 
 ment. A moment's glance shows the difficulty of pass- 
 ing a chain around the pedicle of a tumour thus 
 
 Fig. 31. 
 
 situated. The patient, on a table, was placed in the left 
 lateral semi-prone position, and, when the speculum was 
 introduced, it elevated the perineum and posterior wall 
 of the vagina, and brought completely into view the 
 tumour, as represented in the engraving. 
 
 There is great temptation under such circumstances
 
 OF MENSTRUATION. §£ 
 
 to seize the projecting portion of the polypus with a 
 strong vulsellura or tenaculum, and pull it towards the 
 os externum. But this is not the best thing to do, 
 because it will close up the mouth of the vagina and 
 obstruct both sight and manipulation ; for the mouth 
 of the vagina, even in favourable cases, would hardly be 
 forced open more than an inch and a half from the 
 urethra back to the perineum, and we need all this space 
 for operating. 
 
 Here a small tenaculum was hooked into the tumour 
 at #, and by it the polypus was pushed gently down- 
 wards and forwards against the anterior wall of the 
 vagina. It was held firmly, while the stiffened chain of 
 the ecraseur was passed along the upper or posterior 
 surface of the tumour from a up to the fundus uteri at c. 
 This done, the tenaculum was removed, and the chain of 
 the ecraseur opened out in the cavity of the uterus to a 
 sufficient extent to allow the tumour to pass through it. 
 This was effected by hooking the tenaculum at &, and 
 raising the end of the tumour up towards the posterior 
 wall of the vagina, at the same time that the ecraseur 
 was pressed in the opposite direction. This movement 
 placed the middle portion of the chain parallel with the 
 anterior face of the tumour, while its loop, or distal 
 portion, still remained stationary at c. It was thus made 
 to embrace the pedicle, and it only remained to pull the 
 porte-chaine back at the same moment that the shaft of 
 the instrument was pushed down on the chain, which 
 was tightened closely around the pedicle. The operation 
 was then finished as easily as if the tumour had been 
 wholly outside the body, and that, too, without the 
 least strain or traction on the uterus or surrounding 
 organs. 
 
 This operation was done with the assistance of Dr
 
 84 
 
 UTERINE SURGERY. 
 
 Morpain, Sir Joseph Olliffe, and Dr. W. E. Johnston. 
 Since then (February, 1863) I have had every reason 
 to feel satisfied with the porte-chaine, whether the 
 polypus was in the uterus or simply in the vagina. 
 When I was in Dublin, in August, 1861, Dr. 
 M'Clintock asked me to see a young woman in 
 the Rotunda Hospital who had an intra-uterine 
 polypus. It was about the size of a pullet's egg, 
 and entirely within the cavity of the uterus (fig. 32). 
 She was a virgin ; the vagina was of course small, and 
 
 Fig. 32. 
 
 the mouth of it quite contracted ; thus any manipulation 
 was difficult. We succeeded, however, in getting a rope 
 of wire on the tumour two or three times, and succeeded 
 as often in breaking it ; and thus, for the want of proper 
 machinery, we were compelled to let the case alone for 
 the time being:. If we had then had the Chassaigmac 
 instrument with the porte-chaine, there would have been 
 comparatively little difficulty in removing the tumour 
 at once. 
 
 Intra-uterine polypi grow from the fundus, or from 
 the anterior or posterior walls of the uterus, but more 
 frequently from the anterior. I do not remember to 
 have removed any with simply a lateral attachment. It 
 has so happened that I have seen more polypi attached 
 to the anterior than to the posterior face of the uterine
 
 OF MENSTRUATION. 
 
 85 
 
 cavity. If observation should establish this as a rule, it 
 will be very fortunate in a surgical point of view ; for it 
 is much easier to pass the chain of the ecraseur around 
 the pedicle of a polypus attached anteriorly than pos- 
 teriorly, if -it be entirely intra- uterine. An example of 
 each variety may serve for clinical illustration. Dr. 
 Morpain's case already related is a fair specimen of one 
 variety ; but, as showing the improved methods of 
 modern surgery, I may be permitted to allude briefly to 
 another similar case. 
 
 In February, I860, a lady from one of the eastern 
 States consulted me on account of her sterility. She 
 was thirty-two years old ; had been married ten years ; 
 enjoyed very good general health, and had leucorrhoea 
 and some pain with menstruation, which was not profuse. 
 The uterus was in proper position, but felt larger than 
 natural. I introduced a sponge tent to ascertain the 
 cause of this hypertrophic state. On its removal, the 
 finger passed into the cavity of the uterus detected a 
 
 Fig. 
 
 fibrous polypus of the size of a partridge's egg, attached 
 anteriorly, as represented in fig. 33. Another sponge 
 tent of larger size was introduced, and on its removal
 
 g(3 UTERINE SURGERY. 
 
 six or eight hours afterwards, I succeeded iu passing the 
 chain of the ecraseur around the pedicle, when it was 
 easily and quickly severed. This case strongly illus- 
 trates the present improved methods of exploration ; for 
 here we could not have determined the cause of the 
 uterine enlargement but by passing the finger into the 
 cavity of the organ after dilatation of the cervix. 
 Indeed, before the use of sponge tents we could not by 
 any possibility have diagnosed such a case as this. But 
 now we determine with the minutest accuracy, not only 
 the presence, but the size, position, relations, and 
 attachment of all such tumours. Before the use of 
 sponge tents, if we suspected from rational symptoms 
 an iutra-uterine polypus, we could only wait from month 
 to month — sometimes from year to year — for it to grow 
 and to force its way into the vagina, before we could 
 interfere surgically for its removal. But now we no 
 longer doubt and procrastinate ; we no longer let our 
 patients bleed till they become bloodless and dropsical ; 
 but we ferret out at once the source of mischief, and 
 remove it from its once secure hiding-place. This is a 
 great advance in surgery ; and no man of twenty or 
 thirty years' experience can look back on the days of 
 ergot and Gooch's canula, and contrast them with the 
 present time of sponge tents and the Ecraseur, without 
 a thrill of delight at the progress of our noble calling. 
 
 Having now given clinical illustrations of polypi 
 growing from the os, in the canal of the cervix, and in 
 the cavity of the uterus attached to the anterior wall, 
 I will continue the series by examples of polypi growing 
 from the fundus and the posterior wall. As said before, 
 I do not remember any with a simple lateral attach- 
 ment. 
 
 A. H., aged twenty-six, gave birth to her only child
 
 OF MENSTRUATION. 
 
 87 
 
 when she was but fourteen. Had two or three miscar- 
 riages since, at about the third month. Had menor- 
 rhagia for many years, very profuse, painful, and 
 coagulated, lasting usually ten or twelve days. Had 
 forcing pains during the whole time of the flow, and, 
 singularly enough", they were always worse in the fore- 
 noon. This patient was sent to the Woman's Hospital 
 by Professor J. C. Nott, of Mobile. The womb was in 
 its normal position, and evidently enlarged. The os 
 admitted the end of the index finger to the depth, of the 
 nail. She had just menstruated, and there was a very 
 profuse muco-purulent discharge from the cavity of the 
 uterus. For years her suffering bad been a mystery. A 
 sponge tent unravelled it in a few hours. She had a 
 fibroid polypus attached to the fundus by a short, thick 
 pedicle (fig. 34). It was impossible to place the chain 
 
 Fig. 34 
 
 of the ecraseur around it, through a comparatively con- 
 tracted cervical canal. This was before we had learned 
 the use of wire as a substitute for the chain. AVith a 
 Gooch's canula I put a strong fishing-line around the
 
 gg UTERINE SURGERY. 
 
 pedicle, and severed it with the screw ecraseur. It was 
 difficult to get a cord strong enough to cut through its 
 fibrous tissue. It snapped a large catgut guitar-string, 
 and then a silk cord. With Chassaignac's ecraseur, 
 armed with a porte-chaine, there would have been no 
 trouble. 
 
 So far I have spoken only of successful operations ; 
 but there is such a thing as failure, and even death, 
 in consequence. Fortunately, these are rare. I have 
 removed a great many intra-uterine polypi, and all with- 
 out accident, except in two instances, which were followed 
 by pyseinia. One of these recovered, the other died. 
 This latter was an example of polypus with attachment 
 to the posterior wall by a thick, short pedicle. It was 
 the case of a lady about sixty years old. I was invited 
 to see her by Professor Metcalfe, of New York. She 
 was the mother of a large family of grown-up children ; 
 had ceased to menstruate some ten or twelve years 
 before, but for the last three or four years had suffered 
 alarming haemorrhages, which greatly prostrated her. 
 The uterus was felt to be enlarged, but the os was not 
 larger than the point of a common probe. A small 
 sponge tent was introduced, and on the next a larger 
 one. This dilated the canal of the cervix sufficiently, 
 but the os barely admitted the end of the finger, and 
 felt as inelastic as if bound by wire. Of course, no 
 further effort could then be made. Eight or ten days 
 after this we succeeded in dilating the cervix, so as to 
 explore most satisfactorily the cavity of the uterus, 
 when we found a hard fibrous polypus, with a broad, 
 thick pedicle, attacked to the posterior wall, close to the 
 fundus (fig. 35). This was in May, 1862. I failed to 
 put the chain around the pedicle. Two weeks afterwards 
 another series of sponge tents was followed by another
 
 OF MENSTRUATION. 
 
 89 
 
 failure. The tumour was unfortunately lacerated a good 
 deal by the vulsellum, which was used to draw it down- 
 wards and to fix it while efforts were made to pass 
 the chain around it. Two or three days after this a 
 
 Fig. 
 
 chill ushered in an irritative fever, which unhappily 
 terminated fatallv. Here a valuable life was lost because 
 our art did not furnish the proper surgical appliances 
 for relief. With the ecraseur, as now supplied with the 
 porte-chaine, there is every reason to believe that we 
 would have succeeded in our first efforts. 
 
 In cases like this, occurring in advanced life, we often 
 find it difficult to dilate the os externum. The tent 
 may expand the canal of the cervix to the size of the 
 finger, while the os tineas may not become larger than a 
 No. 10 bougie. Under these circumstances, if we 
 attempt to force the finger into the cervix, the contracted 
 os feels rigid and resisting as if bound round by a fine 
 wire. And here, instead of repeating the tents, it is 
 safer and better to divide with the knife the sharp, well'
 
 90 UTERINE SURGERY. 
 
 defined edges of the contracted os, which will then 
 permit the finger to pass at once to the 
 cavity of the womb. This diagram (fig. 36) 
 represents the relative expansion of a tent 
 worn for six or eight hours, where the canal 
 of the cervix was dilated, while the os tincse 
 remained comparatively contracted : — «, the j 
 cervical portion; /;, the part constricted by 
 the os ; c, the vaginal portion. 
 
 I have now completed the series that I 
 proposed to give as types of this disease. 
 
 Time was when women died of polypi 
 without any effort being made for their 
 relief. This is not so now. No delicate operation is 
 easier ; none more successful. Life is sometimes lost 
 because we think the patient so near death that any 
 interference would only accelerate the fatal issue. This 
 is a great mistake. To save life where death is immi- 
 nent, we are justified in assuming great responsibilities 
 and even in taking great risks. I fear that we some- 
 times hesitate to do our duty by asking ourselves the 
 questioD, " How will it affect me if I fail ? " It has been 
 said of a great American lithotomist that he often 
 refused his skill to bad cases because they might spoil 
 the statistics of his unparalleled success. 
 
 In December, 1S61, Mr. Preterre, an eminent Ame- 
 rican dentist in Paris, asked me to see Madame R., in 
 consultation with her physician. She had menorrhagia 
 for many years, and was extremely prostrated by it, and 
 by a profuse muco-purulent vaginal discharge, which 
 had been present for six or eight months whenever the 
 haemorrhage ceased. She had been seen by many of 
 the most eminent surgeons in Paris, but no one suggested 
 anything for her relief. I found the uterus retroverted
 
 OF MENSTRUATION. 
 
 91 
 
 and greatly enlarged, the fundus extending quite to the 
 hollow of the sacrum, and .seemingly filling up the 
 whole of this region. A glance showed at once that it 
 could be but one of two things — a polypus or a fibroid 
 tumour. The os tincae admitted the end of the index 
 finder. I was anxious to determine the nature of the 
 case, and made gentle but persistent pressure with the 
 finger for some moments through the cervix. It gradu- 
 ally yielded to the force, and the finger, gliding to the 
 cavity of the uterus, detected an enormous fibrous poly- 
 pus, which could not pass outwards because of the 
 retroflexion. I was obliged to be in London the next 
 morning, but promised to return to Paris in a week, for 
 no other purpose than to apply a sponge tent and 
 remove the polypus for Madame R. Five or six days 
 after my departure they telegraphed to me that she was 
 much worse ; that a consultation of physicians had 
 decided that it w r as now too late to attempt any opera- 
 tion, and therefore that it was unnecessary for me to return 
 to Paris. Fortunately, the telegram was not received, 
 and I returned to Paris to find my patient in a state of 
 complete exhaustion. She had a profuse, dirty, offensive, 
 sero-sauguinoleut discharge from the vagina, which 
 poisoned the whole atmosphere of her apartment. Her 
 pulse was small and rapid ; she was quite anaemic, and 
 presented all the appearances of blood-poisoning. On 
 passing my finger into the vagina, I found it entirely 
 filled by an immense fibroid polypus in a state of decom- 
 position. She was evidently dying from the absorption 
 of the detritus of this fetid mass. At my first visit, a 
 week before, this tumour was wholly intra-uterine, but 
 now it filled the vagina. I infer that its escape from 
 the cavity of the uterus was due to powerful contrac- 
 tions provoked by the forcible introduction of the finger
 
 92 
 
 UTERINE SURGERY. 
 
 for exploration, for she grew worse from the moment of 
 nvy visit. She had forcing pains, as of labour, for a 
 while, and afterwards passed into the low condition in 
 which I found her. Its pedicle (as is most usual) grew 
 from the anterior wall. What was to be done ? There 
 was assuredly but one course to pursue. If we allowed 
 this great mass to remain there and slough away, death 
 was absolutely certain. Its speedy removal gave the 
 only hope of rescue. Her physicians consented to its 
 ecrasement, which occupied ten or twelve minutes. 
 Vaginal washes, wine, and a generous diet soon 
 completed the cure. If I had received the telegram, 
 she would certainly have died, and I should have been 
 censured by her friends for hastening the fatal issue, 
 inasmuch as my previous visit was the inauguration of 
 a new phase of her sufferings. If I had been afraid to 
 operate because she was almost in a moribund state, she 
 would unquestionably have been lost. For the success- 
 ful after-treatment of this case I am indebted to Dr. 
 Morpain. 
 
 I have related this case perhaps too minutely, but 
 it is to encourage the young man never to falter in the 
 clear path of duty to his patient, and to show that 
 extreme exhaustion is no barrier to the mere operation ; 
 for, when effected by the ecraseur, there is no danger 
 of haemorrhage, and very little of any other character. 
 
 I have no idea how many polypi Dr. Emmett and 
 myself have removed at the Woman's Hospital and in 
 private practice, and the case of Professor Metcalfe 
 above related is the only fatal one. This great success 
 is certainly due to the fact that we always used the 
 ecraseur or scissors. Ifc would seem that by these the 
 operation is almost always safe, while by deligation it is 
 fraught with great danger.
 
 OP MENSTRUATION. 93 
 
 Dr. Graily Hewitt is wholly opposed to deligation ; 
 so are many other recent writers. Dr. M'Clintock has 
 written most clearly and ably on this question.* He 
 reports ten operations by ligature, of which three were 
 fatal, and 'twenty-four by knife, scissors, or ecraseur, 
 without a single death. He says, moreover (p. 183), 
 that " a very high rate of mortality followed the use of 
 the ligature in the cases reported by Dr. R. Lee ; for, 
 of fifty-nine instances where the ligature was applied, 
 nine of the women died, and two of these deaths 
 occurred before the removal of the tumour was effected. 
 . . . Dr. Lee gives thirty-five other cases where polypi 
 were removed by torsion or excision, and amongst these 
 there is no death." 
 
 After this, it seems to me that it would be not only 
 hazardous, but absolutely culpable in us ever to resort 
 to deligation when there is any chance of immediate 
 ablation either by excision or ecrasement. 
 
 Before closing this subject, I may mention that 
 Dr. J. H. Aveling, of Sheffield, has added a valuable 
 instrument to our surgical resources for the removal of 
 polypi on the principle of ecrasement. It is represented 
 in fig. 37. The thumb-piece a is connected with the 
 projection b by a rod, which slides along a groove 
 in the shaft, which is driven by means of the screw at 
 the handle of the instrument. When the extremity c 
 is placed around the pedicle, the part b is made to 
 sever it by being forced through till it is entirely lost 
 in the fenestral opening in the curved extremity. Dr. 
 Aveling calls this instrument the Polyptrite. It is 
 described in the Obstetric Transactions, vol. 4. 
 
 * " Olinioal Memoirs," pp. 183-186.
 
 94 
 
 UTERINE SURGERY. 
 
 Of Menorrhagia from Fibrous Tu 
 mours. — The uterus is particularly prone 
 to the development of fibroid tumours. 
 They occur at all ages after puberty. They 
 are seen in young girls under twenty, and 
 in the octogenarian, and may vary from the 
 size of a pea to that of the gravid uterus at 
 full term. They are in themselves inno- 
 cuous, except mechanically, as when they 
 exert an undue pressure upon the blad- 
 der, rectum, or pelvic nerves and veins, 
 or when they produce haemorrhages. They 
 frequently prevent conception, but not 
 necessarily and invariably so. They are 
 classed according to the manner of their 
 attachment to the walls of the uterus — as 
 extra-uterine, intra-uterine, andintra-mural. 
 Extra-uterine fibroids grow from any 
 portion of the external surface of the 
 uterus, and may be pedunculated ; or 
 they may be sessile, with a broad immova- 
 ble attachment to its outer muscular tis- 
 sue. 
 The intra-uterine project into the cavity of the 
 womb, and, like the first, may be pedunculated or 
 sessile; and here we make a distinction in practice but 
 not in theory, calling the one a fibroid polypus because 
 it is pedunculated, the other a fibroid tumour because 
 it is sessile, having a broad attachment usually to one 
 wall of the womb ; the one being remedied with com- 
 parative ease, the other with great difficulty. 
 
 The intra-mural are so called because they are em 
 bedded in the walls of the uterus, being interlaced and 
 overlapped in all directions by its muscular fibres.
 
 OF MENSTRUATION. 
 
 95 
 
 Fibroid tumours interfere mechanically with con- 
 ception ; for instance, they may antevert or retrovert 
 the uterus, and throw the os out of its normal relation 
 with the axis of the vagina. They may elevate the 
 whole organ high up in the pelvis, so that the semen 
 may never come in contact with the os even momen- 
 tarily. They may compress the canal so as to produce 
 a mechanical obstruction to the passage of the semen, 
 or they may produce haemorrhages which would be 
 fatal to the life of the germ even if vivified. I have, 
 however, occasionally seen pregnancies where there had 
 been for years large fibroid tumours. 
 
 Of 225 women who had once borne children and then 
 became sterile, 38 had fibroid tumours of various sizes, 
 and variousl v seated — or one in 6^r. Two were fibroids 
 of the posterior lip of the os tineas; the remainder, 
 of the body of the uterus. Of these, 
 
 Six -were pedunculated 
 
 Twenty were sessile 
 
 2 on the anterior "wall. 
 
 2 on the posterior wall. 
 
 1 on the left side. 
 
 1 on the right side. 
 
 2 on the fundus. 
 
 5 on the anterior wall — one very 
 
 large. 
 8 on the posterior wall. 
 5 on the right side — none on the 
 
 left. 
 
 1 in the fundus. 
 7 in the anterior Avail. 
 1 in the posterior wall — very 
 large. 
 
 Nine were intra-mural . . . 
 
 One intra-uteriue — very large and growing from ihe posterior 
 walL 
 
 Of 250 married women who had never borne 
 children, the cause of sterility was found to be compli-
 
 96 
 
 UTERINE SURGERY. 
 
 cated with the presence of fibroid tumours in 57, being 
 at the rate of about one in 4fV. Of these, 
 
 Five were pedunculated 
 
 Twenty-one were sessile 
 
 • • * 
 
 Thirty-one were intra-mural 
 
 None intra-uterine. 
 
 2 on the anterior wall. 
 2 on the posterior wall. 
 
 1 on the fundus. 
 
 8 on the anterior wall — one of 
 them reaching round to the 
 right side, and one to the 
 left. 
 
 10 on the posterior wall — one 
 of them reaching to the right 
 side, and one to the left side. 
 
 2 on the left side. 
 
 1 on the right side, and very 
 large. 
 
 3 in the fundus — one very 
 
 large. 
 23 in the anterior wall — two very 
 
 large. 
 5 in the posterior wall — two very 
 
 large. 
 
 In 100 virgins consulting for some uterine disease, 
 24 had fibroid tumours, or one in 4£. Of these 24, 
 
 Three were pedunculated 
 
 2 on the anterior wall — both very 
 
 large. 
 1 on the posterior wall. 
 
 2 on the anterior wall — one 
 
 large. 
 2 on the posterior wall — one 
 
 reaching round to left side. 
 1 on the right lateral wall — and 
 
 very large. 
 
 Thirteen were intra-mural 
 
 11 in the anterior wall — three 
 
 large. 
 2 in the posterior wall.
 
 OF MENSTRUATION. 
 
 97 
 
 Tyro intra-uterine 
 
 2 to posterior wall — and both very- 
 large. 
 
 One large fibroid attached to sacrum. 
 
 The polypoid fibroids are excluded, because they are 
 considered separately in the previous section on Polypus. 
 Were thev included here, of course the intra-uteVine 
 
 «/ 7 
 
 fibroids would be greatly increased. This arbitrary 
 arrangement is pathologically incorrect, but practically 
 right. 
 
 To recapitulate — Thus, of 605 cases (100 being 
 unmarried, and 505 being married and sterile) 119 had 
 fibroid tumours, either large or small, connected in some 
 way with the utems, being nearly one in 5i. 
 
 The following table embraces the whole at a 
 glance : — 
 
 Of these 119 cases of fibroid 
 tumour : — 
 
 14 were pedunculated . . 
 
 
 Fundus. 
 
 Ant. 
 wall. 
 
 Post, 
 wall. 
 
 Left 
 lateral. 
 
 Eight 
 lateral. 
 
 Total. 
 
 .... 
 
 1 
 2 
 
 4 
 
 6 
 
 15 
 41 
 
 5 
 
 20 
 8 
 3 
 
 1 
 
 2 
 
 • • • • 
 
 1 
 
 7 
 
 • • • • 
 
 • • • • 
 
 14 
 46 
 
 
 
 53 
 3 
 
 1 was sacral 
 
 1 
 
 2 
 
 
 
 1 
 
 2 were on the posterior 
 
 
 
 
 
 
 2 
 
 
 
 
 
 
 
 Total 
 
 3 
 
 7 
 
 62 
 
 36 
 
 3 
 
 8 
 
 119 
 
 
 
 These tables show the great frequency of fibroid 
 growths in connection with the uterus, a thing long ago 
 established by West and others. It will be seen that 
 (62) more than half of the whole number were seated 
 in or on the anterior wall. 
 
 It will be remembered that I have said (page 84) 
 
 7
 
 98 UTERINE SURGERY. 
 
 that we find intra-uterine polypi (which are only pedun- 
 culated fibroid tumours) more frequently attached to 
 the anterior than to the posterior face of the cavity of 
 the uterus. I only state the fact without pretending to 
 explain the why or the wherefore. 
 
 I give these details simply because I have them, and 
 not because I attach much value to such statistics. 
 They are entirely from cases observed in private practice. 
 Had I now access to the books of the Woman's Hospital, 
 it is probable that these figures might be changed, but 
 only relatively. Fortunately for my patients but two 
 of these 119 cases were verified by post mortem evidence. 
 Their diagnosis rests wholly upon the judgment of an 
 individual, which is infallible in no man. 
 
 But I will claim, what I would allow to any one 
 else, that the errors of judgment would be not of fact 
 but of degree — for instance, here is a case of fibroid 
 tumour of the anterior wall — it is as large as a Sicily 
 orange. Of its situation and general outline there can 
 be no doubt, but there may occasionally be a case in 
 which we are a little doubtful whether it be intra-mural 
 or merely sessile. And if the figures above could be 
 varied in anyway, it would be in some such unimportant 
 relation as this. 
 
 The diagnosis of fibrous tumours is much more 
 certain now than it was before the introduction of the 
 uterine probe by Dr. Simpson. Twenty years ago how 
 few of us could tell whether the uterus was anteverted 
 or retro verted ; whether its enlargement, if any, depended 
 upon a mere hypertrophy of its proper tissue, or upon 
 some adventitious growth either within, upon, or near 
 the organ. Now, however, we diagnose uterine compli- 
 cations with the utmost precision — and all by the touch, 
 the tent, and the probe.
 
 OF MENSTRUATION. 99 
 
 As a rule, the diagnosis of fibroid tumours is not 
 difficult. We are more apt to fail in detecting small 
 tumours than large ones, and yet it is easy to map out 
 very minute nodosities on the surface or in the walls 
 of the womb. The whole secret of this consists in 
 getting the body of this organ between the left index 
 finger in the vagina and the right hand in the hypogas- 
 trium, as explained on pages 10 and 11, so that every 
 portion of its surface is minutely traversed, and any 
 deviation from its normal size is accurately measured. 
 
 If it be already anteverted, there is not the least 
 difficulty in this. If it be retroverted, or even in its 
 normal position, then it must be brought sufficiently 
 forward to be grasped between the sensive forces of the 
 two hands. If the walls of the abdomen are very thick, 
 there may be some little obscurity for a while, but a 
 second effort will usually clear it up. If the patient 
 holds the breath, and contracts the abdominal muscles, 
 we may be compelled to etherize her — but this is rarely 
 necessary. But, suppose we have a tumour in the 
 pelvis the size of a small orange, or as large as the fist. 
 Is it in the uterus ? on the uterus ? or quite detached 
 from it ? The sound determines the direction and depth 
 of the uterine cavity, and shows its relation to the 
 enlargement, and this in conjunction with the means of 
 palpation already described. But even then we may be 
 occasionally in doubt whether the enlargement is due tc 
 something in the cavity of the uterus, in its walls, or on 
 the outside — and here the sponge tent comes to our aid, 
 and enables us to explore the uterine cavity by the 
 touch. 
 
 But suppose we have a tumour in the Douglas cul 
 de sac. We ask ourselves the questions — Is it a retro 
 version or flexion ? Is it merely hypertrophy of tht»
 
 100 UTERINE SURGERY. 
 
 posterior wall ? Is it a fibroid, interstitial, sessile, 01 
 pedunculated ? Is it a prolapsed enlarged ovary % Is it 
 a collection of pus, of blood, or of faeces ? The history 
 of the case will give the probable clue to many of these 
 queries ; but the application of the principles of investi- 
 gation already laid down can alone accurately solve the 
 real nature of the malady. Longer minute detail on 
 this point would be profitless. Enough has been said to 
 show the student that positive knowledge of this charac- 
 ter can be acquired only by the ripe experience of self- 
 training. 
 
 As an illustration of the seeming difficulties, but of 
 the real facilities of diagnosis, I here resort to my best 
 argument — a clinical report. 
 
 Mrs. , from the State of Texas, aged twenty- 
 four, married five years, was sterile. Her menses were 
 regular, painles*, lasting three days. She had some 
 leucorrhcea, but consulted me on account of her sterility. 
 
 She had been treated by distinguished professors in 
 four of our largest cities, and all, without exception, 
 told her she had retroversion. On making an examina- 
 tion, I found the opposite state of things, viz. a complete 
 ante version, with a tumour filling up the Douglas cul de 
 sac, and giving to the touch the exact sensation of 
 density and size of a retroverted uterus, with hypertro- 
 phy of posterior wall. 
 
 But by the method of the consentaneous counter-pres- 
 sure with the two hands, the position, size, and relations of 
 the uterus and tumour were readily traced out as shown 
 in this diagram (fig. 88). The left index finger, after 
 exploring anteriorly at &, was carried on till it passed to 
 the posterior cul de sac at b ; then the points of the four 
 fingers of the right hand were pushed firmly backwards 
 and downwards, from e to d, carrying the abdominal
 
 OF MENSTRUATION. 1Q1 
 
 walls from their normal line at c deeply in the direction 
 of the dotted line e d. When this hand was carried 
 as far in this direction as could be done with conve- 
 nience to the surgeon and comfort to the patient, 
 
 Fig. 38. 
 
 it was held there immovably fixed, while the index 
 finger of the left at b was made to elevate the cervix 
 uteri as if to bring the points b and d into contact. If 
 tin- uterus be anteverted, as it was here, then the fundus 
 will be pushed up against the palm of the outer hand at 
 e, to be grasped, as it were, between the two opposing 
 forces, and thus accurately measured — while the same 
 discriminating pressure detects, at the same time, the 
 presence of the tumour/. To be more positive on this 
 point, the index finger was pushed backwards, carrying 
 the posterior wall of the vagina to •/, where it was able 
 to elevate the tumour, passing it up against the points 
 of the fingers at d, while they were still cognizant of 
 the presence of the body of the uterus as already 
 indicated. This examination made the case perfectly 
 plain; but, to fortify these facts, the finger was parsed 
 into the rectum, which confirmed, but added nothing to
 
 1Q2 UTERINE SURGERY. 
 
 the evidence of the previous method. A sound was 
 also passed to the fundus of the anteverted uterus, 
 which would have removed all doubt if there had been 
 any. 
 
 When I told this lady what the trouble was, she 
 said it must be impossible that I should be right, when 
 five or six others, equally entitled to credit, were all of 
 an opposite opinion. 
 
 I asked her not to take my opinion alone, but to go 
 to others if she desired it, and I gave the names of three 
 or four of our most distinguished accoucheurs in New 
 York. In two or three days she returned, saying she 
 did not call on any of the gentlemen I named, but that 
 she had seen another medical man, of deservedly great 
 reputation as a physician, and also of large experience 
 in the treatment of uterine disease, and that he 
 pronounced her case undoubtedly one of retrover- 
 sion. 
 
 Although this case would deceive any superficial 
 investigator, there was nothing easier than its diagnosis 
 by the plan of bi-manual palpation. How often have I 
 seen uterine examinations made by the vaginal touch 
 alone ! And here is the great mistake. This is very 
 well to determine the size and relations of the vagina, 
 and the condition of the os and cervix, but so far as 
 anything else is concerned, it is simply futile. It is 
 merely groping in the dark. The value of the uterine 
 sound cannot be over-estimated when used merely for 
 purposes of diagnosis, whatever may be said of it as a 
 redresser. If we are not able to determine the position, 
 size, and relations of the uterus by the touch alone, the 
 sound is infallible in giving us its depth and direction. 
 If we find a tumour of any sort either before, behind, 
 or to one side of what we usually regard as the normal
 
 OF MENSTRUATION. 
 
 103 
 
 position of this organ, the probe will instantly tell us if 
 it be the body of the uterus or not. 
 
 I use the sound simply as a probe to measure the 
 
 Figs. 39 & 40. 
 
 depth of the uterus, and to show in what direction the 
 fundus lies. For this purpose I have it made of virgin 
 silver or of annealed copper, silvered. It is also 
 smaller than Simpson's sound, and without notches or 
 marks. It is made malleable because it is necessary 
 to chauge the curvature with almost every case. It is 
 smaller to make it universally applicable, whether the 
 canal and os internum be large or small. It is without
 
 104 UTERINE SURGERY. 
 
 indentations or marks, to enable us to keep it thoroughly 
 clean. 
 
 These two diagrams (figs. 39 and 40) represent the 
 relative difference between a uterine probe of malleable 
 silver or copper and the ordinary redresser of hard 
 German silver. They represent the exact size of the 
 instruments as found in the shops. 
 
 The small one can be curved to pass in the suspected 
 direction of the body of the uterus, and, if properly 
 done, never gives pain ; the other, large and rigid, often 
 produces great agony, sometimes by being too large 
 to pass along a narrow canal, but oftener by being 
 forced in a wrong direction. Until I modified the 
 instrument to a simple probe, I dreaded even to attempt 
 its use in any case of suspected anteflexion. But now 
 the diagnosis of the worst case of dysmenorrhoaal ante- 
 flexion is as easy and as painless as that of an old 
 retroflexion with a patulous canal. 
 
 I have often had the greatest difficulty with the 
 German silver sound ; and if I were to say I had seen 
 a score of cases in consultation where physicians assured 
 me it was utterly impossible to pass the sound, I would 
 not exaggerate the number in the least. I have felt 
 and seen so much annoyance on this point that I may be 
 pardoned for a little minutiae. 
 
 The cases that usually give us most trouble are those 
 of complete anteflexion, with a fibroid in the anterior 
 wall. One will serve as an example of the class. Let 
 fig. 41 represent an anteflexion with a fibroid, «, as large 
 as an almond, in the anterior wall. If we should 
 attempt to pass the large German silver sound, in its 
 fixed position, to the fundus uteri, it would inevitably 
 be arrested at Z», it matters not how dexterously we 
 may elevate the fundus with the index finger to
 
 OF MENSTRUATION. 
 
 105 
 
 it 
 it 
 
 Fig. 41. 
 
 had been clone. We 
 can be avoided : nor 
 
 straighten the organ up at 
 the time we make the effort. 
 
 I have seen such exces- 
 sive pain thus inflicted that 
 the patient, could hardly be 
 persuaded to allow a repeti- 
 tion of the process. And I 
 have often passed the small 
 malleable instrument under 
 such circumstances when the 
 patient was not aware that 
 should never inflict pain if 
 should we carelessly shock the nervous system of one so 
 delicately organized, and that too, perhaps, when that 
 organism is so intensified by diseased action as to exag- 
 gerate to an unbearable degree the slightest movement 
 or even sound. 
 
 Valuable as the uterine probe may be for giving us 
 the direction of the fundus uteri, it is not to be depended 
 upon alone to measure its depth, if that should exceed 
 four inches ; and for the simple reason that the curva- 
 ture necessary to pass it along the pelvian axes would 
 make it strike against the anterior wall of the uterus 
 before it could reach the fundus, if this should be six or 
 eight inches deep. 
 
 As an illustration, take the following : A woman 
 thirty-five years old, the mother of two children, had 
 been for several years subject to menorrhagia. The 
 abdomen was about as large as at the full term of preg- 
 nancy. Palpation showed that it was due to an enor- 
 mous tumour, which was either wholly uterine or uterine 
 and ovarian. A physical exploration was necessary to 
 determine this point. The diagram (fig. !>4) illustrates 
 the diagnosis.
 
 106 
 
 UTERINE SURGERY. 
 
 On introducing the uterine probe, it passed four 
 inches, striking the anterior wall of the uterus on a line 
 with the upper edge of the pubes ; but was this truly 
 the whole depth of the organ % A gum elastic bougie 
 
 Fig. 42 
 
 would settle this point. On making the effort, it passed 
 easily more than eleven inches into the cavity of the 
 uterus, measuring from the os tincse. But it is not 
 always easy to pass a bougie. If it is large enough not 
 
 Pig. 43. 
 
 to bend on itself, it may not pass through some narrow 
 point, and so will deceive us. And if it be too small,
 
 OF MENSTRUATION. JQf 
 
 it will bend on itself in the vagina, and hence it will be 
 difficult -to pass it at all. To overcome these objections, 
 take a bougie about No, 6, sometimes smaller, and run a 
 strong wire in it, and give it a gentle curvature at the 
 distal end, as shown in the diagram (fig. 43). Introduce 
 this just within the os uteri, and then hold the handle 
 of the wire, a, firmly in one hand, and push the bougie, 
 £, along it with the other. The wire thus stiffens the 
 bougie external to the uterus, but allows it to pass 
 onwards to the cavity, taking, of course, the easiest 
 route, and measuring accurately its depth. Whether 
 this direction be in the central axis of the organ, ante- 
 riorly or posteriorly, would be afterwards determined 
 by the sponge tent. In this case the bougie passed 
 nearly its whole length into the cavity of the womb, 
 marking a depth of over eleven inches. This proved 
 that its enlargement was due to a fibroid. It was then 
 a question whether this fibroid was intra-mural or intra- 
 uterine. This was proved at once by a very singular 
 fact, viz. that the gum elastic bougie, when introduced 
 into the cavity of the uterus, could be felt through the 
 thin walls of the abdomen, and thinner of the uterus, 
 from just above the pubes, quite to the fundus far above 
 the umbilicus (see fig. 42). This alone showed that the 
 tumour projected into the cavity of the uterus from the 
 posterior wall of that organ. Was it, then, an enormous 
 fibroid polypus — i. e., an intra-uterine pedunculated 
 tumour, or was it a sessile fibrous tumour, with a broad 
 attachment to the uterine walls ? The sponge tent was 
 to unravel that mystery. It was accordingly resorted 
 to ; the finger was then carried up into the uterus, and 
 the anterior portion of the organ was found to be free, 
 while on the posterior, about an inch above the os tincae, 
 we felt a large tense tumour, having attachments poste-
 
 108 UTERINE SURGERY. 
 
 riorly at the cervix, which widened out on either side 
 as the finger was thrown in front and around it. The 
 finger detected its attachment posteriorly below, while 
 the probing with the elastic bougie demonstrated it 
 above ; thus proving that the tumour grew from the 
 posterior wall of the uterus, and that it had a base of 
 attachment along this wall of probably not less than 
 eight or nine inches. The tumour itself was unusually 
 tense to the touch, and we concluded to explore it by 
 puncture. In the presence of Dr. Emmet, Dr. Pratt, 
 and Professor Elliot, I passed a trocar into it at its 
 lowest point, and in the direction of its long axis, and 
 there were discharged more than twenty ounces of a 
 colored serum. The puncture was enlarged for two 
 inches, to prevent its closing. There was at once a 
 sensible diminution in the size and tension of the abdo- 
 men. The discharge kept up for some time ; and this, 
 together with occasional injections into the very fundus 
 of the uterus, with the liquor ferri persulphatis, diluted 
 with three or four parts of water, arrested very promptly 
 the haemorrhages, and the patient was dismissed in two 
 months in a very comfortable condition, and with 
 strength enough to walk six or eight miles. Indeed, so 
 far as the hgernorrhages were concerned, she was cured. 
 She returned in a few weeks with ruddy looks to report 
 that she was in very good health, although the abdomen 
 was seemingly as large as ever. It was evidently a fibro- 
 cystic tumour, its first element remaining in statu quo, 
 while its second was destroyed by the puncture and 
 slitting up of the cyst. Within the course of a year 
 afterwards this poor woman died of cholerine of a few 
 hours' duration, which her physician did not think in 
 any way dependent upon the fibroid tumour. 
 
 We all know that fibroids of the uterus are harmless
 
 OP MENSTRUATION. 109 
 
 unless they produce haemorrhage or press injuriously on 
 some of the pelvic viscera. I have seen many cases 
 where there were fibroids larger than the foetal head, and 
 the patients were not aware of their existence. I was 
 consulted in' Paris in October, 1863, by a lady who had 
 been married fifteen years without offspring, and she 
 wished to know the cause of her sterility. She had a 
 pedunculated fibroid tumour, large enough to rest on 
 the brim of the pelvis, which drew the uterus forwards 
 and upwards, raising its fundus much above the level of 
 the pubes. Her health was perfect in every respect, and 
 she felt no inconvenience from the tumour, which will 
 doubtless never shorten her life a day. 
 
 Of late years a good deal has been written on the 
 treatment of fibroid tumours of the uterus. 
 
 Professor Channing, of Boston, claims to have cured 
 many by internal medication ; while Dr. Simpson seems 
 to have great faith in the long-continued use of the 
 bromide of potassium. Dr. Emmet and myself have 
 tried this and other constitutional remedies in the 
 Woman's Hospital and in private practice, and I am 
 sorry to say we have not been as fortunate as the gentle- 
 man named above. On the contrary, I have never seen 
 the slightest effect produced on such tumours by any 
 internal medication. Dr. Atlee, of Philadelphia, and 
 Mr. Baker Brown, of London, have each attacked uterine 
 fibroids surgically and in a heroic way. 
 
 Dr. Atlee has had a success in enucleation which has 
 not been equalled by any one else. He advocates a 
 total eradication of the adventitious growth ; while Mr. 
 Baker Brown is satisfied with maiming or mutilating the 
 tumour by what he terms a gouging process. His 
 success has also been very great, not in curing the 
 disease, but in curing its worst manifestation — haemor-
 
 110 
 
 UTERINE SURGERY. 
 
 rhage. And with this we should feel well satisfied ; for, 
 as a general rule, I do not think we should interfere 
 with these tumours unless they endanger life. That 
 there are cases in which we must interfere I readily 
 admit ; and the success of Atlee and Brown will justify 
 such a course. I have not been so fortunate as they in 
 attacking very large intra-uterine fibroids. I have lost 
 two patients in the Woman's Hospital as a consequence 
 of operative procedures ; one from an attempt at enucle- 
 ation, the other from the removal of a bit of the tumour; 
 
 Fig. 44. 
 
 the one in imitation of Dr. Atlee, the other in imitation ' 
 of Dr. Brown. The first was the case of an unmarried 
 lady, twenty-eight years old. Menstruation occurred at, 
 sixteen, and continued regular and normal for ten } 7 ears, 
 when it suddenly became abundant and painful. Two 
 years afterwards, in November, 1859, she was admit- 
 ted to the Woman's Hospital. The flow was then 
 profuse, exhausting, and attended with severe forcing 
 pains, from which she suffered for a whole week 
 before the menses made their appearance. The uterus
 
 OF MENSTRUATION. 1H 
 
 was about the size of the organ at the sixth mouth of 
 pregnancy. The os and cervix were small, while the 
 body of the organ was large, hard, and roundish. Its 
 outline and relations are represented in fig. 44. The 
 sound could be passed in the direction of the uterine 
 cavity for only about four inches, being arrested at «, 
 by striking against the anterior wall of the uterus. But 
 the gum elastic bougie showed that the cavity was more 
 than nine inches deep. Then the sponge tent demon- 
 strated that the tumour was intra-uterine, with a broad 
 base of attachment to the posterior wall, beginning just 
 within the os, at e. The great pain preceding and 
 attending each period; the excessive loss of blood at 
 the time ; the increasing prostration ; and the entreaties 
 of the patient, determined ine to enucleate the tumour 
 if possible. The first step towards this was to enlarge 
 the canal of the cervix, which, as before stated, was 
 very small. For this purpose it was split widely open 
 up to the insertion of the vagina, and even to the os 
 internum. The haemorrhage was very profuse, but easily 
 checked. The parts healed before the recurrence of the 
 next flow, which was in no way modified by the opera- 
 tion. The forcing pains and the haemorrhage were 
 quite as great as before. 
 
 After this, the next step of enucleation was taken, 
 viz. cutting open the capsule of the tumour. Instead 
 of making a long incision through this from above 
 downwards, as practised by Dr. Atlee, I simply cut 
 the capsule transversely at e, making an opening in it 
 about two inches and a half long, and then passed a 
 sound for six or seven inches in the direction of the 
 dotted line e b, extensively lacerating the cellular 
 tissue that bound the posterior wall of the uterus and 
 the tumour together. I now think Dr. Atlee's plan
 
 ;Q2 UTERINE SURGERY. 
 
 of incisiug the capsule would have been the best 
 The bleeding was very profuse, but it was wholly from 
 the first incision, and not from the subsequent lacera- 
 tion. This was checked by a tampon. 
 
 After Miss M. recovered from the effects of this 
 operation, it was thought advisable for her to go to 
 the country, and wait the efforts of nature in forcing 
 the tumour down through the artificial opening made 
 in its capsule. 
 
 She returned in two or three months with the mouth 
 of the uterus about two inches and a half in diameter, 
 and a portion of the tumour projecting through it into 
 the vagina. The pain and the haemorrhage were rather 
 worse, whether in consequence of the operation, or in 
 spite of it, I do not know. 
 
 The attachments of the tumour were now further 
 incised, and its adhesions extensively broken up, but 
 unfortunately Miss M. was attacked with diphtheria, 
 from which she barely escaped with her life. So great 
 was her prostration from this disease and the haemor- 
 rhages combined, that she was again removed from the 
 hospital. 
 
 She returned six months afterwards (in October, 
 1860), but the haemorrhages were in no way modified 
 by the process of enucleation, which had been slowly 
 going on for months. The uterus had greatly increased 
 in size, notwithstanding the fact that the tumour, now 
 filling up the whole vagina, was quite as large as the 
 foetal head at full term. Indeed, it seemed that the 
 removal of the obstructions at the cervix uteri only 
 invited and promoted the growth of the tumour down- 
 wards, without dislodging any portion of it from the 
 body of the organ. Its size was so enormous that it 
 was thought advisable to remove all that portion of it
 
 OF MENSTRUATION. J] 3 
 
 that projected through the dilated cervix, preparatory 
 to the real enucleation and ablation of what occupied 
 the body of the womb. 
 
 Accordingly, a cord was passed around it in the 
 direction of the dotted line a 
 (fig. 45), where it was severed. 
 The haemorrhage was fearful, 
 and she lost a large amount of 
 blood before it could be con- 
 trolled by a tampon. She 
 scarcely rallied at all from the 
 effects of the chloroform, and 
 died of exhaustion in thirty-six 
 hours afterwards. FlG 
 
 I think that death in this 
 case was caused by the unexpected and immense loss 
 of blood that suddenly took place in the brief space 
 of time between the severance of the tumour and its 
 removal from the vagina. 
 
 The prolonged use of the chloroform in all proba- 
 bility exerted a very pernicious influence. 
 
 The portion of the tumour removed was so large that 
 it was with great difficulty extracted from the vagina. 
 
 Indeed, to do this, it was necessary to enlarge the 
 ostium vagina? by perineal incisions, one on each side 
 of the fourchette. A similar case to this was operated 
 on at the Woman's Hospital the year before. 
 
 That part of the tumour projecting into the vagina 
 was removed by ecrasement, in October, 1859. Our 
 patient recovered from the effects of the anaesthesia 
 and the operation, and we expected to enucleate the 
 remainder of the tumour, when she was suddenly 
 attacked with peritonitis, four months afterwards, which 
 carried her off. 
 
 8
 
 114 UTERINE 8URGEEY. 
 
 In June, 1861, a widow lady, aged 30, who had 
 been for two years subject to menorrhagia, was ad- 
 mitted into the Woman's Hospital. These periodical 
 haemorrhages were profuse and exhausting, and she 
 had all the evidence of extreme anaemia. The os 
 tincae was small, and the cervix firm and indurated, 
 while the body of the organ was felt to be as large as 
 the two fists. The depth of the uterus was five inches. 
 The enlargement and the haemorrhage were evidently 
 due to one of two things — either a fibroid tumour 
 or a polypus. A spouge tent or two enabled the 
 finger to pass into the uterine cavity, when a very 
 firm and unusually hard tumour was found project- 
 ing from the posterior wall of the uterus, having a 
 broad, strong attachment to its whole posterior surface. 
 A puncture was made in that portion of the tumour 
 nearest the cervix, and a large quantity (eight ounces) 
 of a clear, limpid, transparent, straw-coloured serum was 
 evacuated. To make sure of a radical cure, a bit of the 
 sac of this fibro-cystic growth was removed with scissors. 
 It was elliptical, and about one inch and a half long 
 by three quarters of an inch wide. This was done in 
 imitation of Mr. Baker Brown's gouging process. I 
 had seldom felt so well satisfied with an operation ; but 
 unfortunately irritative fever set in, and my patient 
 died of pyaemia in the course of twenty days. These 
 four cases are all that have been subjected to any opera- 
 tion for radical cure in the Woman's Hospital. 
 
 Two recovered from the operations, but both died 
 within a year afterwards — one from peritonitis; the 
 other from cholerine of a few hours' duration. Two 
 died from the immediate effects of operative pro- 
 cedures — one of these from exhaustion produced by 
 loss of blood aided by chloroform poisoning ; the other
 
 OF MENSTRUATION. \ ] 5 
 
 from pyaemia. It may be thus literally stated that two 
 died and two recovered ; for death in the last two was 
 due to accidental causes which were most probably 
 independent of the operations. 
 
 The complete eradication of an intra-uterine fibroid 
 with abroad sessile attachment is exceedingly hazardous, 
 while the removal of an intra-uterine fibroid with a 
 peduncular attachment is comparatively one of the safest 
 operations in surgery. 
 
 But why take so much time with fibroid tumours? 
 Could the removal of such immense tumours be followed 
 by conception and safe delivery ? 
 
 It might very well be a question, whether such a 
 hazardous operation as the enucleation of a large fibroid 
 tumour should be performed simply for the removal of 
 sterility, and when the life of the sufferer was not 
 jeopardized by severe haemorrhage. But I could very 
 well imagine cases where it would be justifiable. Suppose 
 a dynasty w r as threatened with extinction, and the cause 
 of sterility was ascertained to be an enucleable fibroid: 
 here the perpetuity of a good government and the 
 welfare of the State might depend upon the result. Or 
 suppose an ancient family of great name, influential 
 position, and large fortune, desirous of perpetuating 
 these noble heritages in a line of direct descent : would 
 such an operation be justifiable, if the parties, knowing 
 the risks, were willing to assume the responsibilities ? 
 
 But could we promise the possibility of conception 
 after all had been successfully done ? 
 
 As a rule, while there is menstruation there is 
 ovulation, and any woman that ovulates can be impreg- 
 nated, provided the spermatozoa and the ovum can be 
 brought in contact at the proper time and place, and 
 under favourable circumstances.
 
 HQ UTERINE SURGERY. 
 
 The neck of the uterus may have been destroyed by 
 sloughing, or by other means ; there may be loss of the 
 greater part of the vagina ; there may be partial atresia 
 of it ; there may be an ovarian tumour ; there may be 
 fibroid tumours, pedunculated, sessile, interstitial, or 
 intra-uterine ; there may have been hematocele, pelvic 
 cellulitis, or even carcinoma of the neck of the womb, 
 and yet conception is always possible, provided men- 
 struation, the sign and symbol of ovulation, be such as 
 to warrant a healthy condition of the uterine cavity, the 
 nidus of the new beino;. 
 
 Our literature teems with cases of delivery compli- 
 cated with fibroid tumours in some part of the uterine 
 structure, and our experience and observation teach us 
 that these tumours are a very frequent source of 
 sterility. 
 
 But to return to the question — "Is conception 
 possible, and safe delivery probable, after the enuclea- 
 tion and removal of a large intra-uterine fibroid ?" It is 
 not at all uncommon to see this follow the removal of 
 the intra-uterine pedunculated fibroid, called polypus — 
 and why not the sessile fibroid, called intra-uterine 
 fibroid tumour ? But the proof of this is fortunately not 
 left to hypothesis or analogy. And the question is 
 answered affirmatively by the record of one of the most 
 interesting cases to be found in English medical literature, 
 by Mr. Grimsdale,* of Liverpool. The interest of the 
 subject will justify me in extracting the general features 
 of the case from Mr. Grimsdale's published account. 
 
 * A Case of Artificial Enucleation of a large Fibroid Tumour of the 
 Uterus ; with some Remarks on the Surgical Treatment of these Tumours. 
 By Thomas F. Grimsdale, Surgeon to the Lying-in Hospital, and Lecturer 
 on Diseases of Children, at the Liverpool Royal Infirmary School of Medi- 
 cine. — Liverpool Medico - Chirurgical Journal, January, 1857.
 
 OF MENSTRUATION. J If 
 
 Ou the 12tli October, 1855, Mr. Grimsclale first saw 
 Margaret West, aged 33 years, a stout healthy-looking 
 woman, married three years ; eleven months after 
 marriage (say in 1853) delivered prematurely of a still- 
 born child, profuse Hooding, checked with difficulty ; in 
 1854 conceived a^ain, but miscarried at three months on 
 Christmas ; this also attended with great flooding ; 
 menstruation very profuse, but regular after this, till 
 three months ago (say in July, 1858) ; supposed herself 
 pregnant, but there was no nausea. The uterus was 
 about the size of this or^an at six months, but without 
 the usual elastic feel of pregnancy. A loud bruit heard 
 all over the tumour, cervix uteri pushed forward, os 
 open, lips everted, hard and granular. 
 
 Mr. Grimsdale's diagnosis was, "fibroid tumour of the 
 uterus ; probably pregnancy in addition." He watched 
 her for a fortnight. She had occasional profuse discharges 
 of blood. On consultation with Mr. Bickersteth, they 
 agreed that the safety of the patient demanded the in- 
 duction of abortion at once. Sponge tents were used, 
 the cavity probed for seven inches, the tumour found to 
 be adherent to the whole extent of the posterior wall. 
 
 Mr j Bickersteth made the incision for enucleation 
 with a straight bistoury through the posterior wall of 
 the cervix, about three-quarters of an inch within the 
 canal, and, coming down on the capsule of the tumour, 
 plunged the knife into it ; index finger passed through 
 incision nearly to the second joint, and the tumour was 
 thus separated for some distance from the proper tissue 
 of the uterus. But little bleeding followed the incision, 
 which was plugged, the lint being forced up between the 
 tumour and the uterine wall. 
 
 1st day after operation. — Pulse 96 ; vagina hot ; 
 tampon removed ; vagina syringed.
 
 I 13 UTERINE SURGERY. 
 
 2nd day. — Aborted a four months' foetus and 
 placenta. 
 
 1th day. — Bat little variation ; vagina syringed and 
 opening plugged daily. 
 
 8th day. — Uterine pains; watery discharge ; tumoui 
 began to protrude through the artificial opening, which 
 was dilated a little more; presenting part of tumour 
 soft ; discharge offensive ; pulse 120 ; countenance pale, 
 anxious ; tongue dry ; thirst. 
 
 During the next week her condition changed a little 
 for the better. She took beef-tea, opium, ergot, and 
 had- the vagina syringed twice a day. The tumour 
 gradually dilated the artificial os, when, on the 14th day, 
 the fingers could not reach the uterus; the tumour had 
 passed through, so as to fill the upper part of the vagina 
 It was soft and sloughy ; pulse 96. 
 
 15th day. — Much worse; had a chill this morning ; 
 since then very low; pulse 112 ; thready; tongue dry ; 
 glazy ; countenance anxious ; very desponding; ordered 
 brandy and beef-tea. 9 p.m. — Messrs. Bickersteth, 
 Blower, and Fitzpatrick present ; pulse a little better, 
 but thrilling ; tongue as before ; countenance bad ; put 
 her under the influence of chloroform, which improved 
 the pulse. 
 
 Mr. Grimsdale then passed his hand by the side of 
 the tumour into the cavity in the posterior uterine 
 wall, and easily separated the few attachments that 
 remained at its middle and lower portions. He found 
 the great bulk of the tumour soft and sloughy, some- 
 what like the placenta of a child dead some time in 
 utero, and already separate from the uterus. Pos- 
 teriorly, and high up near the fundus, some firm fibrous 
 bands passed from the uterus to the tumour, which 
 resisted all efforts to break through them they
 
 OF MENSTRUATION. HQ 
 
 extended over about three square inches of uterine 
 surface ; there were eight or ten distinct bands — one 
 as large as the finger flattened out, and containing soft 
 sloughy tissue. Finding it impossible to lacerate 
 these bands, he held his hand in the uterus till 
 Mr. Bickersteth went for a large pair of scissors, 
 which occupied some thirty minutes. Even then the 
 completion of the operation was difficult and tedious, 
 for he says — " After continuous efforts for nearly an 
 hour, I succeeded in dividing entirely its attachments, 
 and removed the tumour, a sloughy mass about the 
 size of an ordinary placenta." There was no haemor- 
 rhage, and withdrawing the hand and the tumour, 
 the uterus contracted down exactly as after the 
 extraction of a placenta, and felt externally to be 
 about the size of a normally contracted uterus after 
 an ordinary labour. From this time her restoration to 
 health was gradual, but sure. In a fortnight all fetid 
 discharges had ceased. In two months the uterus had 
 quite recovered its natural size and position, and on 
 the sixty-eighth day after the operation she began to 
 menstruate. It lasted four days, painless and normal 
 in quantity and quality. 
 
 So far this case is most interesting surgically. If 
 Mr. Grimsdale had not removed the decaying, slough- 
 ing mass as he did on the fifteenth day, his patient 
 would evidently have died of pyaemia in a very short 
 time. But, to me, the most interesting part of the case 
 is to be related. 
 
 The operation was performed on the 4th November, 
 1855 ; the tumour removed on the 20th. Menstrua- 
 tion returned on the 27th January, 185G; again on 
 the 25th February ; and she probably menstruated 
 again about the 24th or 25th of March, for in a foot-
 
 120 UTERINE SURGERY. 
 
 note in Mr. Grimsd ale's report, he says, " Since the 
 above was in type, I have delivered this patient of a 
 well-grown eight-and-a-half months child, stillborn. 
 The membranes ruptured suddenly on the 17th 
 December, 1856. There was a slight discharge of 
 blood soon after, but no pain till the 20th. At this 
 date the fcetal heart-sounds were heard distinctly. 
 The os dilated very slowly ; the presentation was foot- 
 ling; and there was very inefficient expulsive action 
 in the second stas^e of labour. On the morninsr of the 
 22 nd I got hold of the left foot, and completed the 
 delivery. The child had. evidently been dead many 
 hours, the cuticle of the feet having begun to desqua- 
 mate. It measured twenty-one inches in length, and 
 was plump and well . formed. The placenta, large and 
 healthy-looking, came away immediately, without 
 haemorrhage. The uterus contracted well and remained 
 
 so." 
 
 The evident bearing of this case on the subject 
 under consideration is my apology, if any were needed, 
 for giving so minutely its synopsis and sequel. For it 
 is a direct answer to the question, -' Is conception possi- 
 ble and safe deliver)* probable afcer the enucleation and 
 removal of large fibroid tumours?" 
 
 Before dismissing this subject, I may state that Mr. 
 Baker Brown does not now mutilate the fibroid, but 
 satisfies himself with simply incising the os and cervix 
 uteri. But the most philosophical and, indeed, the 
 most successful treatment of haemorrhages from fibroids 
 is that of Dr. Savage, of the Samaritan Hospital. He 
 dilates the canal of the cervix with a sponge tent, and 
 injects the cavity of the uterus with a solution of iodine, 
 which has been so far both harmless and efficient. His 
 f orniula is this : —
 
 OF MENSTRUATION. 121 
 
 R Iodine 3 i- 
 
 loci. Potassium 3 >j. 
 
 Rect. spt. wine § U- 
 
 Water % vi. 
 
 It invariably stops the bleeding, and, he says, 
 when repeated at each occurrence of the flow, for 
 five or six months, the tumours undergo a sensible 
 diminution, and in some instances have entirely dis- 
 appeared. 
 
 I have seen remarkable results from this treatment 
 of Dr. Savage, and if the experience of others should 
 be as fortunate as his, he will have substituted a simple, 
 safe, and most successful method for one fraught with 
 doubt, difficulty, and danger. 
 
 Dr. Kouth* follows the plan of Dr. Savage, but 
 substitutes a solution of the perchloride of iron for 
 the iodine. I have used both agents, and the objection 
 that I make to the iron is, that while it arrests the 
 bleeding promptly, by coagulation, it takes two or 
 three days for the uterus to expel the large masses of 
 coagula, which often provoke very severe forcing pains. 
 Whereas when the iodine is used the patient complains 
 only of a little sensation of internal warmth, which is 
 quite transitory. 
 
 It is very probable that the curative process of 
 Mr. Baker Brown's simple incision of the os, and of 
 Dr. Savage's iodine injection, and Dr. Routh's iron, all 
 depend more or less on bringing about a degree of 
 subacute inflammation in the uterine cavity, for I hear 
 from Dr. Greenhalgh that Mr. Brown's operation when 
 
 * " On some Points connected with Pathology, Diagnosis, and Treat- 
 ment of Pibrous Tumours of the Womb ; being the Lettsomian Lectures,' 
 &c. By C. H. F. Routh, M.D., &c. London : T. Richards. 18G4.
 
 ]_22 UTERINE SURGERY. 
 
 successful always produces a great degree of consti' 
 tutional disturbance, with considerable tenderness over 
 the whole abdomen, but especially in the uterine region. 
 
 I had the opportunity of making a post-mortem 
 examination in a case of fibroid tumour, alluded to on 
 page 1 13, where the removal of a portion of the tumour, 
 nearly as large as a foetal head, was followed by a most 
 marked improvement in the hemorrhage. Indeed, 
 after this it could not be called a menorrhasHa. The 
 woman died four months afterwards of an acute attack 
 of peritonitis, lasting but a few days. On opening 
 the abdomen the evidences of this suddenly developed 
 and rapidly fatal disease were everywhere visible. On 
 laying open the uterus there were found strong old 
 adhesions, here and there, firmly uniting the anterior 
 wall of the uterus to the opposite surface of the tumour, 
 which grew from the posterior wall. 
 
 These bands of adhesion were in all probability the 
 result of the inflammatory action necessarily set up in 
 the part by the recuperative powers of nature after the 
 ablation of the large vaginal portion of the tumour, four 
 months before. This probability is reduced to a certainty 
 when I call to mind the fact that previously to this 
 operation the hand was several times, for the purpose of 
 diagnosis, carried into the uterus, and passed freely and 
 without obstruction between the contiguous surfaces of 
 the uterus and tumour, where they were now found 
 adherent in patches. 
 
 This condition of things must, then, have been the 
 result of the operation four months before, and was 
 most probably the cause of the great improvement in 
 the menstrual flow. 
 
 While we admit that good results may follow the 
 incision of the os and cervix uteri, after Mr. Baker
 
 OF MENSTRUATION. 123 
 
 Brown's plan, and equally good, with less risk, may 
 follow the injecting process, after that of Dr. Savage, 1 
 believe we are not in accord as to their rationale. I 
 venture to suggest that they act beneficially by bringing 
 about the same result, viz., an endo-metritis, minus the 
 suppurative stage. If this be so, then we should adopt 
 the iodine treatment on theoretical as well as practical 
 grounds, as the one most conducive to the production 
 of plastic or adhesive inflammation. 
 
 Dr. Greenhalsrh informs me that he has had five 
 successful cases from the iodine and sponge-tent treat- 
 ment, combined with Recaiuier's method of scraping out 
 fungous granulations, and that they were all cured 
 promptly by a single injection for each ; and that both 
 he and Dr. Savage now use the pure undiluted officinal 
 tincture of iodine, instead of the solution. 
 
 It must not be forgotten that the uterine injection is 
 to be always and invariably preceded by the use of the 
 sponge tent ; that this is an essential part of the treat- 
 ment, and by no means to be neglected, not even if the 
 canal of the cervix should appear to be large enough to 
 permit the easy exit of the fluid. To Dr. Savage we 
 are particularly indebted for this practice, which renders 
 this operation, once most painful and hazardous, now 
 simple and safe. 
 
 Many years ago I relinquished the practice of inject- 
 ing the cavity of the uterus, having seen the most 
 violent and alarming: attacks of uterine colic follow the 
 injection of but one drop of a bland fluid ; but now, 
 according to the plan of Dr. Savage, the cavity of the 
 uterus is made tolerant of any quantity of even the 
 undiluted tincture of iodine. 
 
 Of Menorrhagia from Inversion of the Uterus. — »
 
 124 UTERINE SURGERY. 
 
 Inversion of the uterus is fortunately of rare occurrence, 
 yet as it may happen at any time and in the practice of 
 any one, we shall devote some consideration to it. My 
 countryman, Professor Charles A. Lee,** has given us a 
 very complete monograph on this subject. He has 
 collected from various sources 148 cases, be^innin^ with 
 the writings of Dr. Robert Lee, and ending with those 
 of Dr. Tyler Smith and Professor White, of Buffalo. I 
 would refer the reader to this excellent paper for a large 
 amount of most valuable information which is condensed 
 into a few pages. 
 
 In many cases of inversion the cause is said to be, 
 pulling on the cord.' It sometimes occurs spontaneously, 
 especially when the labour has been very rapid. It 
 doubtless occasionally happens at a period more or less 
 remote after confinement. But I am disposed to believe 
 that an adherent placenta, particularly to the fundus, is 
 the most frequent direct cause of this accident, whether 
 the cord be pulled upon or not. Some five or six years 
 ago, Dr. Lewis A. Sayre, Professor of Surgery in the 
 Bellevue Hospital Medical College, New York, showed 
 me a case of inverted prolapsed uterus, which occurred 
 in a woman who had never borne children. The inver- 
 sion was evidently the consequence of a fibroid polypus 
 attached to the fundus by a short thick unyielding 
 pedicle, which, as it passed through the cervix, must 
 have drawn the fundus with it. This case excited at the 
 time a good deal of interest amongst the medical men 
 connected with the hospital, on account of the obscurity 
 of its history and the difficulties of its diagnosis. The 
 
 * "A Statistical Inquiry into the Causes, Symptoms, Pathology, and 
 Treatment of Inversion of the Womb." By Charles A. Lee, M.D. — Ameri- 
 oin Journal of the Medical Sciences, October, 1860, pp. 313 to 363.
 
 OF MENSTRUATION, 125 
 
 woman had passed the time of menstruation ; she there* 
 fore suffered no longer from haemorrhages, but complained 
 only of the mechanical inconveniences of the proci- 
 dentia. 
 
 Dr. McClintock describes a case so exactly similar to 
 this, that the drawing of it in his book (page 98) would 
 pass for an accurate representation of Dr. Say re's 
 case. 
 
 Dr. Lee's paper contains references to several cases 
 similar to these, reported respectively by Browne,* Hig- 
 gins,f Oldham, Rigby, Le Blanc, and Velpeau, the last 
 four in " Ashwell on Diseases of Women," pp. 403-5. 
 
 Dr. Alexander H. Stevens, of New York, has had a 
 chronic case of inverted uterus under observation for 
 more than thirty years. It had existed for some years 
 before he saw it. His patient suffered from periodi- 
 cal haemorrhages, which ceased with change of life, when 
 the inverted organ diminished in size, as it always does 
 at this critical period. The fundus is now not more than 
 half the size that it was during menstrual life. 
 
 Dr. Charles A. Lee J has seen one of twenty-five 
 years' duration, which had remained undetected till he 
 was consulted. The patient was then forty-five years 
 of ap;e. She had had haemorrhages at intervals, and was 
 quite anemic. In the course of twelve months after- 
 wards (March, 1858) the menses ceased, her health 
 became vigorous, and there was no need of surgical 
 interference. 
 
 Dr. Lee § quotes one case of congenital inversion, 
 
 * DubKn Medical Journal, vol. vi. p. 33. 
 
 f Edinburgh Monthly Journal, July, 1849, p. 889. 
 
 \ American Journal of the Medical Sciences, October, 1860, p. 340, case 140 
 
 § hoc. cit, p. 323.
 
 126 TJTERI3TE SURGERY. 
 
 reported to the French Academy of Medicine by Dr, 
 Williame, of Metz. His paper also contains two cases 
 of inversion occurring at an earlier period of pregnancy. 
 One of partial inversion, reported by Dr. Spae in the 
 Northern Journal of Medicine, July, 1845 ; the other 
 of complete inversion at the fifth month of pregnancy, 
 by Dr. John A. Brady, in the New Yorlc Medical Times, 
 February, 1856. But the most remarkable case of this 
 sort is that of Dr. Woodson,* of Kentucky. The patient, 
 aged twenty-seven or twenty-eight years, pregnant about 
 four months, was ensraored in washing, some distance from 
 the house, when violent labour pains came on, and she 
 was not able to get home. She was greatly alarmed, 
 felt the foetus protrude from the vagina, and took hold 
 of it and forcibly pulled it away, which brought the 
 uterus entirely out, producing complete inversion. She 
 tore off most of the placenta which was adherent, 
 forced the uterus back into the vagina, and did not call 
 for medical aid for five days afterwards. Dr. Woodson 
 then saw her, in consultation with the family physician ; 
 and found the uterus inverted, lying just within the vagina, 
 with a portion of decomposed placenta still adhering. 
 He ordered vaginal washes and an anodyne for the time, 
 and on the next day, the sixth after the accident, he 
 succeeded in replacing the uterus. The loss of blood 
 was not great or alarming, although it had continued 
 from the time the accident occurred. 
 
 The replacement of a chronic inversion was formerly 
 thought to be impossible. Now, however, it is proven 
 
 * American Journal of the Medical Sciences, October, I860, Art. XL, 
 " Complete Inversion of the Uterus at four months of Utero-gestation. 
 Keplaeed six days after the accident." By E. W. Woodson, M.D., of Wood- 
 ville, Kentucky.
 
 OF MENSTRUATION. 127 
 
 to be not only possible, but quite practicable. Dr. 
 Tyler Smith * replaced one after twelve years of inver- 
 sion. It required eight days with the india-rubber 
 air-ball pessary, conjoined with manipulation night and 
 morning for ten minutes at a time. Dr. Charles West f 
 has replaced one of twelve months' standing. He also 
 used the graduated pressure of an india-rubber air-ball, 
 after Dr. T} T ler Smith's plan. Both of these cases reco- 
 vered. Professor White, J of Buffalo, New York, replaced 
 one of fifteen years' standing. The operation was done 
 in fifty minutes, under chloroform. Unfortunately the 
 patient, thirty-two years of age, died of peritonitis 
 sixteen days afterwards. Dr. Noeggerath, § of New 
 York, has succeeded in one case of thirteen years' 
 standing. 
 
 This great revolution in practice in the treatment of 
 chronic inversion is due to Dr. Tyler Smith, who was 
 the first, I believe, in this country, to demonstrate 
 its practicability, and to Professor White, who was the 
 first in America to perform this operation successfully. 
 
 I have had but two cases of chronic inversion. In 
 one, the uterus was removed by the ecraseur ; in the 
 other it was replaced in five minutes under the influence 
 of ether. One had existed for nine months, the other 
 for twelve. One was at the Woman's Hospital ; the 
 other in private practice. The first case was sent to the 
 hospital in June, 1859, by Dr. Maxwell, of Johnstown, 
 New York. 
 
 This patient, aged thirty-nine, married five years, had 
 
 * Medical Times and Gazette, April 24th, 1858. 
 t Medical Times and Gazette, October 29th, 1859. 
 \ American Journal of the Medical Sciences, July, 1858. 
 § American Medical Times, April 26th, 1862, p. 230.
 
 128 UTERINE SURQERY. 
 
 had one miscarriage and two labours at full term, the 
 last on the 26th December, 1858. She was in labour 
 nine hours. The pains continued very strong after the 
 expulsion of the child. The placenta was retained. 
 The physician was obliged to remove it, and in so doing, 
 remarked that something had come down which would 
 have to go back again. The mother of the patient saw 
 a large bleeding mass protruding, which the physician 
 pushed up into the vagina. The haemorrhage and the 
 pains continued for nearly twenty-four hours afterwards. 
 On the next day another physician was called in, who 
 succeeded in checking the haemorrhage and relieving: the 
 constant pains. About a month after delivery, the 
 haemorrhage suddenly returned with great force, but 
 was controlled by a tampon. From this time she was 
 never entirely free from more or less ljsemorrhage, up 
 to the time of her admission to the Woman's Hospital. 
 She was so completely blanched from loss of blood, and 
 so exhausted, that I hardly had a hope of doing anything 
 for her relief. I have seldom seen any one recover from 
 such a state of exhaustion. The pulse was very rapid 
 and feeble, the heart giving full evidence of her anaemic 
 condition. She could not be raised up in bed without 
 fainting, and would often faint while in the recumbent 
 posture. Her recovery from this condition was wholly 
 due to the extraordinary efforts and attention of Dr. 
 Emmet, whose eminent ability I have so often mentioned 
 in these pages. He arrested the flow by a tampon of 
 the liq. ferri persulphatis of Dr. Squibb ; he relieved the 
 disposition to frequent syncope by elevating the foot of 
 the bed, making it an inclined plane, and inviting what 
 little blood she had to the brain ; while by stimulants, 
 tonics, and good nutrition, a little by the stomach and a 
 great deal by the rectum, we had the happiness of seeing
 
 OF MENSTRUATION. 
 
 129 
 
 our patient rally and gain blood and strength enough to 
 undergo operative procedures. We were afraid of chlo- 
 roform in her enfeebled condition. She was therefore 
 cautiously etherized. The hand was then passed into 
 the vagina, the uterus grasped, and steady efforts made to 
 replace the organ. These efforts were continued for nearly 
 four hours. The uterus was partially replaced ; that is, 
 it was reinverted to such a degree as to place the fundus 
 up within the os uteri, but it could not be passed 
 farther. The diagram (fig. 46) would represent what I 
 mean. It took but a short time 
 to reinstate the organ thus far, 
 but no efforts could do more. A 
 tampon, with some styptic lotion, 
 was applied to hold the uterus in 
 situ. And here is where I made 
 the great mistake. If, instead of 
 the styptic tampon, I had adopted 
 Dr. Tyler Smith's, plan with the 
 elastic air-bag, the result might 
 have been different. A day or 
 two afterwards, when the tampon 
 was renewed, I was horrified to 
 
 discover that the vagina, particularly at its posterior 
 cul-de-sac, had an ecchymosed appearance, as if it had 
 been stretched almost to the verge of being ruptured. 
 I am now satisfied that we continued our efforts for too 
 long a time, although they were not made spasmodically. 
 The tampon was changed daily, the uterus beiDg 
 retained as presented in the diagram. There was no 
 pain, no hemorrhage, and our patient ate and slept 
 well, and improved rapidly in looks and strength. 
 
 About eighteen days after this (July 12th) Mrs. R. 
 was placed again under the influence of ether, and 
 
 9 
 
 Pig. 46.
 
 130 UTERINE SURGERY. 
 
 another effort made to replace the uterus; but after 
 an hour's time we were obliged to desist. The late 
 lamented Drs. Valentine Mott and John W. Francis, 
 of the Consulting Board of the hospital, were both 
 preseut at each trial, and they were of the opinion, 
 that in this case the entire ablation of the organ 
 would be a safer operation than to make another effort 
 to reinvert it. A few days afterwards menstruation 
 came on, was exceedingly profuse, and the fundus was 
 again forced somewhat into the vagina in spite of the 
 tampon. The uterus was then pulled down into the 
 vagina, and a strong ligature was passed round the 
 cervix, and firmly tightened by a small screw ecraseur, 
 with the intention of ultimately removing the organ. 
 The ligature controlled at once the haemorrhage, and 
 wholly arrested the circulation of the fundus, as mani- 
 fested by its sudden deep purple colour. But the con- 
 stitutional disturbance was so intense and alarming 
 that we were compelled to remove the ligature ap- 
 paratus at the end of two hours. The great pain, 
 excessive nausea, rapid pulse, clammy skin, jactitation 
 and pinched features were too distressing to be wit- 
 nessed, much less endured, and so the ligature was 
 removed, and opiates were freely given till she was 
 entirely relieved. A general course of invigorating 
 treatment was followed. Menstruation in August 
 lasted eleven days, but the flow was not very great at 
 any time. 
 
 After the September menstrual period, one more 
 effort was made to reinvert the uterus ; but we could 
 effect no more than is shown in the diagram (fig. 46). 
 
 After this she and her husband begged to have the 
 organ removed, as we promised to do it with the 
 ecraseur without "oain.
 
 OF MENSTRUATION. 13} 
 
 Accordingly, on the 1st of November, she was 
 chloroformed, and the chain of the ecraseur was passed 
 round the cervix, near the os, and tightened. When 
 the operation was half finished, a link parted. Another 
 chain was applied, and with this the organ was cut 
 through ; but the broad ligament on the right side was 
 fortunately not wholly severed. As the chain was felt 
 to pass suddenly through the uterine tissue, I was about 
 to remove it and the severed tumour together, when all 
 at once the most fearful haamorrha^e I ever encountered 
 took place, and in an instant the vagina was full of 
 arterial blood. If the bleeding had been from the 
 blood-vessels of that portion of the broad ligament 
 already severed and retracted within the peritoneal 
 cavity, it would have been beyond reach, and, of course, 
 our patient would have died before she could have reco- 
 vered from the effects of the chloroform. Fortunately, 
 the bleeding was from that part of the broad ligament 
 still adherent to the severed uterus. Quickly drawing 
 it forward, I passed the fore and middle fingers through 
 the cervix uteri into the abdominal cavity, and with 
 them compressed the remains of the ligament against 
 the edge of the cervical opening, which promptly 
 arrested the haemorrhage. The blood was then sponged 
 out of the vagina, and the undivided portion of the 
 broad ligament with the artery was tied ; after which a 
 few sponge probangs were passed into the peritoneal 
 cavity, and the blood that had found its way there 
 was carefully removed. It must not be forgotten 
 that the patient was in the usual lateral semi-prone 
 position. The divided edges of the cervix were 
 united by five or six interrupted silver sutures. The 
 one on the extreme right was made to transfix the 
 ligated portion of the broad ligament, which had
 
 132 
 
 UTERINE SURaERY. 
 
 been drawn through into the vagina. The edges 
 of the cervix united by the first intention. The 
 opening through the cervix, before it was closed by 
 the sutures, would easily have admitted the passage 
 of three fingers at a time into the peritoneal cavity. 
 This was rather a fortunate thing under the circum- 
 stances, as it afforded great facility for sponging out 
 the blood from the peritoneal cavity. The patient 
 recovered rapidly. Dr. Emmet gave her opiates at 
 stated intervals for two or three days, with good 
 nutriment. She bad a small vaginal discharge for a 
 short time, till the little projecting portion of broad 
 ligament was removed. Ten days after the operation 
 the bowels were opened by enemata. Two of the 
 sutures were cut off close, and left to be permanently 
 sacculated. 
 
 I have occasionally heard from Mrs. K. since the 
 operation, and she remained in good health. 
 
 This cut (fig. 47) is copied from a drawing made 
 
 mam 
 
 Fig. 47. 
 
 immediately after the uterus was removed. It shows 
 that portion of the ligament in which the bleeding 
 artery was found. The artist has slightly exaggerated 
 the long diameter of the organ.
 
 OF MENSTRUATION. 133 
 
 With mv next case I was more fortunate. This 
 was a case of a lady in Springfield, Massachusetts, who 
 was attended in her labour by one of the most 
 eminent of our New England practitioners. I presume 
 it was an example of spontaneous inversion at. a some- 
 what remote period after confinement, for the character 
 of the physician is a sufficient guarantee that it could 
 not have resulted from any mismanagement on his 
 part; nor could it have occurred spontaneously at the 
 time of his attendance without being detected by him 
 A few weeks after this lady's delivery, her physician 
 went abroad. Some months afterwards she called 
 another physician, who treated her for menorrhagia. 
 She did not improve ; and by-and-by a consultation 
 was held, when the case was ascertained to be one of 
 inversion. 
 
 She was then etherized, and efforts at reduction 
 were made, and continued for an hour without effect. 
 Two or three weeks after this I was sent for ; the 
 patient was etherized as before, and I was able to 
 reduce the inverted uterus to its normal relations in 
 less than five minutes. This was in May, 1860, about 
 twelve months after the labour. The medical brethren 
 present gave me great credit for the facility with which 
 the operation was performed. But its speedy accom- 
 plishment was a little accidental. Introducing the left 
 hand into the vagina, I grasped the uterus, and soon 
 restored it to the position represented by fig. 46 (page 
 129), where the fundus is shown as just within the os 
 uteri. At this moment I changed my hold on the 
 uterus, and, rather by accident than design, deeply 
 indented the right cornu, «, with the thumb of the 
 left hand; the fingers compressed the opposite side of 
 the organ, b, and while the thumb pushed the tissue
 
 134 UTERINE SURGERY. 
 
 in which it was imbedded upwards, the fingers rather 
 acted in a contrary direction on the opposite side ; and 
 to my great surprise, the uterus jumped, as it were, out 
 of my hand, assuming its proper normal position. I 
 certainly had not the remotest idea of restoring the 
 organ under a half-hour's effort. 
 
 The case reported by Dr. Noeggerath was reduced 
 very much on the principle of the above ; but instead 
 of its being accidental, as with me, he reasoned 
 out the process after he had failed by the ordinary 
 method. 
 
 As before said, we are indebted to Dr. Tvler Smith, 
 of London, and Professor White, of Buffalo, for our 
 present success in the treatment of inversion of the 
 uterus. These two distinguished gentlemen seem to 
 have worked out the problem about the same time, and 
 independently of each other. Dr. Tyler Smith takes the 
 slower method of persistent and gradual pressure with 
 the air-bag; Dr. White, the more brilliant but more 
 dangerous plan of immediate reduction by manipulation, 
 under the influence of chloroform. I fear that in my 
 own country we have been too much captivated by the 
 eclat of sudden success. I am sure now that it would be 
 safer to combine the plans of Dr. Tyler Smith and Dr. 
 White. 
 
 I would hesitate a long time before removing another 
 inverted uterus. 
 
 Judging from the experience of my two cases, the 
 great difficulty seems to be in passing the fundus through 
 the os internum. It was easy enough in each instance 
 to reinstate the organ to the condition represented by 
 the diagram (fig. 46). That being the case, I should 
 infer that there were no peritoneal adhesions to prevent 
 the completion of the operation.
 
 UTERINE SURGERY. 
 
 135 
 
 There is one point that I wish to dwell on particu- 
 larly. 
 
 Those who follow the plan of my distinguished 
 countryman Professor White (whom I have imitated), 
 would do well always to make counter-pressure with the 
 outer hand over the abdomen, as represented in this 
 diagram (fig. 48). 
 
 In pushing the uterus upwards by the hand in the 
 
 Fig. 48. 
 
 vagina, there is certainly some danger of lacerating the 
 vagina and tearing the uterus asunder from its attach- 
 ments at the posterior cul-de-sac. Counter-pressure will 
 obviate that danger. Another advantage of counter- 
 pressure is that the fingers pushed down on the uterus, 
 as the cervix is doubled on itself, assist very materially 
 in dilating that portion through which the fundus is to 
 be forced upwards. 
 
 From what I have already said, it would appear that 
 the reduction of an inverted uterus naturally divides 
 itself into two stages : the first, that of pushing the bodv 
 of the uterus up within the cervix, as represented in fig.
 
 136 UTERINE SURGERY. 
 
 45 ; and the second, that of completing the operation by 
 forcing the fundus through the os internum. The first 
 stage is accomplished by directly pressing the body of 
 the uterus upwards, and putting the vagina well on the 
 stretch, which, as Dr. White* says, '* pulls open, first its 
 mouth, then its neck, and finally, if persevered in, doubles 
 the body upon itself also ; " the second, by compressing 
 the fundus laterally, and deeply imbedding the thumb 
 in the cornus uteri (fig. 46, a), by which means we slide 
 one-half of the organ at a time through the os internum 
 instead of the whole fundus, which presents a greater 
 diameter. Pressure antero-posteriorly would avail 
 nothing, because we would simply compress two flat 
 unyielding surfaces together ; but the cornus can be 
 dimpled and forced inwards and upwards by the thumb. 
 It is useless to attempt this manoeuvre till we complete the 
 first stage of the operation. 
 
 I do not think that, as a rule, we should continue 
 our operative procedures more than thirty minutes at a 
 time. If we fail to restore the organ at once, then we 
 should introduce an india-rubber air-bag, after the plan 
 of Dr. Tyler Smith, and wait for our patient to recover 
 fully before trying again. 
 
 But suppose after proper efforts we fail to restore 
 the uterus, should we amputate it ? 
 
 In the hands of Professor Channing, of Boston, and 
 Dr. M'Clintock, of Dublin, amputation of the inverted 
 uterus has proved to be a very successful operation, and 
 one to be justified if all legitimate means of restoration, 
 patiently and perseveringly tried, fail to reinstate the 
 inverted organ. 
 
 * American Journal of the Medical Sciences, July, 1858, p. 23.
 
 OF MENSTRUATION. 
 
 137 
 
 Pig. 49, 
 
 But before taking this last resort, I would, rather 
 than amputate, make longitudinal incisions from the os 
 tincaB along the cervix to a point beyond the os internum, 
 for the purpose of facilitating the 
 process of reduction. 
 
 I would make at least three — 
 one on each side, as represented in 
 this diagram (fig. 49, a a), and 
 another similar on the posterior 
 surface. I say posterior only 
 because it would be easier to make 
 it there than on the anterior surface 
 if the patient be on the left side, with 
 my speculum as it is ordinarily 
 used. The object of these incisions would be to divide 
 the circular fibres of the uterine tissue, and thereby to 
 remove one of the principal barriers to the reduction of 
 the fundus. 
 
 I hope I have said enough to show that we should 
 not resort to the operation of amputation till we have 
 tried persistently and patiently every possible means for 
 reinstating the organ to its normal position. 
 
 The patient in whom I was so fortunate as to restore 
 the organ after twelve months of inversion, subsequently 
 conceived; and thus we see the important bearing of 
 this operation upon the subject of sterility. Even Dr. 
 Tyler Smith's successful case of reduction after nearly 
 twelve years of inversion, was followed by conception ; 
 and these two cases are, I think, sufficient to warn us 
 against a too hasty resort to the operation of amuuta- 
 
 o 
 
 tioii 
 
 I have just heard from Dr. Tyler Smith (July 12th, 
 186/)), that his patient "lias had several children since 
 the operation (in 1856), and that the medical man who
 
 138 UTERINE SURGERY. 
 
 attended her in her first confinement after the reduction 
 of the inversion, says that complete inversion occurred 
 spontaneously after that confinement, which he readily 
 and at once reduced." 
 
 Of Painful Menstruation. — Menstruation may be 
 attended by a general malaise, but should not, as a rule, 
 be accompanied by any very severe degree of suffering. 
 If there is much pain, either preceding its irruption 
 or during the flow, there will generally be a physical 
 condition to account for it, and this will be of a nature 
 to obstruct mechanically the egress of the fluid from the 
 cavity of the womb. The obstruction may be the result 
 of inflammation and attendant turgescence of the 
 cervical mucous membrane, whereby this canal becomes 
 narrowed merely by the tumefaction of its lining coat. 
 But by far the most frequent cause of obstruction is 
 purely anatomical and mechanical. For instance, the os 
 and canal of the cervix uteri may be preternaturally 
 small, or the cervix may be flexed ; or these may be 
 complicated with the presence of a polypus, or with 
 that of a fibroid tumour, in either the anterior or poste- 
 rior wall of the uterus, and occasionally in the antero- 
 lateral portion. 
 
 Of 250 married women who had never borne chil- 
 dren, 129, or more than half, had pain of an abnormal 
 kind attending the menstrual flow. I have been in the 
 habit of dividing these into two classes, calling the one 
 painful, and the other excessively painful or dysmenor- 
 rhoeal. Of these 129, 100 were painful, or 1 in 2£ of 
 the whole number ; 29 were dysmenorrhceal, or 1 in 
 8^0. Of the 100 painful menstruations, 58 had ante ver- 
 sion, or more properly speaking, anteflexion ; 17 of these 
 had fibroid tumours in the anterior wall : 25 had retro-
 
 OF MENSTRUATION. 
 
 139 
 
 version; 7 of these had fibroid tumours in the posterior 
 wail ; and in 17 the position was normal, one of these 
 having a fibroid tumour. Of the 29 dysmenorrhceal 
 cases, 23 had ante version ; 14 of these had fibroid 
 tumours in' the anterior wall : 3 had retroversion ; all of 
 these had fibroid tumours in the posterior wall : and in 
 3 the position was normal. Of the 100 cases of painful 
 menstruation, the os was normal in but 6, unnaturally 
 contracted in 90, otherwise abnormal in 4. Of the 29 
 cases of dysmenorrhoea, properly speaking, the os was 
 not normal in a single case, being contracted in 26, and 
 otherwise abnormal in the other 3. 
 
 The following tabular statement presents the parti- 
 culars at a glance : — 
 
 f Os was normal in but 
 
 -» _.« „ . „. „ contracted in 
 
 Of 100 cases ol painful men- j ~ n .. . 
 
 < Cervix was Hexed in 
 
 struatioo, 
 
 Of 29 cases of excessively painful 
 menstruation, 
 
 ,, congested in 
 
 b There were polypi in 
 
 ' Os was normal in . . 
 
 „ contracted in . 
 
 Cervix was flexed in . 
 
 „ had polypi in 
 
 „ was congested in 
 
 6 
 90 
 
 61 
 
 7 
 2 
 
 
 
 26 
 
 23 
 
 2 
 
 1 
 
 From this it would appear that the pain of menstru- 
 ation is almost wholly due to mechanical causes, for of 
 the whole 129, only 8 had engorgement or congestion of 
 the linins: membrane of the canal of the cervix, and 
 some of these were complicated either with flexure of 
 the cervix, or with fibroid growths in some portion of 
 the body of the uterus. I would not deny that men- 
 struation may be painful merely from a congested state 
 of the cervical membrane, where there is no fibroid 
 growth, no polypus, no contracted os, and no flexure of
 
 140 
 
 UTERINE SURGERY. 
 
 the cervix ; but such cases are rare, while the great 
 majority of dysmenorrhoeal cases have a contracted os 
 and a narrowed cervical canal or a flexed one. In some 
 instances the os is not larger than a pin's head, or it may 
 be large enough to admit a No. 4 bougie. Again, the os 
 may be quite large enough, but the canal may be flexed 
 so as to form a valvular obstruction to the egress of the 
 menstrual fluid. Sometimes we find the os small and 
 the canal flexed without painful menstruation, and here 
 the cervix is not indurated, but soft and elastic to the 
 touch. Of the 129 cases of painful menstruation, but 
 20 had the uterus in its normal position, while 81 had 
 anteversion (31 of these with fibroids in anterior wall), 
 28 retroversion (10 of these with fibroids). 
 
 In a great many cases, in addition to a contraction or 
 
 flexure of the canal, the cervix will 
 be long, pointed, and indurated. 
 If the flexure be anteriorly, we often 
 find the intravaginal portion of 
 the cervix unequally developed — 
 that is, the posterior part, from 
 the os to the insertion of the va- 
 gina at a (fig. 50) may be an inch 
 and a quarter long, while the ante- 
 rior, from the os to the insertion of 
 the anterior cul-de-sac at b : may 
 not be more than one-third as long. 
 The size of the os and the position and relations of 
 the cervix may be ascertained by the touch, as already 
 explained (p. 9). But it is well always to resort to the 
 sound to determine definitely the course, curvature, and 
 contraction of the canal. To the touch and the sight 
 the os may seem to be quite large enough, and then we 
 may find a flexure, perhaps a very acute one, at the 
 
 Fig. 50.
 
 OF MENSTRUATION". 14 [ 
 
 junction of the cervix and body of the womb, due most 
 probably to the presence of a small fibroid in the ante- 
 rior wall of the uterus (fig. 41, page 105). 
 
 According to the facts stated above, it would seem 
 that the pathology of dysmenorrhoea is yet to be written. 
 I am fully of the opinion that it is simply a sign or 
 symptom of disease, to be found in some abnormal 
 organic condition. This may be inflammation, or it 
 may be the cause of inflammation, or it may exist 
 without it. But whether inflammatory or not, its 
 action is mechanical. I lay it down as an axiom, that 
 there can be no dysmenorrhoea, properly speaking, if the 
 canal of th° neck of the womb be straight, and large 
 enough to permit the free passage of the menstrual 
 blood. In other words, that there must be some 
 mechanical obstacle to the egress of the flow at some 
 point between the os internum and the os externum, or 
 throughout the whole cervical canal. 
 
 Dr. Bennet* says, "I have always taught that 
 menstruation may be painful, even acutely painful, 
 from its dawn to its close, without any mischief or 
 impediment existing of any kind whatever." Many 
 years ago I believed all this, simply because Dr. 
 Benuet and others said so ; but now I do not believe 
 in any such doctrine, because experience has taught 
 me otherwise. There is no such thing as what is 
 called " constitutional dysmenorrhoea." There was 
 a time when we looked upon dropsy as an entity, 
 a disease in itself; but now we know that it is only 
 a symptom of various diseases. It is a symptom of 
 disease of the heart, of the kidneys, of the liver; or it 
 may follow haemorrhages or diarrhoea. So is it with 
 
 * Lancet, June 24, 1865, p. 673.
 
 142 UTERINE SURGERY. 
 
 dysmenorrhea: it is only a symptom of disease, which 
 may be inflammation of the cervical mucous membrane ; 
 retroflexion; anteflexion; fibroid tumour in one wall 
 of the uterus or the other; contraction of the os 
 internum or os externum ; flexures of the canal of the 
 cervix, either acute or gently curved, either at the 
 os internum, at the insertion of the vagina, or extend- 
 ing throughout the whole length of the canal : all 
 of w T hich are but so many mechanical causes of 
 obstruction, which must be recognized and remedied if 
 we expect to cure the dysmenorrhea. We do not 
 talk of constitutional toothache, of constitutional colic, 
 or of constitutional fractures, or constitutional dis- 
 locations. Nor should we speak of " constitutional 
 dysmenorrhoea." This is but a high-sounding term 
 that means absolutely nothing. The fact is, that most 
 of the diseases of the uterus are as purely surgical 
 as are those of the eye, and require the same nice 
 discrimination of the true surgeon. And if we fail 
 to detect the abnormal condition that produces dis- 
 eased manifestations, whe'ther of sensation or secretion, 
 it is plainly our fault. For of all organs the uterus 
 is now most subservient to the laws of physical ex- 
 ploration ; and in every case of diseased action, if we 
 cannot map out accurately the peculiar condition of 
 the uterus producing or accompanying it, it is simply 
 because we do not apply our knowledge of those physi 
 cal laws to its investigation. 
 
 The treatment of dysmenorrhea was formerly very 
 empirical. Dewees cured many cases with his ammo- 
 niated tincture of guaiacum, but I have not seen any 
 one who had derived the least benefit from it. The 
 remedy is so nauseous that I could never get a patient 
 to persevere with it. I must confess, however, that of
 
 OF MENSTRUATION. 143 
 
 late years, since I Lave learned more intimately the 
 nature of the disease, I have not prescribed it at all. 
 My friend Professor E. D. Fenner * of New Orleans, 
 has been very successful with the bichloride of mercury 
 in minute doses; but I have no experience with the 
 remedy. Many prescribe belladonna and other nar- 
 cotics, but they can only produce a merely palliative 
 effect. The operation of enlarging the canal by 
 incision is not always successful, but it is the only 
 procedure from which I have derived the least benefit. 
 The whole philosophy of the operation consists in 
 opening the canal and keeping it open, so as to allow 
 the easy passage of the menstrual flow. M'Intosh 
 dilated the cervix with bougies ; but whoever has 
 followed him must have been struck with the uncer- 
 tainty of the result, as well as with its painfulness, to 
 say nothing of its danger. A priori, it would seem a 
 trifling thing to pass a bougie along the cervix uteri, 
 but I have known it to be followed by most serious 
 results. In 1859, Professor Metcalfe, of New York, 
 referred one of his sterile clysmenorrhoeal cases to my 
 care. There was slight anteversion, with a small 
 fibroid in the anterior wall. The os was very small ; 
 the cervix long, pointed, and indurated ; and the canal, 
 though straight, was very narrow. I advised the 
 operation of incising the os and cervix, which was 
 objected to by the lady, although Professor Metcalfe 
 was anxious to have it done. I explained to her the 
 process of dilatation, and she wished to try it. 
 Accordingly, a small bougie was passed in to the 
 depth of two inches, and allowed to remain a few 
 minutes. On the next day a larger one was used, and 
 
 * New Orleans Medical News, 1858.
 
 144 UTERINE SURGERY. 
 
 in two or three days more a conical bougie was passed 
 dilating the os externum to about a No. 9. She com« 
 plained of a good deal of pain at the time, and there 
 was a slight laceration of the contracted os. That 
 night she had a rigor, followed by fever, and a most 
 intense attack of metro-peritonitis, which lasted many 
 weeks, and from which she barely escaped with her 
 life. Her recovery was slow and tedious. This was 
 my last bougie case. I have known several cases of 
 the same sort in the hands of others in my own country, 
 and I have seen two in Paris during my short sojourn 
 there. 
 
 In November, 1861, in Paris, a medical friend asked 
 me to see a case of dysmenorrhcea, which was sterile 
 after a marriage of eight or nine years. The os aud 
 cervical canal were very small; the cervix long, 
 pointed, and indurated. It was just the case for an 
 operation, or there was nothing to be done. I advised 
 him to incise the cervix. He was afraid of it, and a 
 year afterwards he introduced a screw bougie made of 
 ivory deprived of its earthy constituents, which was 
 allowed to remain in the cervix, and dilate it mechani- 
 cally by absorbing moisture, and expanding to twice 
 its original size. A violent attack of metro-peritonitis 
 was the consequence, and I saw this lady when she 
 had been ill about a week. She had a pulse of 140, 
 and continued in a very dangerous condition for a long 
 time, but eventually recovered. 
 
 The other case of metro-peritonitis from mechanical 
 dilatation occurred in the hands of one of the most 
 eminent physicians in Paris. Fortunately the lady 
 recovered after three weeks of fever, attended with 
 very great suffering. 
 
 This experience warns against merely mechanical
 
 OF , MENSTRUATION. 145 
 
 dilatation. But it may reasonably be asked, "Is it 
 more dangerous than splitting up the neck of the 
 womb?" I answer, "Yes." I cannot now say how 
 many hundreds of times (certainly more than five 
 hundred) the operation of cutting open the os and 
 cervix has been done by Dr. Emmet, and myself at the 
 Woman's Hospital and in private practice, and I now 
 remember but a single instance in which it was 
 followed by inflammatory symptoms, and this resulted 
 in pelvic cellulitis and abscess. The case was badly 
 chosen for operation, and if I had known that this 
 patient had had a pelvic abscess once before, I certainly 
 should not have operated on her. The house-surgeon 
 of the hospital inadvertently overlooked this part of 
 the history of the case, and hence the accident. 
 
 Some prefer to dilate the cervix by sponge tents. 
 Foremost amongst these stand the distinguished names 
 of Bennet and Tilt. I have tried this method, and the 
 results were anything but satisfactory. Professor A. K. 
 Gardner, of New York, has used it most extensively and 
 perse veringly, but has now abandoned the practice as 
 unfruitful. Dr. Tilt thinks the incision of the cervix 
 "an unjustifiable operation,"* and objects to it because 
 it produces pain and " flooding to an alarming, if not to 
 a fatal extent." As to the pain, I am sure I have seen 
 far more caused by a bougie than I ever saw by the 
 operation. Indeed the operation is not a painful one. 
 I have often performed it on delicate, timid women, who 
 were conscious that something was being done, but had 
 no idea that it was a surgical operation. I am opposed 
 to operating on any rational being without first explain- 
 ing what is to be done, and the wherefore. In the cases 
 
 * " Uterine Therapeutics," p. 255. 
 10
 
 ^46 UTERINE SURGERY. 
 
 alluded to the operations were performed at the sugges- 
 tion and earnest wish of husbands, who feared that they 
 might not be submitted to if fully explained. 
 
 In 1858 I advised this operation in a case of dys- 
 menorrhceal sterility, sent to me by Dr. Vanderpoel, of 
 Albany, New York. There was anteflexion, with slight 
 hypertrophy of the anterior wall, curved canal, and 
 contracted os. The Doctor had tried the bougie system 
 for some time without any permanent improvement, and, 
 fully satisfied that an operation was necessary, he sent 
 his patient to me. But the very idea of cutting was so 
 terrible to her imagination that she went to another 
 physician, who pronounced the operation " butcherous " 
 and dangerous, and promised to cure her by dilatation 
 alone. Of course this poor frightened, nervous sufferer 
 gladly accepted the alternative, and at once placed 
 herself under his treatment. She remained in New 
 York for several months, undergoing daily dilatation, 
 and then returned home without any permanent 
 benefit. Three months afterwards she consulted me 
 again, and on examination I found the uterus just as it 
 was seven or eight months before. Being now fully 
 convinced that the operation afforded the only hope of 
 relief, she submitted to it. When it was all over she 
 could hardly believe it, and declared that she suffered 
 more each time the bougie was used than she did from 
 the operation. 
 
 But so far as mere pain is concerned, it might be left 
 entirely out of the question in these days of anaesthesia. 
 When, however, we come to speak of the dangers of the 
 procedure, I readily admit that we may debate that 
 point. If, then, we compare the dangers of the opera- 
 tion with those of mechanical dilatation, I do not hesi- 
 tate a moment to declare the former much the safer.
 
 OF MENSTRUATION ]_£« 
 
 while in permanent results it is infinitely superior. For 
 A r bilel have frequently known pelvic cellulitis to follow 
 the use of the bougie and the tent, I have never seen it 
 but once after the operation ; and while the bougie and 
 the tent can only produce temporary improvement, we 
 know that the operation is often followed by a perfect 
 and persistent cure. But it may be asked, is there no 
 risk in the operation? The only trouble that I have 
 encountered is haemorrhage ; but that was in my early 
 operations, and before experience taught me that there 
 was any danger to be apprehended. Now, however, I 
 have no such accident, because I take pains to guard 
 against it. When Dr. Simpson first published on the 
 subject, he said he never had haemorrhage or other 
 unfavourable result, either directly or secondarily ; so 
 that I was emboldened to perform the operation at my 
 house, and allow patients to ride home afterwards. But 
 I was soon undeceived on this point, for in the short 
 space of two months I had five cases of haemorrhage that 
 w r ere truly alarming. One occurred in a lady residing 
 in Jersey city, who rode a distance of five miles in 
 stages after the operation. The bleeding began just as 
 she arrived at her home. She was, of course, very 
 much alarmed, and sent immediately for me, and also 
 for her family physician, who, being near by, soon 
 arrived, removed the dressing, retamponed the vagina, 
 and arrested the bleeding promptly, before I made my 
 frightened appearance. The other cases, though nearer 
 to me, were equally alarming. I then made up my 
 mind never again to operate on patients in the consulting 
 room. I asked Dr. Simpson, when I was in Edinburgh 
 in August, 1861, if the operation was still as safe in his 
 hands as he had at first represented it, telling him, at
 
 148 
 
 UTERINE SURGERY. 
 
 the same time, my experience, when lie declared that be 
 never had any trouble from bleeding. 
 
 How to account for this difference in our experience 
 I could not imagine, unless it should be that I cut more 
 extensively than he did. To satisfy my mind on this 
 score Dr. Simpson kindly invited me to witness the 
 operation in his hands. It was the case of a lady from 
 some of the British possessions. The os was small ; the 
 canal narrow; the cervix long, pointed, and indurated. 
 It was precisely the case to justify the operation, for the 
 gristly induration of the cervix rendered any other 
 method quite out of the question. The operation was 
 performed with the Doctor's usual dexterity. Then a 
 camel's hair pencil, saturated with a solution of the per- 
 chloride of iron, was thrust into the vagina two or three 
 times, and in ten or fifteen minutes from the time we 
 entered the lady's apartment, we were in the street 
 making other visits. He had such confidence in the 
 operation and in his styptic that he did not wait for 
 consequences. Before the operation, he requested me 
 to examine the condition of the cervix uteri by the 
 touch, and I found it as already described. After- 
 wards 1 repeated the touch, and found the cervix as 
 thoroughly divided from the os externum to the os 
 internum as it was possible to do it, proving that the 
 difference in our experience as to haemorrhage did not 
 depend upon any difference in the extent of the 
 operation. I do not pretend to account for the fact, 
 that the operation is not followed by haemorrhage in 
 Scotland while it is in America ; and I would warn my 
 own countrymen to take every precaution against 
 its occurrence, as it is almost the only accident that can 
 attend this operation. 
 
 I may be pardoned for pressing this subject a little
 
 OF MENSTRUATION. 149 
 
 farther. I look upon this operation, simple as it is, a9 
 one of the great surgical advances of the day ; and I am 
 so well satisfied of its merits, that I would warn young 
 men to he careful not to bring it into discredit by 
 permitting an accidental complication that should never 
 under any circumstances be allowed to take place. I 
 know a most talented, promising young physician in my 
 own country, whose reputation was well nigh ruined by 
 blindly following authority, and operating with the 
 belief that there was no danger from bleeding. Having 
 been taught to look upon the operation as a trifling one, 
 devoid of all risk, he unguardedly operated on his 
 patient at his own house, and allowed her in a few hours 
 afterwards to ride home, a distance of four or five miles. 
 Haemorrhage unfortunately supervened ; the doctor was 
 sent for; he was not at home. Some time elapsed 
 before he could be found, and when he reached his 
 patient she was in a collapse from loss of blood from 
 which fthe never recovered. This is the only well- 
 authenticated case of death from haemorrhage that I 
 have known to follow this operation. Of course it could 
 not have happened but for the overweening confidence 
 of the surgeon in the innocuousness of the operation, and 
 it should never happen again. Such an accident as this 
 may be smothered up in a great city, but if it occurs in 
 the hands of a country practitioner, it may wholly ruin 
 him for ever. 
 
 The case above alluded to happened in a small 
 country village, and the public excitement may be 
 imagined when everybody began to discuss the subject, 
 and to censure a noble young physician for causing the 
 sudden death of a citizen who was supposed to enjoy 
 the most vigorous health. An eminent professor of 
 obstetrics testified that the operation was a recognized
 
 |50 UTERINE SURGERY. 
 
 justifiable one; that it had been well done, and that 
 death was the result of a rare and unexpected accident. 
 This testimony was corroborated by others, and thus the 
 popular indignation was appeased, aud the young 
 practitioner reinstated in public confidence. 
 
 But it may be asked, is there no other danger ? I 
 can only here reiterate what I have before stated, that 
 out of the hundreds operated on in the Woman's Hospital 
 and in my private practice, I have seen but the one case 
 of pelvic cellulitis already noticed, which is the only risk 
 of the operation that I know of. While this has 
 occurred but once in my hands from the operation, it 
 has happened frequently under my observation as the 
 result of mechanical dilatation by bougies and sponge 
 tents. 
 
 The position I take is this : that, as a rule, the 
 operation is less painful than the use of the bougie, 
 which must be repeated for months ; that it is entirely 
 devoid of danger from haemorrhage, provided we exer- 
 cise ordinary prudence in the after-treatment ; that it is 
 less frequently followed by pelvic inflammation than 
 either the bougie or the sponge tent ; that it is more 
 certain and permanent in its results than either or both ; 
 and that, if we exclude it, there are great numbers of 
 curable cases which would be placed beyond the pale of 
 treatment. Thus, from my stand-point of view, the 
 operation, when indicated, is always to be j)referred to 
 any and all other means of enlarging the cervical 
 canal. 
 
 T am surprised to find that this operation is so seldom 
 performed in Great Britain out of Edinburgh. In 
 London it is condemned by the great body of the profes- 
 sion, although performed by several eminent men. But 
 where we find one man to uphold it, we may point to
 
 OF MENSTRUATION. J 5 \ 
 
 scores who oppose it. This cannot long remain so ; foi 
 where honesty, intelligence, aud earnest inquiry reign 
 supreme, as they do here, the truth must and will 
 prevail. 
 
 On the 'Continent, so far as I know, this operation is 
 almost completely ostracized. When I went to Paris in 
 September, 18(52, a lady of very high position asked 
 my opinion in reference to her sterility. She had been 
 married thirteen years without issue. On examination, 
 I was convinced that conception could never by any 
 possibility occur unless the neck of the womb were well 
 opened by incision. All sorts of mechanical dilatation 
 had already been fruitlessly employed, producing metro- 
 peritonitis, and leaving the os and cervix as contracted 
 as at the beginning. When the husband asked me, 
 u What are the risks of the operation?" I replied, "In 
 America or England nothing but haemorrhage, and that 
 we control. I cannot say what they would be in Paris, 
 for here you have erysipelas often following the most 
 trifling wounds. Ask your own surgeon about it." 
 They sent for my friend Professor Nelaton, who said 
 that in France the operation would be attended with 
 great risk to life. Such a decision from such an 
 authority of course put the operation wholly out of the 
 question for the time being. However, soon after this I 
 had the good fortune to meet Sir Joseph Olliffe, who 
 invited me to perform the operation on one of his 
 patients in the upper ranks of life. When I told him 
 what I have related above, he said he was perfectly 
 familiar with British and American literature on the 
 subject, and knowing the safety of the operation, would 
 assume all responsibility in the matter. This operation, 
 the first of the sort that I did in Paris, was performed 
 on the 31st of October, 18G2, for Sir Joseph Olliffe,
 
 1 52 UTERINE SURGERY. 
 
 His patient recovered without the slightest trouble ; and 
 on the 2nd of December we operated on the lady whose 
 case was first mentioned. To guard against any risk 
 from the atmosphere of Paris, we went to their chateau, 
 not many leagues from the city. The case got well 
 rapidly, as usual, and conception fortunately occurred 
 seven or eight months afterwards. She is now (Septem- 
 ber, 1865) the happy mother of two beautiful children, 
 — one a boy, sixteen months old ; the other a girl, less 
 than a month old ; and this after a sterile marriage of 
 thirteen years. I am a little minute in this merely 
 historical part of the introduction of the operation into 
 France, for I wish to show that it may be done as well 
 and as safely there as elsewhere. 
 
 My third case was that of a native, and I went with 
 her to the country to perform the operation. The next 
 was an American, operated on in Paris ; then another 
 American ; and then I began to operate on natives of 
 France, and in the city of Paris, with the same fearless- 
 ness that I did on Americans. 
 
 I may be excused for these minute details ; for as 
 the operation was condemned by the highest authority 
 in France, it was important, not so much for myself as 
 for the advancement of surgery, that I should exercise 
 every precaution to guard against accident or untoward 
 results. I have performed this operation twenty-four 
 times on the Continent without accident, except the 
 occurrence of haemorrhage in one case on the sixth day 
 after operation, which was promptly controlled by Sir 
 Joseph Olliffe in my absence. My patients varied in 
 age from twenty-two to forty. They were natives of 
 France, Vienna, Frankfort, England, Scotland, Ireland, 
 and the United States. The operations were performed 
 in the autumn, winter, spring, and summer. ' Twenty
 
 OF MENSTRUATION. J 53 
 
 were done in Paris, two near Paris, and two at Baden ; 
 and in all there was the same rapid and safe recovery 
 from the effects of the operation as I had always seen in 
 New York. Of course this small number of successful 
 operations is not enough to establish fully its acclimatiza- 
 tion and its claims to universal favour there ; but they 
 are certainly sufficient to attract the notice and 
 consideration of the profession in France. 
 
 But we were speaking of painful menstruation and 
 its almost invariable concomitants, contracted os and 
 narrowed cervical canal ; and having said so much in a 
 general way about the various methods of overcoming 
 these, we may now proceed to discuss the plan of ope- 
 rating, together with the after-treatment necessary to 
 protect against haemorrhage and to ensure a patulous 
 canal. 
 
 For the operation of incising the os and cervix uteri, 
 we are indebted to Dr. Simpson. His method is followed 
 by most operators, both in my country and in this. He 
 places his patient on the left side, introduces the index 
 finger of one hand into the vagina, pushes the fundus 
 uteri up if it be ante verted, passes his uterotome (fig. 51) 
 along the cervix through the os internum, springs the 
 blade, and withdraws the instrument, cutting open one 
 
 Fig. 51. 
 
 side of the cervix ; then reintroducing the instrument, 
 the other side is cut in like manner ; thus making a 
 bilateral incision of the cervix larare enough to allow the 
 index finger to be passed to the os internum ; and, as
 
 154 
 
 UTERINE SURGERY. 
 
 before stated, he then passes into the vagina a large 
 camel's-hair pencil, saturated with a solution of the 
 perchloride of iron. 
 
 Dr. Greenhalgh has modified Dr. Simp- 
 son's instrument by giving it two blades, 
 which cut through both sides of the cervix 
 at once, thus ensuring an equilateral unifor- 
 mity of section that cannot always be predi- 
 cated of the single-bladed instrument. His 
 instrument (fig. 52) is a masterpiece of 
 ingenuity, and answers well in his prac- 
 tised hands. But I object to both these 
 methods, because they are done in the dark, 
 and too much is left to the execution of a 
 machine instead of the judgment of the 
 surgeon. 
 
 Suppose it were necessary to amputate 
 an elongated uvula, — by no means an 
 uncommon operation, — would it be judi- 
 cious to run one finger down the throat and 
 guide by it some machine for performing 
 the operation in the dark? Or would it 
 be more surgical and more precise to look 
 into the throat, seize the part with a proper 
 appliance, and amputate it where our judg- 
 ment would determine to be risrlit and best 
 for the individual case? There are ope- 
 rations that must be done by the touch 
 alone ; but we never select this plan if it 
 be possible to aid the manipulatory 
 process by the sight. 
 
 Besides the objections already urged 
 against instruments of this class, there is another to 
 which all instruments on the principle of cutting from 
 
 Fig. 52.
 
 OF MENSTRUATION. 155 
 
 above downwards are obnoxious — viz., that as the ute- 
 rus is uot fixed, it may glide upwards to some extent 
 by the mere centrifugal force of the expanded blade or 
 blades, and thus we can never feel altogether certain of 
 the length and breadth of the cut. Whether too much 
 
 O 
 
 or too little, it is not safely remediable afterwards. 
 
 The operation, as I prefer to perform it, differs from 
 Dr. Simpson's, not in its aim and scope, but merely in 
 its mechanical execution. He and his followers operate 
 in the dark ; I bring everything plainly into view. 
 They cut from within outwards ; I, in the contrary 
 direction, from the os externum upwards to the cavity 
 of the womb. They, as a rule, do not tampon the 
 vagina after the operation ; I always do, for the double 
 purpose of guarding agaiust haemorrhage and ensuring 
 an open os. 
 
 I place the patient on the left side, as for all the 
 operations in uterine surgery. The speculum (fig. 5, p. 
 18) is introduced ; a small tenaculum is hooked into the 
 central portion of the anterior lip of the os tincse ; the 
 uterus is gently pulled forwards ; one blade of a pair of 
 curved scissors is passed into the canal of the cervix till 
 the outer one comes almost in contact with the insertion 
 of the vagina on the side of the cervix, and the portion 
 thus embraced is divided at one blow of the scissors. 
 Then the opposite side is in like manner divided, and 
 the operation is almost finished (fig. 53). It only 
 remains, while the uterus is still held in position by the 
 tenaculum, to sponge away the blood, and pass a narrow- 
 bladed, blunt-pointed knife (at a proper angle with its 
 handle) and divide the small amount of tissue on each 
 side) leading from the scissor-cuts up to the very cavity 
 of the womb. The scissors never cut the whole amount 
 of tissue embraced between the blades. They will spring
 
 256 UTERINE SURGERY 
 
 "back a little, making only a deep notch on each side of the 
 os. The advantage of cutting the edges of the os with 
 
 Fig. 53. 
 
 scissors is that we make the incisions perfectly equilateral 
 and symmetrical. 
 
 Fig. 54 
 
 [I now often use scissors with short straight blades, but curved above the 
 
 joint, as here shown.] 
 
 Fig. 55 represents the knife with the blade in proper 
 position for cutting the left side of the canal. To cut 
 the right side, it is necessary to turn the blade in the 
 opposite direction, as shown by the dotted line. The 
 blade may be fixed firmly at any angle by the screw 
 at the end of the handle, which drives a shaft up 
 into little holes, as seen in fig. 56, where the razor-shape 
 of the blade is also shown. The operation is quickly
 
 OF MENSTRUATION. 
 
 157 
 
 Fig. 55. 
 
 m 
 
 Fig. 56. 
 
 done, and the judgment . 
 of the surgeon deter- 
 mines whether the pe- 
 culiarities of the case 
 demand more or less cut- 
 ting. The haemorrhage is 
 usually unimportant, but 
 sometimes it is profuse ; 
 and I have occasionally 
 seen it come with such a 
 rush that the vagina would 
 be filled before a set of sponges 
 could be washed out. But there 
 is nothing to be feared. Press one 
 or two sponge probangs (fig. 57) 
 right into the neck of the uterus, 
 but at the same time be sure to 
 keep the organ firmly fixed by the 
 tenaculum ; for if the bleeding be 
 profuse, it is a very awkward and 
 unlucky thing to let it slip out, par- 
 ticularly if the vagina is lax and 
 deep. A minute or two will usu- 
 ally suffice to control the bleeding by the pressure of 
 the probangs. When that is done, the dressing may 
 be proceeded with. Two or three small pieces of cot- 
 ton, large enough when moistened to fill up the gaping 
 os, are to be thoroughly saturated with water, then 
 squeezed as dry as possible, and afterwards wetted 
 in a mixture of one part of Deleau's neutral solution of 
 the perchloride of iron with four or five parts of water, 
 or in Dr. Squibb's liq. ferri persulphatis similarly dilut- 
 ed. Squeeze out the superfluous fluid, and place a bit 
 of the cotton in an angle of the wound, pressing a por-
 
 158 
 
 UTERINE SURGERY. 
 
 tion of it up into the cervical 
 canal, and holding it in place 
 with the sponge probang. 
 Apply another bit of cotton 
 similarly prepared on the op- 
 posite side, and press it down 
 with another sponge probang- 
 If necessary, another portion 
 of cotton may be placed cen. 
 trally; then, if there is no 
 bleeding, some cotton wet 
 with water or glycerine, may 
 be laid over the neck of the 
 womb, to be covered with dry 
 cotton to the extent of sup- 
 porting the whole dressing 
 neatly and comfortably in its 
 place. The patient is put to 
 bed, having been perhaps five 
 or six minutes on the table. 
 She eats and drinks as usual, but the recumbent pos- 
 ture is enjoined for a few days. She may pass water 
 lying, or it may be drawn off. The only object of 
 the recumbent posture is to ensure the retention of the 
 dressing in situ. I formerly allowed my patients to sit 
 up and walk about the room the day after the opera- 
 tion ; but I was so often annoyed by the supervention 
 of haemorrhage that I at length adopted the plan of 
 keeping them down till the spontaneous separation of 
 the intra-cervical dressing. 
 
 On the day after the operation, the whole of the 
 vaginal portion of the tampon is to be carefully removed ; 
 placing the patient in the position as for the operation, 
 and using the speculum, which must be introduced so as 
 
 Fig. 57. 
 
 [This cut is introduced here 
 simply to show the mechanism of 
 the sponge-holder, and the proper 
 size of the sponge. We often use 
 too large a sponge to be passed 
 with ease into the cervix. We 
 should have a few much smaller 
 than this.]
 
 OF MENSTRUATION". 159 
 
 not to derange the relations of the dressing. When it 
 is all removed down to the intra-cervical portion, a wad 
 of cotton saturated with Price's glycerine, and large 
 enough to cover completely the cervix and its first dress- 
 ing, is laid over it, and the patient again lifted into bed. 
 The action of this, as already fully explained, is to 
 induce a profuse watery discharge from the vagina, which 
 keeps the part cleanly drained of all secretions or exuda- 
 tions from the decomposition of the blood contained in 
 the original dressing. This glycerined cotton is to be 
 removed and renewed daily till the suppurative process 
 throws off the dressing from the neck of the womb. This 
 will not be under three or four days. In the mean time 
 the glycerine, by its detergent and antiseptic properties, 
 keeps everything sweet and clean ; and its affinity for 
 water, which by osmosis it extracts from the tissues with 
 which it lies in contact, keeps the parts entirely clear of 
 any secretion that might be re-absorbed and poison the 
 blood, if not thus drained off by the chemico-capillary 
 action of the dressing. No one can thus apply glycerine 
 to the neck of the womb and not be struck with its 
 peculiar power and properties. The intra-cervical dress- 
 ing will be loosened on the third day or later, and it 
 may then be gently removed with forceps. If it adheres 
 obstinately, let it alone, but cover it and the whole 
 cervix with the cotton glycerole, and at the next dress- 
 ing it may come away easily. I have frequently provoked 
 bleeding by a little impatience in removing it prema- 
 turely. When it is once safely out, then the cervix is to 
 be plugged with a small bit of cotton glycerole, and the 
 whole covered as before with the same. This dressing 
 is to be renewed daily till the parts have entirely healed, 
 which usually takes from twelve to seventeen days, or 
 perhaps till the recurrence of the next menstrual period
 
 1Q0 UTERINE SURGERY. 
 
 Aiid this reminds me that the operation should always 
 be performed within from three to five days after a men- 
 strual epoch, so that we may have time enough for the 
 healing process to be wholly completed before the recur- 
 rence of the next period. 
 
 There is sometimes great trouble in keeping the 
 mouth of the womb sufficiently open. It never remains 
 just as we cut it. The tendency of all cicatrizing wounds 
 to contract as they heal is wonderfully illustrated here. 
 I have often been amazed to find the os contracted in 
 a month to one-fourth of the size of the original incisions. 
 I have frequently seen it cut open large enough to admit 
 the index-finger up to the os internum, and then close in 
 a few weeks to such a degree as not to admit a No. 4 or 5 
 bougie, and this in spite of persevering efforts to prevent 
 the contraction. This is the case where there is great 
 induration of the cervix, with deposits of fibrous tissue. 
 I have frequently been compelled to repeat the opera- 
 tion, and I remember several patients upon whom I have 
 operated as often as three times in the course of a few 
 months, and even then the result was not wholly satisfac- 
 tory. These may be called exceptional cases, but it is well 
 to know that they are not very rare. Even when the os 
 tincse remains open enough, we may have some trouble 
 in keeping the contracted portion above of normal 
 dimensions. This may be the case if there is much of 
 a flexure, particularly anteriorly. And here I would 
 recommend the occasional passage of a bougie after the 
 first week. Dr. Emmet is in the habit of using the 
 sound as early as the third day after the operation, 
 passing it into the cavity of the womb, and pressing it 
 pretty firmly first against one side of the canal and then 
 against the other in withdrawing it. I have in a few 
 cases followed his example, but with a little timidity.
 
 OF MENSTRUATION. 
 
 161 
 
 Dr. Greenhalgh uses a self-retaining intra-uterine stern, 
 which is very ingenious, and an- 
 swers well in his hands. Dr. 
 Priestley's instrument* (fig. 58) 
 may be found useful under these 
 circumstances. Introduced as an 
 ordinary sound, it is then dilated 
 as shown in the cut. 
 
 Incision of the os often cures 
 dysmenorrhcea ; sometimes it only 
 modifies it. zVnd again, I have 
 seen cases where it produced no 
 beneficial effect whatever. The first 
 menstrual flow after it is usually 
 ushered in without the premoni- 
 tions that had so long harassed 
 the poor sufferer, and she may pass 
 through the whole period with 
 comparative comfort ; but I think 
 it advisable for such patients to 
 take very good care of themselves 
 at each return of the flow, and to 
 avoid all unnecessary exposure or 
 fatigue. If there is pain enough 
 to lie down, I direct an anodyne 
 by the rectum, and for this purpose 
 McMunn's elixir of opium is the 
 very best. It is less apt to nau- 
 seate or to produce headache than 
 crude opium or any of its alka- 
 loids. It is more efficacious by the 
 rectum than by the mouth, because 
 
 Fig. 58. 
 
 * Medical Times and Gazette, March 5th, 1864. 
 11
 
 Ig2 UTERINE SURGERY. 
 
 it is more immediately in conjunction with the nenes of 
 the affected part. 
 
 But suppose the bilateral incision produces no per- 
 manent amelioration, are we to give up the case as 
 beyond the reach of surgery ? By no means. We must 
 then reinvestigate ; for there may still be some mecha- 
 nical obstacle undetected, or, if detected, unrelieved by 
 the operation. For instance, dysmenorrhcea may persist 
 m consequence of an undetected polypus, or of acute 
 flexure with contraction of the canal of the cervix at the 
 os internum ; or it may be tbe result of a curvature of 
 the cervix, at the insertion of the vagina, with elonga- 
 tion of the iutravaginal portion, and a consequent 
 unequal development of its anterior and posterior seg- 
 ments. I propose to give examples of each of these 
 classes. 
 
 I have on more than one occasion found the pain to 
 be due to an undetected polypus, so diminutive as to 
 elude observation. A single illustration will serve as 
 an example of its class, and at the same time be a 
 warning and a guide to the inexperienced. 
 
 Mrs. , aged thirty-two, married at twenty-four, 
 
 sterile, had dysmenorrhoea for some years before 
 marriage, worse after. Her sufferings were excru- 
 ciating for about two hours on the second day. She 
 had in the course of twelve years been treated by 
 sixty different physicians without permanent benefit, — 
 the largest number I ever knew any one person to 
 consult. She had been under the care of many of the 
 most eminent men in at least five or six of the great 
 capitals of Europe, besides her consultations at home. 
 I saw her in January, 1857. Her general health was 
 good ; her only trouble seemed to be the much dreaded 
 dysmenorrhoea.
 
 OF MENSTRUATION. J 53 
 
 The uterus was of normal size and in proper position. 
 Os and cervix both small, but not indurated. I re- 
 sorted to the sponge tent, but found no polypus, no 
 fibroid, and no flexure of the canal. Three days after 
 (January 12), the os presented precisely the same 
 appearance that it did before the use of the tents. 
 The next menstruation was quite as painful as usual, 
 if not more so. As the canal was straight, and the 
 cervix soft, I would hardly have expected severe pain, 
 although the os was rather small. Yet I did not 
 know what else to do but to incise the os and cervix, 
 hoping that some benefit might be derived from it. 
 Accordingly, the operation was performed on the 22nd 
 January, and the parts were healed before the next 
 menstrual period ; but the pain was still the same, 
 and so continued for three or four months, in spite 
 of treatment. I was now quite perplexed. I had 
 used the sponge tent and found no polypus. I had 
 then enlarged the cervical canal without the least im- 
 provement; but the symptoms were so evidently those 
 of mechanical obstruction, that I concluded to make 
 another exploration of the cavity of the uterus. I 
 accordingly introduced a small sponge tent, and on 
 its removal I passed another, larger and long enough 
 to enter the cavity of the womb. On its removal, 
 I had the satisfaction of finding and bringing away 
 a polypus, which was but little larger than a common 
 garden pea. Its attachment and relations, represented 
 in the diagram (fig. 59), suggest at once the rationale 
 of the symptoms. 
 
 The violent agonizing pain always supervened on 
 the second day of the flow. When I first felt the 
 tumour, it was protruding through the os internum 
 after the removal of the tent ; but by the pressure
 
 164 
 
 UTERINE SURGERY. 
 
 ~-^«~-„ 
 
 Fig. 59. 
 
 of the finger it suddenly slipped upwards, and I could 
 
 not touch it again till the fin- 
 ger was gently forced through 
 the os internum to the fundus, 
 when I fortunately seized it with 
 forceps and brought it away. 
 
 My explanation of the pain 
 is this — By the second day coa- 
 gula formed above the tumour, 
 which pressed it downwards, its 
 slender pedicle yielding till it 
 blocked up completely the os 
 internum just like a ball-and- 
 socket valve. Then would come 
 the violent neuralgic throes con- 
 tinuing for two hours or more, 
 till the tumour either dilated the contracted part, or 
 was compelled to retreat again into the uterine cavity 
 by displaced coagula driven between it and the poste- 
 rior face of the uterus by the expulsive efforts of the 
 organ. 
 
 The case illustrates the necessity of a very thorough 
 investigation before a correct diagnosis can always 
 be made out in obscure c^ses. The leeching, the 
 physicking, the blistering, the anodynes, the baths, 
 the mountain excursions, the sea-bathing and sea 
 voyages that this poor patient suffered and endured 
 for years are almost incredible. As contemptible as 
 the little polypus was, it took me nearly four months 
 (shall I say ?) of empirical observation to find out that 
 it was the source of all the mischief. 
 
 It is now plain enough, but the difficulties of dia- 
 gnosis may be appreciated when we remember the 
 history of the case and the great number of dis-
 
 OF MENSTRUATION. 1Q5 
 
 tinguished physicians who were baffled in their honest 
 efforts to elucidate it. 
 
 I have already said that sometimes after the cervical 
 canal is freely opened by the bilateral incision it con- 
 tracts again, and the pain of dysmenorrhea may be 
 just as severe as before the operation, and that this is 
 more apt to be the case if there is much flexure, 
 particularly anteriorly. We shall then in all proba- 
 bility be compelled to repeat the operation, and exer- 
 cise greater care in keeping the canal open afterwards. 
 We may occasionally find the obstruction at the os 
 internum with flexure and contraction, while the lower 
 portion of the canal may be of normal size. This, 
 however, is by no means common. Yet I have seen 
 several examples of it. Its most perfect type I found 
 in a patient of Sir Joseph Olliffe. This lady was about 
 thirty-six years of age, and had suffered from painful 
 menstruation most of her menstrual life. Sir Joseph 
 had dilated the os externum and the cervix up to the 
 os internum, but had never been able to pass a sound 
 through this. One of the most eminent surgeons of 
 Paris saw her in consultation with Sir Joseph about 
 four years ago, and, failing to pass the sound, proposed 
 to enlarge the contracted portion by the use of the 
 actual cautery ! This treatment was not carried out,, 
 and on my arrival in Paris, in the fall of 1862, 
 Dr. Olliffe kindly invited me to see her. I found the 
 fundus lying just behind the inner face of the symphysis 
 pubis, with quite a sharp flexure at the os internum. 
 The sound could be easily passed to the os internum, 
 where it met with an unyielding barrier, and I was 
 obliged to have a small one made, quite probe like, 
 just to suit the case ; and even this could not be passed 
 with the patient on the back ; but by placing her on the
 
 166 
 
 UTERINE SURGERY. 
 
 side, using the speculum, and fixing the cervix with a 
 tenaculum, it passed into the uterine cavity seemingly 
 through a dense inelastic ring of fibrous tissue, which 
 resisted not only the ingress but the egress of the 
 olive-shaped point of the probe. I at once agreed 
 with Sir Joseph's opinion that an incision of the part 
 was the only safe and speedy method of overcoming 
 the difficulty. The neck of the uterus was split bila- 
 terally, just as if it had been contracted all the way 
 
 to the os tincse. When we 
 came to cut the gristly circular 
 band at a (fig. 60), the blunt- 
 pointed knife was passed 
 through it with some little 
 difficulty, and the cuts on each 
 side were attended with the 
 peculiar creaking sensation that 
 we experience in cutting 
 through cartilage. The wound 
 FlG , 60 was treated in the usual way, 
 
 as previously laid down, and all 
 was well by the time of the next menstruation. The os 
 internum was, after the fourth or fifth day, . forcibly 
 pressed open laterally by the sound, as practised by Dr. 
 Emmet. 
 
 But the pain of menstruation may continue even 
 after all our best efforts to enlarge the os internum as 
 well as the cervical canal by the bilateral incision. It is 
 then often the consequence of curvature, with elongation 
 of the vaginal portion of the cervix, accompanying ante- 
 flexion. When this is the case, we shall find the os 
 tincse looking in the direction of the axis of the vagina, 
 the posterior portion of the cervix from the os tincse to 
 the posterior cul-de-sac being two or three times as long
 
 OF MENSTRUATION. 
 
 167 
 
 Fig. 61. 
 
 as the anterior, measuring from the os to the anterior 
 cul-de-sac. I have repeatedly performed the bilateral 
 operation on such cases as this without improvement, 
 and for the best of reasons. If we take a flexible tube 
 the size of the cervical canal, and curve it as represented 
 by the diagram (fig. 61), it flattens out laterally, and 
 the inner concavo-convex surfaces, 
 necessarily brought into close 
 apposition, present an almost val- 
 vular mechanical obstacle to the 
 passage of a fluid in either direc- 
 tion. By referring to the diagram, 
 it will be seen at once that a bila- 
 teral incision could only widen the 
 canal a little transversely, but not 
 at all antero-posteriorly ; that the 
 curvature would remain the same, 
 and consequently the distances 
 
 between the two opposing surfaces of the cervical canal 
 would in no way be modified by such operation. 
 Having so often failed, under such circumstances, to 
 afford the relief anticipated from the bilateral incision, I 
 at last devised and practised the following method. To 
 remove the flexure of the canal would be to remove the 
 obstacle to the easy passage of the menstrual flow. To 
 do this, it is only necessary to split the posterior portion 
 of the cervix from the os tincae in a straight line back- 
 wards, nearly to the insertion of the vagina, and thus the 
 canal of the cervix is made to run in a straight line from 
 the cavity of the uterus to the terminus of the incision 
 at «, instead of curving round to the os tincae. The 
 method of doing this is very simple. The patient as 
 usual on the left side; the speculum introduced; the 
 anterior lip of the os tincse is held by the tenaculum, as
 
 168 
 
 UTERINE SURGERY. 
 
 so often described ; and then with a straight pair of 
 scissors the posterior portion of the cervix is split at cne 
 blow, as far as can be easily and conveniently done by 
 scissors, which would be about as far as represented by 
 the dotted line a c, fig. 61. Then the blunt-pointed 
 knife (fig. 62), bent at a proper angle with its shaft, and 
 cutting backwards, is passed up to the cavity 
 of the uterus, and the part's cut in the 
 direction of the line a d, thus straighten- 
 ing out the canal, and thereby removing 
 the mechanical obstacle due to its flexure. 
 Fig 63 is intended to represent the 
 second stage of the operation. The uterus 
 is firmly fixed by the tenaculum, while the 
 razor-shaped blade of the blunt knife is 
 seen in the act of cutting the canal back- 
 wards. The case is to be treated on the 
 same general principles laid down for the 
 management of the bilateral operation. 
 There is some little care necessary to avoid 
 cutting through the vaginal cul-de-sac into 
 the peritoneal cavity — an unpardonable 
 blunder that no true surgeon could possibly 
 make. The operation has succeeded admi- 
 rably in these cases, but is wholly inappli- 
 cable except in just such cases as the one 
 Fig. 62. above described. I have often performed 
 the operation in this way, and my 
 colleague, Dr. Emmet, has repeated it more frequently 
 than I have ; for the relief it affords is a great tempta- 
 tion to its performance. 
 
 In operating for dysmenorrhcea, we must not lose 
 sight of doing it in such a way as to favour the chances 
 of conception. How often do we hear even medical
 
 OF MENSTRUATION. 
 
 169 
 
 men say, " If she could only have a child it would cure 
 her.' 1 To this I always feel inclined to reply, u If we 
 
 Fig. 63. 
 
 could only cure her, she would have a child." We 
 should remember that the physical causes that obstruct 
 the easy egress of the catamenia, likewise obstruct the 
 easy ingress of the spermatozoa ; and to remove the one 
 is in some degree to relieve the other. If an inflamed, 
 turffid cervical mucous membrane is a mechanical bar- 
 rier to the passage from one direction, it is equally so 
 to it from the other. If a contracted os shuts the door 
 to an outlet, it closes it equally to an inlet. If a cervi- 
 cal canal, flexed to such a degree as to bring its oppo- 
 site walls into close contact, will produce the pain of 
 dysmenorrhcea, it will as certainly prevent the pain of 
 parturition, but only by preventing conception. Thus, 
 to treat dysmenorrhcea successfully, is to treat many, but 
 by no means all, cases of sterility successfully. Those 
 who have adopted the operation of enlarging the canal 
 of the cervix for the cure of dysmenorrhcea, seem satis-
 
 1^0 UTERINE SURaERT. 
 
 fied to rest upon it alone for the relief of sterility. But 
 more remains to be done. 
 
 It would seem that I have already said enough on 
 the subject of dysmenorrhea, and the operations for its 
 relief; but as my views previously published* have 
 been controverted by some of the most eminent medical 
 men in England, I shall say a few words more. 
 
 Dr. Henry Bennetf objects to the operation of in- 
 cising the cervix, because he thinks he can accomplish 
 the same result by sponge tents ; and Dr. Gream,J 
 because he thinks the bougie system, as introduced and 
 practised by M'Intosh, answers every purpose. Dr. 
 Gream says he has seen a case in which the neck of the 
 womb was so largely opened that he could easily pass 
 his finger through it, and touch the membranes of the 
 ovum, at the third month of gestation. His patient 
 aborted soon after ; and he thinks the abortion was not 
 the result of passing the finger into the cavity of the 
 uterus, but of the inability of the organ to retain its 
 contents, in consequence of the extensive division of the 
 circular fibres of the cervix. 
 
 This is, I admit, a very rational inference ; at ail 
 events we must accept the fact, and inquire into its 
 cause. Mr. Spencer Wells § advocates the operation, 
 but says he has seen several cases in which the cervix 
 was too largely incised, and the lips of the os tincse were 
 in consequence everted, rolled back, and almost lost in 
 the insertion of the vagina. This is certainly a very 
 grave objection to the operation of bilateral incision. 
 Bat I have never seen this accident after the operation, 
 
 * Lancet, March 4th and 11th, April 1st, and June 3rd, 1865. 
 t Lancet, June 24th, 1865. \ Lancet, April 8 th, 1865. 
 
 § Lancet, May 27th, 1865.
 
 OF MENSTRUATION. ^71 
 
 as performed by ray method, and, as before stated, Dr 
 Emmet and myself have done it several hundred times 
 
 Let us, then, inquire why it occasionally follows this 
 operation in the hands of English surgeons and not in 
 ours. At first I was disposed to believe that the gen- 
 tlemen alluded to above had encountered unique and 
 isolated cases ; but upon inquiry I am now convinced 
 that this accident does occasionally follow the use of 
 the metro-tome cache. It is well to know this fact, so 
 as to guard against its occurrence. 
 
 A short time as;o, a friend invited me to see a case of 
 fibroid of the uterus, attended by severe haemorrhages, 
 in which he had divided the cervix after the plan of 
 Mr. Baker Brown. The operation had been done by 
 some one before, but the bleedings continued, and my 
 friend, desirous of giving the operation a fair chance, 
 determined to make a more thorough division of the 
 cervix, for which purpose he set the blades of the metro- 
 tome cache very widely, so as to cut deeply. The con- 
 sequence was a complete division of the cervix through 
 the whole of the circular fibres, from the os tincae quite 
 to the cavity of the uterus, which produced the defor- 
 mity that Mr. Spencer Wells speaks of. After seeing 
 this case, I could no longer doubt. Why does this 
 accident happen after the metro-tome cache method of 
 operating, and not after my plan ? The reason is 
 obvious enough, if we consider the difference in the 
 two methods of operating. To illustrate this, let the 
 diagram (fig. 64) represent the natural size of the uterus. 
 This outline is taken from Dr. Savage's* picture of a 
 dissection of a uterus of natural size. I have made 
 
 * " Illustrations of the Surgery of the Female Pelvic Organs." By 
 Henry Savage, M.D., Physician to the Samaritan Hospital for Women. 
 Plate 8, fig. 3.
 
 172 
 
 UTERINE SURGERY. 
 
 the cervix project a little more into the vagina, as we 
 
 Fig. 64. 
 
 usually find it so in the majority of cases requiring 
 operation. 
 
 According to my plan of operating, the dotted line 
 a b would represent the proportion of cervical tissue 
 divided by the scissors (page 156), while the dotted 
 lines a c,b c would represent the extent of the incisions 
 made by the blunt-pointed knife (fig. 55, page 157) up 
 towards the cavity of the uterus. Now, upon this same 
 diagram, let us see what would be the nature and extent 
 of the incisions made by the metrotome cache. We 
 will take Dr. Greeuhalsfh's instrument, as now made in 
 London by Weiss, and in Paris by Charriere, as being 
 the safest and best of its class. Lay it down upon this 
 diagram, with the point at the fundus d, and the shoul-
 
 OF MENSTRUATION. 17c 
 
 der at the os tiucae, hold it firmly as we would in ope- 
 rating upon a patient, then draw the blades slowly down, 
 and the extent of their movements will be shown by the 
 dotted lines e d,fd. 
 
 The two* methods differ theoretically as well as prac- 
 tically. The one is based upon the idea that the obstacle 
 to be overcome usually exists in the lower portion of the 
 cervical canal ; the other upon the belief that it is always 
 found at the os internum. Now, by comparing the in- 
 cisions made by these two methods, it will be seen that 
 the metro-tome cache divides the circular fibres of the 
 cervix to a greater extent at the os internum, and through- 
 out the entire cervix, than is done by my method. 
 
 As before said, too large a division of the cervix is 
 sometimes followed by eversiou and rolling back of the 
 two lips of the os tinose. But why only sometimes ? 
 Large and small are always relative terms. What may be 
 small in one case may be comparatively large in another. 
 The metro-tome cache cuts so much whether the cervix 
 be large or small. We know very well that the size of 
 the cervix varies greatly in the unimpregnated uterus, 
 and that in the class of cases requiring this operation, it 
 is sometimes less than an inch in diameter. Now, if we 
 use an instrument that cuts more than this, it must of 
 necessity cut through the cervix from side to side ; and 
 hence the danger of the accidents that are said to some- 
 times follow this operation. 
 
 I have seen, in several shops, metro-tomes that could 
 be opened from one and a half to two inches. I am not 
 going out of the way to caution my younger brethren 
 against machines of this sort, when I call to mind the 
 fact that a friend of mine recently used one of them, and 
 was afterwards glad to see his patient ultimately recover 
 from the serious consequences of his rashness. If we
 
 174 UTERINE SURGERY. 
 
 must use a metro-tome cache, let us take Dr. Green* 
 halgh's, with its maximum expansion, as shown in the 
 diagram above. 
 
 But why do the lips of the os tincse roll back when 
 the cervix is too extensively incised ? The rationale is 
 this : The longitudinal fibres of the uterus run down 
 from the fundus to be inserted or incorporated antero- 
 posterior^ with the circular fibres of the cervix. These 
 two sets of muscular fibres are antagonistic in their action 
 physiologically. In a normal labour, the contraction of 
 the longitudinal fibres of the body must be accompanied 
 or followed by a relaxation of the circular fibres of the 
 cervix, or the labour could not be finished. They are as 
 antagonistic as are the flexors and extensors of the hand. 
 Destroy the power of the one set of muscles, and the 
 other will inevitably take on a tonic contraction, and 
 draw the hand in the direction of the line of their action. 
 In the operation of dividing the circular fibres of the 
 cervix uteri by the metro-tome cache, if the whole dia- 
 meter of the cervix be cut entirely through, we must of 
 necessity cut the whole of its circular muscular fibres, 
 which destroys their contractility, and removes the force 
 that bound, as it were, in a bundle the terminal extre- 
 mities of the longitudinal fibres, which then take on a 
 tonic rigidity, retracting the divided lips of the os tincae, 
 and producing the deformity that, we must admit, is 
 occasionally seen to follow the metro-tome cache method 
 of operating. 
 
 Whether my explanation be correct or not, does not 
 in the least affect the fact under consideration ; and the 
 young surgeon cannot be too careful, for if he should 
 unfortunately cut too much, there is no remedy for his 
 mistake. It is far better to cut too little, even at the 
 risk of being compelled to repeat the operation.
 
 SECTION III. 
 
 THE OS AND CERVIX UTERI SHOULD BE SUFFI- 
 CIENTLY OPEN, NOT ONLY TO PERMIT THE 
 FREE EXIT OF THE MENSTRUAL FLOW, BUT 
 ALSO TO ADMIT THE INGRESS OF THE SPERMA- 
 TOZOA.
 
 ' SECTION III. 
 
 THE OS AND CERVIX UTERI SHOULD BE SUFFICIENTLY OPEN, 
 NOT ONLY TO PERMIT THE FREE EXIT OF THE MEN- 
 STRUAL FLOW, BUT ALSO TO ADMIT THE INGRESS OF THE 
 SPER ^ATOZOA. 
 
 In the preceding pages we have followed symptomatology 
 to the detection and treatment of organic disease, but 
 now we propose to ask in what particular organic struc- 
 ture varies from a normal condition, irrespective of 
 rational signs ? It will then be necessary to inquire into 
 the normal conditions and relations of the uterus, before 
 speaking of its anomalies, and their influence on concep- 
 tion. 
 
 Anatomists tell us that the uterus is pear-shaped, 
 and flattened a little antero-posteriorly ; that it is from 
 two and a half to three inches long ; an inch and a half 
 wide, more or less, at its largest part ; and about an inch 
 thick ; that it is divided into fundus, body, and cervix ; 
 that its cavity is from two and a quarter to two and a 
 half inches lon^, the canal of the cervix beinsj a little 
 longer than that of the body ; that the os tincse is 
 generally round in the nulliparous uterus ; elliptical and 
 transverse after child-bearing ; and that the cervix is 
 rounded and embraced by the vagina, which is inserted 
 higher behind than before, thus making the posterior 
 intravaginal portion of the cervix a little longer than 
 the anterior. But anatomists do not tell us how far the 
 intravaginal portion of the cervix should project into the
 
 178 UTERINE SURGERY. 
 
 vagina, or what proportion it should bear to the supra- 
 vaginal section, which, by the bye, is an important 
 matter to determine. Not having time or inclination to 
 go to the dead-house for the verification of this point, I 
 shall describe the neck of the womb as I see it in daily 
 investigations on the living. I assume that a normal os 
 tincse, whether round or transverse and elliptical, should 
 be open, and filled with a slippery translucent mucus of 
 slightly alkaline reaction ; that the cervix should be 
 rounded, truncated, and elastic to the touch ; that the 
 intravaginal portion should be about a fifth or not more 
 than a fourth of its whole length, i.e., from a quarter to a 
 third of an inch anteriorly, and a fraction more poste- 
 riorly ; that the canal of the cervix should be straight 
 or curved slightly forward ; and that the axis of the 
 whole organ should stand at about right angles with 
 that of the vagina, being neither anteverted nor retro- 
 verted to any great degree. Any woman with such a 
 state of the uterus will always conceive in three or four 
 months after marriage, if everything else is ri^ht. 
 
 Having laid down this ideal of what the womb 
 should be, an ideal that has not been imagined, but 
 drawn from actual observation in the clinique and the 
 consulting-room, we shall proceed to the examination of 
 the sterile, unimpregnated uterus, to see where and how 
 it may differ from a normal conceptive state. This neces- 
 sarily embraces anomalies or deviations from a normal 
 state ; 1st, of the mouth of the womb ; 2nd, of the 
 cervix ; and 3rd, of the body : and this brings us at 
 once to the third general subdivision of our subject, viz., 
 that the os and cervix uteri should be sufficiently open 
 not only to permit the free discharge of the menstrual 
 flow, but also to admit the iugress of the spermatozoa. 
 
 It might appear, at the first glance, that this propo-
 
 OS TINC^E- ABNORMAL. 1^9 
 
 siticn liad been embraced, and sufficiently discussed, in 
 the preceding article on painful menstruation. But 
 experience teaches us differently ; for instance, how often 
 do we see sterility where there is no symptom of disease 
 so far as physical suffering is concerned ? Menstruation 
 may be perfectly normal, there may be no back-ache, 
 no vesical tenesmus, no bearing-down, no leucorrhcea, 
 indeed, no sign of diseased action ; and when we come 
 to a physical exploration, we may even find the uterus 
 of proper size, in a normal position, and with a straight 
 cervical canal, but the os may not be larger than a pin's 
 head, and if to this be added induration of the cervix, 
 the case is almost necessarily sterile ; for while the os 
 and cervix are capacious enough to transmit the outward 
 flow, the os itself is not capable of admitting the sperm, 
 and without this there can, of course, be no conception. 
 This is not theoretical, and I might give numerous illus- 
 trations in proof, but one will suffice. 
 
 Mrs. X., of fine form and vigorous health, had been 
 married many years (thirteen or fourteen) without 
 offspring. Menstruation regular, normal; never had 
 leucorrhcea, or any other symptom of uterine disease ; 
 and people wondered why such a fine specimen of 
 womankind should not become a mother; and they 
 very generally and erroneously inferred that it could 
 not be the fault of such a physical organization. She 
 consulted many eminent medical men, and took baths 
 and mineral waters, and cordials, elixirs, and nostrums 
 without number. She had submitted to be bougied till 
 an attack of pelvic cellulitis supervening had well-nigh 
 cost her her life. Indeed, I never saw any woman so 
 determined on having offspring, and for that purpose 
 she was read}^ to suffer anything and to take any reason- 
 able risk. On examination, I found the uterus in proper
 
 180 
 
 UTERINE SURGERY. 
 
 position, and rather under size ; but as menstruation was 
 perfectly normal, the size of the organ was not deemed 
 of any great importance. The canal was straight, but 
 the os was exceedingly small, and the cervix felt to 
 the touch like a little round marble, and almost as hard. 
 Of course there was but one thing to be done, viz., 
 to open the os and cervix by the bilateral operation. 
 This lady, who had already suffered so much from dilata- 
 tion, thought the operation a small affair compared to 
 the result hoped for. 
 
 In this case, I was able to say beforehand that she 
 would almost certainly conceive after the operation. 
 Very often we can say to one, "Yes, you are almost 
 
 sure to conceive ;" while to 
 another we are compelled to 
 say, " Conception is probable ;" 
 to another, " It is possible ;" 
 and to others, "It is impos- 
 sible." 
 
 This diagram (fig. 65) re- 
 presents the relative condition 
 of the os and cervix. The ope- 
 ration was done in April, and 
 conception occurred in Decem- 
 ber following. Here there was 
 no dysmenorrhea, as already 
 remarked. And why ? Simply 
 because there was no mechanical obstruction to the flow. 
 The canal of the cervix was small, but straight ; and its 
 mucous membrane was not congested. Had it been a 
 little crooked, there would probably have been pain, for 
 it was very small. But as small as the os was, it per- 
 mitted the easy exit of the menstrual flow, while it 
 prevented the ingress of the sperm. This is proved by 
 
 Pig. 65.
 
 OS TINCLE— ABNORMAL. 
 
 181 
 
 the fact that she was sterile for thirteen or fourteen 
 years, during which time she tried all sorts of remedies 
 to overcome it, and then became pregnant in a few 
 months after the performance of the operation. 
 
 I have seen many other similar cases, and a great 
 many like it artificially produced by the injudicious use of 
 potassa fusa, potassa c. calce, and even nitrate of silver. 
 
 Sometimes the os tincse becomes wholly occluded by 
 the prolonged use of these agents ; more frequently it is 
 partially closed, and the cervix always feels indurated. 
 Whether the induration is due to the action of the reme- 
 dy, or to the inflammation that called for its applica- 
 tion, I shall not pretend to say ; but I have generally 
 found artificial occlusion of the os to co-exist with indu- 
 ration of the cervix. This produces a state of acquired 
 sterility. I have met with it more frequently amongst 
 those who had once borne children, though I have seen 
 it in those who had not. A marked example of this 
 was found in the out-door practice of the Woman's Hos- 
 pital, in a young unmarried woman who had had potassa 
 c. calce applied some months before at one of our dis- 
 pensaries. When the finger was introduced into the 
 vagina, the cervix was found 
 in proper position, but it 
 was perfectly round and hard, 
 and no os was to be felt. 
 When the speculum was 
 used, we found the os com- 
 pletely bridged over by a 
 dense fibrous band of union, 
 with a little opening at 
 each extremity, which would 
 not admit an ordinary-sized 
 probe. Fig. 66 represents the appearance of the os in 
 
 Fig. 66.
 
 ^32 UTERINE SURGERY. 
 
 this case, and shows the two little points a a, whence 
 issued the menstrual flow. 
 
 I saw, in consultation with Sir Joseph Olliffe in Paris, 
 in 186 3, a lady in the higher ranks of life, who had 
 been twice married without offspring, and whose os 
 tincse had been thus artificially agglutinated by the pro- 
 longed use of the nitrate of silver during her first marriage. 
 
 When this mechanical obstruction to the esrress of 
 the menses is thus artificially produced, we may find 
 more or less suffering and general malaise attending the 
 flow, which becomes unusually prolonged, always very 
 dark-coloured, often of tarry consistence, and sometimes 
 offensive. The cessation of the flow is then followed by 
 a dark-brownish fine coffee-grounds-like mucus, which 
 continues for a few days, and frequently irritates the 
 parts with which it comes in contact. The mechanical 
 obstruction at the os preventing the easy outlet of the 
 flow, causes a partial retention of the secretions, which 
 thereby undergo some change, that reacts upon the tis- 
 sues, and produces a sort of subacute endo-metritis. Of 
 course the only remedy is the restoration of the os and 
 cervix to a normal state, by cutting the canal open, and 
 keeping it so. 
 
 This species of artificial occlusion of the os by caustic 
 applications is not, I am glad to say, very common, but 
 I fear it occurs more frequently than it should. Fortu^ 
 nately its effects are easily remedied if they are recog- 
 nized. 
 
 The cases of it that have fallen under my observation 
 did not present themselves on account of the sterility 
 that it engendered, but because of the ordinary symp- 
 toms of uterine disease from which they suffered. Several 
 of these, when cured of the organic difficulty, were 
 rendered fruitful again.
 
 OS TINCLE— ABNORMAL. ^33 
 
 1 have repeatedly said that the subjects of sterility 
 are naturally arrauged in two great classes ; viz., those 
 who have never borne children, and those who, having 
 once conceived, cease, from some cause or other, to con« 
 ceive again. 
 
 Very perfect illustrations of this last class may be 
 found in those who have had the os uteri artificially 
 sealed up by the injudicious use of the potassa fusa or 
 potassa c. calce. Amongst the cases of this sort that I 
 have seen, I now call to mind two ladies, who had been 
 treated by the same physician. 
 
 They are important enough in their bearings on this 
 subdivision of our subject, to give a few particulars. 
 A lady, aged thirty years, married at twenty-one, had 
 two children, the youngest six years old. There was 
 nothing peculiar about the labours, but she was subject 
 to leucorrhoea after the last one, for which she had gene- 
 ral constitutional treatment, and, after a while, local 
 applications of the potassa c. calce, nit. arg., &c. Menses 
 rather profuse but otherwise normal, till about two 
 years ago, they became gradually veiy tedious and pro- 
 longed, lasting nine or ten days, instead of three or four, 
 as they did previously to the potassa c. calce treatment. 
 The flow was now scanty, very dark-coloured, almost 
 black, attended with nausea, nervous irritability, and a 
 sense of utter prostration, together with bearing-down, 
 weight and soreness in the rectum, and neuralgic pains 
 at the end of the coccyx. She also had great tender- 
 ness and sensitiveness at the mouth of the vagina. The 
 fundus was considerably hypertrophied, the cervix was 
 also hypertrophied and indurated, and felt more like a 
 small globe pessary than anything else ; and it was 
 utterly impossible to detect the os tinese by the 
 touch.
 
 184 
 
 UTERINE SURGERY 
 
 Fie. 67 shows about the size and relation of the little 
 opening through which the menses made their tedious 
 escape. The canal was opened by the bilateral incision. 
 The whole cervix was of fibrous hardness, and the resist- 
 ance to the knife was very great. As usual in these 
 cases, there was but little haemorrhage, but there was 
 great trouble in keeping the os open. However, it 
 remained sufficiently so. The next menstruation was 
 normal, and in four months she conceived again, after 
 an acquired sterility of six years, due, firstly, to granular 
 
 Fig. 67. 
 
 engorgement, and its attendant leucorrhcea, and lastly, to 
 the potassa c. calce treatment and its result, occlusion 
 of the os. 
 
 I do not object to the use of potassa c. calce judi- 
 ciously applied, but it is well for us to know that it is 
 ail-powerful to do mischief, while we intend only to do 
 good with it. I feel, therefore, justified in pressing this 
 matter a little more on the attention of the reader. 
 
 Mrs. M., aged thirty-six, three children, youngest six 
 years; some uterine trouble ever since the last labour; 
 was treated for "ulceration" by potassa c. calce three 
 years before I saw her in April, 1856. Her menses,
 
 OS UNCLE— ABNORMAL. 1g5 
 
 scanty, dark-coloured, of a tarry appearance, were now 
 preceded by pain for a week. 
 
 It is a waste of time to give general or even local 
 symptoms. 
 
 The uterus was anteverted,tlie fundus hypertrophied, 
 the cervix almost as hard as cartilage, and the os was 
 contracted to a little round point, that could not be 
 detected by the touch. 
 
 The os was cut open ; the next menstruation was 
 painless and normal, and the enlargement of the fundus 
 soon subsided as a consequence of the easy exit of the 
 menses, and conception occurred a few months after- 
 wards. - 
 
 But I pass from this class of cases to another, where 
 the os is open enough to permit the easy exit of the 
 flow, but where there may still be a mechanical obstruc- 
 tion to the ingress of the spermatozoa. It is not suffi- 
 cient to say that the mouth of the womb is large 
 enough, and that it admits easily the passage of a 
 bougie or a sound. 
 
 To illustrate my meaning I turn to my note-book. 
 Mrs. — — , aged thirty-five, two children, youngest ten 
 years old. She had been in bad health for a long time, 
 and was treated by a very eminent physician, Dr. Duane, 
 of Schenectady, who sent her to me in June, 1856. The 
 uterus was anteverted, and greatly hypertrophied, being 
 three inches and three quarters to the fundus ; the 
 cervix was the seat of fibrous engorgement ; the menses 
 were profuse, lasting five or six days, returning in seven- 
 teen ; and she was anemic and prostrated. 
 
 A course of treatment, local and constitutional, was 
 agreed upon, and Dr. Duane sent his patient to me 
 again in the autumn. She was somewhat improved ; 
 the depth of the uterus was three and a quarter inches
 
 186 
 
 UTERINE SURGERY. 
 
 instead of three and three quarters ; and the hyper- 
 trophy and induration of the cervix were better, but 
 there was little or no improvement otherwise. 
 
 I was at a loss what more to do for her relief, and 
 felt very sure that her ten years of sterility was due 
 not so much to the state of her general health as to 
 the peculiar conformation of the mouth of the womb, 
 which certainly prevented the ingress of the sper- 
 matozoa. Many of us think that a pregnancy will often 
 modify the nutritive functions of the uterus in such a 
 way as to remove engorgements, hypertrophic condi- 
 tions, and even small fibroids. With my mind full of 
 this idea, I asked my patient, rather jocularly, if she 
 would like to have more offspring. She promptly re- 
 plied, "No." "Well," said I, "it's difficult for me to 
 determine what else to do, if you will not consent for 
 me to rectify the condition of the mouth of the womb, 
 so that conception may take place." She did not think 
 it possible, and hardly believed me to be in earnest. 
 
 Now it may be asked 
 what could be the trouble 
 with the mouth of the 
 womb, when she had had 
 children, and when she still 
 menstruated without the 
 least difficulty. From the 
 birth of the last child she 
 had had leucorrhoea, as a 
 consequence of granular 
 engorgement of the cervix. 
 Dr. Duane had cured this long ago, and there still 
 remained, as previously stated, some hypertrophy of the 
 cervix. This, too, he had removed, in a great mea- 
 sure, during the summer, by two small potassa c 
 
 Fig. 68.
 
 OS TINC^E— ABNORMAL. 187 
 
 calce issues, one on each lip of the os tincse. But there 
 still remained the same mechanical obstruction at the 
 os as before, which is represented by fig. 68. A cres- 
 centic-shaped os is by no means uncommon. We 
 often see -it in ante versions, and I have frequently 
 seen it where the position of the uterus was nor- 
 mal. We may have it where there has never 
 been conception, or it may occur after child-bearing, 
 as a consequence of chronic inflammation of the cervix, 
 with hypertrophy of the cervical mucous membrane. 
 Here it presented no barrier whatever to an outward 
 flow; but a glance at the peculiar projection a from the 
 anterior- lip, shows what a perfectly valvular closure it 
 opposed to any inward flow. When this little tubercle 
 a was hooked with a small tenaculum and pulled down- 
 wards, so as to open the canal of the cervix, and permit 
 a view of its cavity, this hypertrophic condition was 
 seen to extend up along the anterior face of the cervix 
 for an inch. The curvilinear dotted line c shows the 
 course of the incision bv which this was removed. It 
 was a triangular wedge, as seen in fig. 69, 
 the apex having reached nearly to the os in- 
 ternum. There was but little bleeding, and 
 this was controlled at once by the pressure of 
 a sponge probang, and then by the applica- 
 tion of a pledget of cotton, wet with a solu- 
 tion of the percbloride of iron. Fig. go. 
 
 The wound was healed by the time of the 
 next menstruation; and my patient went home with 
 the os presenting a perfectly normal appearance. Not- 
 withstanding her feeble state of health, and the length 
 of time since the birth of her last child, conception 
 occurred a month after the operation. She went the full 
 time, and was safely delivered by Dr. Duane of a fine
 
 188 
 
 UTERINE SURGERY. 
 
 boy. But I am constrained to say that the pregnancy 
 produced no good effect either constitutionally or locally. 
 I had occasion to examine the uterus some four or five 
 months after delivery, and its condition was about the 
 same as at the time of conception. The case is valuable 
 only as illustrating one of the mechanical obstacles to 
 conception. It is not exceptional, for I have seen other 
 similar cases. 
 
 Again, the mouth of the womb may be open enough 
 to let the menses flow out freely, and it may be even 
 large enough to admit easily a No. 8 or 10 bougie, and 
 yet be absolutely closed to the ingress of the sperma- 
 tozoa ; and that without any excrescence or malforma- 
 tion. This condition is a very common cause of acquired 
 sterility, and occurs in this way : Labour is followed by 
 a chronic inflammation of the cervix, which becomes 
 hypertrophied ; the inflammation or granular erosion is 
 cured, but the hypertrophic condition conjoined with 
 induration remains, and the two indurated, thickened 
 lips of the os tincse lie in close apposition, yielding 
 readily to any fluid passing down, but opposing any 
 passing up the canal. We too often overlook this cause 
 of sterility, common as it is. We are apt to say the 
 
 mouth of the womb is all 
 right, because it admits a 
 large bougie, and gives free 
 vent from the uterine cavity. 
 Now, what is to be done 
 with such a case ? The os 
 is a straight transverse line, 
 with the two opposite bor- 
 ders crowded obstinately 
 against each other (fig. 70). 
 It is long enough from side to side, but antero-posteri- 
 
 Fig. TO.
 
 OS TINGS— ABNORMAL. 189 
 
 orly it has lost its gaping, graceful oval form, and 
 although quite as large as it ought to be, it is still to all 
 intents and purposes practically closed. Such an os as 
 this may be bougied till both surgeon and patient are 
 mutually tired out, without any result whatever ; and 
 there is but one thing to do, viz., to incise the cervix as 
 for dysmenorrhoea. It may seem paradoxical to enlarge 
 an os that is already large enough, but the only way in 
 which I have ever succeeded in causing a permanent 
 receding of such compressed lips, is by a bilateral divi- 
 sion of the circular fibres of the indurated cervix. 
 
 In March, 1859, a lady, twenty-seven years old, con- 
 sulted me on account of acquired sterility. She had had 
 one child five years before, — no conception since. As 
 she and her husband were both in vigorous health, she 
 wished to know the cause of what was to them a source 
 of great unhappiness. She had been told by her family 
 physician that there was no reason why she should not 
 conceive. On the contrary, I said that conception was 
 utterly impossible, with the mouth of the womb as it 
 was, and explained the necessity of a surgical operation. 
 Being satisfied of its painlessness and its safety, she sub- 
 mitted to it at once. The cervix was hard and gristly, 
 but the incisions produced the desired result of giving 
 the os an elliptical shape. 
 
 It required nice care to prevent a contraction of the 
 os to its former condition. Fortunately all went on 
 well, and in less than twelve months from the elate of 
 the operation the mother was safely delivered of twins, 
 which, she said, made up amply for her lost time. 
 
 In fifteen months after this she gave birth to another 
 child, which proved that the mouth of the womb re- 
 mained properly open. 
 
 I might go on to enumerate various other changes
 
 190 UTERINE SURGERY. 
 
 that take place in the appearance and form of the os> 
 as a result of accident, inflammation, engorgement, or 
 hypertrophy, any and all of which may in some sort in- 
 terfere with the passage of the spermatozoa to the cavity 
 of the uterus. Mauy of these we will recognize and 
 remedy, while great numbers, even when fully under- 
 stood, will baffle our efforts. 
 
 We all know that a protracted labour with impacted 
 head often produces sloughings of the vagina, which 
 result in fistulous openings into the bladder or rectum ; 
 but sometimes we have the impaction in the superior 
 strait before the head has passed through the cervix, and 
 then we may have a sloughing of some part of the cervix 
 without necessarily a fistulous communication with the 
 bladder or rectum. Sometimes we see the anterior lip 
 destroyed ; again the lateral portion of the cervix ; again 
 the posterior lip ; and a few years ago, Professor Isaac 
 E. Taylor, of the Bellevue Hospital Medical College, 
 showed me the entire cervix that had been thrown off 
 by slough, in consequence of impaction. In almost all 
 the cases, the cicatrizing process produces malforma- 
 tions of the os that mechanically prevent conception. 
 I might give an immense number of illustrations of these 
 unfortunate cases, drawn from the records of the Wo- 
 man's Hospital, but one will suffice. 
 
 Fig. 71 represents the appearance of a case that was 
 in the Woman's Hospital in 1856 ; the anterior lip of the 
 os tincse was entirely destroyed, but the posterior being 
 intact, projected slightly forwards, so as to hide the 
 small opening leading to the canal of the cervix. There 
 was a minute vesico- vaginal fistula which was easily 
 cured, but the mouth of the womb remained contracted, 
 puckered, and over-lapped by the posterior lip in such a
 
 OS TINOffi— ABNORMAL. 
 
 191 
 
 way as to form a complete barrier to a subsequent 
 conception. 
 
 Professor Fordyce Barker, of the Bellevue Hospital 
 Medical College, sent me a case in 1858, in which the 
 whole cervix had sloughed off without injury to the 
 
 Fig. 71. 
 
 vagina ; and the cicatrizing process had here produced 
 a complete obliteration of the os. When the finger was 
 passed into the vagina, we could feel the womb as if it 
 were sitting on this canal, seemingly attached to it by a 
 narrow neck, but not projecting into it at all. Here, 
 not only the os but the canal of the cervix was oblite- 
 rated. It was no easy matter to make an opening 
 through this dense isthmus of fibrous tissue up to the 
 cavity of the organ. But I fortunately succeeded, and 
 kept the canal open with an intra-uterine stem for two 
 months, and the patient left the Hospital ; but she 
 returned ia two or three months afterwards, just as she- 
 was when I first saw her. The operation was repeated 
 a second and even a third time, and the canal was 
 eventually obliterated a second and a third time. 
 
 But other deformities of the os tineas may occur of a 
 less formidable character, still resulting in complete 
 sterility. A.s so often said, any organic condition
 
 192 
 
 UTERINE SURGERY. 
 
 whatever that tends to prevent the passage of the 
 spermatozoa, necessarily prevents conception. Wishing 
 to impress this point on the young surgeon, I shall 
 continue clinical illustrations of my meaning. 
 
 A lady, aged twenty-six years, had had two labours 
 at full term, the last six years ago. This labour was 
 violent and very rapid, lasting only half an hour. The 
 child was large, and the head was probably forced 
 through the neck of the womb before it was sufficiently 
 dilated, and the os was, consequently, lacerated from 
 side to side. This healed slowly, but she remained 
 sterile afterwards. 
 
 Fig. 72 represents the appearance of the os : the 
 anterior half of the cervix was twice as thick as the 
 posterior, while the posterior lip of the os over-lapped 
 the anterior, closing it valvularly and perfectly. The 
 
 cervix was indurated, and the 
 cicatrices resulting from the 
 laceration and subsequent 
 healing could be distinctly 
 seen extending laterally from 
 the os to the insertion of the 
 vagina. This lady was anxious 
 for more offspring ; and I 
 proposed to cut off the poste- 
 rior over-lapping lip of the os, 
 as indicated by the dotted line 
 «, which would straighten the 
 canal and open the door to 
 the entrance of the spermatozoa, that is, if the healing 
 process could be managed so as to prevent undue 
 contraction. However, she was frightened at the idea of 
 an operation, and would have nothing done. 
 
 But it may be said. " Your views of conception are 
 
 Pig. 72.
 
 OS TINC^E— ABNORMAL. 
 
 193 
 
 entirely too mechanical." The act of copulation is 
 purely mechanical. It is only necessary to get the 
 semen into the proper place at the proper time. It 
 makes no difference whether the copulative act be 
 performed with great vigour and intense erethism, or 
 whether it be done feebly, quickly, and unsatisfactorily ; 
 provided the semen be deposited at the mouth of the 
 womb, everything else being as we would have it. Thus 
 far I accept the charge of mechanical views. 
 
 To illustrate the principles of the operation above 
 suggested, here is a case in point. A widower in the 
 prime of life, in good health, the father of children, 
 married a young wife, who at the end of five years 
 remained sterile. The fault was not with the husband, 
 as shown by his previous marriage. The wife's men- 
 struation was regular, lasted two days, and not painful 
 to any great degree, except 
 when she was exposed to cold 
 during the advent of the flow. 
 She suffered slightly from con- 
 stipation and haemorrhoids, 
 but her great trouble was 
 leucorrhcea, with pruritus. 
 An examination showed that 
 there was no granular ero- 
 sion of the os, and that the 
 irritating secretion was a pure 
 utorrhoea. 
 
 Fig. 73 represents the an- 
 atomical peculiarities of the 
 os and cervix and the course 
 of the canal. The position of 
 the uterus was normal. The intra-vaginal portion of 
 the cervix was irregularly developed, the anterior 
 
 13 
 
 Fig. 73.
 
 194 UTERINE SURGERY. 
 
 segment being not more than one-fourth as long as 
 the posterior. In other words, the os tincse was fouLcl, 
 as it were, on the anterior face of the cervix instead of 
 being central, as at <x, in a line with the long axis of the 
 cervical canal. The os was very small, but by means 
 of a sponge-tent it was ascertained that the anterior 
 face of the cervix at c was the seat of a granular 
 condition of the cervical membrane evidently giving 
 rise to the morbid secretion that irritated the external 
 parts. 
 
 This lady did not consult me on account of her 
 sterility, but solely for the relief of her physical suffer- 
 ings. Conception would be absolutely impossible in 
 such a case as this. I have seen many like it, and they 
 are of necessity always sterile. Such malformations are 
 evidently congenital. 
 
 Three months of treatment here produced no sort of 
 improvement, either of utorrhoea or pruritus. Sponge- 
 tents and caustic to the granulations at c combined 
 with a tonic invigorating course were wholly useless. 
 
 The question then arose, " What else can surgery do 
 for her relief?" The only way that I could see to cure 
 the utorrhoea, was to open permanently the mouth of 
 the womb, so as to allow a free outlet to the secretions, 
 which seemed to become acrid, by undergoing some 
 change while pent up in the pouch formed in the canal 
 of the cervix. 
 
 Two plans of operation were suggested to my mind. 
 The first to divide the os and cervix bilaterally, and the 
 other to remove the whole of the posterior lip to b. 
 The first plan might relieve the utorrhoea on the 
 principle that we adopt in curing a sinus by making a 
 capacious outlet for its contents, whereby it is kept 
 constantly drained ; but I felt very sure it would never
 
 OS TINC.E— ABNORMAL. 295 
 
 relieve the sterility, because the redundant josterior 
 flap would always naturally over-ride and over-lap the 
 anterior portion, and prevent the upward passage of the 
 spermatozoa ; and because I had on several occasions 
 tried it under like circumstances without success, and I 
 feared that there would be no permanent cure if the 
 sterile condition were not overcome. 
 
 I did not then know of the plan of splitting open 
 the posterior lip backwards, as illustrated in fig. 63, 
 page 169, or I v/ould, in all probability, have adopted 
 it at the time. I determined, however, on amputation, 
 or exsection of the posterior portion of the cervix up 
 to the dotted line b, as being the best method of both 
 insuring a good outlet for the leucorrhoea and a good 
 inlet for the semen. The operation was done in April, 
 1857, with the assistance of Dr. Emmet and Dr. 
 Scudder, then house-surgeon at the Woman's Hospital. 
 The patient left us in a fortnight, which was entirely 
 too soon after such an operation, for we were thus 
 deprived of using all means to prevent an undue con- 
 traction of the os by the granulating process. How- 
 ever the utorrhcea and the pruritus were eventually 
 cured. A conception in due time, and a natural labour 
 at full term, have proved, as far as one case can, the 
 correctness of the principles of the operation adopted 
 for the relief of this and analogous cases. 
 
 I might go on to enumerate various other modifica- 
 tions in the size, form, and relations of the os tinea?; 
 but we have had enough of this to impress upon the 
 mind of the young surgeon the importance of imitating 
 nature as much as possible, if we expect to attain the 
 object of our efforts.
 
 SECTION IV. 
 
 THE CERVIX UTERI SHOULD BE OF PROPER 
 SIZE, FORM, AND DENSITY.
 
 SECTION IV. 
 
 THE CERVIX UTERI SHOULD BE OF PROPER SIZE, 
 FORM, AND DENSITY. 
 
 Of 250 married women who had never borne children, 
 the condition of the cervix was particularly noticed in 
 218, the remaining 32 being excluded on account of 
 other complications, that would mar or counterbalance 
 any influence that the peculiarities of the cervix might 
 exercise over the sterile condition. Of these 218 — ■ 
 
 'Flexed in 19 
 
 The cervix 
 was . . . 
 
 i) 
 
 and conical 
 
 and indurated 
 
 31 
 21 
 
 Straight, conical, and indurated in 4 " 
 
 „ „ and elongated . „ 109 
 
 „ elongated, but not indurated . „ 7 
 not conical, but hypertro^hied and 
 
 ■n 
 
 3) 
 I) 
 
 indurated . 
 
 Granular . . . . 
 
 ,, and conical 
 
 14 
 
 10 
 
 3 
 
 71 
 
 ■ 147 
 
 Now of this number we find — 
 
 213 
 
 71 flexed, of which 52 had a conical cervix 
 147 straight, „ 123 „ „ 
 
 218 175 
 
 Thus we have a conoid cervix in nearly 85 per cent, 
 of all cases of natural sterility. 
 
 This shows very plainly the great influence that this
 
 200 UTERINE SURQERY. 
 
 peculiar abnormal form of the cervix exerts ovtr the 
 sterile condition ; and when we remember the fact that 
 it is almost always associated with a contracted os, we 
 are constrained to acknowledge its importance. 
 
 Having said that the cervix should be of proper size, 
 form, and density, let us consider its variations in size 
 from a normal standard. 
 
 It is normally about half the length of the uterus, 
 and projects into the vagina from a fourth to the third 
 of an inch anteriorly, and a fraction more posteriorly. 
 The intra-vaginal portion is rounded, truncated, and 
 elastic to the touch ; but it may vary from this in many 
 particulars. It may be hypertrophied or elongated, or 
 it may not project into the vagina at all. It may be 
 flexed, indurated, engorged, or granular ; but in the 
 sterile, as shown in the table above, it is most frequently 
 of conical form, whether straight or flexed ; and with 
 the indurated conoid form there is, as before said, almost 
 invariably associated a contracted os. 
 
 But, independently of its mere form, if the cervix 
 projects into the vagina a full half-inch, it is very likely 
 to be associated with the sterile state ; if an inch, the 
 case is almost necessarily sterile ; if it should be still 
 more elongated, say one and a half or two inches, it 
 becomes absolutely so ; and if it does not project into 
 the vagina at all, it is equally sterile. 
 
 Elongation of the cervix is very common, while its 
 defective development is comparatively rare. This 
 elongation is sometimes real and sometimes only appa- 
 rent. It is real when the cavity of the uterus is more 
 than two inches and a half deep, and the additional 
 depth is seen to be due to the unnaturally developed 
 cervix. It is only apparently too long when the depth 
 of the cavity is normal and yet the cervix evidently
 
 CERVIX UTERI— ABNORMAL. 201 
 
 projects too far into the vagina, in consequence of the 
 vagina beins: inserted too hi^h on the cervix. But 
 whether really or apparently too long, the same treat- 
 ment is necessary. If the elongated cervix is more than 
 an inch, the body of the uterus will almost of necessity 
 be thrown backwards, because the neck projecting so 
 far into the vagina, can only accommodate itself to the 
 opposite wall, by taking the direction of its axis. This 
 position of the cervix must be attended with a retro- 
 version of the body, or if this be in a normal position, 
 then, as a rule, the cervix must be flexed anteriorly. 
 Sometimes it may result in complete procidentia, but we 
 have only now to deal with the fact, and not its conse- 
 quences. 
 
 Suppose we find the cervix too long, what are we to 
 do with it ? Some of our best authorities tell us to melt 
 it down with the potassa c. calce or potassa fusa when it 
 is greatly hypertrophied. I never tried to do this, but 
 I have seen cases of hypertrophy after they were sub- 
 jected to the process, and I have no hesitation in saying 
 that it is not the safest, easiest, and best thing to be 
 done. What is better then ? Amputation ; and for this 
 there are two methods — the knife and the ecraseur, the 
 former of which 1 here greatly prefer. The objection to 
 the ecraseur is that it makes a lacerated surface to heal 
 by granulation, which takes a long time, often leaving 
 the os tincse contracted. Another objection to it is the 
 uncertainty of amputating just where we place the chain, 
 which often draws in more tissue than we intend, and 
 removes more than we wish. So great has been this 
 trouble, that some of the German surgeons have given 
 np the ecraseur altogether in operations on the neck of 
 the womb, because the attachment of the bladder and, 
 in some instances, the posterior cul-de-sac of the vagina,
 
 202 
 
 UTERINE SURGERY. 
 
 have been injured, and even the peritoneal cavity opened 
 by its greedy grasp. It might be supposed that these 
 accidents are hypothetical, but unfortunately I can tes- 
 tify personally to the truth of, at least, one of them. 
 
 Fig. 14, 
 
 A lady from Connecticut was sent to the Woman's 
 Hospital in October, 1860, with a cancroid tumour of the 
 cervix, about the size of a Sicily orange. It grew from 
 the whole cervix. Fig. 74 is intended to represent its 
 relative size and position. There was no doubt as to the 
 nature of the disease, nevertheless it was determined to 
 remove it. The patient was etherized, and placed on the 
 left side, as in all such operations. The speculum was 
 introduced, and the chain of the ecraseur was carried 
 around the base of the tumour, just at the reduplication 
 of the vaginal cul-de-sac autero-posteriorly, the parts re- 
 maining in situ as represented in the diagram. 
 
 The ecraseur was worked in the usual way; the late 
 Professor V. Mott was sitting on my right, watching the 
 process. He had great objections to the instrument on
 
 CERVIX UTERI— ABNORMAL. 
 
 203 
 
 philosophic grounds, and I was anxious to prove to him 
 that it should be accepted as a valuable addition to our 
 surgical resources, which, however, I failed to do. He 
 M r as on the eve of leaving before the operation was fin- 
 ished, when I said, " Please wait a few minutes, Doctor ; 
 it is almost through." He sat down again, and in a 
 moment I was surprised by the sound of air rushing in 
 and out of the vagina, with all the regularity of, and 
 synchronously with, inspiration and expiration, at the 
 same time that the tumour, obeying the slight traction 
 on the ecraseur, came without the least resistance to the 
 mouth of the vagina. Two or three quick turns of the 
 chain cut it off entirely, and on its removal I was horri- 
 fied to find an immense hole of a semilunar form, in the 
 cul-de-sac of the vagina, through which we could look 
 for three or four inches up into the peritoneal cavity, 
 and observe the movements of the viscera with every 
 respiratory act. 
 
 Fig. 75 represents the appearances of the parts. The 
 
 Fig. 75. 
 
 uterus adhered anteriorly at 5, but posteriorly and late- 
 rally it was completely severed from all vaginal con-
 
 204 UTERINE SURGERY. 
 
 nections. To have closed the parts properly, we should 
 have united the edge of the posterior cul-de-sac a to the 
 posterior portion of the uterus from which it was sepa- 
 rated ; but as we all looked upon the case as necessarily 
 and immediately fatal, and as the nice adaptation of the 
 parts would have been tedious, compelling us to keep 
 our patient longer under the influence of ether than we 
 wished, we concluded to make quick work of it. The 
 edges of the vagina anteriorly, and all the way around, 
 were rapidly denuded, and six silver sutures were passed, 
 as in the operation for vesico-vaginal fistula, and the two 
 opposite borders of the vagina were neatly approximated, 
 leaving the neck of the uterus within the peritoneal 
 cavity. But for the drainage of its secretions a catheter 
 was passed into the peritoneal cavity at the central point 
 of union opposite c, which was left slightly open for this 
 purpose. A severe peritonitis followed, from which she 
 fortunately recovered. 
 
 This operation was witnessed by a large concourse 
 of medical gentlemen ; amongst whom were the venerable 
 Dr. Mott, Dr. Emmet, Dr. Pratt, Dr. Rives, then house- 
 surgeon, and many others. It is the only instance in 
 which I have seen any accident from the use of the 
 ecraseur. Of course the inclosure of the cervix within 
 the peritoneal cavity was all wrong, and should not be 
 done again under similar circumstances, and would not 
 have been done then if we had had the remotest idea of 
 the possible recovery of the patient. The peritoneal 
 cavity was kept constantly drained, by means of the 
 tube, through which we frequently injected tepid water, 
 which gave great comfort to the patient. 
 
 It was worn for about three weeks, when the open- 
 ing became fistulous and remained patent. Greatly to 
 my surprise, the patient recovered entirely from the
 
 CERVIX UTERI— ABNORMAL. 205 
 
 effects of the operation, and in a few weeks returned 
 Lome in a very comfortable condition ; but soon symp- 
 toms of the old cancroid disease began to manifest them- 
 selves, and she died of cancer some eight or ten months 
 after leaving the Hospital. The idea of drainage-tubes 
 for the peritoneal cavity, and of injecting this cavity 
 through them, belongs to my countryman Dr. Peaslee, 
 who has fully established the safety and efficiency of the 
 practice, after the operation of ovariotomy, where there 
 are poisonous secretions to be evacuated. The reader 
 will find Dr. Peaslee's cases reported in the American 
 Journal of the Medical Sciences* 
 
 Amputation of the cervix uteri belongs essentially to 
 French surgery. It was a very frequent operation in 
 the hands of Lisfranc. He amputated the cervix in 
 ninety-seven cases, and lost but two patients. 
 
 Lately Huguier has brought it more prominently 
 before the profession in generalizing it for all cases of 
 what he terms hypertrophic elongation. His success is 
 all that could be desired. Huguier's were all procidentia 
 cases, mostly with elongation of the supra-vaginal portion 
 of the cervix ; but we are here to consider the operation 
 as applicable only to infra-vaginal elongation, without 
 necessarily a procidentia. 
 
 In my early amputations with the ecraseur, the os 
 tincae was so often puckered and contracted, that I 
 adopted the plan of doing the operation at two periods ; 
 thus, I would with scissors split the cervix bilaterally, 
 nearly down to the insertion of the vagina, and then 
 remove one-half of it ; for instance, the anterior por- 
 tion #, at b (fig. 76) ; wait one or two menstrual periods 
 
 * American Journal of the Medical Sciences, January, 1856, p. 49, April, 
 1863, p. 363 ; July, 1864, p. 47.
 
 206 
 
 UTERINE SURGERY. 
 
 for the parts to heal, and then remove the remaining 
 half. 
 
 This was getting to be the method pretty generally 
 adopted at the "Woman's Hospital till October, 1859, 
 
 Fig. 76. 
 
 when we hit upon the following plan and in the follow- 
 ing way. A lady from North Carolina was sent to me 
 by her physician for amputation of the cervix. Her 
 time being limited, she was very anxious to return home 
 as soon as possible. I therefore determined to remove 
 the whole cervix at one operation with the ecraseur. 
 Just as she was fully etherized, Dr. Pratt, the house- 
 surgeon, reported that our only ecraseur was broken ; 
 and without any choice in the matter, I was compelled 
 to amputate with scissors. By hooking a tenaculum in 
 the anterior lip of the os tincae, the cervix was pulled 
 gently forwards, and held firmly, while with scissors it 
 was split bilaterally nearly to the insertion of the vagina, 
 still holding on with the tenaculum ; the anterior half 
 was quickly cut off with scissors and then the posterior 
 half. I intended to leave the stump to heal over in the 
 usual way by the granulating process, which would have 
 taken from three to five or six weeks, but, while examin- 
 ing the wound, and waiting for the bleeding to cease, 
 the idea all at once occurred to me to cover over the cut
 
 CERVIX UTERI— ABNORMAL. 
 
 207 
 
 surface with vaginal mucous membrane, just as we cover 
 over the stump of an amputated arm or leg by skin, after 
 the circular method. I immediately passed four silver 
 sutures, two on each side of the canal of the cervix, 
 through the cut edges of the vagina, antero-posteriorly, 
 which drew this membrane over the stump of the cervix, 
 covering it completely, but leaving a small oval opening 
 in the centre to correspond with that of the cervical 
 canal. 
 
 The parts healed by the first intention ; the sutures 
 were removed in nine or ten days, and my patient was 
 soon on her way home, not having suffered in the least 
 from the effects of the operation. From that time on 
 I have adopted this method of amputation, and have 
 every reason to think that the healing by the first 
 intention in this operation is relatively as superior to 
 that by granulation as it is in any other amputation. 
 
 Fig. 77 represents the cervix after amputation, with 
 
 Fig. 77. Fig. 78. 
 
 the wires passed through the cut edges of the vagina 
 ready for covering over the stump.
 
 208 UTERINE SURGERY 
 
 Fig. 78 is to represent the appearance of the stump 
 after the sutures are twisted and cut off. 
 
 But it may be asked what are the risks of the opera- 
 tion ? I think they are few. Lisfranc lost two patients 
 out of ninety-seven ; Huguier operated thirteen times 
 without any bad result. I have operated more than 
 fifty times, thirty-six by this method, and lost one 
 patient. This case occurred unfortunately just at a time 
 when the hospital atmosphere suddenly became unfavour- 
 able to all surgical operations, and we had serious acci- 
 dents to follow the slightest operation, before we were 
 aware that we were breathing a poisoned air. If we had 
 known of this epidemic condition, this patient would not 
 have been operated upon at that time, for such was the 
 state of our over-crowded wards that we were obliged to 
 thin them out, and stop all operations for five or six weeks. 
 But is there no danger in the operation per -se f The 
 only one that I know of is that of opening the perito- 
 neal cavity by cutting too high up on the posterior half 
 of the cervix. 
 
 This accident happened in the hands of a very 
 accomplished accoucheur in New York, and his patient 
 recovered without the least bad symptom. But, not- 
 withstanding this fortunate escape, it must be looked 
 upon as a danger to be carefully avoided. Take this 
 method of amputation all in ail, I do not think it is 
 attended with any more risk than that of incision of the 
 os and cervix. Theoretically it should be safer, inasmuch 
 as the one is healed universally by the first intention, 
 while the other is an open granulating surface for fifteen 
 days or more. But if offspring be very desirable, and 
 if a long cervix should seem to be the only or principal 
 barrier, there are but few women who would not take
 
 CERVIX UTERI— ABNORMAL. 
 
 209 
 
 the slight risks of the operation for the fulfilment of a 
 hope so precious. 
 
 I have not as yet had many cases of pregnancy to 
 follow amputation of the cervix, but I am well satisfied 
 now, that if amputation had been performed in many 
 cases in which I simply cut the open cervix, conception 
 might have occurred, where it has not. 
 
 On page 194 is recorded a case of pregnancy follow- 
 ing the amputation, or rather exsection of the posterior 
 portion of the cervix ; and I have another case where it 
 followed the removal of the anterior half of the cervix. 
 The circumstances were these. Mrs. A., aged thirty ; 
 married seven years ; one child six years ago ; it died 
 young ; no conception since ; very anxious for offspring; 
 exceedingly unhappy. A minute detail of symptoms is 
 unnecessary. She had retroversion, with hypertrophy 
 of the posterior wall of the uterus ; while the cervix 
 was hypertrophied, elongated, and indurated. She was 
 under treatment at times from October, 1857, to the 
 spring of 1859. From the very beginning I told her I 
 did not see how she could ever conceive with such a 
 condition of the neck of the womb ; and I wished then 
 to amputate it, but she was afraid of the operation, and 
 could not make up her mind to it. At last I told her 
 that I could not expend any more time on her case, 
 unless she submitted to amputation of the cervix. She 
 consented, and entered the Woman's Hospital. I was 
 then in the habit of performing the operation at two 
 periods. 
 
 Dr. Francis, Dr. Mott, and Dr. Green, of the consult- 
 ing board, and Dr. Emmet, were present at the operation 
 on the 8th July, 1859. The cervix was split bilaterally 
 with scissors, and the anterior half was removed. She 
 left the hospital in a fortnight, with the expectation of 
 
 14
 
 210 UTERINE SURGERY. 
 
 returning on the 1st of October for the removal of the 
 other half. But fortunately the next menstruation was 
 followed by conception. She went the full term, and 
 was safely delivered. 
 
 In 1862 the greatest number of my amputations 
 were performed. It was then a question with many of 
 my medical friends whether the operation would not in 
 itself prove a barrier to conception. The case of half- 
 amputation above related, and the one on page 194, 
 were then my only facts bearing on the question. But 
 now I have two cases proving that it in no way inter- 
 feres with conception. It is true that in these the ope- 
 ration was not performed with any view to conception, 
 but simply for the removal of disease that baffled all 
 other treatment. One was a patient of Professor Met- 
 calfe, of New York. She was the mother of one child, 
 and had been in bad health ever since its birth. 
 
 The position of the uterus was normal, the cervix 
 was hypertrophied, but not indurated, the os was lace- 
 rated back through the posterior lip, nearly to the inser- 
 tion of the vagina, and the cervical mucous membrane 
 projected in voluminous granular folds, giving rise to 
 constant leucorrhoea. Various remedies had been used 
 without any improvement ; and as Doctor Metcalfe had 
 already exhausted our routine of local treatment, I pro- 
 posed amputation as the speediest and surest method of 
 getting rid of the diseased condition, and the operation 
 was done in May, 1862, Dr. Metcalfe, Dr. T. G. Thomas, 
 and Dr. Emmet assisting. The operation was performed 
 as already described, and the stump covered over with 
 vaginal mucous membrane by passing the sutures antero- 
 posteriorly. Haemorrhage came on two or three days 
 afterwards, which gave Dr. Metcalfe and Dr. Thomas a 
 little trouble ; but she soon got well without any other
 
 CERVIX UTERI— ABNORMAL. 211 
 
 accident ; and Dr. Emmet writes me that conception 
 occurred four months after the operation. 
 
 The other case was that of a lady who had borne one 
 child four years before. She is the daughter of an 
 eminent physician. She had retroversion with enlarge- 
 ment of the posterior wall, and hypertrophic elongation 
 of the cervix. This condition of the cervix seemed to 
 be a barrier to a rectification of the malposition, and it 
 was determined to amputate it. With the assistance 
 of Dr. Emmet and Dr. Pratt, the operation was per- 
 formed in June, 1862, and she conceived in October 
 following. 
 
 These facts I present as an answer to any question 
 in regard to the influence of amputation upon con- 
 ception, and to show that the operation per se does 
 not interfere with it. I have been minute and a little 
 tedious in detail, because I shall soon have occasion to 
 insist on the performance of this operation in a class 
 of cases where, as yet, it has not been recommended. 
 
 An opposite condition of the cervix, viz., defective 
 development, may be a cause of sterility, and I may 
 mention it in this relation. We occasionally find the 
 womb undeveloped or in quite a rudimentary state, and 
 here menstruation may be wholly absent, or so slight 
 as scarcely to attract attention. In such cases little or 
 nothing is to be done. But now and then we find the 
 womb large enough, and menstruation abundant, but 
 the cervix does not project into the vagina. These are 
 always sterile and usually dysmenorrhceal. The canal 
 of the cervix will be very small and usually flexed. 
 
 As a type, I may give an illustration. Dr. W. E. 
 Johnston called on me in December, 1863, with a 
 patient of his, who had been married ten years without 
 issue. She had consulted Velpeau, Nelaton, Ricord,
 
 212 
 
 UTERINE SURGERY. 
 
 Trousseau, and thirty-two other physicians of Paris. 
 Her dysrnenorrhcea was fearful. She usually took 
 anodynes, and had leeches applied by the speculum 
 at each menstrual period. The symptoms and suffer- 
 ings of such cases are too well known to require 
 detail here. The finger passed into the vagina, found 
 only a blind pouch, but it was sufficiently capacious. 
 No cervix projected into it, but the uterus could be felt 
 on the right of the mesial line, sitting, as it were, on the 
 vagina, and attached to it by a narrow crooked isthmus 
 of fibrous tissue, which was the undeveloped cervix, 
 along which a probe could be passed to the fundus, a 
 depth of two inches and a half. On the left of the 
 uterus was a mass of condensed cellular tissue half 
 the size of an English walnut, probably the remains of 
 a pelvic abscess that occurred some four or five years 
 ago. The circle a b (fig. 79) represents the place that 
 should have been occupied by the cervix, while the 
 point c shows the actual opening leading to the uterus. 
 
 Fig. 79. 
 
 Fig. 80. 
 
 This point was once more obscure than at present, and 
 some one of her physicians had split up a bit of vaginal 
 membrane that overlapped, and made the canal more
 
 CERVIX UTERI— ABNORMAL. 213 
 
 valvular and tortuous than it is now ; still this produced 
 no improvement in her sufferings. 
 
 Fig. 80 shows the neck of the womb resting on the 
 vagina instead of projecting into it. Of course there 
 would be but one course here to pursue, viz., to cut 
 open the canal of the cervix, and keep it open after- 
 wards. But the operation would require great nicety, 
 on account of the narrow undeveloped state of the 
 cervix just where it comes in contact with the vagina. 
 However, nothing was attempted in this case ; she was 
 an only child, and her father was afraid to let her 
 submit to a surgical operation. 
 
 But let us leave these extreme cases, whether of 
 hypertrophic or defective development, and pass to the 
 consideration of such conditions of the cervix as we 
 meet commonly and daily in sterile women. 
 
 At the beginning of this section I said, " the cervix 
 should be of proper size, form, and density." Having 
 now spoken of the size and its variations, we may ask 
 ourselves what is a proper form or shape. 
 
 It should be rounded and truncated. Now, if we 
 turn back to the table on page 199, we will see that 
 of 218 sterile women the cervix was flexed in 71. Of 
 these, 19 were supra- vaginal curvatures complicated with 
 some version of the fundus from a normal position. The 
 flexure was associated with a conoid torm in 52 cases, 
 in some of which there were also malpositions of the 
 body. It was straight, conical, and indurated in 4 
 straight, conical, indurated, and elongated in 109 
 straight, conical, elongated, and not indurated in 7 
 granular and conical in 3. 
 
 It is thus shown that a conoid form of the cervix, 
 whether flexed, straight, elongated, or not, is found in 
 the great majority of cases naturally sterile, being here
 
 214 
 
 UTERINE SURGERY. 
 
 175 out of 218. We must 
 discriminate between natural 
 and acquired, or accidental 
 sterility; and here let it be 
 remembered that we speak 
 only of those married women 
 who have never conceived. 
 
 I know not how I can 
 better describe what I mean 
 by a conical cervix than by 
 
 Let fig. 81 re- 
 normal type of a 
 truncated cervix, 
 we imagine the 
 
 diagrams. 
 
 present a 
 
 rounded, 
 Fig. 81. NoWj if 
 
 cervix extended in the direction of the dotted line #, 
 we shall have a not unfrequent form of conoid cervix, 
 which will almost universally be associated with a con- 
 tracted os, and be almost as constantly indurated. A 
 moderate degree of conoidity like this may be remedied 
 very easily, and if everything else is right, we may cal- 
 culate with a good deal of certainty on the removal of 
 the sterility. For this purpose the operation of incising 
 the os and cervix as for dysmenorrhoea will suffice. 
 The operation does not alone enlarge the os, but if the 
 circular fibres of the cervix be properly and thoroughly 
 divided, the lips of the os tincse, instead of being puck- 
 ered to a little round point, evert and roll back from 
 each other, giving the cervix more of the natural feel 
 of a truncated cone than of a pointed one, as before; 
 and thus while it becomes truncated it also becomes 
 shorter, or, in other words, while it assumes a more 
 natural form, it also takes on a more natural size. 
 This is the mildest and most favourable of the conoid 
 form. Its type is represented in fig. 65, p. 180. But
 
 CERVIX UTERI— ABNORMAL. 
 
 215 
 
 if the cervix be extended in the direction of the dotted 
 line Z>, then its mere incision will not so easily restore 
 it to anything like a normal condition. 
 
 We sometimes find the cervix as conical as a mole's 
 head, gradually tapering from the insertion of the 
 vagina almost to a point at the os tincae, being very 
 much longer than it is broad. Calling to mind the 
 fact that in 218 cases it was straight, conical, and 
 elongated in 116, or more than half, I now think that 
 the great mistake I have made in the treatment of 
 these cases, was that of simply incising the os and 
 cervix ; and the same mistake has been made by all 
 other surgeons. 
 
 I now propose to amputate a portion of the cervix 
 in all such cases, for the purpose of giving it as near 
 a normal form as possible. For instance, in fig. 82, let 
 the cervix be amputated at the 
 point designated by the dotted 
 line. 
 
 We have all been afraid to trun- 
 cate the cervix in this way (if any 
 of us ever thought of it before), 
 and were satisfied with simply 
 splitting it up for the relief of the 
 pain of menstruation, thinking that 
 if we were successful in this we 
 might hope for success in other things. I have cut open 
 the neck of the womb, and often seen conception follow 
 soon after; and I have cut open scores, nay, hundreds 
 of others, sometimes with relief to suffering ; but how 
 often have I been disappointed in the great object of the 
 operation! And why? I now see that, in many cases, 
 more must be done than to open the canal of the cervix. 
 When I run my eye over the list of cases in which 
 
 Fig. 82.
 
 216 
 
 UTERINE SURGERY. 
 
 the operation has been quickly followed by conception, 
 I discover that while almost all had a contracted os, all 
 had also a cervix of no unusual length ; and when 1 
 examine closely all those who have had a division of 
 the os and cervix without its being followed by con- 
 ception, I find almost every one of them either with 
 an elongated conical cervix, or with some other com- 
 plication equally if not more unfavourable. Does not 
 the inference follow from this, that if we expect to treat 
 such cases with more certainty and greater success, 
 we must, other things being equal, approximate a nor- 
 mal condition as much as possible, by truncating the 
 cervix to a proper size and form ? 
 
 It was but the other day I had the opportunity of 
 examining the cervix of an unmarried lady upon whom 
 I had performed amputation two years ago ; and so 
 perfectly normal was the appearance of the os and 
 cervix, that there wera no evidences whatever of the 
 fact that an operation had ever been done. 
 
 Before closing this subject, I may give a few more 
 illustrations of the conical cervix. For instance, it may 
 be found with a flexure, the anterior and posterior 
 portions being unequally developed, as in fig. 83; and 
 here we may cut open the cervix bilaterally, or split 
 the posterior lip directly backwards; but 1 think it 
 would be much better to amputate in the direction of 
 the dotted line, and afterwards to cut open the cervix 
 bilaterally, if the prime object of all treatment be 
 offspring. 
 
 Again, we may have the conical cervix with a 
 straight canal ; the whole organ having the feel of a 
 hard inverted cone (fig. 84). 
 
 These cases I have always cut open bilaterally, but 
 I can call to mind few that were followed by conception.
 
 CERVIX UTERI— ABNORMAL. 
 
 217 
 
 In all such cases I am now very sure that it would be 
 better to amputate, and restore the cervix at once to a 
 normal condition. 
 
 Pig. 83. 
 
 Fig. 84. 
 
 It is not at all uncommon to find a concoid cervix 
 accompanied with retroversion. Sometimes the mal- 
 position seems to be the result of the elongated conoid 
 cervix pressing against the posterior wall of the vagina. 
 Conception is impossible in a womb of this relative size, 
 form, and position (fig. 85). 
 
 Fig. 85. 
 
 These examples of conoidity are enough to impress 
 upon our minds its general character and appearance ; 
 but there are cases that cannot be called conoid, and 
 yet are to be treated in the same way if we expect 
 offspring. For example, I saw, in consultation in Paris, 
 in May, 1863, a lady, about 27 years old, who had been
 
 218 
 
 UTERINE SURGERY. 
 
 married six or seven years without offspring. She had 
 had dysmenorrhoea ever since her marriage, and had 
 been treated by very distinguished physicians, one of 
 whom told her that she might possibly fall into the 
 hands of some surgeon who might wish to cut open the 
 neck of the womb, against which he would most 
 seriously protest, as an operation fraught with danger. 
 It is useless for me to dwell upon her menstrual suffer- 
 ings, and general nervous, irritable condition. There 
 was auteversion, with hypertrophic enlargement of the 
 fundus antero-posteriorly, as at or, b (fig. 86). 
 
 Fig. 86. 
 
 The cervix was curved, as shown in the diagram. 
 The posterior lip overlapped the anterior, giving the os 
 a crescentic shape. The anterior lip was granular. The 
 cervix was not, properly speaking, conoid ; but it was 
 elongated, too long for easy conception, even if it had 
 been straight and patulous. The canal of the cervix could 
 not be called contracted, and yet the flexure was such 
 as to bring the antero-posterior surfaces in close apposi- 
 tion, like laying the bowl of one spoon in another, which 
 always presents a very complete obstruction to the 
 egress of the menstrual flow. As a consequence of this 
 mechanical barrier, she had a persistent endometritis, as
 
 CERVIX UTERI— ABNORMAL. 219 
 
 seen by the dark brownish mucus that was always found 
 hanging from the cervical canal. 
 
 I here proposed to divide the cervix bilaterally, at 
 the same time saying that amputation would give us a 
 better chance for permanent relief. 
 
 Her medical attendant agreed to the operation of 
 incising the os and cervix. Our object was to relieve 
 the dysnienorrhcea and endometritis by opening the 
 canal, knowing full well that it would be a most difficult 
 thing to render it permanent unless we could keep the 
 posterior lip everted or rolled backwards. However, 
 the operation was thus performed, much against the 
 wishes of the patient herself, who begged for amputa- 
 tion, as affording her the surest, if not the safest, method 
 of cure. Her first menstruation after the operation was 
 entirely painless, but unfortunately it did not remain so, 
 and further treatment was necessary. In cases like 
 this I am sure it would be better to amputate the cervix 
 first, and then incise it at some subsequent period. 
 
 If experience should prove that I am correct in my 
 views in regard to the necessity of amputating an 
 elongated conoid cervix, for the purpose of augmenting 
 the chances of conception, 1 feel that it is important to 
 simplify the operation as much as possible. The ampu- 
 tation of the cervix by scissors, as I have always done 
 it, is easy enough in the hands of a practised surgeon, but 
 every one will not find it always so easy to make a good 
 even stump by this method. I have not been able to 
 get a pair of scissors curved sufficiently to do the work 
 neatly. But I think I have at last hit upon something 
 better, which I would term the uterine guillotine. This 
 instrument is made in London by Mayer, and in Paris 
 by Charriere. The idea of the uterine guillotine 
 occurred to me in this way. In July last (18G5) my
 
 220 UTERINE SURGERY. 
 
 friend Dr. Henry Bennet invited me to amputate a a 
 elongated hypertrophied cervix in a patient of his who 
 had had procidentia for a long time. The cervix pro- 
 jected from the vulva about an inch and a half. It was 
 necessary to remove three-fourths of an inch of it. Dr. 
 
 Fig. 87. 
 
 Bennet held the uterus firmly with a double tenaculum 
 forceps (fig. 87), seizing the cervix autero-posteriorly, 
 just above the point of election for the amputation. I 
 then caught hold of the end of the cervix, and with a 
 bistourie cut it instantly off. The stump was covered 
 over with mucous membrane in the usual way with 
 silver sutures. The operation was done so quickly and 
 withal so neatly, that I immediately said, "Why should 
 we not have an instrument, like those for the tonsils, 
 to amputate the cervix all at once, while the organ is in 
 situ?" This idea I gave to Mr. Mayer, and fig. 88 
 represents the instrument. It consists simply in adding 
 a blade to the ecraseur. At first I had a wire to con- 
 strict the part to be amputated, but I found that it 
 would bend a little from a right line when tightened, 
 and so strike the edge of the knife as it was pushed 
 forwards; then, at M. Charriere's suggestion, a loop of 
 narrow watch spring doubled three or four times was 
 substituted, giving a flat surface along which the blade 
 glides without obstruction.
 
 CERVIX UTERI— ABNORMAL. 
 
 221 
 
 J\ 
 
 In applying the instrument, let the loop f encircle 
 the cervix where we wish to cut it off ; ^ 
 
 turn the screw-nut b till the loop em- 
 braces the part firmly and immovably ; 
 transfix the' cervix with the needle by 
 means of the slide d ; then push the 
 blade e quickly forwards by forcing 
 down the shaft #, and the part will be 
 instantly cut through. The dotted 
 lines I, i, j show the relations of the 
 loop, needle, and knife, when the opera- 
 tion is finished. The patient is to be, 
 of course, in the left lateral semi-prone 
 position, and the operation executed 
 without traction on the uterus. The 
 stump is to be covered over with 
 mucous membrane, as previously de- 
 scribed and figured (p. 207). There is 
 always some contraction of the os ex- 
 ternum after all amputations of the 
 cervix. It is better as a rule to let 
 things take their course, and in two or 
 three months afterwards cut open the 
 os and cervix, and treat it just as we 
 would under ordinary circumstances 
 requiring such an operation. If we 
 attempt to keep the os normally open, 
 there is danger of interfering with the 
 covering of the stump ; and if we re- 
 sort to the operation of incising it too 
 soon after the amputation, say just 
 after the next menstrual flow, we may 
 in our manipulations tear the vaginal 
 covering of the stump from the surface to which it has 
 
 Fig. 88.
 
 222 UTERINE SURGERY. 
 
 recently adhered. I "have had this accident happen 
 in my own hands; and hence the warning to guard 
 against it. 
 
 Induration of the cervix is so often an attendant of 
 the sterile condition that it is appropriate to speak of it 
 here in connection with the size and form of the cervix. 
 It may be natural or acquired ; natural when we find a 
 little gristly-feeling cervix in a dysmenorrhceal case, 
 where there is often a small fibroid in the anterior wall 
 of the uterus ; acquired, when we find it following a 
 chronic inflammation of the cervix, in which the granular 
 condition disappears after a very long time and perhaps a 
 long treatment. I have no specific treatment to suggest, 
 and I look upon it as important, more particularly as it 
 may influence the size, form, and relations of the os and 
 cervix. If there is a deposit of fibrous tissue in the 
 cervix, as a result of inflammatory action, I know of no 
 short way of causing its absorption, and I deal with it 
 only incidentally, as my attention is directed to the rec- 
 tification of the anatomical and mechanical peculiarities 
 already discussed. I know that physicians give altera- 
 tives, absorbents, and general constitutional remedies, 
 and apply all sorts of things locally ; that they melt 
 down the cervix with potassa cum calce ; but even then 
 the induration remains; and I would prefer immediate 
 amputation to this tedious uncertain process. It is sup- 
 posed that the drain of the caustic issue softens the 
 parts ; but I have not seen it so, and some years ago I 
 often used this potent agent. I must say, however, that 
 Professor Fleetwood Churchill's iodine treatment has in 
 my hands produced a greater amelioration in these cases 
 than anything else; but it is tedious. Dr. Churchill 
 tells me that I have failed with it because I have not 
 persevered long enough in its use. I beg leave here to
 
 CERVIX UTERI— ABNORMAL. 223 
 
 refer the reader to his learned and classic work on the 
 Diseases of Women for minute information oa thia 
 point. 
 
 Dr. Barnes has recently (June 7th, 1865) presented 
 a paper to the London Obstetrical Society, in which he 
 discusses very ably the influence exercised by the conoid 
 cervix upon the sterile condition. The following sum- 
 mary* is extracted from the report of the Secretary, 
 Dr. Meadows : — " Dr. Barnes described and figured the 
 form of cervix uteri which projected into the vagina as 
 a conical body, the vagina appearing to be reflected off 
 at a point nearer the os internum than normal. The os 
 externum was unusually minute, scarcely admitting the 
 uterine sound. This (the os externum) was the real 
 seat of constriction. The os internum was normally a 
 narrow opening, and in these cases of dysmenorrhcea 
 and sterility it was commonly found to be uf normal 
 character. It was therefore unnecessary to divide it. It 
 was, moreover, dangerous to divide it, on account of the 
 close proximity of the large vessels and plexuses run- 
 ning into the uterus on a level with it Discussing 
 
 the question of treatment, Dr. Barnes showed that dila- 
 tation was unsatisfactory ; that incision of the os inter- 
 num as practised by Dr. Simpson's single bistourie cache, 
 and by Dr. Greenhalgh's double bistourie cache, was 
 unsafe and superfluous. He objected to the latter instru- 
 ment, especially that it must cut as it was set, that it 
 was too much of an automatic machine, not leaving 
 scope for the judgment of the operator. His (Dr. 
 Barnes's) own instrument, constructed like a pair of 
 
 * Lancet, July 15th, 1865 : " On the Dysmenorrhcea, Metrorrhagia, Ovari- 
 tis, and Sterility associated with a Peculiar Form of the Cervix Uteri, and 
 the Treatment by Division," By Robert Barnes, M.D.
 
 224 UTERINE SURGERY. 
 
 scissors, acted on the same principle as Dr. Sims's ; it 
 divided only the os externum, so as to open the cavity 
 of the cervix, the part to be cut being first seized 
 between the two blades. The operation was perfectly 
 free from risk ; the haemorrhage was usually slight, and 
 a good os was made. He had performed the operation 
 many times, both in hospital and private practice, and 
 was well satisfied with the results. One advantage of 
 incision over dilatation was, that it relieved the engorge- 
 ment and inflammation." 
 
 Dr. Barnes's admirable paper gave rise to a length- 
 ened discussion ; he and Mr. Baker Brown alone, amongst 
 all the speakers, holding the same views that I do in 
 regard to the relative infrequency of contraction at the 
 os internum as compared with that at the os externum.
 
 SECTION V. 
 
 THE UTERUS SHOULD BE IN A NORMAL POSITION— 
 i. e., NEITHER ANTEVERTED NOR RETRO VERTED 
 TO ANY GREAT DEGREE. 
 
 16
 
 SECTION V. 
 
 THE UTERUS SHOULD BE IN A NORMAL POSITION L e., 
 
 NEITHER ANTEVERTED NOR RETRO VERTED TO ANY GREAT 
 DEGREE. 
 
 Before treating of displacements of the uterus, let us 
 first fix in our minds a correct idea of its normal position 
 and relations. Not wishing to write one unnecessary 
 page, I shall, as hitherto, avoid minute anatomical and 
 histological detail, which can be better learned from anv 
 of our text-books. I would say, however, that some of 
 the discrepancies of authors may be reconciled when we 
 remember that one speaks of the condition of things in 
 the living subject, and another in the dead. Thus, one 
 will tell us that the uterus is about two and a half inches 
 deep, while another will say it is less. Both are right; 
 for the uterus, an erectile organ, full of blood, is larger 
 and longer in the living body than in the dead. The 
 knowledge of one is gained in the clinic ; of the other in 
 the dissecting-room. 
 
 I do not know of any anatomical plates that repre- 
 sent correctly the position and relations of the pelvic 
 organs. The artist has not succeeded perfectly in this 
 cut (fig. 89), but it is near enough to give us a good 
 general idea of the subject. 
 
 [I was at great pains to get a correct outline of a 
 vertical section of the pelvic bones as here shown. For 
 this I am under special obligations to M. Pean, of Paris, 
 Prosecteur des Hopitaux, who politely afforded me every 
 facility at Clamart, both in its museums and dead-house ;
 
 228 
 
 UTERINE SURGERY. 
 
 also to my talented young friend Edward Souchon, of 
 New Orleans, Louisiana, who made for me repeated dis- 
 sections, which were photographed, and from which Mr. 
 Vien made the drawing.] 
 
 Fig. 89. 
 
 The uterus occupies, normally, very nearly a central 
 position in the pelvis, being, perhaps, a little nearer to 
 the sacrum than to the pubes. Its long axis should 
 stand at about right angles to that of the vagina ; the 
 fundus pointing in the direction of the umbilicus, and 
 the os tincae towards the end of the coccyx. The fun- 
 dus may be tilted a little one way or the other without 
 the position being necessarily abnormal. The condition 
 and contents of the bladder and rectum may temporarily 
 influence it to some extent. If it turn forwards pr back- 
 wards for 25 u or 30°, it does not amount to a malposi- 
 tion ; but if to 40° in either direction without soon recti- 
 fying itself, it is abnormal, and usually goes from bad to 
 worse, till the malposition becomes persistent. A glance 
 at the cut will show us that if the uterus fall backwards 
 in a line drawn from the os to the promontory of 
 
 0m
 
 UTERINE DISPLACEMENTS. 229 
 
 sacrum, it will describe an angle of 45°, and will present 
 its broadest surface to the pressure of the superincumbent 
 viscera, which will necessarily force it eventually lower 
 and lower ; and if it turn forward to the same extent, the 
 same power exerted on its broad posterior surface neces- 
 sarily increases this abnormal tendency. But an ante ver- 
 sion never goes relatively to so great an extent as a 
 retroversion, simply because it meets with more resist- 
 ance. Anteversion often stops at 45°, but may go to 
 90°, as when we have a complete version, with the 
 whole organ lying flatly down on the anterior wall of 
 the vagina, and parallel with it, while a retroversion sel- 
 dom or never stops under 90°, and often goes to 135°, 
 simply because there is less opposition to its downward 
 progress. 
 
 It then follows that if the fundus of the uterus is 
 found constantly lying just behind, or even near, the 
 symphysis pubis, it is an anteversion ; but if it is found 
 lying persistently back under the promontory of 
 the sacrum, it is a retroversion. But when only the 
 body of the uterus is turned forwards or backwards, the 
 os seeming to be in rather a normal relation with the 
 vagina, there is necessarily a bending of the cervix some- 
 where between the os externum and the os internum, 
 and we call this a flexion. Most, but not all, versions 
 become flexions ; so that, as a general rule, they are 
 but different stages or degrees of the same thing. I 
 have not, therefore, thought it of practical importance 
 to say that out of so many anteversions and retrover- 
 sions, there was such a proportion of flexions, simply 
 because these distinctions will not modify the general 
 principles of treatment. 
 
 Time was, and not very long ago, when the diagnosis 
 uterine displacements was attended with great difii- 

 
 230 UTERINE SURGERY. 
 
 culty, but there is nothing easier now. Formerly, all 
 uterine disease was known under the sweeping term of 
 prolapsus ; a term that has been used so vaguely and 
 indefinitely that it should be banished from uterine tech- 
 nology ; for in England it is applied to a descent of the 
 organ through the vulvar outlet, while in my own coun- 
 try it is often applied to its various intrapelvic devia- 
 tions. Formerly, if any woman here had a little vesical 
 tenesmus with a constant sense of weight in the pelvis, 
 and bearing down, it was called a prolapsus ; but now 
 we know very well that these symptoms may exist as a 
 sign of engorgement, or granular erosion of the os, 
 without the least displacement of the organ. 
 
 To be accurate, then, the malposition should be ascer- 
 tained exactly, and we should apply to it the term that 
 would express precisely the deviation from a normal 
 position. If we use the term retroversion, of course we 
 all understand it, because its meaning is defined. If we 
 say anteversion, for the same reason, there can certainly 
 be no misunderstanding. If we say antero-lateral version, 
 it is equally significant of the position, provided we add 
 the qualifying adjectives, right or left, as the case may 
 be. If we say procidentia, we mean that the cervix 
 uteri has passed beyond the mouth of the vagina, to a 
 greater or less degree ; but to say there is prolapsus is 
 to hide up the real condition of the uterus under a vague 
 generality. I therefore use the terms anteversion and 
 retroversion to designate the relative deviations of the 
 body of the uterus from a normal position while within 
 the pelvic cavity, and the term procidentia to designate 
 its passage out of the pelvis through the mouth of the 
 vagina. 
 
 Ante versions are often clu? to adventitious develop- 
 ment of some sort in the anterior wall; retroversions
 
 UTERINE DISPLACEMENTS. 231 
 
 frequently occur as a sequence of debility, or relaxation 
 in the ligaments that support the uterus. In both we 
 often find an enlargement of that portion of the body 
 which is most dependent. In the first, this enlarge- 
 ment frequently induces the deviation; in the second, 
 it is oftener the consequence of it. 
 
 When we remember that about every eighth mar- 
 riage is sterile, we see the necessity of investigating all 
 particulars that can by any possibility bear upon the 
 elucidation of this important subject. At the beginning 
 (page 2) I said that I had, for obvious reasons, divided 
 my sterile patients into two classes ; viz., natural, and 
 acquired sterility. The following table shows at a 
 glance what an influence mere displacements of the 
 uterus must exercise over the sterile condition in each 
 of these classes : — 
 
 ? o °: 0f Anteversions. Retroversions. „ , Tot .^ 
 
 Cases. ■ tt " lc c '°*" Malpositions. 
 
 1st Class 250 103 68 171 
 
 2nd Class 255 61 111 172 
 
 Total 505 164 179 343 
 
 Thus we see in 250 married women, who had never 
 borne children, that 103 had ante version, and 68 retro- 
 version ; while in 255 who had once borne children, 
 but for some reason ceased to conceive before the 
 natural termination of the child-bearing period, 61 had 
 anteversion, and 111 retroversion, the sum total in each 
 class bearing almost exactly the same relation to the 
 number observed, being about two-thirds of the whole. 
 Hence we infer that if the malposition exercises an 
 influence to prevent conception in the one class, it is 
 of equal importance in preventing it in the other. The 
 mere position of the uterus is here stated without
 
 232 UTERINE SURGERY. 
 
 reference to causes or complications. T have purposely 
 avoided saying how many of these had granulations, 
 engorgements, hypertrophies, fibroids, ovarian cysts, or 
 other complications. The table shows that two-thirds 
 of all sterile women labour under some form of uterine 
 displacement, without reference to the particular cause 
 of such displacement; and that the anteversions and 
 retroversions in the two classes are in inverse propor- 
 tion : the anteversions in the first being about equal to 
 the retroversions in the second ; and the retroversions 
 of the first nearly the same as the anteversions of the 
 second. 
 
 Without further general remarks, let us proceed to 
 consider in turn these various forms of displacement. 
 I have not thought it worth while to make a distinct 
 heading for anterolateral flexions. They comprise but 
 a small class, and are almost always secondary, being 
 the result of some other affection. 
 
 Of Anteversion. — According to the tabulated state- 
 ment above, nearly one-third of all sterile women have 
 anteversion. In natural sterility the proportion is 1 
 in 2*42 ; in acquired, it is 1 in 4*18, being nearly twice 
 as frequent in the first as in the second. 
 
 It would here be appropriate to lay down the rules 
 of diagnosis in reference to this particular form of dis- 
 placement ; but as its principles have been already 
 amply stated, whether by bi-manual palpation or probing 
 (see pages 7, 8, and 101 to 105), it is unnecessary to 
 repeat them here. I will now only say that we are never 
 under any circumstances to probe the uterine cavity till 
 we have by the touch first ascertained its probable direc- 
 tion ; and then the sound is to be curved or not, accord- 
 ing to the suspected curvature of the canal of the cervix.
 
 UTERINE DISPLACEMENTS. 238 
 
 Anteversion may depend upon a variety of causes ; 
 sometimes the uterus seems to be bent upon its own 
 axis, in consequence of an abnormal elongation of the 
 organ. For instance, suppose the sound passes three 
 inches and -a half into the cavity of the uterus, we 
 would then say it is at least an inch too long. This 
 must depend upon one of three things: either an elonga- 
 tion of the intra-vaginal portion of the cervix ; elonga- 
 tion of the supra-vaginal portion ; or hypertrophy of the 
 fundus. If on the first, the touch, sight, and absolute 
 measurement will at once determine it ; if on the second, 
 the unerring bi-manual palpation will demonstrate to 
 our sense of touch, a long, delicate, slender, flexible 
 supra- vaginal cervix;' if on the third, it can be equally 
 as well measured and judged by the touch alone, pro- 
 vided we apply the principles of diagnosis already re- 
 ferred to. 
 
 We sometimes find the uterus undeveloped, entirely 
 too small, often not more than an inch and a half deep; 
 and again, it is not uncommon to find it over-developed, 
 with the supra-vaginal portion of the cervix long and 
 slender ; and when this is the case, the fundus must 
 of necessity fall one way or another, and most usually 
 forwards, producing anteversion or flexion. 
 
 Again, anteversion seems to be occasionally the re- 
 sult of a shortening of the utero-sacral ligaments ; or else 
 these ligaments become shortened by the long-continued 
 malposition. Nothing is more common in old retrover- 
 sions than to see the anterior wall of the vagina con- 
 tracted in consequence of the long-continued malposi- 
 tion; and here it often presents a formidable barrier 
 to a permanent rectification of the displacement. Now 
 in the same way it is presumable that the utero-sacral 
 ligaments, if not congenitally too short, may become
 
 234 UTERINE SURGERY. 
 
 shortened by long disuse, just as the round ligaments 
 may become relaxed and lengthened by long error of 
 position. 
 
 Be this as it may, we sometimes meet with ante- 
 versions where we encounter great difficulty, and inflict 
 great pain in drawing the os tincse forwards. In these 
 cases the vagina is long and narrow, and the os tincae, 
 instead of pointing towards the end of the coccyx, may 
 look directly back towards the hollow of the sacrum. 
 
 Now, if we here insert a tenaculum into the anterioi 
 lip of the os tincaa, and pull it towards the urethra, feel- 
 ing at the same time unusual resistance to this traction, 
 there will be one of two things to account for it : either 
 the fundus of the uterus is bound down anteriorly by 
 adhesions, or the cervix is held back posteriorly by 
 shortened utero-sacral ligaments. If the first, which is 
 very rare, then it will be impossible to elevate the fun- 
 dus to a normal position by the usual method of elevat- 
 ing the anterior cul-de-sac of the vagina up behind the 
 inner face of the pubes with the left index finger, while 
 the fundus is pushed backwards by the other hand act- 
 ing upon it in the hypogastrium through the parietes 
 of the abdomen ; but if it be due to the second, then, 
 by introducing the index finger into the rectum, or even 
 to the posterior cul-de-sac of the vagina, at the same 
 time that we draw down the cervix with the tenaculum, 
 we shall feel the utero-sacral ligaments as tense and 
 resistent as two well-stretched guitar-strings. I must 
 admit that such cases are not very common ; but their 
 infrequency makes it the more important to be able to 
 recognize them when we meet with them. 
 
 One of the most common causes of anteversion is a 
 small fibroid in the anterior wall, as represented in fig. 
 00. It is very interesting to observe the influence of
 
 UTERINE DISPLACEMENTS. 
 
 235 
 
 such tumours in producing the various displacements 
 of the uterus. If a fibroid uot larger than an English 
 walnut is attached in any way to the posterior wall of 
 the uterus above the level of the os internum, it almost 
 invariably pulls the uterus over backwards, producing 
 retroversion ; but if a similar-sized tumour is attached 
 to the posterior wall of the uterus below the level of the 
 os internum, whether it be pedunculated or not, it will 
 almost as invariably push the fundus of the uterus over 
 forwards, or produce anteversion. In other words, a 
 small tumour of the body of the uterus posteriorly will 
 produce retroversion, while the same sized tumour of the 
 cervix posteriorly will produce anteversion ; and vice 
 versa, a small tumour in the anterior wall of the body 
 anteverts the uterus, but if it grow anteriorly below the 
 
 •~.tt> 
 
 it 
 
 Fig. 90. 
 
 i'lG. 91. 
 
 level of the os internum, it invariably retroverts it. 
 The reasons are anatomical and most obvious. Let fio\ 
 91 represent the uterus in its normal relations with the 
 axis of the vagina. A small tumour on the posterior 
 wall at a will, as before said, retrovert the uterus, but a 
 similar-sized one attached low down on the cervix at h 
 will as invariably antevert it. In the first instance the
 
 236 UTERINE SURGERY. 
 
 uterus obeys the laws of gravity, by which an additional 
 weight on one side of the fundus must pull it in the 
 direction of said force ; while in the second instance, the 
 tumour finds a point d'appui in the utero-sacral liga- 
 ments, rectum, and cul-de-sac of the vagina, which 
 oppose its downward pressure ; and thus, as the tumour 
 grows, it gradually pushes the fundus forwards. 
 
 For the same reasons a tumour anteriorly at d, as a 
 rule, anteverts, while one at c invariably retroverts 
 the uterus, because it finds a point of resistance in the 
 walls of the bladder at its junction with the cervix. 
 Another reason for this curious law of displacement 
 in consequence of small growths on the supra-vaginal 
 cervix may be found in the fact that the tumour acts 
 like a splint upon the side of the naturally slender and 
 flexible cervix. These rules are applicable to small 
 tumours only, and all tumours must have had a small 
 beginning. When they grow large enough to rest 
 upon the brim of the pelvis, they elevate or depress 
 the body of the uterus more by their volume and rela- 
 tions to the pelvic cavity than by the mere place of 
 their accidental attachment. 
 
 I have in many instances seen the cervix curved, 
 anteriorly where it seemed to be produced by an amor- 
 phous growth on its posterior surface. The relative 
 
 position and outline of this anomalous 
 projection is represented, in fig. 92, a. 
 I do not know what to call it ; it is 
 not a fibroid tumour. To the touch 
 it has a fibro-cartila^inous feel : I 
 suppose I have seen a dozen cases of 
 it. It is very uniformly of the 
 
 Fig. 92. J J 
 
 shape and form here represented, 
 always pointed below ; it almost always projects, as
 
 UTERINE DISPLACEMENTS. 237 
 
 here, a little below the insertion of the vagina. I 
 have never found anything like it growing on any 
 other portion of the uterus. I have seen it in two cases 
 in which there was no curvature of the cervix. Each 
 of these was sterile, each had the cervix incised ; one 
 conceived four months afterwards, the otjier in eight. 
 Both of these had had metro-peritonitis some time before 
 I saw them. From these two cases we may infer that 
 this growth may possibly be the product of inflamma- 
 tory action, and that it does not, per se, interfere with 
 conception and child-bearing. In the other instances I 
 could not trace its history to any predisposing cause. 
 The first, case of this anomalous growth that I ever saw 
 was in the Woman's Hospital, in 1856, in a young Irish 
 girl, who had painful menstruation as the consequence 
 of a curved contracted cervical canal. Dr. Emmet and 
 myself called it the cock's-cornb excrescence. We called 
 it this merely to give it a name. The name was sug- 
 gested by the form of the growth, by its mobility, by 
 its gristly feel, and by the manner of its attachment. 
 
 It has a sessile attachment to the neck of the womb, 
 perhaps half an inch wide above, growing narrower as 
 it descends. It can be diagnosed with the greatest faci- 
 lity by the bi-manual method of palpation. Indeed I 
 never consider any obscure condition of the uterus 
 thoroughly made out till we manipulate the whole 
 surface of the organ almost as completely as if we had 
 it outside of the body. This affection is not described 
 in the books, but I have no doubt that others will find 
 it where they have not, as yet, suspected anything of 
 the sort ; and the professional mind once directed towards 
 it, I have as little doubt that some one will be able, 
 some time or other, to give us its pathological appear- 
 ances from post-obit examinations.
 
 238 
 
 UTERINE SURGERY. 
 
 But to return to anteversions. We may have them 
 from other causes. We often see granular engorgement 
 of the anterior lip, accompanied by a corresponding 
 engorgement, or hypertrophy of the anterior wall of the 
 uterus. And here there is always anteversion. Some 
 think that these corresponding conditions of the cervix 
 and body anteriorly are pathologically one and the same 
 thing ; but we often see the engorged condition of the 
 os and cervix cured without the least impression being 
 produced, either on the hypertrophy of the anterior wall 
 or on the relative position of the fundus. 
 
 We sometimes have the uterus bound down by liga- 
 mentous adhesions, the result, most probably, of some 
 former peritoneal inflammation. These cases are com- 
 paratively rare ; but that they do exist is proved both by 
 observation on the living, and by post-mortem examina- 
 tion. We more frequently find ligamentous adhesions 
 in retroversions tlun in anteversions. 
 
 Of course we can do nothing for the rectification of 
 malpositions dependent upon adhesions, nor as a rule 
 will they require any interference, for the adhesions 
 naturally sustain and support the uterus in its abnormal 
 relations, and protect it against the pressure of the super- 
 incumbent viscera, which would otherwise force it still 
 lower in the cavity of the pelvis. In those cases in which 
 I have found the uterus bound down by adhesions, there 
 was little or no complaint of the symptoms ordinarily 
 attendant upon such displacement. 
 
 So far as the treatment of the sterile condition in 
 connection with anteversion is concerned, I fear that our 
 efforts must be confined almost wholly to seeing that the 
 os tincse is open enough, that the cervix is of proper form 
 and size, and that the secretions of the vagina and of the 
 cervix are suited to the viability of the spermatozoa.
 
 UTERINE DISPLACEMENTS. 
 
 239 
 
 The introduction of the uterine sound by Simpson 
 constitutes an era in obstetric surgery. Before this we 
 knew as little about the rectification of displacements 
 as we did about their diagnosis. It was, and is still, used 
 as a redresser of displacements, in retroversions, with 
 much show of science and precision, if not of skill and 
 success ; but in anteversions with none of these. As a 
 mere probe, it is, as I have said before, very valuable, 
 although the practised touch seldom needs its aid ; but 
 as a redresser, it is capable of doing great mischief, and 
 should no longer be used as such. Even as a probe, 
 merely to determine the course, curvature, and exact 
 depth of the uterine cavity, it is 
 possible to do harm with it. 
 
 In anteversion I now seldom ever 
 use it in the dorsal decubitus ; but 
 place the patient in the left lateral 
 semiprone position, as for all uterine 
 operations. When the cervix is 
 brought into view, it is pulled gently 
 forwards by a small tenaculum (figs. 
 14 and 53), and then the annealed 
 probe (fig. 40), more or less curved 
 to suit the previously ascertained or 
 suspected curvature of the canal, is 
 to be introduced with great gentle- 
 ness. As soon as it passes the os 
 internum, it goes to the fundus al- 
 most by its own weight, simply by 
 elevating the handle of the instru- 
 ment towards the sacrum. We can 
 never do harm or even produce pain, if we adapt the size 
 and curvature of the probe to the peculiarities of the 
 individual case. We may occasionally need one not 
 
 Fig. 93.
 
 240 UTERINE SURGERY. 
 
 larger than that shown in fig. 93, and we sometimes need 
 to curve it quite as much iu complete anteflexion, such 
 as are represented in figs. 41 and 60. 
 
 Putting the cervix on the stretch by means of the 
 tenaculum hooked into the anterior lip of the os greatly 
 facilitates the use of the probe in difficult cases, by 
 fixing the uterus and by straightening the curvature 
 of the canal. I am sure that much harm has been 
 done with the sound; 1st, by having it too large; 2nd, by 
 having it too straight, or always fixed at the same curva- 
 ture, as shown in fig. 39 ; and 3rd, by using too much 
 force. Again let me repeat that we are never to forget 
 that it is simply a probe, and that we are to handle it as 
 delicately as we would a probe for any other surgical 
 purpose. 
 
 While we then accept the sound as a probe, we must 
 wholly reject it as a redresser. For diagnosis it is 
 valuable ; for treatment it is dangerous. During the 
 learned discussion in the French Academy of Medicine 
 a few years ago, on the uses and abuses of this instru- 
 ment, the fact was fully established, that it had, per- 
 haps more than once, been forced through the fundus 
 uteri, and that death was the consequence of this rude 
 and awkward accident. This could only have happened 
 by using it with violence as a redresser. There is some 
 show of philosophy to justify ics use in retroversion, but 
 why it should ever have been used to replace an ante- 
 verted uterus I cannot understand ; and yet I have seen 
 patients with anteversion, who had for months been 
 subjected to the introduction of the sound almost daily ; 
 I need hardly add, without the least benefit. 
 
 To replace in this way, or in any other, an anteverted 
 uterus with the expectation of its remaining in a normal 
 position by this means alone, is perfectly futile ; for it
 
 UTERINE DISPLACEMENTS. 241 
 
 invariably falls back into its abnormal position the 
 very moment that the force is removed that replaced it. 
 
 For the replacement of an anteverted uterus we 
 need no instrument whatever. The process is simple 
 enough, and is effected easier and better by mere 
 manipulation than by any instrumental aid. The 
 bladder empty, the patient on the back, introduce the 
 left index finger, as shown in fig. 1, to the anterior 
 cul-de-sac ; make pressure outwardly with the other 
 hand, to be sure that the uterus is anteverted ; then 
 remove the outer pressure, and with the index finger 
 still resting a little anterior to the cervix, elevate the 
 os tincae in the direction of the pubes, by carrying the 
 anterior wall of the vagina on the point of the index 
 finger up behind its inner face ; — this pressure bringing 
 the cervix forwards and upwards, necessarily elevates 
 the fundus from its bed behind the pubes and throws 
 it slightly upwards ; — now push the ends of the fingers 
 of the right hand on the outside from above, down 
 into the hypogastrium closely behind the pubes, so 
 that the fingers of the two hands shall feel that there 
 is nothing between them but the thin walls of the 
 abdomen and the thinner walls of the vagina and 
 bladder. While the right hand is thus held firmly, 
 the fingers occupying, as it were, the place just filled 
 by the fundus uteri, quickly slide the left index from 
 the anterior to the posterior cul-de-sac of the vagina, 
 and push this before it till the finger lies snugly up 
 behind the cervix uteri ; then elevate it, as it were, 
 against the points of the fingers of the right hand, with 
 which push back the fundus, and retrovert the whole 
 organ while we hold it up almost in contact with the 
 abdominal parietes. 
 
 Thus we are able not only to straighten up the 
 
 16
 
 242 UTERINE SURGERY. 
 
 organ, but to manipulate every portion of the external 
 surface of the uterus : the fundus and body, before we 
 attempt to replace it (fig. 1) ; the remainder by the 
 above manoeuvre. 
 
 This is ordinarily easily done, even in very fat woman, 
 because nature provides a sulcus between the fatty 
 deposit in the walls of the abdomen, and the pubic 
 covering in which the outer hand is readily carried 
 down behind the pubes as above directed. 
 
 We only find trouble in delicate, nervous, hysterical 
 women, where there is involuntary spasm of the abdo- 
 minal walls, or where the cervix uteri is firmly held 
 back by shortened utero-sacrai ligaments. 
 
 It is by thus passing the left index finger behind the 
 cervix uteri, and then drawing the whole organ directly 
 forwards, almost against the inner face of the pubes, and 
 pushing the ends of the fingers of the outer hand down 
 behind the uterus instead of before it, that we can dia- 
 gnose with the greatest accuracy fibroid tumours, whether 
 sessile or pedunculated, and such offshoots as are repre- 
 sented in fig. 92, page 236. It was but the other day 
 that a friend of great eminence in the profession asked 
 my opinion in reference to a fibroid suspected to be in 
 the posterior wall of the uterus. He was hesitating 
 whether to attack it through the cavity of the uterus or 
 through the cul-de-sac of the vagina. By this bimanual 
 method of palpation alone, I was able in a moment to 
 say that the tumour, nearly as large as the foetal head at 
 term, was pedunculated, and that the pedicle, about an 
 inch long and three-fourths of an inch thick, was attached 
 to the posterior face of the uterus, about half-way 
 between the insertion of the vagina and the fundus 
 uteri (fig. 1)4). It is not necessary to say more about 
 the peculiarities of the case here, except that in the
 
 UTERINE DISPLACEMENTS. 
 
 243 
 
 course of a few minutes my friend was perfectly con- 
 vinced of. the exactness of the diagnosis. 
 
 But to return to the subject of ante version. So far 
 as the mechanical treatment of anteversion per se is con- 
 
 FiG. 94. 
 
 cerned, I know of but one instrument that has the power 
 of rectifying the position perfectly and at once, and that 
 is the intra-uterine stem (with disk) of Dr. Simpson. 
 But unfortunately the risks of the instrument are too 
 great ; and I know but three practitioners in my own 
 country who have not, after repeated trials, discarded it 
 altogether. These are Professor Peaslee and Professor 
 Conant, of New York City, and Professor Mack, of 
 Buffalo. 
 
 In the practice of the Woman's Hospital, Dr. Emmet 
 and myself were long ago compelled to discontinue its 
 use, on account of frequent accidents, such as haemor- 
 rhage, metritis, and pelvic cellulitis. Sometimes a small 
 Meigs's gutta-percha ring will afford relief, not so much 
 by rectifying the position as by elevating the organ 
 slightly in the pelvis, and taking some of its weight 
 from the bladder. Sometimes we derive considerable 
 comfort from a small globe pessary, particularly if it can 
 be made to rest just anterior to the cervix uteri. For
 
 244 UTERINE SURGERY 
 
 this purpose I have now and then attached a stem to 
 the globe, which projects externally, and is curved ap 
 over the pubes, to prevent the ball from running down 
 into the posterior cul-de-sac. 
 
 Fig. 95 will represent a very common form of ante- 
 version. Now, if we introduce a globe pessary an inch 
 and a quarter in diameter, it will ordinarily pass to the 
 very bottom of the vagina at a, resting there under the 
 cervix, and elevating it, while the fundus will be thereby 
 rather depressed anteriorly than otherwise ; thus aggra- 
 vating the malposition : but if we attach a malleable stem 
 
 to the globe, and curve it externally at 
 the proper length to prevent it from 
 passing further than the anterior cul- 
 de-sac, its tendency is to throw the 
 fundus upwards in a normal direction 
 by its pressure or traction on the an- 
 terior wall of the vagina at b. Its 
 action is readily understood by press- 
 ing the index finger forcibly up behind the symphysis 
 pubis, which easily elevates the anteverted uterus. If 
 the ball be too large, its pressure here will retro vert the 
 uterus, just as a tumour growing low down on the cervix 
 anteriorly will throw the fundus backwards. 
 
 But all instruments with external projections annoy 
 and irritate a naturally sensitive nervous system, already 
 rendered more irritable by disease, and are to be avoid- 
 ed if possible, i 
 
 It was the fashion a short time ago to use a sponge, 
 with a string for its removal. To this practice there 
 are two serious objections: 1st, nothing could be more 
 disgusting than a sponge thus worn for six or eight 
 hours ; and 2nd, the sponge always swells considerably 
 by absorbing moisture, and soon patients feel the need
 
 UTERINE DISPLACEMENTS. 245 
 
 of increasing its size, and they generally get to intro- 
 ducing two instead of one. The patient that once con- 
 tracts the habit of wearing a spouge in the vagina will 
 find it very difficult to break it up. 
 
 But what is better than this, and, indeed, better than 
 almost anything of the sort, is the application of a small 
 wad of cotton, not more than an inch in diameter when 
 moderately compressed, which may be used simple or 
 moistened with glycerine, or otherwise medicated. In- 
 stead of expanding, it gets smaller by the pressure of 
 the parts. A pessary of simple cotton should never 
 be retained more than twenty-four hours : moistened 
 with glycerine, it may be worn two or three days, or 
 till it come away spontaneously. The cotton pessary 
 secured with a string for its removal, is to be applied 
 by means of a porte-tampon, described and figured fur- 
 ther on. 
 
 In very aggravated cases of anteversion, where the 
 whole organ lies flatly down on the anterior wall of the 
 vagina aud parallel with it, we often, indeed almost 
 always, find the vagina unusually deep, with the ante- 
 rior wall greatly elongated. For such cases I devised 
 and executed an operation in 1857, which has answered 
 a most admirable purpose. 
 
 It was under these circumstances. A lady was sent 
 to me by Professor Josiah C. Nott, of Mobile, Alabama, 
 in December, 1856, who had a most complete antever- 
 sion, the fundus uteri being drawn down behind the 
 inner face of the pubic symphysis by a fibroid tumour 
 on the fundus anteriorly. Fig. 96 represents the rela- 
 tive position of the uterus and tumour a. I have never 
 seen a more complete anteversion. The diagram does 
 not in any way exaggerate any of the details of the case. 
 She had a cervical leucorrhcea, which was cured in a
 
 246 
 
 UTERINE SURGERY. 
 
 few weeks ; but the cystorrhcea, vesical tenesmus, and 
 malposition, with its other inconveniences, persisted. 
 For the relief of the displacement I tried all sorts of 
 pessaries, but nothing did any good. ' The pelvis was 
 
 Fig. 96. 
 
 deep, the vagina capacious, the anterior wall unusually 
 
 long, and the uterus laid down on and parallel with it. 
 
 I discovered that the malposition could be entirely 
 
 rectified by hooking a tenaculum in the anterior lip 
 
 Fig. 97. 
 
 of the os tincse, and drawing the cervix down towards 
 the urethra. By continuing this traction till the cervix 
 was brought forward about an inch and a half, the fuudus 
 rose up in the pelvis into rather a normal position, not-
 
 UTERINE DISPLACEMENTS. 
 
 247 
 
 withstanding the weight of the tumour on its anterior 
 portion. When the os tincse was thus drawn forwards, 
 the elongated, relaxed anterior wall of the vagina was 
 naturally folded upon itself, presenting the appearance 
 of an enormous anterior cul-de-sac, as at d, fig. 97. 
 
 Under these circumstances, could anything have been 
 more positively indicated than an operation, to retain 
 the uterus in the position in which it was thus held by 
 the tenaculum ? 
 
 The operation of shortening the elongated anterior 
 wall of the vagina, by attaching the cervix uteri to it at 
 the point <?, was therefore most naturally a self-suggested 
 affair. It was very simple, and as a mere operation 
 must always be a successful one ; whether it will, when 
 successful, always produce relief of suffering, time and 
 further experience can alone determine. 
 
 Two semilunar surfaces a half-inch wide, and running 
 nearly across the anterior wall 
 of the vagina, the one in jux- 
 taposition with the cervix, and 
 the other an inch and a half 
 or more anterior to it, were 
 carefully denuded of the va- 
 ginal mucous membrane, as 
 shown in fig. 98. They were 
 then closely united by seven 
 silver sutures, as in the opera- 
 tion for vesico-vasfmal fistula. 
 The patient was put to bed, 
 and a self-retaining catheter 
 worn for a few days ; after 
 which the urine was drawn off 
 when necessary. At the end of ten or twelve days 
 the sutures were removed, the union of the two sur-
 
 248 UTERINE SURGERY. 
 
 faces being perfect. The patient retained the recum- 
 bent posture for a week longer, to allow the cicatrix 
 to get strong enough to resist any traction that might 
 be made by the bladder, rectum, or uterus itself. 
 
 The uterus was held as nicely in its proper position 
 by this bridle of vaginal tissue as it was previously by 
 the tenaculum ; and fortunately she was wholly relieved 
 of the suffering symptoms, of which she had so long 
 complained before the operation. 
 
 Twelve months afterwards this lady gave birth to a 
 son. I saw her husband a year after the birth of the 
 child, and he reported his wife as enjoying most 
 excellent health, never having felt the slightest symp- 
 toms of her old troubles at any time since the operation. 
 I am sorry to say I have performed this operation in 
 but two other instances. I have seen many cases suita- 
 ble for it, but they have been satisfied to put up with 
 some clumsy mechanical contrivance rather than submit 
 to an operation. As I have not seen the case above 
 related since the confinement, I cannot say what effect 
 the labour produced on the cicatrix, but I should expect 
 to find it intact. 
 
 In 1859, a young lady aged twenty-six was sent to 
 the Woman's Hospital with just such an anteversion 
 as the one above related, except that the fibroid on the 
 fundus of the uterus was much larger. She was a 
 patient off and on for twelve months, and Dr. Emmet 
 and myself exhausted all our mechanical ingenuity (and 
 patience too) without producing the least benefit. 
 
 At last I proposed to her the operation above 
 described, telling her at the same time that it had been 
 done but once before. She readily accepted it; and 
 the operation was performed in May, 1860, with perfect 
 success, and with almost entire relief to all her suffer-
 
 UTERINE DISPLACEMENTS. 249 
 
 ings. I have seen this young lady repeatedly since; 
 the hst time in July, 1862. being then twenty-six 
 months after the operation, and the uterus remained just 
 as it was when she first left the Hospital. 
 
 I performed this operation a third time in 1860, at 
 the Woman's Hospital ; the patient left soon after- 
 wards, and as I have not seen or heard from her since, 
 I cannot say what was its effect upon her health ; but 
 the operation, as such, was as successful in every 
 particular as in the other two instances. 
 
 I would not be understood as recommending this 
 operation as a universal one in anteversion. It is to be 
 resorted .to only when the anterior wall of the vagina is 
 unusually long, and when the uterus lies down parallel 
 with it, presenting the fundus just behind the inner face 
 of the symphysis pubis. 
 
 Of Retroversion. — While the table on page 231 
 shows that about one-third of all sterile women have 
 anteversion from some cause or other, it also shows that 
 another third suffer from retroversion ; although these 
 two forms of displacement vary in the two classes of 
 natural and acquired sterility ; the anteversions, as 
 before stated, predominating in the first, and the retro- 
 versions in the second. 
 
 The uterus is retroverted when the fundus falls 
 backwards under the promontory of the sacrum or 
 whenever it passes an angle of 45° in that direction 
 from its normal position. But, as before said, it never 
 stops at 45°, seldom at 90 u , and often goes to 135°. 
 Thus we may have different degrees of this version. 
 We can ordinarily diagnose a retroversion by the 
 bi-manual method of palpation, already more than once 
 described ; but if at any time we are in doubt, the
 
 250 
 
 UTERINE SURGERY. 
 
 uterine probe will easily, and with great certainty, 
 settle the point. If we find a tumour in the retro 
 uterine region, and doubt whether it be the fundus of 
 the uterus or not ; and if Ave can pass the probe into 
 it to the depth of two inches and a half, then it is the 
 fundus ; but if it pass two inches and a half or more 
 in some other direction, then it is not the fundus. 
 There is no need of our ever beinc: in doubt as to 
 a retroversion. The physical signs elicited by the touch 
 and the probe are invariable and indubitable. I have 
 already said so much on these two methods of diagnosis, 
 that more is here unnecessary. 
 
 Pig. 99. 
 
 Fig. 89, page 228, represents the uterus in a normal 
 position. Fig. 99 represents the uterus retroverted from 
 its normal position a to an angle of at least 90°. In 
 retroversions like this there is ordinarily a greater degree 
 of vesical tenesmus than in ante versions. This is
 
 UTERINE DISPLACEMENTS. 251 
 
 explained by the fact that in the one the neck of the 
 bladder is the seat of pressure, while it is the fundus in 
 the other. The diagram represents the manner in which 
 the neck of the bladder may be jammed against the 
 symphysis 'pubis if the uterus is much hypertrophied. 
 Here it is not relatively augmented in its long diameter. 
 It also shows how awkwardly the fundus of the bladder 
 is pulled back by its attachment to the cervix uteri, and 
 how the cervix occupies the place, as it were, of the 
 has fond of the bladder. 
 
 It is possible in many instances to replace a retro- 
 verted uterus by manipulation alone, simply by pushing 
 the cervix back with the index finger till the os looks in 
 the direction of the hollow of the sacrum, and as the 
 fundus rolls upwards, grasping it with the outer hand 
 through the walls of the abdomen and pulling it for- 
 wards. We can thus often produce a complete ante- 
 version of the organ. But it is not always easy to do 
 this, particularly if the pelvis is deep, the uterus large, 
 the vagina long, and the patient fat. It is then neces- 
 sary to resort to instrumental aid, the simplest of which 
 are two or three sponge probangs, with sponges not 
 larger than the ball of the thumb. 
 
 For this purpose place the patient on the left side, 
 as for all uterine operations, introduce the speculum, 
 push one of the sponge probangs gently, firmly, forcibly 
 into the posterior cul-de-sac, holding it there steadily till 
 the cervix uteri is raised from its contact with the ante- 
 rior wall of the vagina; then place the other sponge 
 against the cervix anteriorly, and gently push it back 
 towards the posterior cul-de sac, at the same time that 
 the pressure is continued by the first one. This will 
 generally roll the fundus over forwards, and elevate it 
 from its bed in the utero-rectal pouch.
 
 252 UTERINE SURGERY. 
 
 Thus let fig. 99 represent a retroverted uterus witb 
 the speculum and the first sponge probang in situ. The 
 pressure with the probang mu"4 be made in the direction 
 of the dotted line b uuder the fundus uteri, directly 
 towards the hollow of the sacrum, or in other words, in 
 the direction of the proper axis of the vagina. The 
 tendency of this is at once to throw the fundus upwards, 
 by tilting the cervix downwards and backwards. When 
 this has been carried as far as possible, then the pressure 
 of the second sponge against the anterior face of the 
 cervix completes the rectification of the malposition, — 
 provided we are careful to make the pressure in the 
 right direction. If the handle of the sponge probang 
 be carried far back towards the perineum or the blade 
 of the speculum, in the direction of the dotted line c, it 
 will strike against the cervix uteri or in the anterior cul- 
 de-sac, and of necessity retrovert the uterus to a greater 
 degree, by pushing the cervix upwards and forwards 
 instead of downwards and backwards. But if the handle 
 of the probang be kept close to the urethra, the pressure 
 will be made in the direction of the line b, which neces- 
 sarily causes the uterus to revolve on its own axis, the 
 cervix taking the relative position just occupied by the 
 fundus, while this rises up above the promontory of the 
 sacrum. We shall generally, but not always, succeed in 
 this simple way in restoring the uterus to its proper 
 position. 
 
 If we produce any pain by this process, it will be 
 in consequence of pressure against the hypertrophied 
 tender posterior wall of the uterus, or against a pro- 
 lapsed supersensitive ovary, or something else abnormal, 
 in the Douglas cul-de-sac, all of which it is important 
 to ascertain by the touch before making efforts at 
 replacement. Then if we use two sponge probangs for
 
 UTERINE DISPLACEMENTS. 
 
 253 
 
 pressure in the posterior cul-de-sac instead of one, we 
 avoid the production of pain ; but instead of pushing 
 the sponges back in a direct line, centrally over the os 
 tincae, we cross them, laying one on the left side of the 
 cervix, and -the other on the right, as shown in fig. 100, 
 a b. They will naturally cross just over or very near 
 the urethra. I have had them 
 fastened together at the crossing, 
 making one automatic machine of 
 the two ; but this does not answer 
 so well, because we may sometimes 
 need to change the point of pres- 
 sure of one probang and not of the 
 other. We may not only need to 
 change the direction of the force, 
 but we may also wish to use more 
 or less with one than the other; 
 and we can do all this with greater 
 facility with the two sponges as 
 they are. 
 
 For instance, suppose we wish 
 to change the pressure of the pro- 
 bang a more to the left, the handle 
 is at once thrown to the riidit and 
 it takes the direction of the dotted 
 line d' and in like manner we may 
 act with b. When we are satisfied 
 that the fundus has been rolled up 
 out of its old bed, which is to be 
 
 presumed when the os tincse looks directly back towards 
 the posterior wall of the vagina, instead of towards the 
 symphysis pubis, then we are to apply the probang c 
 against the cervix, and push this in a straight line back- 
 wards. 
 
 Eia. 100.
 
 254 
 
 UTERINE SURGERY. 
 
 Fig. 101 shows the uterus somewhat elevated from 
 its abnormal position, towards the promontory of the 
 sacrum. We may push the organ up thus far, and sup- 
 pose that we have reduced the dislocation, because the 
 
 Fig. 101. 
 
 os and cervix have been forced back into a normal rela- 
 tion with the axis of the vagina. But the operation is 
 not yet finished. Holding the sponges in position, the 
 speculum is removed, and the patient requested to turn 
 from the side on the back ; then pass the left index fin- 
 ger into the vagina, and place it against the anterior 
 face of the cervix ; hold it firmly there, and remove the 
 sponges, one at a time ; then while the cervix is still 
 pushed backwards by the finger, bring the other hand to 
 make the outer pressure (bi-manual). If we can with 
 this grasp the fundus of the uterus, and bring it towards 
 the symphysis pubis, then we are sure that we have sue-
 
 UTERINE DISPLACEMENTS. 
 
 255 
 
 ceecled ; if not, we have only crowded the cervix back- 
 wards, flexing it upon itself and leaving the fundus in its 
 abnormal position, almost as it was before (fig. 102). 
 
 Fig. 102. 
 
 This is more apt to happen when the pelvis is deep, 
 and the supra-vaginal portion of the cervix is long and 
 slender. If our patient is too much fatigued to change 
 her position to the dorsal decubitus for the bi-manual 
 examination, we can ascertain the degree of success of 
 the effort at replacement by passing the uterine sound 
 while the patient is still on the left side. If it pass 
 easily the proper distance in the direction of the normal 
 position of the uterus, then it is all right; but if it pass 
 back towards the hollow of the sacrum, then it is all 
 
 wrons;. 
 
 It is better not to fatigue our patient too much, and 
 if we do not succeed to-day, it will be as well to wait
 
 256 
 
 UTERIXE SURGERY. 
 
 till to-morrow. When we attempt anything of this 
 sort, we must always be sure that the bowels are not 
 constipated; and we must not forget to have the blad- 
 der emptied before trying to reduce the dislocated 
 uterus. 
 
 Fig. 103 represents a retro verted uterus completely 
 
 Fig. 103. 
 
 restored to its normal position by the pressure of two 
 sponge probangs alone. 
 
 We often succeed by the simple process above 
 detailed ; but suppose we fail in our second effort, or 
 suppose we are in doubt about adhesions binding the 
 fundus down in its abnormal position, what are we then 
 to do ? We then j^roceed otherwise ; and it is here 
 absolutely necessary to use an intra-uterine force. 
 
 Dr. Simpson was the first to teach us how to dia- 
 gnose, and how to rectify a retroversion. He passes his 
 uterine sound to diagnose the position, and then turning
 
 UTERINE DISPLACEMENTS. 
 
 257 
 
 it half a circle, the retroverted fundus is necessarily 
 elevated towards the promontory of the sacrum. But 
 as I have frequently said before, this operation often 
 produces great suffering, and sometimes haemorrhage, 
 and I have pot for many years used Simpson's sound 
 as a redresser. I have not seen any more serious 
 accident from it. Some object to the instrument, and 
 ostracize it altogether; because perforation of the fun- 
 dus and death have followed its injudicious use. This 
 is not wise or logical. I object to it only as a redresser. 
 Its whole principle of action is wrong; and hence the 
 pain and suffering it produces. I only wonder it has 
 not done greater mischief. Let us for a moment look 
 at its modus operandi. 
 
 Fig. 104 represents a retroverted uterus with Siinp- 
 
 FlG. 104 
 
 son's sound introduced as a redresser. Now, if we 
 turn the handle of the instrument a on its own axis 
 half a circle, the distal end will elevate the uterus from 
 its abnormal position to that shown by the dotted 
 figure c; but in doing this it will describe a semicircle 
 of but little less than two inches and a half radius, 
 
 17
 
 258 
 
 UTERINE SURQERY. 
 
 sweeping the fundus round with the whole weight of 
 the organ, supported principally on the very end of the 
 instrument, which in its gyration changes its point of 
 pressure from the posterior to the anterior face of the 
 uterine cavity. To elevate the fundus still more, we 
 push the handle b back towards the perineum, which 
 thrusts the uterine end upwards. Is it to be wondered 
 at, then, that we occasionally meet with patients who 
 look upon the uterine sound with the most painful 
 recollections ? Seeing that an intra-uterine force was 
 occasionally absolutely necessary for the rectification of 
 this malposition, I devised the following instrument in 
 
 Fig. 105. 
 
 1856, and have used it ever since. Its whole principle 
 of action is that of elevating the fundus in a straight
 
 UTERINE DISPLACEMENTS. 25S 
 
 line instead of a circle, and of supporting the weight 
 of the organ on a disk at the os tincse instead of the dis- 
 tal end of the instrument at the fundus. For this it is 
 only necessary to make a joint or hinge in the sound, 
 about two inches from its uterine extremity, and fix a 
 disk or plate there, as a point of support for the weight 
 of the uterus. For instance, let fig. 105 represent a 
 retroverted uterus, with a jointed sound a introduced, 
 the joint being at the os. Now all that we have to do 
 with such an instrument is to push the mouth of the 
 womb downwards and backwards into the posterior 
 cul-de-sac in the direction of the place which was at the 
 inception .of this movement occupied by the fundus. By 
 this manoeuvre the os tincae describes the small arc of 
 a circle represented by the dotted line c/, while the fun- 
 dus, being elevated in a right line, describes a larger 
 one, and takes the position b ; the handle or shaft of the 
 instrument being represented by the dotted line c. If 
 the instrument be properly adjusted, this operation is 
 effected without suffering to the patient or injury to the 
 uterus. If there are adhesions, we can measure very 
 accurately their resistance and extensibility. I now 
 remember two cases in which from this cause it was 
 impossible to elevate the uterus more than 4.5° above 
 the axis of the vagina. 
 
 Fig. 106 represents the uterine elevator with the 
 uterine stem a set at an angle of 45°, being the proper 
 angle for an ordinary retroversion : c is the ball or disk 
 for the support of the weight of the uterus. It revolves 
 on its own axis in a line with the shaft, permitting 
 the stem a to describe a whole circle, except 5)0°, — 45° 
 on each side of the shaft. This ball is perforated 
 with seven holes (the stem occupying the eighth), made 
 in a line around its centre, for the reception of a pointed
 
 260 
 
 UTERINE SURGERY. 
 
 rod, concealed in the tubular shaft, which is pulled 
 
 down by the ring b, and flies 
 back again when we let the ring 
 go, so that the movements of the 
 uterine stem a can be promptly 
 arrested at any desired point in its 
 elevation, simply by letting go the 
 ring b, which, with the rod, is driven 
 up by a hidden spiral spring in the 
 handle below. The little perforations 
 in the ball are placed intentionally at 
 the proper distances to mark off 
 angles of 45° in the revolutions of 
 the stem. 
 
 This instrument is simply Simp- 
 son's sound with a joint or hinge two 
 inches from its uterine extremity ; but 
 its modus operandi is very different. 
 One elevates the uterus in a right 
 line ; the other in a circle totbe right 
 or left : one supports the weight of 
 the organ on a ball at the os ; the 
 other principally on the point of the 
 sound in the uterine cavity : one 
 elevates the uterus by a power ex- 
 erted on the cervix ; the other by 
 a like power on the fundus : one 
 seldom produces pain, the other often 
 does. 
 
 V- This instrument is sometimes 
 valuable in assisting us to diagnose 
 the relative position of small tumours 
 on or near the uterus. Thus, sup- 
 pose we have the uterus impaled with the stem a at 
 
 Fig
 
 UTERINE DISPLACEMENTS. 261 
 
 right angles with the shaft, its body being thus held 
 firmly in the centre of the pelvis, with the fundus 
 pointing to the umbilicus, — by pulling the handle 
 of the instrument forwards while it is thus rigidly 
 fixed, we can draw the body of the uterus towards 
 and very near the inner face of the symphysis 
 pubis ; by pushing it back, we can carry it directly 
 backwards as far as the depth of the vagina and the 
 sacral promontory will allow it to go ; by turning the 
 handle from side to side, we can at will throw the fundus 
 to the right or left, as we please, and all this without 
 injury to the organ itself, for its whole weight is sup- 
 ported, as- before said, not on the point of the instru- 
 ment, as when we execute any of these movements with 
 Simpson's sound, but on the disk at the os tincae ; and 
 while we are thus changing the position of the uterus, 
 we can by a finger in the vagina or rectum, and by 
 palpation externally, determine whether any suspected 
 tumour be attached to the uterus by sessile adhesions or 
 by ligament only, or whether the two be entirely sepa- 
 rate and independent of each other. The iutra-uterine 
 portion of the elevator is malleable, because we may 
 sometimes wish to curve it a little to suit the peculiari- 
 ties of some special case. 
 
 Ordinarily this stem should not be more than two 
 inches long. It should never be long enough to touch 
 the fundus uteri by any possibility. In its use we should 
 be careful to keep the ball or disk always pressed well 
 up against the os tincaa ; for if it should slip down half 
 an inch or more, we shall fail to elevate the fundus, 
 as the whole power of the instrument will then be 
 expended only in pushing the os tincae backwards and 
 doubling the cervix on itself. 
 
 I published an account of this uterine elevator in the
 
 262 
 
 UTERINE SURGERY. 
 
 January number of the American Journal of the Medi- 
 cal Sciences for 1858 ; and since then it has been vari- 
 ously modified by different writers, but not at all 
 improved. Dr. Gardner and Dr. Dewees, of New York, 
 and others, have added a screw to move the stem, which 
 is objectionable, because it robs us of the faculty of 
 determining the power of resistance by the sense of feel- 
 ing. When we have a freely movable joint, as in this 
 instrument, it is easy to judge of the weight of the 
 uterus, and to determine the amount and decree of 
 adhesions, when present, by noting the exact point at 
 which we feel their resistance. 
 
 But suppose we elevate the uterus, whether by this 
 means or any other, will it remain in its normal position 
 simply by placing it there? Never. I have known 
 physicians to replace a retroverted uterus day after day 
 for months, but I never knew a case cured by it. It is 
 certainly important in many cases to rectify the malposi- 
 tion, but more than this remains to be done to render it 
 permanent. For this purpose the organ must be not 
 only replaced, but it must be retained in its normal 
 position by some mechanical means. In old cases, 
 where the uterus is tender and irritable, it will be well 
 not to resort to a pessary at once. It is better to replace 
 the uterus a few times and apply simply a wad of cotton 
 wet with glycerine, for the double purpose of supporting 
 the uterus in situ for a while, and of removing engorge- 
 ment by the depleting power of the glycerine already 
 described (pp. 71, 72, 158). Whenever by this means 
 or others we remove all irritability or engorgement that 
 may have been present, we must adjust a pessary of 
 some sort to hold the organ in its normal position. 
 
 Much has been written on the subject of uterine 
 displacements, and very opposite views have been enter-
 
 UTERINE DISPLACEMENTS. 263 
 
 tained of its treatment. Some look upon it as a matter 
 of no great importance, while others are ready to at- 
 tribute to it every nervous symptom that the patient 
 may suffer. Some condemn pessaries and ostracize them 
 altogether,, while others advocate them perhaps too uni- 
 versally. Like most disputed points, there is some truth 
 on "both sides. I have seen much harm produced by 
 pessaries, and so have I by bleeding, by purgatives, by 
 opium, by quinine, and by other powerful remedies ; but 
 I do not see why we should wholly repudiate remedies 
 or instruments because they have been used injudiciously. 
 I have also seen much benefit from the application of 
 the principles of mechanics to the treatment of uterine 
 displacements, but I am well aware that there are cir- 
 cumstances under which they are inapplicable. 
 
 I have seen cases in which Simpson's intra-uterine 
 stem (fig. 107) had produced very serious results, such 
 as metro-peritonitis. I have seen Hodge's 
 open lever pessary (fig. 110) dig holes in the 
 anterior walls of the vaerina almost through 
 into the bladder. I have often seen Meigs's 
 ring-pessary (fig. Ill) cut a sulcus in the 
 posterior cul-de-sac of the vagina deep enough 
 to burrow the finger in. I have seen Zwang's 
 pessary (fig. 108) sever the urethra from 
 the neck of the bladder, cutting quite down 
 to the vesical membrane, but not through it. I have 
 known one case where the disk of a vaginal stem-pessary 
 (fig. 109) passed into the cavity of the uterus, and 
 remained incarcerated there for several days, Avith the 
 cervix closely contracted around the stem, till it was 
 removed by Professor Lewis A. Sayre. of the Bellevue 
 Hospital College, New York ; and I have seen Gariel's 
 India-rubber bag-pessary iiitlated till it distended the
 
 264 
 
 UTERINE SURGERY. 
 
 Pig. 108. 
 
 vagina so enormously that it seemed 
 to occupy almost the whole of the 
 pelvic cavity ; and I have heard of 
 other pessaries producing fistulous 
 openings into the rectum and the 
 bladder. But notwithstanding all 
 this, I advocate and daily use pessa- 
 ries in some form or other; be- 
 cause, if I did not, I should turn 
 away a multitude of cases without 
 doing anything at all for their relief. Pessaries are 
 necessary evils. We should always do without them 
 
 if possible ; but if it be im- 
 possible, then it is the part of 
 wisdom to resort to such ap- 
 pliances as will best answer 
 the indications of the indi- 
 vidual case. 
 
 The man who is not a mechanic should never trust 
 himself to use a pessary. Even with a correct under- 
 standing of uterine mechanology, we will often make 
 mistakes, — 
 
 1st. In resorting to pessaries where there is metritic 
 inflammation in some form. 
 
 2nd. In selecting an inappropriate instrument. 
 3rd. In making it too large ; sometimes too small ; 
 and 
 
 4th. In allowing it to remain too long without 
 removal. 
 
 Even if we feel pretty sure of the form of the instru- 
 ment as applicable to the case, it is difficult for us to get 
 our ideas of the size of the vagina down to a proper 
 level. We more frequently make them too large than 
 too small. After we succeed in getting the pessary to 
 
 Fig. 109.
 
 UTERINE DISPLACEMENTS. 265 
 
 fit accurately, we should never send our patient off till 
 she is taught to remove and replace it with the same 
 facility that she would put on and pull off an old slipper. 
 A pessary is a thing to be worn like a glass eye, only 
 when awake. As a rule, it should be pulled off at 
 night, and put on in the morning, if needed ; and if 
 every poor woman who is compelled to use such an aid 
 for the support of the uterus, was always taught to 
 understand the principles of its action, and to remove 
 and replace it every clay or two, there would be none 
 of the accidents alluded to above, to damage their repu- 
 tation for usefulness. But the greatest mistake that we 
 make is that of taking a single model and applying it 
 universally. What would be thought of the hatter who 
 expected one hat to fit every head ? Of the shoemaker 
 who expected one shoe to fit every foot ? Of the dentist 
 who expected the cast of one alveolar arch to fit every 
 other % The idea is most preposterous ; and yet. we 
 have been but little less wise in our mechanical treat- 
 ment of uterine displacements. 
 
 I have seen the inside of an immense number of 
 vaginas, and I never saw two that were in all particulars 
 exactly alike. They are as different from each other as 
 are our faces and noses. In Mr. Preterre's (of Paris) 
 great collection of palatine fissure-casts, numbering now 
 some 600 or more, each one has its peculiar anomalies, 
 and each its peculiar apparatus. I would not be under- 
 stood as meaning that 600 cases of uterine displacement 
 would need as many differently constructed instruments ; 
 but I mean this, that every individual case is a study of 
 itself, and that its complications and peculiarities must 
 be investigated, understood, and respe/ted, if we expect 
 to treat them snfely and successfully. But as I intend 
 to deal here with pessaries only in relation with the
 
 266 UTERINE SURGERY. 
 
 sterile condition, further general remarks are uncalled 
 for. 
 
 I do not pretend to say that a retroverted or an 
 anteverted uterus is incapable of conception ; but of this 
 I am certain, if conception occurs when the uterus is 
 greatly anteverted or greatly retroverted, it is rather 
 accidental thau otherwise, and would have occurred with 
 greater facility if this organ had been in a normal posi- 
 tion, other things being equal. 
 
 When we call to mind the fact that of 255 cases of 
 acquired sterility (page 231), 111 had retroversion 
 and 61 anteversion ; and of 250 cases of natural 
 sterility, 68 had retroversion and 103 anteversion, 
 we may have a right, as I have said before, to suspect 
 that the position of the uterus is a matter of some 
 importance in the treatment of the sterile condition. 
 Of course many of these cases of malposition were 
 complicated with fibroids, or flexures, or engorgements, 
 or hypertrophies, or a conical cervix in those who have 
 never borne children. But even if all these be rectified, 
 we may still have sterility as a consequence of malposi- 
 tion alone. At all events, the frequency of malposition 
 renders it an important element in the treatment of the 
 sterile condition. 
 
 Although I have been for a lon^ time aware of the 
 fact that malposition of the uterus had much to do 
 with sterility, I never had the slightest idea of treating 
 this last in connection with the malposition till 1855 ; 
 and it occurred to me in this way. I was consulted in 
 July, 1855, by a lady who had been under the treat- 
 ment of Professor Hodge, of Philadelphia. The his- 
 tory of her case gave the following facts. She was 
 twenty-three .years old, married at seventeen, in July, 
 1849; bad a two months' miscarriage in March, 1851;
 
 UTERINE DISPLACEMENTS 
 
 267 
 
 from which she slowly recovered, and was sent to 
 Professor Hodge by her medical attendants in May 
 following. He found the uterus retroverted, and 
 applied his pessary immediately. She remained in 
 Philadelphia seven weeks; had but one menstrual 
 period after the pessary was applied ; and returned 
 home still wearing it. Her physicians there pronounced 
 her pregnant, but did not remove the instrument till 
 September, and her child was born in March follow- 
 ing. This appeared to me at the time a most remark- 
 able revelation ; and I asked this lady how it happened 
 that she had sexual intercourse while she wore an 
 instrument. She replied simply, " It happened so." 
 "Often?" said I. "Oh, yes; just as if there had 
 been no instrument there." The idea of adjusting an 
 instrument that would permit sexual intercourse at 
 the same time that it held the uterus in situ was to me 
 a novel one. Since then I have acted upon it, and think 
 it of great importance. 
 
 Hodge's instrument, as first invented by him, is 
 made of silver and then gilt. It is in the shape of the 
 letter [Ji w ^ tn tne tw0 parallel branches curved on the 
 flat to suit the curvature of the vagina. 
 
 Fig. 110 represents the in- 
 strument. The cross-bar con- 
 necting the two branches is 
 to be pushed up behind the 
 cervix uteri after the organ is 
 replaced ; the great convexity 
 of the branches rests on the 
 posterior wall of the vagina; 
 and the open end looks in the 
 direction of the symphysis pubis; 
 while the extremities of the branches rest auteriorly, one 
 
 Fig. 110.
 
 268 UTERTXE SURGERY. 
 
 on each side of the neck of the bladder. Theoretically 
 and practically the instrument is admirable, when neatly 
 fitted and properly managed. Its expensiveness was the 
 chief objection to its general use. Dr. Hodge modified 
 his instrument for ante-versions, by placing a cross-bai 
 on its front or open end, thus closing it up entirely, and 
 making a sort of sigmoid parallelogram of it (fig. 112). 
 This form of the Hodge instrument is commonly 
 adopted by the profession in my own country, whether 
 it be made of silver, block-tin, vulcanite, or gutta-percha. 
 We seldom use the other one. 
 
 Hodge's instrument may be found in the shops 
 variously modified. For instance, they are made of 
 hard rubber, and sold in great quantities ; but these are 
 very dangerous, for they are generally too large, and 
 are fashioned into anything but the right shape ; and I 
 have found it impossible to give them the proper equi- 
 lateral curvatures by heating them in boiling water as 
 is recommended. What is better than the hard rubber, 
 but not so cleanly, is a copper wire covered with gutta- 
 percha. But even here we have a right to complain of 
 all our instrument-makers ; for they have taken the 
 common insulated telegraphic wire, cut it into slips of 
 various lengths, and most clumsily fastened the two 
 ends of these together in a ring, and then curved them 
 as we find them. They do this to sell them a few 
 pennies cheaper. This is poor economy ; for they often 
 get fractured where they have been joined ; the secre- 
 tions then enter the little cracked fissures, and the 
 instrument becomes a source of irritation instead of 
 comfort. Instead of this, the malleable copper wire 
 should be first made neatly into a ring or parallelogram 
 and then smoothly covered with gutta-percha, not 
 varnished. I have persuaded at least two instrument-
 
 UTERINE DISPLACEMENTS. 
 
 269 
 
 makers (Mr. Weiss and Mr. Charriere) to remedy this 
 evil. Away with cheap things ! whether drugs or 
 instruments, for our sick, especially for our sick women ; 
 and more especially still when they are afflicted with 
 such fearful calamities as we are now considering. 
 
 But my country holds another name equally as hon- 
 oured and resj^ected, and equally as authoritative as 
 that of Hodge, in advocacy of the mechanical treatment 
 of uterine displacements. In 1853, Professor Charles 
 D. Meigs published his report on uterine diseases before 
 the American Medical Association, in which he promul- 
 gates the same views so long taught by his illustrious 
 confrere, Professor Hodge. 
 Dr. Meigs's instrument differs 
 from Hodge's, but its princi- 
 ple of action is the same. 
 While Hodo-e's is a curved 
 parallelogram, Meigs's is sim- 
 ply a ring, acting upon the 
 same principle of distending 
 the vagina antero-posteriorly, 
 by making the posterior cul- 
 de-sac and the inner face of 
 the symphysis pubis the points 
 of support. It, too, holds the 
 neck of the womb back in its 
 proper place, and does not 
 interfere with sexual intercourse. Meigs's ring pessary 
 is made of watch-spring, fashioned into a circle, two, 
 two and a half, two and three-quarters, and three inches 
 in diameter, and then coated with gutta-percha (fig. 
 111). 
 
 It is introduced with great facility, by compressing 
 its opposite sides, thus elongating it in one direction, 
 
 a. 
 
 Fig. 111.
 
 270 UTERINE SURGERY. 
 
 — dotted line #, while its diameter in the other is 
 diminished. As soon as it passes the arch of the pubes, 
 it recovers its original form, but seldom ever becomes 
 perfectly circular again, unless it is a very small instru- 
 ment. If a large one, it takes an oval form after being 
 worn for any length of time. 
 
 These are often worn for a good while ; but in a 
 general way, as before stated, I am opposed to the. 
 principle. I have often removed the Meigs ring-pessary 
 after it had been worn continuously for ten or twelve, 
 months. In five or six weeks it becomes coated with 
 a thick layer of brownish sordes, having a most dis- 
 gusting smell. This, of itself, must irritate the vaginal 
 mucous membrane, independently of mischief resulting 
 from prolonged mechanical pressure. I have seen one- 
 case in which the Meiers ring had ulcerated a sulcus in 
 the posterior cul-de-sac deep enough to hide the little 
 finger in it. I was surprised that it had not perforated 
 the peritoneal cavity ; but a close investigation revealed 
 the wonderfully protective powers of nature in throwing 
 out lymph, and increasing the thickness of the tissues 
 through which the instrument had gradually cut its 
 way. Here the position of the womb had not been 
 wholly rectified. The pelvis was deep, and the instru- 
 ment had merely pushed the cervix backwards, while 
 the fundus was still retro verted. Perhaps this was well 
 for the patient, for the cul-de-sac of the vagina and the 
 posterior wall of the uterus seemed to be agglutinated 
 firmly together, — doubtless the result of the pressure 
 and ulceration of the ring, for I had examined this case 
 some months before the ring was applied, and there was 
 nothing of the sort then. 
 
 I saw another case at the Woman's Hospital in 1861, 
 where a Meigs ring had been worn continuously for
 
 UTERINE DISPLACEMENTS. 271 
 
 nearly twelve months. At first it produced great relief, 
 but after a while there was an excessive mucopurulent 
 discharge from the vagina, and it was for this that 
 advice was sought at the Hospital. 
 
 We often see pessaries of this sort produce mischief 
 by being too large, but here it was the contrary. The 
 cervix and a portion of the anterior wall of the vagina 
 seem to have gradually descended too far through the 
 small ring, and to have become almost strangulated. 
 It had cut a deep circular sulcus all around the cervix, 
 deeper posteriorly and on the sides than anteriorly; 
 and in this sulcus the ring was entirely hidden from 
 view except just at the neck of the bladder, where it 
 was more superficial. On the removal of the instrument, 
 which was both difficult and painful, its bed was seen 
 to be a deep suppurating chasm, with granulating edges 
 that had entirely overlapped the ring behind and on 
 the sides. The cervix uteri was also very granular, and 
 greatly engorged, seemingly in consequence of the stran- 
 gulating pressure of the ring. All of this disappeared 
 with the filling- up and healing of the sulcus, which 
 occurred in the course of a fortnight. 
 
 While I advocate, and daily use pessaries of some 
 sort, it is but just that I should say all I know against 
 them, simply as a warning of danger to others. In this 
 case the fault was with him who applied the instrument, 
 and turned his poor patient adrift without giving her 
 instructions in its use. I have seen more mischief from 
 the Meigs ring than from Hodge's instrument. I pre 
 sume the reason is, that when it was first introduced it was 
 a cheaper instrument than any other then in vogue ; was 
 therefore more universally used ; and, consequently, pre- 
 sented comparatively larger opportunities for observation. 
 If the object be to cure the sterile state while we
 
 272 
 
 UTERINE SURGERY. 
 
 treat the malposition, I always use an instrument on 
 the same principle as those above described. Besides 
 the Hoclge and Meigs instruments, as we find them in 
 the shops I often use rings made of block-tin softened 
 by the addition of a little lead. These I introduced in 
 1856. They are made of different sizes, varying from 
 two to three inches in diameter. The material, if tubu- 
 lar, may be a third of an inch in diameter ; much less if 
 solid. It matters not whether it be of block-tin or 
 gutta-percha, so it is malleable. Select a ring to suit 
 the capacity of the vagina ; compress it gently between 
 the hands till it takes an oval form. It is then in imita- 
 tion of a Meigs ring, and may be soused; but sometimes 
 it is better to give it the natural curvature of the vagina, 
 after Hodge's plan, by making the distal end Z>, fig. 112, 
 
 Pig. 112. 
 
 pass up behind the neck of the womb, while the proxi- 
 mal end a has a slight counter-curvature where it 
 presses the neck of the bladder against the symphysis 
 pubis. Great nicety is necessary in fitting an instrument 
 so as not to injure by pressure the neck of the bladder, 
 the posterior cul-de-sac, or the floor of the vagina, upon 
 which rests the great curvature. It will be difficult to 
 get one instrument with its exact proportions to fit any 
 two cases ; and it is often difficult to fit any given 
 case. It has frequently taken me a fortnight, 
 and sometimes much longer, to adjust an instrument
 
 UTERINE DISPLACEMENTS. 
 
 273 
 
 accurately; and sometimes it has been utterly impossible 
 for me to do it at all. When I succeed in fitting the 
 case exactly, i. e. in supporting the womb in its normal 
 position without undue pressure on the vaginal parietes, 
 I usually send the model made of this malleable mate- 
 rial to the instrument-maker, to be duplicated in vulca- 
 nite or silver, if the patient is to leave my care wearing 
 an instrument. The block-tin pessary is quite as good 
 as a silver one ; but then the patient in removing and 
 replacing it may spoil its shape, and make it hurtful 
 instead of beneficial. If, however, the patient lives near 
 enough for me to see her occasionally, I seldom order 
 any other instrument than the block-tin one. 
 
 As I said before, the case related on p. 266 gave me 
 new views of practical utility, that were not lost ; for a 
 lady, twenty-six years old, soon after this came with her 
 husband to consult me on account of her sterility (ac- 
 quired). She had had one child six years before. It 
 died early, and they were exceedingly anxious for more 
 offspring. She had been treated at different times by 
 several distinguished physicians, all of whom put her 
 through "a course of caustic,"* but her symptoms 
 remained the same, and her sterility persisted. On 
 examination, I found the pelvis deep, the vagina capa- 
 cious, the perineum relaxed, and the uterus completely 
 retroverted, but not difficult to replace. The posterior 
 wall was, as in all such cases of prolonged malposition, 
 somewhat hypertrophiecl, and there was also some little 
 engorgement of the posterior lip. Her symptoms of 
 vesical tenesmus, bearing down, &c, were evidently the 
 result of the error of position, and I told them it was 
 
 * It was unfortunately the fashion a few years ago in my own country to cau- 
 terize the neck of the womb, without reference to conditions or indications. 
 
 18
 
 274 UTERINE SURGERY. 
 
 quite impossible for her to conceive with the uterus in 
 its abnormal position. I concluded to treat the case 
 entirely mechanically, but it was very difficult, for I did 
 not then possess the tact in adapting an instrument to 
 the peculiarities of the case, that observation and enlarg- 
 ed experience can alone give. It took me nearly a 
 month to adjust it so that it could be worn without pain 
 or undue pressure ; but once fitted, there was no incon- 
 venience from it ; on the contrary, the greatest comfort. 
 The ring, moulded as described, was fully three inches 
 and one-eighth in diameter before giving it the form of 
 a sigmoid parallelogram. A special injunction was that 
 it should be worn during sexual intercourse. Concep- 
 tion occurred in three months. She continued to wear 
 the instrument till after the third month, when the 
 uterus had risen up above the brim of the pelvis, and 
 then it was removed. She was delivered, at full term, 
 of a fine healthy boy, which was turned over to a wet- 
 nurse. She was in hopes that conception would soon 
 occur again, but it did not ; and at the end of eighteen 
 months she returned to ask an investigation of her con- 
 dition, and, if necessary to insure an early conception, 
 the reapplication of the instrument. 
 
 I found the uterus precisely as it was when I first 
 saw her. It had no self-adjusting power whatever. It 
 could be replaced with facility, but dropped back as 
 soon as the finger was removed. I gave it as my 
 opinion that conception could hardly occur again with 
 the uterus persistently retroverted. I therefore re- 
 applied the same instrument with injunctions to wear it 
 as before during coition. Conception occurred in eight 
 weeks afterwards. About fifteen months after the birth 
 of the second child, she came again, and I found the 
 uterus precisely as it was at the first consultation.
 
 UTERINE DISPLACEMENTS. 275 
 
 I adjusted another instrument to prop it up, and gave 
 the same injunctions, and in ten months afterwards 
 she was again a mother. 
 
 Now, in this case, I believe that conception could 
 have been' brought about as easily five years sooner, if 
 the same treatment had been adopted. 
 
 To establish the utility of the pessary during coition, 
 in cases of sterility dependent upon retroversion, I 
 must continue my notes. The case above was uncom- 
 plicated. There was simple relaxation of all the pelvic 
 supports of the uterus, and it tilted over backwards, 
 and will remain so always, unless it be propped up 
 mechanically. Occasionally a malposition of this sort 
 is cured by a pregnancy, but often it is not. 
 
 In 1856, a lady was brought to the Woman's 
 Hospital, who had been bed-ridden for more than two 
 years. She was thirty-two years old ; was married at 
 twenty ; gave birth to a child in ten months, but she 
 remained sterile afterwards. She became a widow, 
 and married again at thirty. Twelve months after- 
 wards she ran hurriedly into the garden to bring in 
 some clothes that had been hung out to dry. On 
 reaching up quickly, she felt something suddenly give 
 way in the pelvis ; she had great pain, and immediately 
 went to bed, suffering also from nausea, vomiting, and 
 excessive prostration. Her physician was sent for, and 
 attended her for many months, but without much 
 improvement. I found the uterus completely retro- 
 verted, and greatly enlarged, with the fundus directed 
 towards the left sacro-iliac symphysis. The enlargement, 
 or rather elongation of the organ, was due to a fibrous 
 tumour growing from the fundus, which explained its 
 diagonal direction, for it was too long to lie retro verted 
 in the median line. To remove the fibrous tumour was
 
 276 UTERINE SURGERY. 
 
 out of the question; to allow* the uterus to remain 
 where I found it, was to consign her to her fate without 
 an effort for her relief. My only hope of affording her 
 any permanent benefit was in elevating the uterus, 
 supporting it in position, and giving her the possibility 
 of a conception. When it was so elevated into position, 
 the tumour could be distinctly felt on the fundus, above 
 the promontory of the sacrum. But of course it would 
 fall back into its old position, as soon as the finger and 
 the uterine elevator were removed. By repeating this 
 every day for a week, the uterus became sufficiently 
 tolerant of manipulation to allow the use of an intra- 
 vaginal support. A malleable block-tin ring, about two 
 inches and a half in diameter, w*as fashioned into the 
 form of a parallelogram, and curved on its long axis, as 
 already described, so as to give it a slight sigmoid 
 flexure. The vagina was rather small, and great care 
 was necessary not to inflict injury by undue pressure in 
 the posterior cul-de-sac, or against the neck of the 
 bladder and the symphysis pubis. The instrument was 
 worn at first for a few hours, but soon it was worn dur- 
 ing the whole day, and after a short time she was able 
 to walk. In two or three months she returned home, 
 not cured it is true ; but the uterus was elevated into a 
 proper position, and there supported by the simple 
 little contrivance already described. With the hope 
 that conception would take place, she was directed to 
 wear the uterine supporter always during coition. Six 
 months after leaving the Hospital she returned for 
 observation, and was found to be pregnant four months 
 and a half, having conceived in six weeks after return- 
 ing home. She had worn the instrument all the time 
 except when she removed it for cleaning. 
 
 She went the full term and was safely delivered. I
 
 UTERINE DISPLACEMENTS. 271 
 
 saw her some months after the birth of her child. The 
 uterus was in its proper position, but the tumour was 
 about the same. Without mechanical aid here, I do not 
 see how it would have been possible to have done any- 
 thing at all for this poor sufferer. There was nothing 
 whatever attempted for her but the replacement of the 
 dislocated uterus, with this vaginal splint, as it were, to 
 support it in its proper relations. This case might be 
 called cured, so far as the mere position of the womb 
 was concerned. It is very probable that the fibrous 
 tumour had existed a long time on the fundus, and that 
 it assisted by its weight when the uterus was suddenly 
 retroverted in holding it down in its abnormal position, 
 and I have as little doubt that the same condition now 
 assists in holding the uterus erect. The pelvis in this 
 case was of ordinary capacity, while in the case pre- 
 viously related it was very deep, with a rather straight 
 sacral promontory. 
 
 It might be supposed a priori that any instrument 
 in the vagina would interfere with coition. I usually 
 make it a rule to explain the necessity of the treatment 
 to the husband as well as the wife. So far as our sex is 
 concerned, the knowledge of the presence of a vaginal 
 support might be an unpoetical association ; but if it is 
 properly adjusted, it is not at all in the way. Some- 
 times the wife has insisted that it was not necessary for 
 the husband to know that the uterus was thus artificially 
 braced up. The instrument should be neither too large 
 nor too small, and should fit snugly up behind the 
 symphysis pubis. 
 
 In 1861 I was consulted by a young widow, who had 
 a proposition of marriage. Daring her first marriage 
 she had had one full term labour, and three or four mis- 
 carriages at about the third month. Her physicians told
 
 278 UTERINE SURGERY. 
 
 her that she would probably always miscarry at the 
 third month. It was her opinion that few men would 
 many if they did not expect to be blessed with off 
 spring, and she herself looked upon children as necessary 
 to the complete happiness of married life. With these 
 views she was unwilling to marry unless she could have 
 some assurance that the habit of aborting could be 
 broken up ; and upon this point my opinion was asked. 
 I found the uterus completely retroverted, with some 
 enlargement of the posterior wall from long error of 
 position. I explained to her that her miscarriages were 
 almost certainly due to the retroversion ; that conception 
 would in all probability occur with her, and that the 
 j)regnancy would go to its full term, provided the uterus 
 was kept in its normal position, till it got large enough 
 to rise above the brim of the pelvis. On this assurance 
 the offer of marriage was accepted ; and in two months 
 my patient was ready for its fulfilment. 
 
 Having adjusted an instrument to hold the uterus in 
 proper position, and having instructed her in its man- 
 agement, the wedding day was fixed at the time she 
 expected to finish the menstrual period. The marriage 
 took place early in January, on the very day of the 
 cessation of the flow. The happy couple immediately 
 left for New Orleans, and in a month afterwards I 
 received a note from my patient saying she was undoubt- 
 edly pregnant. 
 
 As she did not wish to consult any other physician, 
 and as I was exceedingly anxious for her to pass the 
 third month without a miscarriage, I directed her to 
 wear the instrument till she quickened, and then to 
 remove it. At the full term she was safely delivered. 
 
 Now here was a case in which the husband had no 
 idea that there had ever been any uterine disease or any
 
 UTERINE DISPLACEMENTS. 
 
 279 
 
 mechanical treatment, and does not know it to this day. 
 The case is valuable as showing the protective power of 
 a normal position against the dangers of abortion. There 
 is no more common cause of abortion than retroversion, 
 if we except imprudent and excessive coition, and for 
 the simplest of all reasons. A retroverted womb is 
 impregnated ; impregnation only aggravates the mal- 
 position ; the uterus and its contents grow apace till it 
 is jammed with the fundus under the promontory of the 
 sacrum, from which it has no natural tendency to escape. 
 When it gets to the third month, it must either rise 
 above the brim of the pelvis, or throw off its contents. 
 If it fail to do the one, the other generally takes place. 
 If we do not detect the malposition, and rectify it in 
 time, a miscarriage is the almost inevitable result. I am 
 sure I have often prevented miscarriage by rectifying a 
 retroverted uterus. 
 
 Here is an example. A lady, twenty-eight years 
 old, had had two labours at full term. Afterwards she 
 had a miscarriage at the third month. She subsequently 
 became pregnant, and at the end of two months and a 
 half she was again violently threatened with all the 
 symptoms of a speedy miscarriage. I found the uterus 
 retroverted, with the cervix against the pubes, and the 
 fundus jammed under the sacral promontory. The 
 uterus was gently replaced, and a Meigs ring three 
 inches in diameter was introduced to hold it in its proper 
 position. The rectification of the malposition was imme- 
 diately followed by a relief of all uterine symptoms. 
 The instrument was worn for a month, bein^r changed 
 every three or four days. She went the full time, and 
 was safely delivered. This case serves very well as an 
 illustration of a principle, and as an example of its class. 
 The cases already narrated as exhibiting the influence
 
 280 
 
 UTERINE SURGERY. 
 
 of the pessary in facilitating conception, and, therefore, 
 in curing the malposition, were such as had conceived 
 previously. But I have frequently seen the same thing 
 in the naturally sterile. In 1858 Dr. Silas D. Scuclder, 
 then house-physician at the Woman's Hospital, found 
 amongst the out-door patients a woman married ten 
 years without issue, who was very desirous of offspring. 
 She had retroversion, but what the complications were, 
 if any, I do not know. However he fitted a malleable 
 block-tin ring to the vagina, and she conceived in two 
 months afterwards. He allowed her to wear the instru- 
 ment long enough to guard against a miscarriage (three 
 months), and she went the full term. 
 
 In 1857 a lady from the South consulted me in 
 reference to her sterility. She had been married fifteen 
 years without conceiving. Her beautiful physique and 
 fine general health were all that could be desired ; but 
 she had painful menstruation. The uterus was retro- 
 verted, and she had a fibrous tumour, as large as an 
 English walnut, in the posterior wall, while the os was 
 contracted and the cervix indurated. 
 
 The uterine sound, sponge tent, and bi-manual pal- 
 pation, showed that the enlargement a (fig. 113) was 
 
 Fig. 113. 
 
 a distinct tumour, and not a mere hypertrophy of tissue, 
 as we so often see in old retroversions. The indications
 
 UTERINE DISPLACEMENTS. 281 
 
 were the same as if there had been no fibroid tumour ; 
 viz., to enlarge the os and cervix by incision, and theu 
 to adjust an instrument to hold the uterus in situ 
 during coition. From the contraction of the os and the 
 induration of the cervix, I was satisfied that the case 
 would have been sterile even with a normal position 
 of the uterus. Besides, given a perfect state of the os 
 and cervix, the malposition would militate against the 
 probabilities of conception. Therefore the os and cervix 
 were divided bilaterally in April, 1857. The ring was 
 fitted after the next menstruation in May, and in August 
 she conceived ; but unfortunately a fall, three months 
 afterwards, in November, produced a miscarriage ; and 
 she had another miscarriage in June, 1858, at about the 
 third month. This, too, was associated with an acci- 
 dental fall. It was accompanied by great loss of blood, 
 and followed by a serious metritic inflammation, from 
 which she did not recover tor several weeks, during 
 which time she was carefully attended by Dr. Griscom, 
 of New York. As soon as she was able to leave the 
 city, we sent her to Saratoga to recuperate, and she re- 
 turned to New York in November, her general health 
 being again very good. It was now eighteen months 
 since we began to treat her case. She had had two mis- 
 carriages, which we might have attributed to the fibroid 
 tumour, if the attending circumstances had not each 
 time been sufficient to have produced the unfortunate 
 result. But the worst feature of the case was that we 
 were now precisely where we started, for the metritic 
 inflammation following the last miscarriage had repro- 
 duced the contracted puckered condition of the os, 
 which now looked as if it had never been subjected to a 
 surgical operation ; while the cervix felt, perhaps, more 
 gristly than before. What was to be done? We were
 
 282 UTERINE SURGERY. 
 
 all in a hurry for another conception. Her husband 
 could not remain much longer away from home. I pro- 
 posed to repeat the operation of incising the os and 
 cervix, to which, like a true woman, she at once assent- 
 ed, and it was done after the next menstruation. In a 
 few weeks (January, 1859), she was pronounced, fit for 
 the married, life. The os was open, and the uterus held 
 erect by a well-adjusted instrument, which, as before, 
 she was directed to wear during coition. Conception 
 fortunately occurred just after the next menstruation, 
 and we watched her most carefully during the whole 
 period of utero-gestation. She wore the instrument 
 nearly up to the time of quickening, when it was re- 
 moved altogether. ■ She now acknowledged to having 
 removed it as soon as she found out she was pregnant, 
 each time before, which doubtless had much to do with 
 the miscarriages that followed the falls. She went 
 safely the full term, and was delivered by Dr. Grrisconi, 
 of a son, on the 1st December, 1859. 
 
 We kept this patient in the horizontal position for 
 five or six weeks after confinement, with the hope that 
 a perfect involution would be effected before she re- 
 sumed the erect posture, and that the uterus might 
 stand a good chance of remaining in its proper position 
 afterwards without instrumental aid. When she left 
 for the South, two mouths after her delivery, the uterus 
 remained in a normal position ; but the best evidence 
 of a perfect cure having been effected, is afforded by the 
 fact that fifteen months after her confinement in New 
 York, she was safely delivered of twins at her home in 
 the South. 
 
 This case is interesting in many particulars :— » 
 1st. It shows, what has been observed by others, 
 and what I have seen many times before and since,
 
 UTERINE DISPLACEMENTS. 283 
 
 that a fibroid tumour does not necessarily impede 
 conception, gestation, or delivery, all other things being 
 equal. 
 
 2nd. It shows that it is possible, even in very diffi- 
 cult cases, 'to understand the obstacles to conception, and 
 to remove them by persistent continued effort, if our 
 patient has sufficient fortitude and endurance. 
 
 3rd. It shows that it is possible to cure a retrover- 
 sion, and even to cause the disappearance of a fibroid 
 by the modified nutrition of utero-gestation. 
 
 I am aware that this reiteration of cases is irksome ; 
 but, as I have said before, I write mainly for the young 
 and inexperienced ; and how am I to impress upon 
 their minds the truth of my views but by giving them 
 the facts and circumstances that have gradually led my 
 own convictions where I myself find them, without 
 any prejudices or preconceived opinions on the sub- 
 ject? 
 
 I could here detail many, very many cases like those 
 already related ; but enough has been said, and I leave 
 this part of the subject with the simple statement of the 
 above facts, which strike me as having an important 
 bearing on the subject under consideration. 
 
 It might be supposed from what I have said about 
 pessaries, that every case of retroversion is capable of 
 being rectified by an instrument. If so, let me hasten 
 to correct the error. I am sorry to say that there are 
 numbers of cases in which a pessary is absolutely out 
 of the question. In many women the vagina is so deli- 
 cately organized that it is perfectly intolerant of any 
 hard substance, and in a few, about the time of change 
 of life, it will not bear the presence of a soft sponge, 
 or even a bit of cotton. In some there is a chronic 
 metritis, which forbids mechanical means ; and in
 
 84 UTERINE SURGERY. 
 
 others peri-uterine inflammation or a prolapsed inflamed 
 ovary. 
 
 We occasionally find a retroversion conjoined with 
 an anteflexion. When this is the case, the infra-vaginal 
 cervix is almost always too long; and we often find the 
 supra-vaginal portion indurated, tender, and very sensi- 
 tive, just above the insertion of the posterior wall of 
 the vagina. In such cases it will be impossible for the 
 patient to wear a pessary, on account of its pressure 
 behind the cervix. I have not as yet amputated a cervix 
 under these circumstances, but I am very sure that it 
 would be better to do this, if we wish to treat the sterile 
 condition successfully. I have been in the habit latterly 
 of managing these obstinate cases simply by introducing 
 a plug of fine cotton, or, as it is called in Eug- 
 land, cotton-wool. I have alluded to this before, p. 
 245. 
 
 A pessary of cotton can be worn with great comfort 
 if the vagina itself is in a normal condition. In pre- 
 paring it, we must be careful not to pull the cotton in 
 pieces, but let it be one compact mass of the desired 
 size, carefully tied in the middle with a strong thread 
 for its ready removal. We may use it simply so, or 
 medicated with glycerine or tannin, or anything else we 
 may wish. If it is unmedicated, it must not be worn 
 longer than twenty-four hours. It is enough to wear 
 it while awake. If we use glycerine, we may leave this 
 tampon pessary two or three days, or till it falls out. 
 The glycerine is disinfectant, and the cotton remains 
 without odour. It is important for the convenience and 
 comfort of the patient, to teach her to apply and remove 
 the cotton pessary herself. For this purpose I have 
 invented a porte-tampon, which answers a most admi« 
 rable purpose.
 
 UTERINE DISPLACEMENTS. 
 
 285 
 
 Fig. 114 represents the porte-tampon. The requisite 
 quantity of cotton, tied in the middle with a strong 
 thread some eight or ten inches long, 
 is placed in the porte-tampon ; the lid 
 is shut; the instrument is introduced 
 like an ordinary speculum, the patient 
 on the back ; it is to be pushed firmly 
 and forcibly backwards and downwards 
 under the cervix to the posterior cul- 
 de-sac. When we are satisfied that it 
 can go no further without producing 
 pain, then the piston is to be pushed 
 forwards ; the tampon is left in its place, 
 and the instrument is withdrawn. The 
 string previously attached to the cotton, 
 hangs from the vagina, and with this 
 the tampon is removed when necessary. 
 One, and almost the only objection to 
 the cotton nowadays, is its expensive- 
 ness. Tow is much cheaper, and an- 
 swers tolerably well. I have had many 
 patients who could not remain long 
 enough under treatment to be radically 
 cured of engorgements, <fec, who have 
 gone away with a porte-tampon and 
 appropriate remedies, using it them- 
 selves, and getting well without further 
 aid. I have had a few who suffered 
 from hemorrhages that demanded the 
 tampon, and who were able to control 
 these by applying it themselves by means of this instru- 
 ment. Of course they had to charge the porte-tampon 
 four, five, or six times, fixing a string to each bit of 
 cotton. I only recommend this where the patient is far 
 
 Fkj. 111.
 
 286 UTERINE SUROERY. 
 
 removed from prompt medical aid, and where even a 
 small loss of blood is to be carefully avoided. 
 
 I have had lately under my care two most obstinate 
 cases of retroversion in which no sort of pessary could be 
 worn except cotton ; without the cotton pessary, the uterus 
 in each was turned back to an angle of more than 100° 
 from a normal line, but with this pushed snugly up into 
 the posterior cul-de-sac, the organ was comfortably sus- 
 tained in position. Each of these patients conceived 
 during the time of using this instrument. They were 
 taught to apply the tampon on rising in the morning, 
 and to remove it on going to bed at night. These are 
 the only cases in which as yet I have seen pregnancy 
 follow the use of this sort of pessary. One of them 
 was a patient of Sir J oseph Olliffe. We tried a variety 
 of pessaries, and were compelled to give up all of them, 
 and resort to the cotton pessary, and the result was as 
 stated. 
 
 A year ago, I incised the cervix uteri in a case of 
 dysmenorrhea where there was a retroversion, with 
 anteflexion, and elongation of the cervix, with indura- 
 tion and great tenderness of its posterior portion, just 
 above the insertion of the vagina. The dysmenorrhcea 
 and the engorgement of the organ were relieved ; but 
 the retroversion continued, with its attendant symptoms 
 of pain across the hips, dragging sensations, &c. On 
 account of the tenderness of the cervix when pressed 
 above the posterior cul-de-sac, it was impossible for 
 her to wear any of the instruments that I am in the 
 habit of using. But she could wear a small tampon of 
 cotton with the greatest comfort. She writes: "The 
 uterine support has, I am sure, done great things for 
 me. I now use it about every other day : last month 
 every day. My idea is that it has quite succeeded in
 
 UTERINE DISPLACEMENTS. 
 
 287 
 
 its purpose, and that I am as well as any one need 
 be. 
 
 Sometimes the broad, flat porte- 
 tampon above figured is difficult of in- 
 troduction, even in those who have borne 
 children ; and then I have been com- 
 pelled to resort to one made after this 
 fashion (fig. 115). The cotton, which" 
 must be properly prepared, is to be 
 pushed in at the open end of the instru- 
 ment, and this is to be applied as before 
 directed. 
 
 Of Procidentia. — Whenever the cervix uteri passes 
 through the mouth of the vagina, we call it a proci- 
 dentia, whether it be to a slight or a great extent. 
 Thus a procidentia may be complete or incomplete : 
 complete, when the vagina is inverted and protruded 
 externally ; incomplete, when the cervix uteri alone 
 passes down without bringing the vagina with it. It is 
 only occasionally that we see the cervix alone projecting 
 between the labia for an inch or two, and remaining 
 thus stationary for a long time ; usually it goes from bad 
 to worse, till it eventually passes entirely through the 
 vulva, forming a tumour of great size, which, at its most 
 dependent part, presents the os tincge often ulcerated 
 and bleeding. This tumour is a veritable hernial mass, 
 consisting sometimes of the whole uterus, but oftener of 
 its elongated cervix, the has fond of the bladder, and 
 occasionally intestine, with the inverted vagina as its 
 outer covering. 
 
 Fig. 116 represents an incomplete procidentia, and is 
 a type of its class. - See Dr. Beimel's case, on p. 220. 
 
 Fig. 124, p. 30.5, represents a complete procidentia, 
 and may be taken as a type of its class.
 
 288 
 
 UTERINE SURGERY. 
 
 Several separate and independent conditions must 
 conspire to produce a result so opposed to the designs 
 of nature. Thus there must always be a broad pubic 
 arch with very divergent rami and a relaxed perineum ; 
 and then the axis of the uterus must be turned back in 
 a line with that of the vagina and the pelvic outlet; in 
 other words, there must be a retroversion. With the 
 uterus anteverted, a procidentia is utterly impossible, 
 be the attendant circumstances what they may. Occa- 
 sionally we see it as a result of the abnormal pressure 
 
 ^iVl*.i>iJ. 
 
 Fig. 116. 
 
 of an irregular mass of fibroid tumours, which fill the 
 pelvis and crowd the uterus down ; but not even then 
 without the co-operating conditions above cited. 
 
 In very old cases of procidentia, the vagina, from 
 long exposure to the air, becomes dry, and assumes
 
 UTERINE DISPLACEMENTS. 
 
 289 
 
 almost a dermoid appearance. It is the opinion of 
 many, that the cervix uteri is the first in the order of 
 exit, that it always comes down, to open like a wedge 
 the parts through which the whole mass descends. I 
 cannot say, that this is not so at first, but I can with 
 the greatest confidence say that it is not so in the great 
 majority of cases, when they become chronic. 
 
 Fig. 117. 
 
 In an old procidentia, the vagina attains enormous 
 proportions, in consequence of its being constantly 
 expanded by the distending power of its hernial con- 
 tents. To observe the order of descent in a case like 
 this, reduce the parts to their normal relations, and let 
 the patient force them out again, whether in the erect 
 
 19
 
 290 UTERINE SURGERY. 
 
 posture or on the back, and we shall see the anterior 
 wall of the vagina, first forced downwards against the 
 perineum, in the form of a cystocele ; a slight straining 
 pushes this beyond the vulva, and the cervix follows 
 immediately, bringing down the posterior wall of the 
 vagina. If we would reduce a procidentia with ease, we 
 must invert this order ; push back the posterior cul-de- 
 sac first ; then the cervix ; and then the anterior wall of 
 the vagina and bladder follow as a matter of course. 
 
 Fig. 117 is from a photograph of a patient of Dr. 
 Thierry-Meig, in Paris, and represents a cystocele as 
 the first stage of procidentia. By a little effort she 
 could effect its complete protrusion. She is a Grerman, 
 twenty-three years of age, the mother of three children, 
 the youngest being five months old. She is a street- 
 sweeper, and has had procidentia ever since her last 
 confinement. Besides this she has haemorrhoids, as seen 
 in the cut. 
 
 Sometimes we find the intra- vaginal cervix elongated, 
 but oftener the supra- vaginal. Occasionally we see a 
 complete descent of the whole uterus through the vulva. 
 However, I have met with but few cases of this sort. 
 One of these was shown to me by Dr. Chepmell, of Paris. 
 It was the case of a maiden lady, some forty years old, 
 who had been subject to it for twelve or fifteen years, 
 and often suffered greatly from retention of urine, and 
 the other ordinary attendants of this affection. The 
 doctor tells me that he has repeatedly found the proci- 
 dentia girdled by an ulcerated sulcus at its neck, and 
 seemingly bordering upon the verge of sphacelus, in 
 consequence of its obstructed circulation. Its great 
 peculiarity consisted in the fact that the uterus was but 
 one inch and a half deep. Many eminent medical men 
 had seen the case before, and were of opinion that the
 
 UTERINE DISPLACEMENTS. 291 
 
 utero-cervical canal was obstructed at this depth by 
 some mechanical barrier that prevented the further pas- 
 sage of the probe ; but we were able to settle this point 
 very easily, by palpation alone, while the uterus was in 
 the pelvis-; and when it came down, it passed entirely 
 through the vulva, and we could easily grasp it between 
 the two hands, by passing the index-finger of one hand 
 into the rectum, and hooking it forwards over the 
 fundus, while pressure was made by the other on the 
 front of the tumour, just below the urethra. Indeed we 
 could even tilt the fundus downwards and backwards 
 across the long axis of the procidentia ; and this move- 
 ment gave us great facility in diagnosing the contents 
 of this great hernial protrusion, which consisted of 
 intestine as well as of uterus and bladder. In this case 
 the vagina was immense, the perineum greatly relaxed, 
 and the pubic rami unusually divergent. 
 
 But while we only occasionally find a procidentia 
 thus associated with a uterus, under or even of normal 
 size, we often find it where there is hypertrophy of some 
 part of this organ. For instance, there may be hyper- 
 trophy of the cervix, or merely elongation of its intra- 
 vaginal portion, or of the supra-vaginal portion ; if the 
 former, the body of the uterus may be of normal pro- 
 portions ; if the latter, it is more apt to be hypertro- 
 phied. And sometimes the cervix is elongated in its 
 two segments, both infra and supra-vaginal. 
 
 In these cases of cervical elongation, we often find 
 the utero-cervical canal four and five inches deep ; the 
 supra-vaginal portion of the cervix being slender, atte- 
 nuated, and, when examined per rectum, feeling not larger 
 than the finger. This elongation is evidently secondary. 
 I believe it to be a sequence of the procidentia, for we 
 are more apt to find supra-vaginal elongation where the
 
 900 UTERINE SURGERY. 
 
 £i %1 *J 
 
 fundus uteri is from some cause or other too large to 
 pass out of the pelvis. If the body of the uterus passes 
 out of the pelvis, there is no supra- vaginal elongation; 
 if not, there is ; and for the simplest reason. Suppose 
 the cervix uteri projecting through the vulva, the fundus, 
 from some cause, cannot follow, but remains fixed, as it 
 were, within the pelvis by hypertrophic or fibroid 
 enlargement ; the cervix once through the vulva, pres- 
 sure around it from above soon pushes down the two 
 culs-de-sac, resulting in a de facto hernia. This gets 
 larger and larger, and the uterus retained in the pelvic 
 cavity becomes one of the principal points of support 
 for this mass, which hangs by the cervix, and the cervix 
 consequently becomes not hypertrophied but attenuated 
 and elongated, feeling like a mere cord, not more than 
 half its normal size. And this elongation is gradually 
 produced by these two antagonistic forces ; one acting 
 on the body of the uterus to retain it in the pelvic 
 cavity, the other on the lower end of the cervix, to push 
 it downwards. 
 
 When the procidentia is due to a mass of tumours 
 filling the pelvic cavity, and crowding the uterus down- 
 wards, as I have seen in several instances, we cannot, 
 I regret to say, promise much relief. 
 
 Fig. 118 represents a procidentia of more than twenty 
 years' standing, in a woman nearly seventy years of 
 age, whose pelvis was filled with a number of small 
 fibroids of bony hardness. One large tumour is not so 
 apt to produce procidentia as several smaller ones, 
 say from the size of an orange to that of the fist, 
 loosely bound together; because the single one may 
 grow large enough to rise above and rest upon the 
 brim of the pelvis, while the smaller ones accommo- 
 date themselves to the pelvic cavity, displacing what-
 
 UTERINE DISPLACEMENTS. 
 
 293 
 
 ever may interfere with their develornnent. The above 
 was the largest hernial procidentia I have ever seen. 
 It reached nearly half-way down the thighs, and con- 
 tained a large quantity of intestine. When it was 
 reduced She felt less comfortable than when it pro- 
 truded. On this account no effort was made for its 
 relief. 
 
 Huguier has written extensively on procidentia 
 
 Fig. 118, 
 
 uteri, find I believe he was the first to point out the 
 distinctive characteristics of its anatomical peculiarities. 
 He found elongation of the cervix in all cases, either 
 above or below the insertion of the vagina; and he 
 suggested and performed amputation of the neck of 
 the uterus in every case, and with great success. For
 
 294 
 
 UTERINE SURGERY. 
 
 special information in regard to his views, I must refer 
 the reader to his memoir.* 
 
 I amputate the cervix only when its lower segment 
 is too large or too long, and projects so far into the 
 vagina as to present a mechanical obstacle to the 
 retention of the uterus in situ when replaced. This 
 will be sufficient in some cases, such as that met with 
 by Dr. A. K. Gardner, of New York, who amputated 
 a cervix weighing §iv. 3 1 j - 3ij., which is, perhaps, "the 
 largest on record as having been removed during life."f 
 Dr. Gardner says, "The organ drew up far into the 
 vagina after the portion was removed, and in order to 
 arrest a persistent haemorrhage it was necessary to draw 
 it down into view with hooks." Of course all such 
 cases as this are readily cured by amputation, and, as a 
 rule, it is the only thing to be done. But this is nob a 
 type of the great class of cases that w r e are called upon 
 to treat. If there should be elongation of the infra- 
 vaginal cervix, amputation is the remedy ; but we often 
 find procidentia without any extraordinary elongation 
 of the infra-vaginal portion of the cervix. There is then 
 nothing to amputate. ■ 
 
 In these cases Mr. Baker Brown, Dr. Savage, and 
 others, contract the vulvar outlet by the perineal opera- 
 tion ; but generally I prefer to narrow the vagina above, 
 which usually very effectually retains the uterus in some- 
 thing like a normal position within the pelvis. 
 
 * " Memoire sur les Allonge ments hypertrophiques du Col de 1' Uterus 
 dans les Affections designees sous les noms de Descente, de Precipitation 
 de cet Organe, et sur leur traitement par la resection, ou 1 amputation de la 
 totalite du Col, suivant la variete de la Maladie." Par P. C. Huguier, 
 Membre de l'Academie Imperiale deMedecine, &c. Paris: J. B. Bailliere et 
 Fils. 1860. 
 
 t "Amputation of the Cervix Uteri." By A. K. Gardner, M.D , Pro£, 
 &c. &c.
 
 UTERINE DISPLACEMENTS. 095 
 
 The idea of narrowing the vagina is by no means 
 new. I suppose we may justly claim it for the great 
 Marshall Hall. However I do not think the operation 
 ever succeeded till my own day, — and this success is 
 due wholly to metallic sutures. 
 
 I propose now to give a brief sketch of the steps by 
 which we arrived at the method of operating herein 
 advocated. 
 
 In 1856, Dr. Warren Stone and Dr. Axson, of New 
 Orleans, referred a patient of theirs to my care, who 
 had had procidentia for three years. She was about 
 thirty years of age, tall, slender, and bony, and had 
 enjoyed good health till the yellow-fever epidemic of 
 1853, in New Orleans. The labour, lifting, and fatigue 
 which she underwent as a nurse during that terrible 
 epidemic left her with a double inguinal hernia and a 
 complete procidentia uteri. I have seldom seen a more 
 distressing case. She wore a double truss for the 
 hernial protrusions ; and, for the procidentia, the largest 
 globe-pessary that I ever saw. But notwithstanding the 
 immense size of the globe, which was nine inches in cir- 
 cumference, it was impossible for her to retain it in the 
 vagina by any bandage ; so it was constantly slipping 
 away, and that too at rather inopportune moments. I 
 arranged a pessary with a stem and a " ' bandage, which 
 kept the parts within the pelvis. In the course of two 
 months she had regained some 25 pounds of flesh, and 
 was on the eve of returning home harnessed up with 
 trusses and bandages to a most uncomfortable degree, 
 when I happened to ask her if she would be willing to 
 submit to a surgical operation, if we could promise to 
 get rid of the pessary and its bandage. She promptly 
 replied, "Yes." 
 
 Previously to this we had been in the habit of per-
 
 29Q UTERINE SURGERY. 
 
 forming the perineal operation after the plan of Mr. 
 Baker Brown, and for some reason we had not been 
 successful. Dr. Emmet and myself both thought that 
 we could hardly promise any better success by it in this 
 case than we had formerly met with. This was the first 
 time that I had had a good opportunity of observing 
 and studying the manner in which the procidentia 
 occurred. After replacing it and allowing it to descend 
 again, which always occurred very quickly on assuming 
 the erect posture, I noticed, as before described, that the 
 descent was not at first by the protrusion of the cervix 
 uteri, but invariably by a prolapse of the anterior wall 
 of the vagina, which always preceded the cervix, and 
 drew down the uterus. I found that this cystocele was 
 but another hernia (she had double inguinal hernia), 
 and I discovered that she could not force it down again, 
 when simply the point of the index finger was held in 
 the auterior cul-de-sac. Then by pinching up the ante- 
 rior wall of the vagina into a longitudinal fold, with two 
 tenacula or a pair of forceps, I saw that the parts had 
 no tendency whatever to come down ; and that it was 
 impossible for our patient to force them down if we thus 
 prevented the anterior wall of the vagina from descend- 
 ing. Hence the idea of wholly removing the redundant 
 portion of the anterior wall of the vagina occurred to 
 me ; but it did not occur to me to operate simply by 
 removing strips of vaginal mucous membrane. I seri- 
 ousty proposed to this lady to make a complete vesico- 
 vaginal fistula, by removing at once, as it were, a large 
 portion of the base of the bladder with the anterior wall 
 of the vagina. She agreed to it ; and I laid the plan of 
 operating before the Consulting Board of the Hospital, 
 and it was adopted. The vagina and its outlet were 
 enormous. When the patient was placed on the knees,
 
 UTERINE DISPLACEMENTS. 
 
 297 
 
 or on the left side, with the perineum elevated by the 
 speculum, it presented about the relative proportion 
 shown in fig. 119. The measurements made repeatedly 
 by Dr. Emmet and myself, gave the following propor- 
 
 FiG. 119. 
 
 tions. From the meatus urinarius to the perineum, 
 a to Z>, when this was pulled back by the speculum, 
 was three inches ; from the meatus urinarius to the pos- 
 terior cul-de-sac, a to <?, five inches and a quarter ; 
 broadest transverse diameter, four inches and a quarter ; 
 broadest antero-posterior, d to e, three inches and a half. 
 Proposing to excise the anterior wall of the vagina, 
 I hooked it up with a tenaculum at c/, pulled it Avell 
 towards the posterior wall, 6, and then grasped the base 
 of the mass thus elevated with a pair of curved forceps 
 made for the purpose, on the principle of Record's phy- 
 mosis forceps, which held the parts firmly embraced, 
 while with scissors cutting under the forceps I removed, 
 at once, a very large portion of the anterior wall of the 
 vagina. The portion removed measured two inches and 
 a half transversely, by two inches and five-eighths longi- 
 tudinally, and was very thick. The chasm made by 
 this operation was fearful ; the lateral retraction of the
 
 298 
 
 UTERINE SURGERY. 
 
 divided edges being so g^eat as to present at a superficial 
 glance some difficulty in bringing them together by 
 sutures. There was, however, no trouble whatever. 
 Fig. 120 would represent a side view of one blade, 
 
 Fig. 120. 
 
 a, of the forceps, as it grasped the portion <?, to be 
 removed. The bleeding was not profuse ; but I at once 
 rapidly filled the chasm with cotton, to stop the hsenior- 
 rhage by pressure. A few minutes sufficed for this ; 
 and then the tampon was removed for the purpose of 
 closing the edges of the opening by transverse sutures. 
 My surprise was equalled only by my delight, when I 
 found that I had not succeeded in doing what I intend- 
 ed ; for instead of excising the base of the bladder with 
 the anterior wall of the vagina, I had, by the tenacu- 
 lum, simply raised the hypertrophied vaginal tissue up 
 between the blades of the forceps, luckily separating 
 it from the lining membrane of the bladder, which 
 remained intact. Thus by a mere accident, the opera- 
 tion was really far better than if I had succeeded in 
 accomplishing what theoretically I proposed to do. 
 
 Fig. 121 would represent about the relative propor- 
 tion of vaginal tissue here removed. The lateral edges
 
 UTERINE DISPLACEMENTS. 
 
 299 
 
 were brought together longitudinally by seven or eight 
 silver sutures passed transversely, as represented in the 
 diagram. She was soon well, and is so to this day. 
 The operation was done nine years ago. The good 
 
 result in this case led me to operate on others after- 
 wards, by a simple denudation of the vaginal epithelium 
 to the same extent as shown above. One great objec- 
 tion to this method was, that the necessarily tedious 
 scarification permitted the loss of too much blood ; 
 another was the danger of an abscess forming in conse- 
 quence of the central part of the scarified portion not 
 being closely embraced by the sutures. For instance, it 
 will be seen by reference to the diagram, that when the 
 sutures were closed, bringing the outer edges into 
 apposition, the central portion of denuded tissue not 
 included by them would necessarily be thrown into a
 
 300 UTERINE SURGERY. 
 
 fold that would project the mucous membrane of the 
 bladder into a sort of longitudinal ridge along the has 
 fond. I was at first afraid that this loose tissue might 
 not be held firmly enough together to unite by the first 
 intention; and in one instance an abscess formed that 
 gave rise to some constitutional disturbance. But its 
 nature and seat being detected, the removal of a suture 
 at the upper angle of the wound, near the cervix uteri, 
 promptly evacuated the matter, and relieved all suffering. 
 However, this method of operating was continued till 
 1858, when an elderly woman, with an enormous pro- 
 cidentia of fifteen or twenty years' standing, was sent 
 to the Woman's Hospital, by Dr. Duane, of Schenec- 
 tady. It was a very bad case indeed. I operated by 
 the plan of simple denudation of the mucous mem- 
 brane over a surface extending from the neck of the 
 bladder to the neck of the uterus, and being two 
 inches and a half in its largest transverse diameter; 
 the lateral edges were united by silver sutures, and 
 the parts healed kindly. But I did not remove 
 tissue enough, and there was a considerable cystocele 
 left. 1 felt pretty sure that the original trouble 
 would be reproduced, unless she should wear con- 
 stantly some sort of a pessary. Accordingly I fitted 
 one, and sent her home in a very comfortable condition. 
 I was quite satisfied, and so was my patient; but when 
 she got home, the physician who had had charge of her 
 case before she consulted Dr. Duane, ridiculed the idea 
 of her being cured by a surgical operation, if it were 
 necessary for her still to wear an instrument afterwards. 
 Although she was perfectly comfortable, she returned in 
 two or three months, and asked to be readmitted to the 
 Hospital. She said she wished simply to prove to her 
 physician at home that she could be cured by an
 
 UTERINE DISPLACEMENTS. 
 
 301 
 
 operation, so as not to be compelled to wear a pessary. 
 Her pluck challenged my inventive faculties, and then 
 it was that I devised another method of operating. 
 For instance, instead of the broad scarification of the 
 anterior wall of the vagina, as before, I simply removed 
 the mucous membrane in the form of a V (fig- 122, 
 a £), the apex being near the neck of the bladder, and 
 
 Fig. 122. 
 
 the two arms extending up on the sides of the cervix 
 uteri. These two denuded surfaces were brought 
 together by silver sutures passed transversely, thus 
 making a longitudinal fold narrowing the vagina and 
 crowding the cervix backwards. This simple operation 
 was thus repeatedly performed, and always successfully, 
 by Dr. Emmet and myself, at the Woman's Hospital, 
 from 1858 to 1862, when I left New York. 
 
 In Paris I had occasion to perform it for Sir Joseph
 
 302 
 
 UTERINE SURGERY. 
 
 Olliffe on an old lady sixty-five years of age, who had 
 had procidentia for twenty years. The parts united ; 
 the uterus was held in its place, and she returned home 
 in a fortnight. Her general health was very feeble, in 
 
 Fig. 123. 
 
 consequence of a long residence in India; and in two 
 months the whole cicatrix gradually gave way, and the 
 procidentia was reproduced. This was the first and 
 only case of failure that I had ever seen after this 
 method. The operation was subsequently repeated ; 
 but this time, instead of a V" sna P e d scarification, it was 
 made in the form of a trowel, as represented in fig. 123, 
 the point presenting below, the shoulders above in the 
 anterior cul-de-sac. The denuded surfaces a c and b d 
 were brought together by transverse silver sutures. A 
 small portion of tissue was left undenuded at e, between 
 c and d, for the purpose of permitting the escape of '
 
 UTERINE DISPLACEMENTS. 3(3 
 
 any secretions naturally forming in the shut pouch 
 
 Although she is an opium-eater, and frequently has 
 attacks of diarrhoea, in consequence of its inordinate use, 
 as we often see, the operation was successful, and the 
 uterus still remains in its normal position. This last 
 operation was performed with the assistance of Sir 
 Joseph Olliffe and Dr. Johnston, of Paris, and Professor 
 Pope, of St. Louis. 
 
 Dr. Emmet* has recently called attention to a source 
 of trouble when the operation is performed by a simple 
 V-shaped denudation, as shown in fig. 122. He says, 
 " Previous to the time of Dr. Sims's removal to Europe 
 in 1862, we both had operated frequently without the 
 necessity for any modification occurring. 
 
 "In September, 1862, after three months of great 
 suffering, one of the first patients operated on by Dr. 
 Sims in this manner, presented herself at the Hospital, 
 for relief. She stated that, during four years, she had 
 been entirely relieved by the operation, when, suddenly 
 (while in the act of lifting) she was seized with a 
 persistent tenesmus, greatly aggravated in the upright 
 position. 
 
 " On examination, the line of union was found per- 
 fect, with no prolapse of the vaginal wall. But the 
 neck of the uterus had slipped behind the septum into 
 the pouch, thus throwing the fundus into the hollow of 
 the sacrum, and fixing the organ in this position. With 
 great difficulty, the neck was disengaged. On returning 
 the uterus to its normal position, immediate relief was 
 
 * New York Medical Journal, vol. i., No. I. April, 1865. " A Radical 
 Operation for Procidentia Uteri." By Thomas Addis Emmet, M.D., Surgeon 
 to the Woman's Hospital.
 
 304 UTERINE SURGERY. 
 
 obtained, aud she was discharged without further treat- 
 ment." This case was subsequently operated upon by 
 Dr. Emmet. 
 
 After this, Dr. Emmet hunted up two patients upon 
 whom he had operated eighteen months before, and he 
 found the uterus retro verted in each one, with the cervix 
 resting behind the pouch made by bringing together the 
 two denuded surfaces a b, fig. 122. To remedy this 
 defect, in his subsequent operations he simply denuded 
 the vaginal mucous membrane in a line across the cul- 
 de-sac between these two points, as shown by the dotted 
 line <V%- 122, making a regular triangle with its apex 
 at the neck of the bladder, and base at the cervix uteri. 
 In January, 1864, Dr. Emmet operated on a very unruly 
 patient, who, during the night after the operation, "got 
 up and walked about the ward for several hours, and 
 continued, in spite of all remonstrance, to follow her 
 own inclination. On the twelfth day, it was discovered 
 that four sutures (near the neck of the bladder) had 
 torn out, and through the gap a portion of the relaxed 
 base of the bladder protruded. The sutures were all 
 removed at the time, and every hope of success aban- 
 doned. Before her discharge, it was found on examina- 
 tion that the entire line of union had gradually parted, 
 with the exception of the cross scarification, in front of 
 the cervix uteri. The fold thus formed (as in a sling) 
 had retained the organ perfectly in place, although 
 below, a cystocele existed. Future experience must 
 demonstrate how far the formation of this fold can alone 
 be relied on under other circumstances ; yet it is evident 
 that in many cases this will prove all that is necessary to 
 retain the uterus in situ." 
 
 It is always interesting to watch the slow degrees by 
 which true principles of treatment are established. The
 
 UTERINE DISPLACEMENTS. 
 
 305 
 
 idea of narrowing the vagina for the cure of procidentia 
 was first suggested by Marshall Hall, but I do not know 
 that the operation ever succeeded. Then I carried out 
 the principle by cutting away the whole of the redun- 
 
 fjA 
 
 gOL/PZ* 
 
 Fig. 124. 
 
 dant portion of the anterior wall of the vagina (fig. 120). 
 This I afterwards modified by simply denuding a large 
 oval surface on the anterior wall, and uniting its lateral 
 edges by silver sutures. This was further modified by 
 making a ^-shaped scarification (fig. 122), and produc- 
 ing a veritable fold in the wall of the vagina. Then I 
 made the TJ trowel-shaped, by turning its upper ends 
 inwards across the axis of the vagina, in Sir Joseph 
 Olliffe's case, fig. 123. Then Dr. Emmet made 
 this a complete triangle, and eventually an accident 
 showed him that merely a narrowing of the vagina just
 
 306 
 
 UTERINE SURGERY. 
 
 at the anterior cul-de-sac, at least in one case, answers 
 every purpose of holding the uterus in its place. 
 
 The mechanical execution of this operation is a matter 
 of some nicety, but it is by no means difficult. Suppose 
 we have such a case as the one represented in fig. 124, 
 which may be taken as a type of its class ; we wish to 
 narrow the vagina to keep the parts in their normal 
 relations. We would suppose, a priori, that the opera- 
 tion could be done more easily and exactly with the 
 uterus thus protruded ; but it is a great mistake. The 
 uterus must first be restored to its proper position, and 
 if the os tinca3 is ulcerated, as here represented, or if 
 the vagina is dry, scaly, and skin-like, it will be well to 
 apply glycerine on a tampon of cotton, for a few days, 
 till the ulcerations are healed and the vagina assumes 
 more of a normal appearance ; after which 
 the operation may be performed. For 
 this purpose, the patient is to be placed 
 on the left side, as so often before de- 
 scribed, with my speculum introduced to 
 pull back the perineum and posterior wall 
 of the vagina. We can then get an 
 accurate idea of the dimensions of the 
 over-distended vagina, and with a small 
 tenaculum hooked into the mucous mem- 
 brane on each side of the middle line of 
 the anterior wall, we can approximate 
 these surfaces, and thus determine whether 
 we should make the denudation of tissue 
 to a greater or less extent on either side. 
 There was at first some little trouble in 
 making the two arms of the V equilate- 
 ral ; sometimes one would diverge a little 
 more from the median line on one side than the other 
 
 Fig. 125. 
 
 i •
 
 UTERINE DISPLACEMENTS. 
 
 307 
 
 but this was overcome by using an ordinary malleable 
 uterine sound curved as represented in fig. 125. Its 
 convexity rests centrally along the middle line of the 
 anterior wall, the distal end pushes back the cervix uteri, 
 while the counter-curvature lies in contact with the ure- 
 thra. By thus pushing the neck of the uterus back in a 
 straight line, while the anterior wall is depressed cen- 
 trally, the curvature of the sound is hidden from view by 
 the lateral folds of the vagina, which fall over it and meet 
 in the middle line, showing us exactly where the tissue 
 is to be removed for the purpose of uniting the parts 
 that thus so naturally and easily come together. With 
 the parts thus held, it is very easy to denude two sur- 
 faces a third of an inch wide or more, extending, seem- 
 ingly, almost in parallel lines from the neck of the blad- 
 der upon each side of the cervix uteri. To make the 
 transverse line of denudation join the upper ends of these 
 two arms of the V, we remove the curved sound and 
 pull the cervix downwards with a small tenaculum. 
 
 Fig. 126. 
 
 We must be careful not to make the arms of the V too 
 divergent, and at the same time we must avoid running
 
 308 UTERINE SURGERY. 
 
 tliem too closely together. They should, when united 
 by sutures, relieve the cystocele without putting the 
 parts too much on the stretch. The sutures are, of 
 course, to be passed transversely, beginning below, as 
 represented in fig. 121. The sound is to be retained, 
 pushing the uterus backwards till we come to pass those 
 near the cervix uteri. These should be made to em- 
 brace all the denuded tissue, a d. excluding: the unde- 
 nuded portion e (fig. 123). I think it very important 
 to leave a drain here, as before said, for the discharge 
 of the normal secretions of the pouchy. 
 
 Fig. 126 represents the speculum in position, and the 
 curved sound pushing back the cervix and depressing 
 the anterior wall of the vagina. 
 
 Dr. Emmet bends the end of the sound into the form 
 of a ring, to fit around the cervix uteri. Sir Joseph 
 Olliffe suggested the same thing to me when I operated 
 on his case in Paris, but instead of this I have had simply 
 a little tenaculum fork at the end of the instrument 
 (fig. 125), to be hooked into the mucous membrane, just 
 at the junction of the anterior cul-de-sac and the vagina. 
 This answers the purpose of fixing the cervix during the 
 whole time of the operation, for it is to be retained, as 
 represented in the figure, till we come to close up the 
 sutures. Indeed, the sutures are all to be drawn closely 
 before we remove it. 
 
 Fig. 127 represents the instrument superficially 
 transfixing the mucous membrane, as above described, 
 pushing the cervix backwards and depressing the ante- 
 rior w T all of the vagina, which rolls over it in voluminous 
 folds, forming a deep central sulcus, along the borders 
 of which the denudation is to be made, and which should 
 be more or less divergent, according to the peculiarities 
 and necessities of the individual case.
 
 UTERINE DISPLACEMENTS. 
 
 309 
 
 When the operation is finished, the patient is to be 
 put to bed, the bowels are to be constipated for a week, 
 with a dose or two of some form of opium in the twenty- 
 four iiours ; the bladder is to be emptied by catheter 
 
 \ 
 
 Fig. 12T. 
 
 when needed, for two or three days, and the recumbent 
 posture is to be enjoined for two or three weeks. The 
 lower sutures may be removed in eight or ten days ; the 
 upper should remain a fortnight, unless there is some 
 special reason for their earlier removal. The patient is 
 usually discharged at the end of a month from the time
 
 310 UTERINE SURGERY. 
 
 of the operation, sometimes sooner. I consider this 
 operation one of the safest in surgery. I never saw any 
 serious accident from it, and never saw it fail but once, 
 and that was in the case of Sir Joseph OllifiVs patient 
 (page 302), who was subsequently cured. I have 
 operated repeatedly on patients over sixty, and on two 
 that were seventy years of age. 
 
 Sometimes, as in cases complicated with rectocele, it 
 is necessary to narrow the posterior wall of the vagina, 
 as well as the anterior. If so, I prefer to make two 
 operations, allowing a period of six or eight weeks to 
 intervene between them. 
 
 It is not my intention to draw a parallel between 
 this and the perineal operation for procidentia. I only 
 wish to add another resource to our means of permanent 
 cure in this distressing affection. I may state, however, 
 that I was first driven to the expedient of working out 
 this process in consequence of repeated failures of the 
 perineal operation in my hands : not that the operation, 
 as such, ever failed, but that the new perineum made by 
 it often gave way, in consequence of the persistent pres- 
 sure of the parts above. So far as mere surgical resources 
 are concerned, we have now three processes from which 
 to choose ; always, of course, adapting this choice to the 
 peculiar exigencies of the case. 
 
 1st. Amputation of the cervix according to the plan 
 of Huguier, when its infra-vaginal portion is too long. 
 I have often seen procidentia cured by this alone. 
 The case of Dr. Bennett, related on page 220, is an 
 example. 
 
 2nd. The perineal operation, as performed by Mr. 
 Baker Brown, Dr. Savage, and others. 
 
 3rd. The operation of narrowing the vagina by the 
 trowel or triangular-shaped denudation on its anterior
 
 UTERINE DISPLACEMENTS. 31 \ 
 
 wall, as herein illustrated, and as performed by Dr. 
 Emmet and myself. 
 
 But we occasionally meet with those who are so ill- 
 advised as to object to any surgical operation whatever. 
 What then are we to do ? Meigs's ring and Hodge's 
 lever utterly fail to do any good whatever; globes, disks, 
 and inflated air-bags all fall out ; and Zwang's pessary is 
 the only mechanical apparatus that promises any benefit ; 
 and in old women this cannot be tolerated on account 
 of the excessively delicate condition, after change of 
 life, of the vaginal mucous membrane ; for as life 
 advances, the vagina becomes more aud more intolerant 
 of any foreign substance. Under these circumstances, 
 the best pessary is simply a small tampon of cotton, wet 
 with glycerine, which may be introduced in the morn- 
 ing, to be worn all day. With the porte-tampon, figured 
 on page 285, it is easy enough for the patient to do this 
 every day for herself. 
 
 In April, 1865, Dr. Johnston, of Paris, asked me to 
 see a case of procidentia, in a French laundress, about 
 forty years of age, where there was an enormous hyper- 
 trophy of the cervix uteri (two inches in diameter), due 
 to the development of numerous little cysts in its sub- 
 stance, varying from the size of a grain of wheat to that 
 of a garden pea. Some fifteen or twenty of these were 
 opened, discharging a ropy honey-like fluid ; the uterus 
 was then replaced, and a tampon of cotton wet with a 
 solution of tannin in glycerine was applied. This dress- 
 ing was repeated every other day for a month or two, 
 when she became so comfortable that she did not 
 desire the operation for a radical cure. When she 
 stops the use of the tampon, the uterus descends on 
 lifting a heavy weight or taking a long walk, but 
 she can now protect herself perfectly against this
 
 312 UTERINE SURGERY. 
 
 accident by applying the cotton pessary with the 
 porte-tampon. 
 
 In 1853, Professor Fordyce Barker, of the Belle vue 
 Hospital Medical College, wrote a paper on the treat- 
 ment of procidentia by the use of tampons wet with a 
 solution of tannin. Considerable success attended this 
 method in his hands, but it seemed to fall into disuse. 
 Perhaps the porte-tampon, as in the case above, may 
 assist to re-instate the practice. When patients will not 
 submit to a radical operation, I have no doubt that this 
 plan may answer a good purpose, even if it does not 
 cure the case permanently. 
 
 I had the honour of presenting a paper on Prociden- 
 tia at the November meeting (1865) of the Obstetrical 
 Society, which formed the basis of an extended discus- 
 sion. At this meeting, Mr. Spencer Wells called my 
 attention to the fact, that Marshall Hall's idea of nar- 
 rowing the vagina was put into execution by the late 
 Mr. Heming, and that at least one case had been success- 
 fully operated upon. The report of this case may be 
 found in Heming's translation of Boivin and Duges 
 (1834), page 53, and is dated November, 1831. It 
 affords me pleasure to make this correction.
 
 SECTION VI. 
 
 THE VAGINA MUST BE CAPABLE OF RECEIVING 
 AND OF RETAINING THE SPERMATIC FLUID.
 
 SECTION VI. 
 
 THE VAGINA MUST BE CAPABLE OF RECEIVING AND OF 
 RETAINING THE SPERMATIC ELUID. 
 
 We here propose to pass in review the usual obstacles 
 to the introduction of the semen, and then the condi- 
 tions that prevent its retention or sojourn in the vagina. 
 For it is not enough that the semen be deposited in the 
 vagina ; it must not be immediately ejected. 
 
 What, then, are the ordinary obstacles to its intro- 
 duction? They are mostly anatomical or mechanical, 
 and may be arranged under the following heads : 
 
 1st. The hymen may be imperforate or nearly so. 
 
 2nd. There may be vaginismus ; i. e. hymeneal 
 hyperesthesia with a spasmodic contraction of the 
 sphincter vaginae. 
 
 3rd. There may be atresia of the vagin? 
 
 4th. The vagina may be wanting. 
 
 1. Our medical literature contains the history of 
 many cases in which the hymen was so tough as to 
 resist all reasonable efforts at penetration. And very 
 many in which it has been found completely occluded, 
 with retention of the menstrual flow. It is a little sin- 
 gular that I have never met with an example of either 
 of these conditions. 
 
 All the cases of impenetrable hymen that I have 
 seen were examples of vaginismus, where the obstruc- 
 tion was not in the mere resisting power of this mem- 
 brane, but in a spasm of the sphincter muscle, the result 
 of the irritable condition of the hymen.
 
 316 UTERTNE SURGERY. 
 
 Where the hymen is hermetically sealed up with a 
 retention of the menses, it is easy enough to open it and 
 evacuate the imprisoned secretion by a "crucial incision," 
 as it is termed. 
 
 It is against this " crucial incision " that I would 
 seriously warn the inexperienced ; as, simple as the ope- 
 ration is, it is fraught with great danger, — not per se, but 
 in the consequence of a rapid evacuation of the retained 
 fluid. Whenever it is necessary to perform an operation 
 for retained menses, whether it be on the hymen, the os 
 uteri, or at any point along the vagina between the two, 
 it should always be done by a simple puncture with an 
 exploring needle, leaving the gradual evacuation of the 
 flood to nature and to time. The object of this is to 
 allow the uterus time to contract as its contents slowly 
 ooze away This is a matter of importance only where 
 there is a considerable amount of fluid. If there is not 
 more than an ounce or two, I do not think it makes any 
 difference whether we evacuate it suddenly or slowly. 
 
 The probable amount of fluid may be estimated 
 simply by palpation, which determines with sufficient 
 accuracy the size of the uterus with its contents. 
 
 If the uterus be but slightly enlarged by the retained 
 fluid, we may open it fearlessly ; but if it approach the 
 size of the foetal head, we should do it with the greatest 
 caution. 
 
 Death has often speedily followed an incision of the 
 hymen, where there was retention of the menses. Of 
 course, the mere wounding of the hymen has nothing 
 whatever to do with the fatal result, which seems to be 
 due to pyaemia. Some think that this is caused by the 
 admission of air into the cavity of the uterus, which, 
 having been over-distended, fails to contract as rapidly 
 as the fluid is evacuated. At the Woman's Hospital we
 
 VAGINISMUS. 
 
 317 
 
 have had repeatedly to evacuate large quantities of 
 retained menses, and we have never seen any accident 
 follow. All our cases were the result of atresia of some 
 part of the vagina, or of the os tincse. One only was 
 seemingly idiopathic, the others the result of sloughing 
 from difficult labour. 
 
 We have always punctured the occluded portion with 
 an exploring needle, or made a very small opening with 
 the tenotomy knife usually found in our pocket cases ; 
 and, knowing the dangers of the operation, I must again 
 insist on this point. If I had now to operate on the 
 hymen of a delicate young woman, whose uterus and 
 vagina held six or eight ounces of fluid, I would give her 
 ergot till its specific action was produced on the uterus, 
 and then make a small puncture in the hymen ; and 
 this for the purpose of insuring uterine contraction 
 while the fluid was bein^ evacuated. I cannot do better 
 than to quote here Dr. Graily Hewitt, the latest and one 
 of the best authorities on the diseases of women.* — " The 
 plan ordinarily adopted has been, by means of a lancet, 
 or bistoury, or trochar, to make an opening in the hymen 
 sufficient to allow of the escape of the chief part of the 
 retained blood at once, and at the time of the operation. 
 I would suggest that an opening just large enough to 
 allow of the escape of a very minute quantity of fluid 
 be made at first, and that this opening should be made 
 obliquely in the obstructing membrane, giving it a 
 valvular character. The fluid should be evacuated gut- 
 tatim. If the opening become closed, a second and 
 similar opening to be made the following day, or two or 
 three days later, and a firm but gentle support given to 
 
 * " The Diagnosis and Treatment of the Diseases of Women." By 
 Graily Hewitt, M.D., &c, &c. London. 18G3.
 
 318 UTERINE SURGERY. 
 
 the abdomen by the aid of a bandage during the whole 
 period of the evacuation of the fluid ; the patient to be 
 kept in a state of absolute rest. The aperture in the 
 hymen should not be increased in size until the uterus 
 has returned to its proper dimensions, the object-being, 
 at first, simply to allow the fluid to escape in the most 
 gradual manner possible." 
 
 Dr. Arthur Farre has given me the particulars of a 
 case of retained menses, which was seen some forty 
 years ago by his father, an eminent physician of his 
 time. A young lady in the country had retention of 
 the menses; pregnancy was suspected by the family 
 physician ; Dr. Farre was sent for to decide the nature 
 of the case; but before his arrival the hymen was 
 ruptured spontaneously ; a large quantity of retained 
 menses was suddenly evacuated ; irritative fever set in, 
 and the patient -died in a few days. Although I have 
 frequently heard of a fatal result in similar cases, as a 
 consequence of surgical interference, this is the only 
 one in which I have known it to happen in this way. 
 
 2. Vaginismus. — By the term vaginismus I mean 
 an excessive bypersesthesia of the hymen and vulvar 
 outlet, associated with such involuntary spasmodic 
 contraction of the sphincter vaginae as to prevent 
 coition. This irritable spasmodic action is produced 
 by the gentlest touch: often the touch of a camel's- 
 hair pencil or fine feather will produce such agony as 
 to cause the patient to shriek out, complaining at the 
 same time that the pain is that of thrusting a sharp 
 knife into the sensitive part. This is worse in some 
 than in others. In a very large majority, the pain and 
 spasm conjoined are so great as to preclude the possi- 
 bility of sexual intercourse. In some instances it will
 
 VAGINISMUS. 319 
 
 be borne occasionally, notwithstanding the intolerable 
 suffering ; while in others it will be wholly abandoned, 
 even after the act has been repeatedly and, as it were, 
 perfectly performed. 
 
 We can, hardly make a mistake in the diagnosis of 
 this affection. It could be confounded only with imper- 
 forate hymen or atresia of the vagina, the true nature 
 of which is easily ascertained by examination. In these 
 there is not necessarily inordinate pain on being touch- 
 ed. There is only a mechanical impediment to the 
 passage of a probe or the finger into the vagina, while 
 in the other the gentlest touch, as said before, produces 
 excessive suffering, and this is the chief diagnostic. 
 
 To examine a case of suspected vaginismus, place the 
 patient on the back, with the legs flexed; separate 
 gently the labia. The patient will exhibit signs of 
 alarm and agitation, — 'not that we hurt her, but she 
 feels an indescribable, insuperable dread of being hurt. 
 She is like a timid, nervous person who has once had a 
 pointed instrument thrust into the exposed pulp of an 
 inflamed nerve in a decayed tooth. The very idea of 
 its repetition throws her into a nervous rigour. The 
 degree of general disturbance will depend upon the 
 peculiar temperament of the individual. But be this as 
 it may, when we come to explore the seat of trouble, 
 the strongest will and stoutest frame will exhibit unmis- 
 takable signs of excruciating suffering ; for the gentlest 
 touch with the finger, a probe, even with a feather, pro- 
 duces great agony. The sensitiveness is at all parts of 
 the vaginal outlet. It is very great at and near the 
 meatus urinarius on each side where the hymen takes its 
 origin ; and greater still near the orifice of the vulvo- 
 vaginal gland ; but often the most sensitive point is at 
 the fourchette, where the hymen projects upwards. The
 
 320 UTERINE SURGERY. 
 
 whole vulval or outer face of the hymen is sensitive, but 
 it is more so along its reduplication or base. The touch 
 of a probe or a camel's-hair pencil is sufficient. 
 
 But while the outer face of the hymen and the adja- 
 cent parts are so sensitive, if we turn the patient on the 
 left side and separate the nates and vulva so as to pass 
 a sound through the hymen without touching its outer 
 surface, and then make pressure with it laterally or 
 backwards on the inner or vaginal aspect of this mem- 
 brane, we will not find there any abnormal degree of 
 sensitiveness. 
 
 Touching the outer surface of the hymen in any por- 
 tion of its reduplication, produces not only pain, but an 
 involuntary spasm of the sphincter muscle both of the 
 vagina and anus. In some instances, the sphincter ani 
 feels as hard as a ball of ivory ; and one of my patients 
 supposed it to be a tumour that would require exsec- 
 tion. The supersensitiveness is diagnostic ; the spasm 
 pathognomonic. 
 
 The most perfect examples of vaginismus that I have 
 seen were uncomplicated with inflammation ; but I have 
 met with several cases in which there was a redness or 
 erythema at the fourchette. Usually, the hymen is 
 thick and voluminous, and when the finger is forced 
 through it, its free border often feels as resistant as if 
 bound by a fine cord or wire. 
 
 By the term blepharismus, or blepharo-spasmus, we 
 mean an involuntary painful spasmodic contraction of the 
 orbicularis palpebrarum, with great supersensitiveness, 
 or intolerance of light. By the term laryngismus, we 
 mean a spasmodic contraction of the vocal apparatus^ 
 producing stridulous inspiration ; and, by analogy, I call 
 this painful spasmodic contraction of the mouth of the 
 vagina, vaginismus.
 
 VAGINISMUS. 321 
 
 I presented a paper on this subject to the Obstetrical 
 Society of London in December, 1861,* from which I 
 will here extract a few particulars. 
 
 In May, 1857, I was called to see a lady, aged forty- 
 five years, who was married at twenty, and had been an 
 invalid ever since. Menstruation, always painful, had 
 just ceased. She had great irritability of the bladder, a 
 sense of bearing down, and other symptoms of uterine 
 derangement. But to me the most remarkable thing in 
 her history was the fact that she had remained a virgin 
 notwithstanding a married state of a quarter of a cen- 
 tury. Some two or three years after marriage her phy- 
 sician discovered a sanguineous mucous tubercle at the 
 meatus urinarius, which he removed, and then attempted 
 to dilate the vagina with graduated bougies, which pro- 
 duced great suffering, without the least permanent im- 
 provement. She consulted the most eminent surgeons 
 in the principal capitals of America, and subsequently 
 visited London and Paris for the same purpose ; but no 
 one gave a satisfactory solution of the case, nor advised 
 anything more than the bougie system, which had been 
 already fruitlessly exhausted. 
 
 Her nervous system was in a deplorable condition. 
 She was exceedingly impressible, the slightest noise 
 being intensely disagreeable. She was able to walk 
 only across her room, but did not often venture on this 
 experiment, being confined most of the time to her 
 couch, where she gave herself up to unceasing intellec- 
 tual effort. 
 
 I attempted to make a vaginal examination, but failed 
 completely. The slightest touch at the mouth of the 
 
 * "Obstetrical Transactions," 1862, voL H. 
 21
 
 322 UTERINE SURGERY. 
 
 vagina produced intense suffering, throwing her nervous 
 system into great commotion ; there was a general mus- 
 cular agitation ; her whole frame shivered as if with the 
 rigours of an intermittent ; she shrieked and sobbed 
 aloud ; her eyes glared wildly ; tears rolled down her 
 cheeks, and she presented altogether the most pitiable 
 appearance of terror and agony. Notwithstanding all 
 these outward involuntary evidences of physical suffer- 
 ing, she had the moral fortitude to hold herself on the 
 couch, and implored me not to desist from my efforts if 
 there was the least hope of finding out anything about 
 her inexplicable condition. After pressing with all my 
 strength for some moments, I succeeded in introducing 
 the index finger into the vagina up to the second joint, 
 but no further. The resistance to its passage was so 
 great, and the vaginal contraction so firm, as to deaden 
 the sensation of the finger, and thus the examination 
 revealed only an insuperable spasm of the sphincter 
 vaginae. I candidly told her husband I knew nothing 
 whatever about the case, had never seen or heard of 
 anything like it, and therefore could promise nothing. 
 However I suggested the propriety of their going to 
 New York, for further investigation under anesthesia. 
 They acted promptly on this suggestion, and I invited 
 the late Dr. John W. Francis, Dr. Emmet, of the Wo- 
 man's Hospital, Professor Van Buren, and Dr. Kissam to 
 see her with me. The two latter-named gentlemen 
 assumed the responsibility of the etherization. Pre- 
 viously to the anaesthesia I attempted to make a vaginal 
 examination, when the sama train of symptoms was 
 manifested as on the former occasion. But as soon as 
 she was fully under the influence of the ether, I found, 
 greatly to my surprise, the mouth of the vagina com- 
 pletely relaxed and the vagina itself perfectly normal.
 
 VAGINISMUS 303 
 
 It was not large, but certainly quite as well developed 
 as it ought to have been at her time of life and undei 
 the circumstances. The uterus was retroverted, and 
 there was a small polypoid excrescence about the size oi 
 a pea hanging from the os tineas. This was removed, 
 not with the expectation of its exerting any influence on 
 her peculiar condition, but to prevent the risk of its 
 future growth. I gave the opinion that it was a spas- 
 modic contraction of the sphincter vaginas, resulting 
 from an irritable condition of the nerves of the part, 
 which I could not explain. When asked if it was possi- 
 ble to cure it, I said — " I do not know, for the books 
 throw no light on the subject ; but it appears to me 
 that the only rational treatment would be surgical." 
 However I declined to do anything, on the ground that 
 an untried process was not justifiable on one in her 
 position in society, the hospital being the legitimate 
 field for experimental observation. 
 
 This case is an exaggerated example of its class. I 
 have seen several nearly, but not quite, as bad. The 
 high intellectual endowments of this lady, her elegant 
 culture and fine social position, as well as her long 
 suffering, all conspired to make her case one of much 
 thought and great anxiety to me ; and it was not easily 
 dismissed from my mind. It was the first case of the 
 sort I had ever seen, and I could not help wondering if 
 it would be the last. But about fifteen months after 
 this, Professor Pitcher, of Detroit, Michigan, sent me 
 another similar case, except that the lady had been 
 married but two years. She had the same instinctive 
 dread of being touched, the same muscular agitation 
 and shivering of the whole frame, and the same pain 
 and spasm of the sphincter on attempting to pass the 
 finger into the vagina. As this lady's husband threat-
 
 324 
 
 UTERINE SURGERY. 
 
 ened to obtain a divorce, I looked upon her case as a 
 proper one for experiment. Explaining to her fully our 
 ignorance on the subject, I proposed a series of experi- 
 mental incisions, which she readily assented to. Think- 
 ing that the division of the irritable spasmodic outlet 
 was the only rational operative procedure, I divided first 
 only the edges of the hymeneal membrane on each side 
 of the fourchette. There was no relief. Waiting for 
 the wounds to heal, I then divided the parts again at 
 the same points, but extending the incisions deeply 
 through the mucous membrane and through some of the 
 fibres of the sphincter muscle. This was followed by 
 some improvement ; she could bear the introduction of 
 one finger without very great pain, and could even 
 tolerate two, but it was with considerable suffering. I 
 now saw that the hymen itself was the focus of the 
 excessive irritability, and I then proposed to cut it out 
 entirely, and afterwards to repeat the lateral incisions as 
 before, making them deeper, and rendering the dilatation 
 permanent by the use of a properly constructed bougie. 
 By this time the mother of my patient came to the 
 conclusion that I was experimenting on her daughter. 
 I told her it was true, and attempted to justify the pro- 
 priety of the course when a lawsuit and a divorce were 
 in prospect. The mother, however, was inexorable, and 
 unfortunately removed her daughter from my care. But 
 her improvement was so great that I had no doubt of 
 her ability to fulfil the duties of a wife under some 
 difficulties. The experience gained by this case was of 
 gieat value to me. 
 
 A few weeks afterwards, January, 1859, another case 
 fell into my hands. This patient was the wife of a clergy- 
 man, and had been married six years. Sexual intercourse 
 was impossible. Several surgeons had been consulted, but
 
 VAGINISMUS. 32 A 
 
 without any explanation of her condition, and of course 
 without any relief. On examination, I discovered a 
 sanguineous, mucous, painful tumour at the meatus urina- 
 rius, and notwithstanding the experience already related, 
 I persuaded myself that this tubercle was alone the 
 source of all her trouble. It was removed, and its seat 
 cauterized. In due time she returned home, but came 
 back to me in a few days to report a persistence of her 
 former sufferings. On a more minute examination, I 
 found it to be in all particulars just such a case as those 
 previously related, but not quite so intense in its mani- 
 festations. The slightest touch with a feather or with a 
 camel's-hair pencil at the reduplication of the hymeneal 
 membrane produced as severe suffering as if she were 
 cut with a knife. While this lady was under observa- 
 tion (April, 1859), a fourth case of the same sort came 
 under my care, that of a woman who had been married 
 three years. Sexual intercourse had been imperfectly 
 accomplished a few times during the first few weeks after 
 marriage. She innocently supposed that all women had 
 to suffer as she did, and tried to bear it ; but her sufferings 
 ■were so severe that at last she looked with the greatest 
 terror upon the approaches of her husband. At her 
 earnest entreaties, he ceased all efforts at sexual inter- 
 course, and they lived together like brother and sister. 
 But at last the mother of the poor timid girl began to 
 wonder why, after three years of married life, her 
 daughter, who seemed to be healthy and had a healthy 
 vigorous young husband, did not become pregnant, and 
 ventured to speak of her disappointment ; whereupon 
 the daughter hesitatingly explained it all to the mother, 
 who immediately brought her to see me, when I found 
 precisely the same condition of things already described. 
 A few weeks after this, Dr. Harris, of East Thirtieth
 
 326 
 
 UTERINE SURGERY. 
 
 Street, New York, sent me another case (the fifth). 
 His patient had been married two and a half yeais, and 
 sexual intercourse was impossible. I now (June 18th, 
 1859) had three cases all at one time under observation ; 
 but to cut short this long narrative, I may here say that 
 they were all, after many experiments and disappoint- 
 ments, perfectly cured in the following August. 
 
 From personal observation I can confidently assert 
 that I know of no disease capable of producing so much 
 unhappiness to both parties of the marriage contract, 
 and I am happy to state that I know of no serious 
 trouble that can be cured so easily, so safely, and so 
 certainly. 
 
 Treatment. — The treatment consists in the removal 
 of the hymen, the incision of the vaginal orifice, and 
 subsequent dilatation. The last is useless without the 
 first two, but is essential to easy and perfect success 
 with them. I usually make two operations, but it may 
 all be done at once. 
 
 Placing the patient (etherized) on the left side, I 
 seize the hymeneal membrane with a delicate pair of 
 forceps just at its junction with the urethra on the left 
 side, and putting it on the stretch, clip with properly 
 curved scissors till the whole is removed in one con 
 tinuous piece. 
 
 In some cases the haemorrhage requires a compress 
 of lint. In two instances the bleeding was excessive, 
 but easily checked with the Liq. Ferri Persulphatis. 
 The cut surface usually heals entirely in three or four 
 days, after which the operation for a radical cure may 
 be performed. Notwithstanding the removal of the 
 thick, sensitive hymen, the cicatrix marking its original 
 place at the mouth of the vagina is exceedingly sensi* 
 tive, and in some instances feels hard and tense, as if
 
 vaginismus. 327 
 
 a wire or small cord were constricting the outlet. This 
 I divided at various points and in divers ways during 
 ray early experiments, and finally arrived at the follow- 
 ing method, as being the surest and best. 
 
 Place the patient (fully etherized) as for lithotomy, 
 on the back ; pass the index and middle fingers of the 
 left hand into the vagina, separate them laterally, so as 
 to dilate the vagina as widely as possible, putting the 
 fourchette on the stretch ; then with a common scalpel 
 make a deep cut through the vaginal tissue on one side 
 of the mesial line, bringing it from above downwards, 
 and terminating at the raphe of the perineum. This cut 
 forms one side of a Y« Then pass the knife again into 
 the vagina, still dilating with the fingers as before, and 
 cut in like manner on the opposite side from above down- 
 wards, uniting the two incisions at or near the raphe, 
 and prolonging them quite to the perineal integument. 
 Each cut will be about two inches long, i. e. half an inch 
 or more above the edge of the sphincter, half an inch 
 over its fibres, and an inch from its lower edge to the 
 perineal raphe. Of course this will vary in different 
 subjects according to the development of the parts in 
 each. To perfect the cure it is necessary for the patient 
 to wear for a time a properly adapted bougie or dilator. 
 I use a dilator made usually of glass, sometimes of 
 metal or ivory. I prefer glass because it is easily kept 
 clean, and being transparent, it is easy to see the cut 
 surface, and indeed the whole vagina, without removing 
 it. If there is much bleeding, I introduce the dilator 
 at once ; but usually I wait twenty-four hours, when it 
 is worn one, two, three, or four hours at once. Its 
 introduction is attended with a sense of soreness, but 
 with none of the peculiar agonizing suffering so character- 
 istic of the original disease.
 
 328 
 
 UTERINE SURGERY. 
 
 The patient will generally wear the dilator two hours 
 in the morning and two or three hours in the afternoon 
 or evening; sometimes for a longer period. I have 
 known a few who wore it six or eisfht hours at a time. 
 I have often been astonished at the rapidity with which 
 the cuts sometimes healed, the cure being seemingly 
 facilitated by the pressure of the glass tube. 
 
 I direct the dilator to be worn daily for two or three 
 weeks, or longer, or till the parts are entirely cured and 
 all sensitiveness removed. 
 
 The dilator is a tube about three inches long, slightly 
 conical, open at one end, closed at the other, and an 
 inch and a quarter or an inch and a third in diameter 
 at the largest part, near the open or outer end. 
 
 There is a depression or sulcus on one side for the 
 urethra and neck of the bladder (fig. 128). 
 
 The outer open end allows the pressure of the 
 atmosphere to assist in retaining it easily in the vagina. 
 
 Fig. 128. 
 
 When closed at both ends, it is much more difficult to 
 retain it in situ, even with a well-adjusted X bandage. 
 The depression for the urethra is very important, for I 
 found that a perfectly round cylinder, worn for three or 
 four hours, always injured the urethra ; and, moreover, 
 this urethral depression assists the self-retaining capacity 
 of the instrument. 
 
 Dr. Rottenstein, a celebrated American dentist in
 
 vaginismus. 309 
 
 Paris, lias recently made for me a dilator of vulcanite, 
 which answers very well. It is quite as cleanly as glass, 
 and is not so liable to be broken. 
 
 While these pages were going through the press, I 
 had occasion to operate on a lady fifty-four years of 
 age, who was married at eighteen, a widow at twenty, 
 and married again at forty. During her first marriage 
 copulation was effected occasionally, but it was under 
 most trying circumstances, and with the most intense 
 suffering. During her last marriage it was impossible. 
 I found the mouth of the vagina a little reddish, inflamed, 
 and excessively irritable, the slightest touch with a probe 
 producing intense agony. The finger could be passed 
 into the vagina, but it caused great suffering. It was, 
 and had always been, a well-marked case of vaginismus. 
 The hymen did not present any undue development, and 
 I simply incised the parts on each side of the middle 
 line, through to the verge of the perineum. The whole 
 vulvar outlet was unnaturally small, and the incisions 
 were extended well through the outer edge of the peri- 
 neum. A glass dilator was worn three or four hours a 
 day for a month ; but at the end of this time the mouth 
 of the vagina was just as sensitive and as spasmodic as 
 before the operation. 
 
 I now determined to remove all the hypertrophied 
 tissue at the fourchette and divide anew the parts 
 beneath. Wishing to make pressure with the dilator 
 more in the direction of the fourchette and perineum 
 than laterally, I had the instrument made as repre- 
 sented in fig. 129, which seems to be a great improve- 
 ment on the purely cylindrical instrument. Instead of 
 expanding the outer end of the dilator, as seen in fig. 
 128, it is often necessary to roll its border inwards to 
 prevent pressure on the labia.
 
 330 
 
 UTERINE SURGERY. 
 
 In some instances the instrument is too long, and 
 produces pain by pressure against the cervix uteri. It 
 will then be necessary to make it shorter. The down- 
 ward curvature of the conical extremity, as here repre- 
 sented, prevents it from striking against and hurting the 
 uterus. 
 
 ElG. 129. 
 
 I have now operated on thirty-nine cases of vaginis- 
 mus, and in every instance with perfect success. Many 
 of these were complicated with other causes of a sterile 
 condition, such as painful menstruation, contracted os, 
 conical cervix, fibroid tumour, or malposition. But 
 notwithstanding this, six conceptions have followed the 
 operation. Some others, from whom I have not heard, 
 have probably conceived, and a few more of them will 
 almost certainly do so. They have usually been so well 
 satisfied with the removal of the vaginismus that they 
 did not care to undergo any further treatment for a 
 condition that might be attended to at a more conve- 
 nient season. 
 
 Churchill, Debout, and some others, have thought 
 that a state of vaginismus could hardly exist long where 
 the husband possessed strong copulative capacity ; but 
 I am sure this is an error ; for I have seen several 
 instances in which the virile power of the husband was 
 unusually strong, but yet powerless to overcome the
 
 VAGINISMUS. 331 
 
 obstruction ; and I have seen two cases that had been 
 subjected to the most powerful means of dilatation, long 
 continued, and to a great degree ; and yet the spasmodic 
 action remained just the same. One of these has now 
 been married eighteen years ; and for six months she 
 submitted, many years ago, to the torture of a tri valve 
 dilator passed into the vagina, and opened to its widest 
 extent : and all for no purpose. So great was her dread 
 of the peculiar paiu of this affection that her husband 
 could not persuade her to submit to an operation at my 
 hands, and thus she remains as at her marriage. 
 
 I have operated on those who had been married 
 seventeen years, fifteen years, twelve years, and so on 
 down to two years. In a few instances sexual inter- 
 course had been imperfectly accomplished, but in the 
 great majority of cases it had never been consummated. 
 In two instances, the husbands, though young and 
 vigorous, were so excitable that the semen was quickly 
 lost, but in both of these cases the vaginismus was so 
 inveterate that I am sure it would have persisted even 
 under other circumstances. 
 
 Dr. T. G. Thomas, of New York, gave me the history 
 of a case in which a physician etherized his patient, and 
 then left her to her husband, who cohabited with her 
 with the greatest ease ; but he could not repeat the act 
 when she was not etherized. Fortunately, the period 
 was well chosen, for this single act of copulation was 
 followed by conception. I have known other cases 
 where conception occurred without the introduction of 
 the virile organ. The seminal fluid was lost at the 
 mouth of the vagina, and a little was doubtless injected 
 through the hymeneal opening, and made its way to the 
 cavity of the uterus. 
 
 Sir Joseph Olliffe has given me the history of a case
 
 332 UTERINE SURGERY. 
 
 of this sort, where conception occurred without pene- 
 tration of the hymen. It is not uncommon to hear of a 
 pregnancy at full term where the hymen is unruptured. 
 I presume that all such cases are examples of vaginis- 
 mus. 
 
 Many surgeons are of opinion, since I first described 
 this affection, that it is sufficient to forcibly dilate the 
 mouth of the vagina, or to incise it, and then use the 
 dilator ; but I am well satisfied that the plan of remov- 
 ing the hymen entirely is much the best ; not only of 
 removing the hymen, but of removing any and every 
 super-sensitive point. 
 
 In 1863, I saw a lady with vaginismus who had been 
 married six years, and during all this time she had sub- 
 mitted to sexual congress, notwithstanding the intense 
 suffering that it occasioned her. I found the hymen 
 unbroken, but dilatable. It was exceedin^lv tou^h, 
 and would stretch almost like an india-rubber string I 
 used my speculum, pulling the perineum far back 
 towards the coccyx, which opened the mouth of the 
 vagina sufficiently for any purpose. This was attended 
 with great pain, but the hymen did not give way. I 
 excised it, divided the fourchette, and used the dilator 
 till the parts were healed. She went home, but return- 
 ed in a few days to say that sexual intercourse was as 
 unbearable as ever. On a minute examination, I found 
 a small tubercle of indurated tissue on the right side of 
 the mouth of the vagina, not larger than a grain of 
 wheat. It was very sensitive even to the touch of a 
 camel's-hair pencil. It was hooked up with a tenacu- 
 lum, and cut out, and immediately the peculiar sensitive- 
 ness of the part was gone. The relief afforded was as 
 sudden as it would have been bv the removal of a sub- 
 cutaneous neuromatous tumour. Indeed it has always
 
 vaginismus. 333 
 
 appeared to me that the symptoms of vaginismus were 
 neuromatous. However, my friend Professor Alonzo 
 Clark, one of the ablest pathologists in my own country, 
 has frequently examined the vaginismus hymen for me, 
 and could not find any enlarged nerve filaments running 
 through it. 
 
 The case above related was cured by the slight ope- 
 ration performed the second time. 
 
 Fig. 130 represents the exact size of the hymen in 
 this case, immediately after its removal. The indenta- 
 tion on its left side corresponds precisely with the seat 
 of the little tubercle removed at the second operation, 
 and which was doubtless the result of the imperfect 
 excision of the thickened base of the 
 hymeneal membrane. This case proves 
 very conclusively how important it is to 
 exsect the hymen in its totality ; for here 
 a small point was left which produced great 
 suffering afterwards. But to show to a 
 greater certainty the propriety of this 
 course of treatment, I will here relate a 
 most remarkable case that fell under my observation a 
 few years ago. 
 
 A lady, aged thirty, was married at twenty-one. 
 Vigorous efforts at copulation were made fruitlessly for 
 five or six weeks. The husband and wife were both 
 young and of course ignorant on the subject, and were 
 not surprised that there was difficulty at the beginning ; 
 but soon they began to debate the point of asking medi- 
 cal advice. At last the wife became worn out with the 
 oft-repeated and painful efforts at coition, and agreed to 
 a consultation. 
 
 The family physician was called, who supposed that 
 there must be some unusual degree of disproportion in
 
 334 UTERINE SURGERY. 
 
 the relative development of their respective genital 
 organs, and advised sexual intercourse while the wife 
 was etherized. This was soon done and the wife knew 
 nothing of it. But when the act was attempted the 
 next day and the next, it was found to be utterly impos- 
 sible. After a week's fruitless trial, the physician was 
 sent for again, and again she was etherized, and coition 
 effected with the greatest ease. But it was subsequently 
 impossible when she was not etherized. The husband 
 was tall, athletic, and muscular; says he is not subject 
 to hasty ejaculation, and possesses extraordinary copula- 
 tive powers. So that it was not the fault of the husband 
 that the vaginismus did not yield to penetration and 
 dilatation. But the subsequent history of this interest- 
 ing case bears still more strongly on this point. Suffice 
 it to say that it became the business of the physician to 
 repair regularly to the residence of this couple two or 
 three times a week to etherize the poor wife for the 
 purpose above alluded to. They persevered, hoping 
 that she would become pregnant and that delivery would 
 cure her. This etherization was continued for a year, 
 when conception occurred. But during the whole period 
 of utero-gestation, etherization was necessary to coition. 
 After the birth of the child there were a few copula- 
 tions without ether, but it was exceedingly painful, and 
 soon the pain became so severe that they were compel- 
 led to resort to ether again. At the end of another year 
 of ethereal copulation, there was another conception, 
 which resulted in an abortion at the third month. After 
 this she was etherized constantly for nearly another 
 year, when at last they saw no hope of a cure, and be- 
 coming alarmed at the frequent repetition of the anaes- 
 thesia, they concluded to give it up altogether. And 
 when they consulted me there had been no effort at
 
 vaginismus. 335 
 
 copulation for three or four years. They Lad consulted 
 other physicians in the mean time, but no one explained 
 the case or proposed a remedy. 
 
 The mouth of the vagina was barely large enough to 
 admit the index finger. The seat of the hymen was 
 red, inflamed, thickened, indurated, and exceedingly 
 sensitive to the slightest touch with the finger, a probe, 
 or a feather. There was a reddish blotch, about the 
 size of half a split pea, at the orifice of each vulvo- 
 vaginal gland. The perineum had been lacerated 
 down to the fibres of the sphincter muscle, and now a 
 tense, inelastic modular band extended across the 
 fourchette, and was lost in the thickened tissue occupy- 
 ing the original seat of the hymen. This entire ring 
 was quite as sensitive to a gentle tonch as the most 
 marked case of vaginismus could be ; indeed, it was a 
 vaginismus now, notwithstanding the fact that coition 
 had been accomplished scores, nay, hundreds of times, 
 and that a labour at full term and a miscarriage had 
 also occurred to break up the morbid condition, if it 
 could be done by the mere mechanical action of dis- 
 tension. I would not pretend to deny that we can dilate 
 a case of vaginismus so as to permit sexual intercourse, 
 but in most of the cases so treated the act is very painful. 
 In every case that I have operated upon by removal of 
 the hymen, and then by division and dilatation, sexual 
 intercourse has been accomplished without pain. 
 
 The course to be pursued in the case we are de- 
 scribing was very plain, viz., to remove the whole ring 
 of thickened tissue that encircled the mouth of the 
 vagina, and particularly the cicatricial portion at the 
 fourchette. This was done, arid then the septum 
 between the fourchette and the rectum was divided on 
 each side, down through the fibres of the sphincter
 
 336 UTERINE SURGERY. 
 
 muscle and the fourcliette to the perineal raphe. This 
 left a very thin partition between the two outlets. 
 After this a glass vaginal dilator was introduced, and 
 worn almost constantly. A larger one was used in a 
 day or two, and in a fortnight sexual intercourse was 
 accomplished for the first time without pain. Where 
 there is cicatricial tissue, as in this case, there is danger 
 of a relapse, and hence greater necessity for a prolonged 
 use of the dilator. This remarkable case presents 
 many points of interest, not the least of which is the 
 fact that the two conceptions took place while she was 
 in a state of complete anaesthesia. 
 
 3. Atresia Vagina. — This, of course, forms an 
 obstacle to the reception of the seminal fluid. It may 
 be congenital or accidental, — more frequently the latter, 
 and oftener the result of tedious labour, followed by 
 sloughing. The records of the Woman's Hospital 
 present a number of cases of atresia, a few of which will 
 serve as examples. 
 
 I have seen but one case that might be called con- 
 genital ; and that was in a young girl aged eighteen, who 
 entered the Hospital in October, 1857, complaining of 
 great pain every month without ever having had the 
 slightest show. She had taken aloetic purgatives and 
 other emmenagogues without benefit. 
 
 On examination, a rounded tumour, half as large as 
 a fcetal head, supposed to be the uterus, could be felt in 
 the hypogastrium. The finger passed through the 
 hymen, which was very rigid, detected a hard inelastic 
 tumour, three-quarters of an inch beyond it, the vagina 
 seemingly ending there in a cul-de-sac. By passing 
 the finger into the rectum, it came in contact with the 
 tumour felt through the vagina, and which appeared
 
 ATRESIA VAGINAE. 
 
 
 to be the upper two-thirds of the vagina distended 
 with something hard and inelastic, and continuous 
 with the tumour that rose above the symphysis pubis. 
 
 The rational symptoms and anatomical relations all 
 pointed -to retention of the menses by occlusion of tbe 
 lower third of the vagina. But to the sense of touch 
 per rectum, with supra-pubic pressure or palpation, it 
 felt exactly like an osteo-fibroid tumour. The lower or 
 vaginal part of the tumour was quite as unyielding to 
 pressure as the upper part or uterine portion. 
 
 Fig. 131 represents the relations of the uterp- 
 
 FlG. 131. 
 
 vaginal tumour, formed by the occlusion of the walls 
 of the vagina. A very small puncture was made into 
 the tumour, through the occluded vagina where tbe 
 tissue seemed to be about a half inch thick. The 
 fluid gradually oozed away. There was no constitu- 
 tional disturbance; and the patient experienced only 
 relief from its evacuation. When the uterus was 
 found diminished to its normal size, we ventured to 
 enlarge the opening sufficiently to pass the index 
 finger up to the os tincae, and we kept it dilated 
 
 22
 
 338 UTERINE SURGERY. 
 
 to this moderate extent till the divided parts were 
 covered with mucous membrane. The os and cervix 
 uteri presented a remarkable state of granular erosion, 
 extending over the adjacent portion of vagina, and 
 giving rise to a profuse albuminoid leucorrhceal dis- 
 charge, which yielded to appropriate treatment in the 
 course of a month. The next menstruation was normal 
 and she left the Hospital with the vagina slightly- 
 narrowed at the original seat of occlusion. 
 
 This case might have been congenital, or the oppos- 
 ing sides of the vagina might have formed adhesions bv 
 inflammatory action during childhood. 
 
 We have seen at the Woman's Hospital atresia in 
 great variety from sloughing of the soft parts and 
 consequent cicatrization. Sometimes the mouth of the 
 vagina is closed, or nearly so ; again, we may have a 
 contraction and closure of its middle portion ; and, 
 again, the upper part of the vagina and the neck of the 
 uterus may be agglutinated together in one dense mass 
 of fibro-cellular tissue, while we may occasionally find a 
 complete obliteration of this canal, from the neck of 
 the bladder quite to the os tincse. In all cases the 
 treatment is the same; viz., to restore the canal, if 
 possible, and to keep it open, by the use of the glass 
 dilator, till the newly exposed surfaces become covered 
 with mucous membrane. In some instances this will 
 be done in three or four weeks. The constant wearing 
 of the dilator greatly facilitates the healing of the 
 raw surfaces and the conversion of mere cellular into 
 mucous tissue. There is always such a tendency to 
 contraction that I have directed the dilator to be used 
 every day for a long period of time. 
 
 I have seen a great many cases of occlusion of the 
 vaginal outlet, where there was an opening perhaps
 
 ATRESIA VAGINAE. 
 
 339 
 
 not larger than a small probe for the passage of the 
 menstrual flow. I have seen several in which it was 
 impossible to find this small opening till the occurrence 
 of the flow indicated it. From these I will select but 
 one to -illustrate the treatment. A lady, forty-six 
 years old, was placed under my care in April, 1858, to 
 be treated for atresia. She was married at fourteen ; 
 became a mother at fifteen ; labour tedious ; head 
 impacted ; delivery instrumental ; child still-born ; 
 sloughing of soft parts ; slow recovery ; atresia vaginae ; 
 sexual intercourse impossible afterwards. Eminent 
 surgeons were consulted, amongst others the distin- 
 guished Drs. Physic and Dewees, of Philadelphia, in 
 1828. Nothing was done. No attempt even was ever 
 made to open the passage. In a few years afterwards 
 her husband died. Strange as it may seem, this 
 lady married again in three years. In three years 
 more she was a widow for the second time. But the 
 most unaccountable thing is, that she married again, 
 after remaining a widow for nearly eighteen years and 
 knowing at the same time that she had had perfect 
 occlusion of the vagina for nearly thirty years. She 
 had been married the third time about twelve months 
 when I saw her. The mouth of the vagina was sealed 
 up, as it were, by a cartilaginous barrier, quite un- 
 yielding to the strongest pressure. But there was a 
 small valvular opening through which the menses made 
 their exit. 
 
 This little opening barely admitted a small probe ; 
 but this could be passed the whole depth of the vagina, 
 and its point could be felt by the finger in the rectum 
 depressing the recto-vaginal septum, as it was pushed 
 onwards to the os tinea?. Menstruation was normal, 
 and the uterus, of natural size, was in proper position.
 
 340 UTERINE SURGERY. 
 
 The vagina was normal above the point of occlusion, 
 which was a little anterior to the neck of the bladder, 
 as shown by fig. 132. 
 
 This case was operated on in June, 1858, the late 
 Drs. V. Mott and John W. Francis, with Dr. Emmet, 
 assisting. A small blunt-pointed bistoury was passed 
 through the little opening into the vagina, and the 
 
 gristly structure was divided 
 from side to side, and then the 
 blade of the knife was turned 
 downwards and backwards, 
 cutting outwards, parallel, as 
 it were, with the ascending 
 ischial ramus, first on the right 
 and then on the left, keeping 
 Em. 132. -the index finger in the rectum, 
 
 to avoid making a recto-vaginal fistula. 
 
 In this way the mouth of the vagina was made quite 
 large enough, and when the finger was passed in, it 
 was found to be sufficiently capacious above. The glass 
 dilator was introduced, and I had the happiness of 
 sending this lady away in the course of a month perfectly 
 fitted for the married life. 
 
 I directed her to wear the instrument a while every 
 day for an indefinite period, to guard against the com- 
 mon accident of relapse 
 
 I might relate many more very curious and interesting 
 cases illustrating this point, but I forbear, as enough 
 has been said to establish the principles that are to guide 
 us in practice. 
 
 4. Congenital Absence of the Vagina. — I have 
 seen five cases of congenital absence of the vagina, 
 and in all of them there was no uterus. One of
 
 ABSENTIA VAGIN.E. 341 
 
 these, shown to me by Dr. Livingston, of New York, 
 had been married seven or eight years. She was mar- 
 ried young, and, of course, had no idea of her peculiar 
 condition. The labia were normally developed, and 
 the membranous tissue between the meatus urinarius 
 and the fourchette had by constant use been pushed 
 up between the base of the bladder and the rectum 
 till it was developed into a blind pouch, into which 
 the finger could be passed to the depth of nearly 
 two inches. • 
 
 As it would serve no practical purpose to dilate on 
 this subject, I shall leave it here, simply saying that 
 the diagnosis in such cases is easy enough with a finger 
 in the rectum, and a sound in the bladder, alternating 
 the latter with supra-pubic pressure. 
 
 At the beginning of this section, I said that " the 
 vagina must be capable of receiving and of retaining 
 the spermatic fluid. 1 ' 
 
 Having now considered such obstacles as would 
 prevent the deposit of the seminal fluid in the vagina, 
 we may turn to such conditions as prevent its retention 
 there when once introduced. 
 
 It has only been about three or four years since I 
 found out that' some vaginas would not for a moment 
 hold a drop of semen. 
 
 There are no two vaginas exactly alike. They differ 
 in length, in their various diameters, in their relations 
 with the bladder and rectum, in their course with 
 regard to the pelvian axes, and in their relation with 
 the axis of the uterus. They sometimes refuse to retain 
 the semen when they are very capacious ; again, when 
 they are too short. In this last instance, there will 
 probably be found a disproportion between the sizes 
 of the respective genital organs of the two sexes.
 
 342 UTERINE SURGERY. 
 
 A young woman, married five years, without issue 
 consulted me on account of her sterility. The cervix 
 was rather indurated ; the os was small. I cut it 
 open, and the os afterwards presented quite a normal 
 appearance. As there was nothing otherwise ab- 
 normal about the uterus, I told her she would almost 
 certainly conceive in four or five months. She 
 patiently waited eighteen months, and then came to 
 me again in despair. The condition of the uterus 
 was now all that I could have wished it. to be; but 
 the vagina, as before said, was rather short. For 
 the first time I now suspected that perhaps the fault 
 lay here. I requested her to come to me at some early 
 day, two or three hours after sexual intercourse. She 
 came the next morning. I did not find any signs of 
 spermatozoa in the mucus of the vagina, or in that of 
 the cervix uteri. I then began to suspect that the fault 
 lay with her strong, vigorous husband. I asked her if 
 she seemed to retain anything after coition. She said 
 it all appeared to pass off instantly. In such a case, 
 all false delicacy must be laid aside ; it is a matter of 
 the gravest scientific importance, and must be treated 
 as such. 
 
 I told her and her husband that I must see her just 
 after sexual intercourse. The time was appointed ; I 
 was at the house, and in four or five minutes after the 
 act I saw my patient ; and the vagina did not contain 
 a drop of semen, but it was on her person and napkin 
 in the greatest quantity. The microscope showed that 
 it was perfectly normal. What was to be done ? The 
 vagina was short — too short ; it could not be made 
 longer. When the finger was pushed forcibly against 
 the posterior cul-de-sac, in the direction of the dotted 
 line a, fig. 133, it yielded to the pressure, and
 
 SHORT VAGINA. 343 
 
 as the finger was withdrawn, the cul-de-sac sprang 
 forward, almost as if it were made of a thin sheet of 
 India-rubber. This reaction of the distended vagina 
 evidently ejected all the semen that did not at once 
 regurgitate in the very act of ejaculation. Of course 
 the remedy was self-suggestive. As we could do no- 
 thing to change the size or form of the vagina, we had 
 only to order what was so evidently indicated — some- 
 thing to prevent the forcible impingement of the male 
 organ against the posterior cul-de-sac. This had the 
 desired effect ; the semen in sufficient quantities was 
 retained, and conception occurred in three months, 
 after a sterile marriage of nearly seven years. I now 
 think it probable that the operation performed on the 
 cervix uteri was not at all necessary ; for never till I 
 saw this case had I the remotest idea of such a state 
 of things as I have here described. 
 
 Fig. 133 would represent about the relations of the 
 vagina and uterus in the case 
 described above. 
 
 But it must not be inferred 
 that all short vaginas are neces- 
 sarily associated with a sterile 
 condition. I have seen several 
 cases in which the vagina had FlG 133 
 
 been almost wholly destroyed by 
 
 the sloughing process, and in which the neck of the 
 uterus had also sloughed away to a great extent : 
 where, in fact, the vagina was not more than two 
 inches deep, and yet conception occurred with the 
 greatest facility ; but in every one of these cases the 
 upper part of the vagina was fixed with the open os 
 presenting at its bottom ; it was unyielding, inelastic, 
 did not give before pressure, and, of course, did not
 
 3J..J. UTERINE SURGERY. 
 
 rebound on its removal. Thus it was possible for th* 
 semen to enter at once into the canal of the cervix. 
 
 Amongst several cases of this sort, I now call to 
 mind one of vesico- vaginal fistula, sent to the Woman's 
 Hospital, in 1857, by Dr. Dimond of Auburn, New 
 York, in which almost the whole anterior wall of the 
 vagina, a large part of the cervix, and the posterior 
 cul-de-sac, and a large portion of the posterior wall 
 of the vagina, were lost. There was but a small strip 
 of the anterior wall, just at the neck of the bladder ; 
 the fistulous opening was two inches wide, reaching 
 from one pubic ramus across to the other, through 
 which the inverted fundus of the bladder fell into the 
 vagina, presenting at its posterior border the open 
 mouths of the ureters, from which we could see the 
 urine passing off as it was secreted. This case was 
 cured, but the vagina was not more than two inches 
 deep. I had but little thought that she would ever 
 conceive again; but in ten months after returning home 
 she became a mother; and again, in about fifteen 
 months after this, she gave birth to twins. In four 
 other cases like this, the vagina was quite as short, and 
 in all it was fixed and inelastic at its upper part ; and 
 in all, the intra-vaginal portion of the cervix uteri had 
 been destroyed by the sloughing process, and the os 
 presented itself as a little gaping slit in the centre of 
 the fibrous structure that formed the upper boundary 
 of the vagina, which stretched across the pelvis like 
 a cord of cartilage. 
 
 In all these cases but one, the shortening of the 
 vagina tilted the fundus uteri backwards, and placed the 
 axis of the uterus in a direct line with that of the vagi- 
 na, so that the meatus urethras must, at the moment of 
 ejaculation, have been in direct contact, and in a straight
 
 VAGINA— NON-RETAINING. 
 
 345 
 
 line with the open end of the canal of the cervix uteri. 
 I have seen many sterile wombs, where I thought the 
 sterile condition could be overcome if it were possible 
 to imitate artificially the unfortunate state of things here 
 produced accidentally, i. e., fixing immovably the open 
 os in a direct line with the ejaculative force. This 
 would lead me now to enquire into the rationale of 
 the entrance of the semen into the cavity of the uterus ; 
 but I shall leave this for the next section. 
 
 But sometimes the vagina does not retain the semen 
 even when it is of large proportions. When this is the 
 case we almost always find the uterus retro verted. 
 
 Fig. 131. 
 
 I have now but little doubt that, in many cases of 
 retroversion, in which I have seen pregnancy follow the 
 rectification of the malposition, the sterile state was due 
 to the fact that the vagina did not retain the semen.
 
 346 
 
 UTERINE SURGERY. 
 
 I do not mean to say that in all cases of retroversion 
 the semen is not retained : far from it ; for I know that 
 it is often retained in ample quantities, in even the 
 worst cases of retroflexion, such as that shown in fig. 
 134. 
 
 The philosophy of this is plain enough ; for the 
 vagina is here almost in its normal relations, with what 
 should be the proper axis of the uterus, although this 
 is flexed out of its normal position. The uterine mal- 
 position that is most unfavourable to the retention of 
 the semen by the vagina is that of retroversion, with 
 the os tincse lying close up behind the inner face of the 
 pubes, and the fundus, of course, thrown backwards 
 below the level of the vaginal axis. I made this discov- 
 ery of the ejecting power of the vagina, where there is 
 retroversion, only within the last few years. It occurred 
 in this way. A sterile patient, in good general health, 
 had painful menstruation, a contracted os, and a retro- 
 verted uterus. The indications were to enlarge the os 
 and to rectify the malposition. Accordingly I cut open 
 the os and cervix, and then, wishing to see if the semen 
 entered the cervix, I directed her to come to me some 
 morning after sexual intercourse. She did so, but I 
 found no traces of spermatozoa. 
 
 I then said, " I must see you soon after the act of 
 coition ;" and told her to remain quietly, in the horizon- 
 tal position, till I should arrive. I saw her in six or 
 eight minutes afterwards, and there was not a vestige 
 of semen in the vagina, but it was found in the greatest 
 abundance outside and on the napkins. The vagina 
 was very capacious, far above the average size ; and I 
 could hardly believe my senses when I found that it 
 contained nothing. It was then arranged that I should 
 see my patient in fifty or sixty seconds after coition, and
 
 VAGINA — NON-RETAINING. 34.7 
 
 I fouDcl precisely the same state of things, viz., not a 
 sign of semen in the vagina. Now, let us see why this 
 was so. But first it might have been supposed that it 
 was due to hasty ejaculation. Proper inquiry settled 
 that question in the negative by the evidence of both 
 man and wife. Why, then, was there no semen in this 
 very capacious vagina immediately after a normal copu- 
 lation ? Let us look at its anatomical relations. The 
 uterus was retroverted, but anteflected ; the cervix was 
 long and pointed, and rested against the urethra; the 
 body of the uterus was somewhat hypertrophied ; the 
 anterior wall of the vagina rather short, in consequence 
 
 ■^.......6 
 
 Fig. 135. 
 
 of long error of position ; the vagina was otherwise very 
 large, and the perineum relaxed. The finger carried to 
 the bottom of the vagina, at its reduplication, «, fig. 
 135, could push this back towards the hollow of the 
 sacrum relatively as far as b; this would necessarily 
 throw the fundus upwards; the withdrawal of tht 
 finger would let it fall down again, but its momentum 
 would carry it a little lower than the point at which it 
 rested in equilibrio. There was nothing easier of de- 
 monstration than this see-saw movement of the uterus 
 by pushing the posterior cul-de-sac backwards. Now 
 the tendency of this falling of the organ by the sudden 
 removal of a force thus impinging against the point #, 
 is to depress the fundus still more, which thereby pro- 
 portionally elevates the cervix; this draws up also the
 
 348 UTERINE SURGERY. 
 
 cul-de-sac of tbe vagina, and rolls out, as it were, what- 
 ever has been deposited in it. In this particular case, 
 the vagina would spring back from b to a, and this of 
 itself would eject the fluid. Besides, in all cases when 
 we examine the condition of the uterus immediately 
 after coition we shall find the organ presenting signs of 
 exhaustion, if I may be allowed such an expression ; for 
 instance, if the uterus is in a normal position, or even 
 moderately anteverted, we shall find the upper part of 
 the vagina relaxed, and passively holding a large quan- 
 tity of semen, in which the cervix uteri is submerged ; 
 the uterus itself seems to be fatigued, and drops by its 
 own gravity down towards the rectum, where it lazily 
 sinks to the bottom of the little pool of semen. 
 
 Nothing has surprised me more than the difference 
 in the relative condition of the uterus and vagina 
 before and after sexual congress. I have had occasion 
 to examine many cases under these circumstances, and 
 I have uniformly found this as I have here described 
 it ; and when there is retroversion the fundus sinks 
 still lower after coition than before, and this neces- 
 sarily elevates the os tinese still farther from the semi- 
 nal fluid, if any of it have been retained. I have seen 
 many cases of retroversion latterly where the semen 
 was not retained. I could give some most interesting 
 details on this point, but enough has been said to show 
 the importance of the subject, to illustrate its philoso- 
 phy, and to indicate the proper treatment ; which, of 
 course, would be to place the uterus in its normal 
 position, and to retain it there by means of a proper- 
 ly-fitted instrument to be worn during sexual congress. 
 In the case figured above, amputation of the cervix at 
 the point indicated by the dotted line would be advis- 
 able before attempting further treatment.
 
 SECTION VII. 
 
 FOR CONCEPTION, SEMEN WITH LIVING SPERMA- 
 TOZOA SHOULD BE DEPOSITED IN THE 
 VAGINA AT THE PROPER TIME.
 
 SECTION VII. 
 
 FOR CONCEPTION, SEMEN WITH LIVING- SPERMATOZOA 
 SHOULD BE DEPOSITED IN THE VAGINA AT THE 
 
 PROPER TIME. 
 
 This proposition naturally involves three considera- 
 tions : 
 
 1st. The nature and properties of semen. 
 
 2nd. Its passage to the cavity of the uterus ; and 
 
 3rd. The proper time for this. 
 
 The seminal fluid, as ejected in the act of copula- 
 tion, is composed of the secretion of the testes, mixed 
 with that of the vesiculse seminales, prostate and Cow- 
 per's glands. 
 
 The office of the testes is to secrete the semen, which 
 is composed of the liquor serninis, granules, and sper- 
 matozoa. 
 
 If we take a drop of semen from the vagina imme- 
 diately after sexual intercourse, and place it under the 
 microscope, we shall see the hurried movements of 
 seemingly thousands of spermatozoa. But this is not 
 the best way of studying the phenomena of their move- 
 ments. The best plan is to take a drop of mucus from the 
 canal of a perfectly normal cervix uteri some fifteen or 
 twenty hours after sexual intercourse. We shall then 
 be better able to examine the spermatozoa ; for we shall 
 see them in the fluid that serves as the means of their 
 finding their way towards the ovum. We shall find 
 them moving more slowly, more cautiously, if the term 
 may be allowed. Suppose we select any one sperma-
 
 352 UTERINE SURGERY. 
 
 tozoon for observation, and note particularly its various 
 actions and movements. It will swim first one way and 
 then another, or move in a straight line across the field 
 of vision ; and perhaps turn abruptly to retrace the 
 path already traversed. It it encounters a large epithe- 
 lial scale it stops, places its head against it, as though 
 trying to push it forwards ; and when it fails so to do, 
 it turns and moves off slowly in another direction, 
 perhaps to encounter another opposing obstacle, to 
 pause a moment and make another effort to overcome 
 it, and then to turn again in search of some new field 
 of exploration. 
 
 Fig. 136, #, represents the appearance of sperma- 
 tozoa in a normal state. With the spermatozoon motion 
 is life, and as long as it lives it moves. When the tail 
 ceases its movements, the organism is dead. The alter- 
 nate lateral movements of the caudal portion drive the 
 
 \ 
 
 Fig. 136. Fig. 137. 
 
 head forwards. If by any accident this be injured, thea 
 the movements of the body or head are in accordance 
 with the nature of the power exerted by the injured 
 part. 
 
 For instance, if the extreme point of the tail should 
 be curled up, either by an injury or be held so by
 
 SPERMATOZOA. 353 
 
 inspissated mucus, as is represented in fig. 136, h, then 
 the movements of the spermatozoon will be in a straight 
 line, as shown by the arrow. If the injury be such as 
 to give a permanent gentle curvature to the middle of 
 the tail, as shown in fig. 137, then its movements will 
 be in a circle, because the extremity drawing constantly 
 against the resisting fluid always in one direction, will, 
 of course, drive the head always in a corresponding 
 direction. For instance, if the tail be permanently 
 turned to the left, as here represented, then, with every 
 contraction of it, the head will be driven round to the 
 left; and if to the right (fig. 138), then it will turn in 
 a circle to the right. But when we find a spermatozoon 
 injured so as to be doubled on itself in the middle, with 
 
 
 Fig. 138. Fig. 139. 
 
 the tail reaching up by or beyond the head, as shown 
 in fig. 139, then its movements will be in the opposite 
 direction to the curvature, because the moving power 
 will be expended at the very end of the caudal portion, 
 and this force necessarily drives the head in an opposite 
 direction. 
 
 Spermatozoa cease to move only when life is extinct. 
 Under favourable circumstances, they live many hours ; 
 but under unfavourable circumstances they die quickly. 
 For instance, any great variation in temperature is fatal 
 to their existence. 
 
 23
 
 54: UTERINE SURGERF. 
 
 For impregnation, the semen must contain living 
 spermatozoa. It has been pretended by some that it 
 may take place without them. They are to be found 
 in all animated nature. I should as soon think of con- 
 ception without the presence of semen, as to suppose it 
 possible without spermatozoa. 
 
 A short time ago it was generally supposed that 
 sterility was a thing that belonged almost wholly to the 
 opposite sex. Mr. Curling* has recently brought this 
 subject prominently before the profession, and has 
 established very conclusively that sterility in the male 
 does positively exist, and that it may depend upon — 
 
 1st. Congenital malposition of the testes. 
 
 2nd. Chronic inflammation of these glands ; and 
 
 3rd. Stricture. 
 
 In the first and second, the testes fail to produce 
 spermatozoa; in the third, the semen regurgitates into 
 the bladder. 
 
 When the testes are retained in the abdomen, they 
 seem to remain in a rudimentary state, and never attain 
 the power of secreting semen with spermatozoa. 
 
 Mr. Curling's admirable paper contains a number 
 of cases illustrating this fact, and he arrives at the very 
 just conclusion that the semen of such testes being 
 devoid of the fructifying principle, is wholly incapable 
 of procreation. Mr. Curling says that Mr. Poland and 
 Mr. Cock have each seen cases of procreation where 
 the testes never descended into the scrotum ; but in 
 neither of these cases had the semen been examined 
 microscopically. The inference in both instances is 
 
 * " Observations on Sterility in Man," with cases. By T. B. Curling, 
 F.R.S., Surgeon to the London Hospital, &c. Reprinted from the 
 British and Foreign Medico- Chirvf jical Review. April, 1864.
 
 SPERMATOZOA. 
 
 355 
 
 plain: either that there are exceptions to the lule that 
 a retained testis does not furnish spermatozoa ; or that 
 the claims to paternity in their cases were entirely out 
 of the question. The latter the most probable, as there 
 are no fycts to substantiate the former. 
 
 In the French school this subject has been very 
 thoroughly investigated. The writings of Goubaux, of 
 Follin, of Gosselin, and Godard, all go to prove that a 
 retained testicle is, as a rule, whether in man or animal, 
 incapable of producing spermatozoa, and that semen 
 without spermatozoa is incapable of procreation. In 
 some instances, one testis has been found in the abdo- 
 men, and the other in its normal position in the 
 scrotum ; and here, the one has invariably been defi- 
 cient, and the other prolific in spermatozoa. 
 
 But while the presence of spermatozoa is essential 
 to fecundation, their absence has no sort of influence 
 upon impotence. By impotence, we understand an 
 incapacity for copulation ; by sterility, an incapacity 
 for fructification. Thus a man may be impotent and 
 not sterile ; and sterile but not impotent. I have 
 known many men who performed the act of coition 
 with the greatest vigour, whose semen was perfectly 
 devoid of the slightest trace of spermatozoa; and on 
 the other hand, how often do we encounter those who 
 are incapable of the least effort at copulation, but whose 
 semen is loaded with spermatozoa. In the first class, 
 ignorance of their real condition is bliss ; while in the 
 second, the certain knowledge of their infirmity pro- 
 duces the greatest misery. 
 
 The seminal fluid may be destitute of spermatozoa 
 in consequence of an obstruction of the excretory ducte 
 of the testes. This is the result usually of acute inflam- 
 mation of these organs. Gonorrhoea has been regarded
 
 356 
 
 UTERINE SURGERY. 
 
 as a disease of no very serious importance ; but when 
 we see it often producing a double orchitis, which may 
 leave the subject of it sterile for ever afterwards, we 
 should look upon it rather as an affection likely to be 
 attended with the most disastrous consequences. 
 
 I now call to mind three young men whom I treated 
 for double orchitis, following gonorrheal inflammation, 
 about twenty-five years ago, which left in each a 
 chronic double epididymitis. They have been married 
 many years without issue. It is true their wives may 
 have been sterile. On this point I cannot do better 
 than to quote from Mr. Curling,* who says : — 
 
 "In 1853, M. Gosselin made known some curious 
 researches in relation to this subject. He carefully ex- 
 amined the semen in twenty men who had been attacked 
 with double epididymitis after gonorrhoea. In fifteen 
 of these cases which were comparatively recent, a callo- 
 sity existed in the tail of the epididymis at the time 
 they seemed to be cured. In all, the genital functions 
 appeared fully restored and the sperm normal. The 
 semen was repeatedly examined at intervals of several 
 weeks, but no spermatozoa were detected. M. Gosselin 
 lost sight of all but two cases, and in these the return 
 of spermatozoa in the semen occurred after some 
 months, and coincidently with the complete disappear- 
 ance of the induration in the epididymis on one side. 
 In the remaining five of the twenty cases the double 
 epididymitis had occurred several years previously. 
 One man, aged forty -five, had been attacked twenty 
 years before, but the left callosity no longer existed, 
 and spermatozoa were found in the semen. In another 
 man the disease dated back . five years, and had left a 
 
 * Loc. cit.
 
 SPERMATOZOA. 35(7 
 
 considerable induration at the lower part of each epidi- 
 dymis. The general health was good. No spermatozoa 
 could be detected. In the three other cases the disease 
 had occurred ten, six, and four years before. There was 
 hardness on both sides. The testicles were otherwise 
 unaltered. The indications of virility were quite satis- 
 factory, and the semen presented its usual appearance. 
 The individuals had all been married several years, but 
 had no children. The sperm was carefully examined 
 and found destitute of spermatozoa. One of them had 
 had children by a former wife before the attack of 
 double epididymitis. Since the publication of the pre- 
 ceding observations, M. Gosselin has met with two 
 cases of men who, after suffering from bilateral epididy- 
 mitis during their youth, had retained an induration on 
 each side. They had been married several years and 
 had no children. In both the virile powers were not, 
 apparently, weak, but the sperm was entirely wanting 
 in spermatozoa. 
 
 Thus it will be seen that inflammation of the testes 
 is a matter of grave importance. And this is so whether 
 it be the result of specific causes, of accident, of cold, or 
 of translated parotitis. I have known one case of epidi- 
 dymitis from mumps, where the testes lost the power of 
 generating spermatozoa. It is a curious and fortunate 
 circumstance that epididymitis, by whatever cause pro- 
 duced, in no way weakens the sexual appetite, or the 
 power of gratifying it. 
 
 Semen destitute of spermatozoa has the usual sui 
 generis odour, but lacks the appearance of uniformity 
 that belongs to the normft secretion. When viewed by 
 a transmitted light, we usually see little whitish flakes 
 of mucus floating through it. But I have seen two 
 instances in which it had the colour and appearance
 
 358 UTERINE SUBOERY. 
 
 of good semen, although wanting spermatozoa It is 
 insoluble in hot or cold water, and floats about in it 
 iinmiscibly in cloudy flakes like ordinary mucus. It 
 is more translucent than good semen, less milky, and 
 less opaque. Under the microscope it presents the 
 appearance of ordinary mucus. I have seen samples 
 of semen full of spermatozoa, but loaded with mucus, 
 which probably came from the glandular apparatus 
 at the neck of the bladder. I know of one case 
 illustrating the fact that a man is not necessarily 
 sterile because his semen possesses too large a proportion 
 of mucosity. 
 
 Normal semen will drop from the end of the syringe 
 in drops as easily as water. A small quantity falling 
 into a glass of water is, by slight agitation, imme- 
 diately diffused or dissolved in it. Abnormal semen 
 full of mucus will not leave the mouth of the syringe 
 quickly or suddenly, but ropes off for an inch or more 
 before it breaks into a drop ; and when it falls into 
 water it preserves its tenacity, and but a small part of 
 it is dissolved. It floats about in shreds, and eventually 
 settles at the bottom of the glass in the form of a 
 whitish sediment. 
 
 Sometimes sterility in the male depends upon a 
 stricture obstructing the outward passage of the semen, 
 which consequently in the act of copulation regurgitates 
 into the bladder. This condition of things is, of course, 
 
 O 7 7 
 
 curable by the proper treatment for stricture. 
 
 At the beginning of this section I said that, to ensure 
 conception, " semen with living spermatozoa should be 
 deposited in the vagina at the proper time." 
 
 It is the vulgar opinion, and the opinion of many 
 savants, that, to ensure conception, sexual intercourse 
 should be performed with a certain degree of complete*
 
 SEXUAL CONGRESS. 359 
 
 ness, that would give an exhaustive satisfaction to both 
 parties at the same moment. Even Roubaud* has 
 devoted many pages to the consideration of frigidity in 
 the woman. How often do we hear husbands complain 
 of coldness on the part of wives ; and attribute to this 
 the failure to procreate. And sometimes wives are dis- 
 posed to think, though they never complain, that the 
 fault lies with the hasty ejaculation of the husband. 
 Both are wrong. 
 
 God has given us appetites* and desires, and endowed 
 the act of copulation with a pleasurable erethism, 
 simply that we might be forced to " multiply and 
 replenish." But for this, the human family might, long 
 ago, have been numbered with the fossils that repre- 
 sent extinct species. No ; it matters not how awk- 
 wardly and unsatisfactorily the act of coition may be 
 performed, so that semen with the proper fructifying 
 principle be placed in the vagina at the right 
 moment; and, on the contrary, it matters not how 
 perfectly aud satisfactorily it may be done, if the semen 
 lacks this fecundating power. I have known many 
 men who knew but little of mere animal sensuality, 
 and whose wives knew less, and yet they were blessed 
 with large families ; and, on the contrary, I have known 
 some who were differently constituted, and yet they 
 were perfectly sterile. 
 
 It might be thought that I am here overstepping the 
 bounds of propriety, even in a work purely surgical ; 
 but I justify myself by the fact, that a false philosophy 
 has gained almost universal credence ; and that young 
 medical men, with a correct knowledge of facts as 
 
 * " Traite de l'lmpuissance et de la Sterilite chez l'Homme et chez la 
 Femme." Par le Dr. Felix Roubaud. Paris : J. B. Bailliere, 1865.
 
 360 UTERINE SURGERT. 
 
 they truly exist, may do much to render many families 
 happier, by setting them right on a point of more vital 
 importance to domestic happiness than many of us have 
 ever dreamed of. 
 
 Let us turn to pages 331 and 332, and read over 
 the cases in which conception took place while the 
 wives were etherized, and ask ourselves what agency 
 mere sensual enjoyment could have had in bringing 
 about the result. Our literature furnishes many cases 
 where the seminal fluid lias been lost at the mouth of 
 the vagina ; where the hymen has remained intact ; 
 and where, nevertheless, conception readily occurred. 
 
 I have seen cases of this sort ; so has Sir Joseph 
 Olliffe; and so has Dr. Campbell, of Paris. Most of 
 these were cases of vaginismus, where the pain 
 and spasm of the sphincter vaginae were such as to 
 preclude penetration, and the semen was lost at the 
 ostium vaginae, a little passing through the hymen. 
 
 M. Tardieu,* Dean of the Faculty of Paris, relates 
 a remarkable instance of conception following lascivious 
 titillations under most unnatural and unfortunate circum- 
 stances. Here the semen was habitually lost at the 
 ostium vaginae, with the belief that conception could 
 not occur unless the act of coition was fully consum- 
 mated. But the sequence proved otherwise ; and M. 
 Legrand, who delivered her, found the young girl's 
 vagina virginal. 
 
 I once requested the husband of a lady who had 
 vaginismus, to let me see his wife an hour after sexual 
 intercourse, for the purpose of determining whether any 
 semen ever entered the vagina. He had not attempted 
 
 * " E ude Medico-legale sur les Attentats aux Mceurs." Par Ambroise 
 Tardieu, Professeur, &c. Paris: J. B. Bailliere et Fils, 1859, page 99.
 
 SPERMATOZOA. 3QJ 
 
 it for ten days or more, and lie said he was so nervous 
 at the idea that he lost the semen at the moment of 
 contact, and hence the effort amounted to nothing. 
 
 In consequence of this accident, I did not see the 
 patient at the appointed time ; but visited her a few 
 hours later for some other purpose, and removed about 
 ten drops of clear translucent mucus from the canal of 
 the cervix. The attempt at copulation was made at 
 eight a.m., the patient did not rise from bed till eleven. 
 At twelve I saw her, and then removed the cervical 
 mucus. I intended to make a microscopic examination 
 of it at once, but circumstances put it out of my 
 power, and I did not do this till midnight, being twelve 
 hours after its removal, and sixteen hours after the 
 attempt at intercourse. 
 
 In this cervical mucus I found a solitary spermato- 
 zoon, which manifested the greatest activity. I exa- 
 mined the whole of the ten drops of mucus, but could not 
 discover another one, nor was there any in the vaginal 
 mucus. How did only one spermatozoon and no more 
 find its way into the canal of the cervix ? Perhaps not 
 more than a drop, or half a drop, of semen passed 
 through the little hymeneal opening. The patient lay 
 in bed three hours afterwards. During this time this 
 stray spermatozoon had travelled three inches and a 
 half from the hymen to the os tincae (for the vagina was 
 very long and narrow), and had entered into the canal 
 of the cervix, while the remainder of the seminal fluid 
 passed off in resuming the erect posture. The case is 
 curious, as showing — 
 
 1st. That semen can be thrown into the vagina with- 
 out penetration. 
 
 2nd. That a spermatozoon can, in a comparatively 
 short time, move over a considerable distance ; and
 
 362 UTERINE SURGERY. 
 
 3rd. That it can live a long time out of the body, 
 provided the temperature is not too low. This observa- 
 tion was made on one of the hottest days in July. 
 
 We know very well that the semen, or rather it; 
 fructifying principle, the spermatozoa, must pass into the 
 cavity of the uterus, if not further, to render conception 
 possible. How is this done ? Does it enter the canal 
 of the cervix in the act of ejaculation? or do the sper- 
 matozoa afterwards, by their locomotive powers, gradu- 
 ally wend their way up the canal of the cervix? 
 
 I am not aware that any observations on the living 
 subject have before been made upon this point. A few 
 post-mortem examinations, made in cases of sudden' death 
 after coition, have demonstrated the presence of sperma- 
 tozoa in the cavity of the uterus ; but this does not settle 
 the questions raised above. The fact that pregnancy 
 has frequently occurred without penetration, proves very 
 'conclusively that the spermatozoa can and do traverse 
 the whole length of the vagina ; that they then can and 
 do enter the canal of the cervix, and passing along this 
 narrow strait, that they can and do pass on till they 
 reach the ovum, and. fertilize it. But this is not the 
 usual way in which this is done. 
 
 T have over and over again examined the condition 
 of the uterus after coition, and often in four or five 
 minutes after it ; and I have usuallv found the state of 
 things described on page 348. I have also frequently 
 removed the mucus of the cervical canal immediately 
 after sexual intercourse, first a drop from the os tinea?, 
 and then a drop or two from an inch higher. If the 
 neck of the womb is in a normal condition, with an open 
 os tincse filled with healthy mucus, we shall always find 
 spermatozoa in it, in greater or less numbers, if we exa- 
 mine it immediately after coition.
 
 SPERMATOZOA. 3 Q 3 
 
 Thus we see that they enter the cervix, as it were, 
 suddenly. My explanation of this physiological pheno- 
 menon is, that the cervix is pressed forcibly against the 
 gluns by a contraction of the superior constrictor vagi* 
 nae ; that .this pressure necessarily forces out the contents 
 of the canal of the cervix ; that the parts subsequently 
 become relaxed, the uterus returns suddenly to its normal 
 condition, and the seminal fluid filling the vagina, neces- 
 sarily rushes into the canal of the cervix by a process 
 similar to that by which a fluid would pass into an India- 
 rubber bottle slightly compressed, so as to expel a por- 
 tion of its contents before placing its mouth in a fluid 
 of any sort. 
 
 If the uterus is in a normal condition, we shall 
 always, as a rule, find spermatozoa in the canal of the 
 cervix immediately after coition. If the uterus is greatly 
 retroverted, we shall not ; and if it is greatly anteverted 
 we shall not. And why ? Because, in the first instance, 
 the os tincse will be too close to the symphysis }3ubis, and 
 if it is subjected to any such pressure as that alluded to 
 above, it will, for anatomical reasons, be such as to com- 
 press the posterior lip of the os tincse up against the 
 anterior, which will have no effect in exhausting the 
 canal of the cervix ; and in the second instance, where 
 there is a complete anteversion, with the os looking in 
 the direction of the hollow of the sacrum, the same act 
 and the same pressure would only force the anterior lip 
 of the os tincae up against the posterior, creating no 
 vacuum, and making no room for the newly introduced 
 fluid. 
 
 From this it will be seen that I believe the cervix 
 uteri to be shortened in the erethismal climax of coition, 
 by pressure exerted upon it in the direction of its long 
 axis when its position is normal, which is impossible in
 
 364 UTERIXE SURGERY. 
 
 any greatly abnormal position. I have spoken of a 
 superior constrictor vaginae, and attributed to it a cer- 
 tain office — that of compressing the glans forcibly against 
 the os titicsB at a certain moment. I have made no dis- 
 sections to prove the existence of such a special muscle ; 
 but that it does exist, and that some anatomist will dis- 
 sect and describe it, I feel perfectly confident, for I have 
 seen the manifestations of its presence hundreds of 
 times. In uterine examinations with the patient on the 
 left side and my speculum introduced, we may now and 
 then see the posterior wall of the vagina just opposite 
 the os tincsB gradually contracted and corrugated, till it 
 is brought almost in contact with the cervix, evidently 
 by circular bands of muscular fibres that occupy the 
 superior portion of the vagina. 
 
 We are more apt to see this in patients that are 
 alarmed, and manifest some degree of general nervous 
 agitation. I have witnessed this over and over again, 
 and what one man sees another will be sure to discover 
 when his attention is turned in the proper direction. 
 It matters not whether this explanation is correct or 
 not, provided other observers establish the fact that 
 the semen finds its way at once into the canal of the 
 cervix. 
 
 We have already discussed many of the mechanical 
 obstructions that prevent the passage of the semen to 
 the cavity of the uterus ; and we have seen that the 
 great difficulty is to be found almost uniformly in the 
 cervix. 
 
 It has, hence, occurred to many philosophic minds, 
 to overleap this barrier at once, by throwing the fructi- 
 fying agent right into the cavity of the uterus. But 
 the practical execution of this is surrounded by many 
 difficulties. For instance, how delicate and difficult
 
 SPERMATOZOA. 
 
 M5 
 
 would it be to arrange every tiling preparatory to such 
 a procedure. Then, as to the temperature of instru 
 merits ; for the slightest variations of this, whether of 
 heat or cold, are inimical to the life of the spermatozoa. 
 Then as, to the quantity of semen to be introduced, 
 whether much or little ; the delicacy of the apparatus 
 for this, and the proper time for the operation. When 
 all these circumstances are taken into consideration, we 
 can appreciate the difficulties of the practical execution 
 of a thing that would at first appear to be theoreti- 
 cally so simple Ever since the days of Spallanzani 
 and Rossi, who, with a syringe, injected the semen of 
 the dog into the vagina of the bitch, and saw impreg- 
 nation follow, it has been supposed by many that in the 
 human subject this mechanical process might be carried 
 still further, by injecting the semen into the cavity of 
 the uterus from the canal of the vagina. But I know 
 of no published account of any experiments of this 
 sort. 
 
 Some years ago, I made a series of this kind, and 
 actually saw conception follow this process in one 
 instance. Dr. George Harley, Professor, <fcc, in Uni- 
 versity College, London, informs me that he has 
 repeatedly performed the experiment of injecting the 
 semen into the cavity of the uterus, but with no result. 
 I have given up the practice altogether, and do not 
 expect to return to it again ; but as others may feel 
 disposed to try further experiments in this direction, I 
 shall here give them the advantage of my experience. 
 
 Before undertaking this we must satisfy ourselves 
 that the semen is perfectly normal, and that it does 
 not and cannot enter the canal of the cervix in the 
 natural way. 
 
 In all my cases there was a contraction of the cana]
 
 366 UTERINE SURGERY. 
 
 of the cervix, and in two there was quite a flexure at 
 the os internum ; and experimental observations proved 
 that the semen never entered the canal of the cervix 
 in any one of them. In all of them the operation of 
 incising the os and cervix would have been the proper 
 course to pursue ; but my patients were too timid, would 
 not submit to it, and accepted the uncertain alternative 
 of uterine injection. In my first experiments this was 
 often more painful than any operation, for it frequently 
 produced severe uterine colic. I had no data to guide 
 me, and I began by slowly injecting three or four drops 
 of the seminal fluid, which produced very severe 
 symptoms; then two drops, and then one, till finally 
 I determined that half a drop was quite enough. 
 Indeed, I have no idea that this quantity ever gets into 
 the cavity of the uterus in Nature's own way, and I 
 now wonder why I should have begun these experi- 
 ments in such a heroic manner. Suffice it to say that 
 I have seen conception follow this artificial fructification 
 once, and once only. The case is of sufficient import- 
 ance to give it in detail. 
 
 My patient was twenty-eight years old ; had been 
 married nine years without issue ; and had had more or 
 less dysmenorrhoea all her menstrual life. It was often 
 attended with great constitutional disturbance, such as 
 nausea, vomiting, and sick headache. She had retro- 
 version, with hypertrophy of the posterior wall, an 
 indurated conical cervix, a contracted canal, which was 
 particularly contracted at the os internum, in conse- 
 quence of the flexure incidental to the malposition ; 
 and superadded to all these mechanical obstructions, 
 the vagina never retained the semen. I examined 
 this case several times very soon after sexual inter- 
 course, and I never found a drop of semen in the
 
 SPERMATOZOA. 
 
 367 
 
 vagina, although it was placed there in the greatest 
 abundance. 
 
 This patient was willing to submit to anything but a 
 surgical operation. Could any case 
 have presented a greater number of 
 difficulties to be overcome ? The 
 first thing to be done was, of 
 course, to rectify the malposition, 
 and to keep the uterus in its 
 normal relations by means of a 
 properly adjusted pessary, with the 
 hope that the vagina would re- 
 tain the semen. This point has 
 been &o fully discussed in Section 
 V., that it is unnecessary to say 
 more here than that I fortunately 
 succeeded in doing this, and a 
 sufficient quantity of semen was 
 retained, though the most of it 
 passed off. This part satisfactorily 
 arranged, we were now ready for 
 the uterine injections. These ex- 
 tended over a period of nearly 
 twelve months. Some of them 
 (two) were made just before men- 
 struation ; the others (eight) were 
 made at different periods, vary- 
 ing from two to seven days af- 
 ter it ceased. Beginning* with 
 three drops, I at last injected half 
 a drop. Fig. 14<). 
 
 Fig. 140 represents the instrument with which these 
 experiments were conducted, with the exception of the 
 bulb at the end of the tube. It is made of glass. T. e
 
 3G8 
 
 UTERINE SURGERY. 
 
 piston can be drawn out easily for the purpose of taking 
 up the semen ; but for the purpose of graduating exactly 
 the quantity to be injected, there was a little screw nut, 
 a. which could be turned against the piston-rod, upon 
 which a screw was cut. Tins prevented the piston from 
 being forced down, except by the action of the screw. 
 When we wished to force out the contents of the syringe, 
 half a revolution of the piston forced out half a drop, a 
 whole revolution a whole drop, and so on, just as 
 does Pravaz's instrument for the endermic injection of 
 morphine. The greatest care was necessary in manag- 
 ing the temperature of the syringe. I placed it in a 
 bowl of warm water, with a thermometer to mark 98° 
 Fah., taking care to have it no more and no less. 
 But as the removal of the instrument 
 from the bowl of water to the vagina 
 would be necessarily attended with a dimi- 
 nution of temperature, I adopted the plan 
 of allowing it to remain about a minute 
 in the vagina before drawing up any of 
 the semen into it ; and this for the pur- 
 pose of insuring it to be the same tempe- 
 rature as the fluid in which the sperma- 
 tozoa disported. 
 
 Fig. 141 represents the exact size of 
 the glass-tube, used the last time in this 
 case ; a is the point at which a string 
 was tied, as a guide and a guard to pre- 
 vent its being introduced too far into 
 the cavity of the uterus. This was exactly 
 one inch and nine-sixteenths from the end, 
 which I think is quite as far as we should 
 introduce the instrument. Thus it was not 
 carried so far as to iujure the lining membrane of the 
 
 Fig. 141.
 
 SPERMATOZOA- 369 
 
 uterus, or to mar the vitality of the ovum, if it had 
 already reached this cavity. 1 feared that I might have 
 done one or both of these in some of my earlier experi- 
 ments. In this particular case, about four drops of semen 
 were taken up ; the instrument was cautiously carried 
 into the canal of the cervix, till the point was in close 
 contact with the os tincsB; then the piston-rod was 
 slowly turned half a revolution, which as slowly forced 
 out half a drop of semen ; the instrument was held in 
 situ for ten or fifteen seconds and then withdrawn, and 
 the patient lay quietly in bed for two or three hours 
 afterwards. 
 
 Under these circumstances, at this, the tenth trial, 
 conception took place, and everything went on favour- 
 ably till the fourth month, when a fall and a fright 
 unfortunately produced a miscarriage, from which the 
 mother recovered with the greatest difficulty. I have 
 related this case minutely, because I presume it is the 
 first and only authentic case in which artificial fertiliza- 
 tion has been successful in the human species; and 
 because it furnishes about the sum and substance of 
 my knowledge on the subject which may be of any 
 possible service as a guide to future observers, who may 
 have the curiosity, leisure, courage, and perseverance 
 to experiment further in this direction. 
 
 The experiments above alluded to were made on 
 half a dozen different patients. During the two years 
 that I was engaged in them, I made fifty-five uterine 
 injections. I think I am entitled to subtract about half 
 the number as having been badly done, or having been 
 made with badly constructed instruments, or under inju- 
 dicious circumstances. If so, then they show one concep- 
 tion out of about twenty-seven trials. I have very little 
 doubt that we shall learn still more about embryology ; 
 
 24
 
 370 UTERINE SURGERY. 
 
 and some years hence, when we shall better understand 
 the laws of conception, I doubt as little that some one 
 will be able to apply the principles sought to be esta- 
 blished by these experiments with more exactitude than 
 I have. If we understood more about the proper period 
 for conception, this mechanical fertilization might be- 
 come exact enough to depend upon it in such cases as 
 would be otherwise impracticable. 
 
 Science, even in our own day; demonstrates now and 
 then the wisdom of laws given under the Mosaic dis- 
 pensation. As an instance, I have only to refer to the 
 recent discovery of Trichinae in swine, as showing not 
 only its occasional unfitness, but its positively poisonous 
 qualities as an article of diet under some circumstances. 
 Then, again, the laws bearing on the uncleanness and 
 the purification of women in menstruation, are in accord- 
 ance with the accepted doctrines of the day, in regard 
 to the period of fitness for conception. " But if she 
 be cleansed of her issue, then she shall number to 
 herself seven days, and after that she shall be clean." 
 — Levit. xv. 28. 
 
 It is jiretty well established that menstruation is the 
 sign of ovulation ; that it is preparatory to the recep- 
 tion of the ovum ; that the ovum reaches the cavity of 
 the uterus in from two to ten days after menstruation ; 
 and that it must be fertilized at some point between the 
 ovary and the os internum, by coming in contact with 
 the spermatozoa. Dr. Ritchie* of Glasgow believes, with 
 many other modern Physiologists, that the uterus itself 
 is the normal seat of conception. 
 
 * " Contributions to Assist the Study of Ovarian Physiology and Patho- 
 logy." By Charles G. Ritchie, M.D., &c, &c, p. 101. John Churchill & 
 Sons. 1865.
 
 SPERMATOZOA. 371 
 
 Now, if all this be so, it follows that the best time 
 to insure this fructification is within the ten clays follow- . 
 ing menstruation. This is the generally accepted doc- 
 trine in regard to the most fitting time for conception. 
 I have no doubt that conception may take place at any 
 period whatever, relatively to the return of menstrua- 
 tion ; but there is hardly a question that it occurs more 
 frequently within the ten days following this period. 
 I know of several instances in which it undoubtedly 
 occurred within the week preceding the expected return 
 of the flow. 
 
 Sir Joseph Olliffe and I sent a patient of ours to Spain, 
 in the spring of 1864. She had been under treatment 
 for menorrhagia for three or four months, and lived 
 entirely apart from her husband during the whole of 
 this time. They were ordered to live apart till she 
 should pass over one period in Spain. Everything went 
 on according to our prescription till about forty-eight 
 hours before the expected appearance of the flow, when 
 by accident, as sometimes happens, the injunction of the 
 doctors was momentarily forgotten, and the period did 
 not come at the expected time. Indeed, she conceived, 
 and in due time was delivered of a daughter. 
 
 The husband of a lady of great eminence, aged thirty, 
 the mother of three sons, the youngest three years old, 
 was absent in the Holy Land for five months, and re- 
 turned exactly five days before the expected recurrence 
 of his wife's menses. He spent but one night at home, 
 being suddenly called off for several days by some 
 urgent business. His wife conceived, and bore him a 
 daughter. 
 
 I had a lady, aged twenty-eight, nearly two months 
 under treatment for some cervical disease. The case 
 was treated entirely with tampons of cotton-wool, wet
 
 372 UTERINE SURGERY. 
 
 with glycerine, holding in solution various remedies, 
 such as tannin. When she was thought to be well 
 enough to return home, her husband came for her. I 
 wished to see if the secretions were normal. Sexual 
 intercourse took place, at my request, two days before 
 the expected return of menstruation. It did not appear. 
 She had conceived, and in due time a son was born. 
 
 I can vouch for the reliability of the parties alluded 
 to above. I have related these three cases to illustrate 
 the fact, that conception can and does take place just 
 on the eve of the approach of menstruation ; a thing, 
 by the bye, that is not denied. I could give several 
 reliable cases where the circumstances were such as to 
 prove that conception could only have occurred within 
 a week or ten days following the cessation of the flow. 
 
 When I was engaged in the philosophic experiments 
 of artificially introducing the semen into the cavity of 
 the womb, I had to make some fifteen or twenty essays 
 before I was satisfied of the quantity of semen to be 
 introduced, but as to the proper time for this I never 
 felt entirely sure. For those who are very anxious for 
 offspring, I usually order sexual intercourse on the third, 
 fifth, and seventh days after the flow has ceased ; and on 
 the fifth and third before its expected return ; and but 
 once on ench day. For the most obvious reasons this 
 should always be on going to bed at night, instead of 
 just before rising in the morning. The horizontal pos- 
 ture favours the retention of the semen ; the erect its 
 expulsion. I am satisfied that too frequent sexual in- 
 dulgence is fraught with mischief to both parties. It 
 weakens the semen. In other words, this is not so rich 
 in spermatozoa after too great indulgence ; and when 
 carried to the extent of a debauch, the fluid ejected may 
 be wholly destitute of spermatozoa. Thus it will be
 
 SPERMATOZOA. 373 
 
 seen that it 13 much better to husband the resources of 
 both man and wife. The sexual act should never be 
 done except at the spontaneous prompting of nature. 
 It is very curious to contemplate the bounties of nature 
 when we come to view the provisions made for fructifi- 
 cation, whether in the vegetable or animal kingdom. 
 We know that but little semen and but few spermatozoa 
 are needed for fertilizing the ovum. We see this in pis- 
 ciculture, and we may infer it in all creation. I do not 
 know that any one has ever thought of measuring the 
 quantity of semen ejected in the act of copulation, nor 
 do I know that it would be possible to arrive at this 
 point accurately ; but accident led me to make some ob- 
 servations on this subject, which I here place on record 
 as a matter of physiological interest, if not of therapeu- 
 tical importance. 
 
 In most women a considerable part of the semen 
 passes off with the completion of the copulative act, and 
 the separation of the sexes, while a large part of it re- 
 mains in the vagina to gradually ooze away. It has so 
 happened that I had two patients whose vaginas seemed 
 to hold almost all that they received. It has been my 
 duty to examine them a few minutes after coition, and 
 the perineum and nates appeared to be almost as dry as 
 if nothing of the kind had taken place. The quantity 
 of semen retained by the vagina seemed to me to be so 
 oreat, that I was induced on several occasions to remove 
 it with a syringe, and to measure it subsequently, and I 
 found that ordinarily there was about a drachm and ten 
 minims. Of course, this did not comprise all that was 
 deposited there, for a very considerable portion must of 
 necessity always be removed by the male, merely by the 
 attraction of cohesion. 
 
 It would be important to determine how long sper-
 
 374 UTERINE SURGERY. 
 
 matozoa can live in the matrix. On this point we need 
 more extended experiments, for I do not think that their 
 duration of life has } 7 et been fully established. Dr. S. 
 R. Percy,* of New York, reports a case in which he found 
 "living spermatozoa, and many dead ones," issuing from 
 the os uteri, eight and a half days after the last sexual 
 connection. During this time the husband of the pa- 
 tient had been from home. 
 
 I have examined the semen many times with the view 
 of determining this point, and think I can safely say 
 that spermatozoa never live more than twelve hours in 
 the vaginal mucus. But in the mucus of the cervix they 
 live much longer. At the end of twelve hours, while 
 all are dead in the vagina, there are but few dead ones 
 to be found in the cervix. When the cervical mucus is 
 examined from thirty-six to forty hours after coition, we 
 shall ordinarily find as many spermatozoa dead as alive. 
 But my observations on this point could not, under the 
 nature of things, be accepted as the rule, for they were 
 all made upon those who were, or had been, the subjects 
 of uterine disease in some form or other. 
 
 Here is the report of an observation made upon a 
 patient who is perfectly reliable: — "Sexual intercourse 
 at eleven p.m. on Saturday. A microscopic examina- 
 tion of the secretions was made on Monday, at three 
 p.m., just forty hours afterwards. The vaginal mucus 
 contained a few dead spermatozoa — none alive ; the cer- 
 vical mucus contained great numbers very active — a few 
 dead." 
 
 The above is copied from notes made at the time. I 
 saw no reason why many of these active spermatozoa 
 should not have lived for a still longer time. Many of 
 
 * American Medical limes, March 9th, 1861.
 
 SPERMATOZOA. 375 
 
 them lived six hours after their removal. This was in 
 July. 
 
 Before closing this subject, I shall give a few exam- 
 ples illustrating the best time for sexual congress after 
 menstruation, to insure conception. 
 
 A menstruation took place on the 7th and ended on 
 the 10th of the month. Sexual intercourse happened 
 once on the 11th. On the morning of the 12th, the 
 lady went to a sea-side watering-place, where she remain- 
 ed more than a month, leaving her husband at home. 
 She had always been regular, but her period did not 
 appear on the 5th of the following month as she expect- 
 ed. Fearing that the sea-bathing had something to do 
 with the non-appearance of the menses, she sent for a 
 physician, who ordered her to stop the baths, and gave 
 her some strong emmenagogues to provoke the flow, but 
 it did not come. The next period passed, and it was 
 found, greatly to her surprise, that she was pregnant. 
 She went the full time, and a son was born. 
 
 I operated on a lady, thirty years old, who had been 
 married fifteen years without offspring. I directed her 
 to have sexual intercourse on the third, fifth, and seventh 
 days after the cessation of the menses. She menstruat- 
 ed on the 8th of the month, ceased on the 12th, had 
 sexual intercourse on the 17th, and a son was born on 
 the 16th nine months afterwards. 
 
 In the case of uterine injection spoken of on page 368, 
 menstruation began on the 2d of the month, finished on 
 the 6th, sexual intercourse took place on the 12th, the 
 uterine injection was only five or six minutes afterwards, 
 and conception dated from that time. 
 
 Here, then, is one case where conception occurred on 
 the day after the flow ceased, and only four days from 
 the time it began ; another in which it probably took
 
 376 UTERINE SURGERY. 
 
 place five days after the flow ceased, and nine days 
 from the time it began ; and another in which it took 
 place six days after the flow ceased, and ten days after 
 it began. I might give other facts like the last two, but 
 I forbear. They accord very well with the received 
 doctrines of the day as to the proper time for concep- 
 tion, viz., about a week, more or less, after the cessation 
 of the flow. 
 
 I hope I have said enough to show that, for the pur- 
 pose of conception, "semen with living spermatozoa 
 should be deposited in the vagina at the proper time."
 
 SECTION Till. 
 
 THE SECRETIONS OF THE CERVIX AND VAGINA 
 
 SHOULD NOT POISON OR KILL THE 
 
 SPERMATOZOA.
 
 SECTION VIII. 
 
 THE SECRETIONS OF THE CERVIX AND VAGINA SHOULD 
 NOT POISON OR KILL THE SPERMATOZOA. 
 
 The vagina and the canal of the cervix each secrete a 
 mucus peculiar to itself. That of the vagina is acid; 
 that of the cervix very slightly alkaline. These secre- 
 tions become changed in character and consistence by 
 any inflammatory action set up in the glandular appara- 
 tus that gives rise to them. We shall consider their 
 deviations from a normal condition, 
 
 "1st. Of the vaginal secretions ; and 
 
 2nd. Of the cervical. 
 
 1. The vagina is subject to an inflammatory action, 
 which may arise from a specific cause or not. 
 
 Vaginitis is a most troublesome affection ; it matters 
 not from what caaje it originates. It usually has a spe- 
 cific origin, but it may arise spontaneously ; sometimes 
 it is secondary to some irritating discharge from the 
 uterus. Sir Charles Locock* says: "There is one ma- 
 terial point connected with leucorrhcea, and especially 
 where the discharge is purulent or of an acrid charac- 
 ter. In such instances it is well known that sexual in- 
 tercourse will often bring on a train of symptoms very 
 much resembling gonorrhoea in the male. This, when 
 occurring between husband and wife, has often led to 
 much domestic unhappiness, from the supposition of one 
 
 * a 
 
 Cyclopaedia of Practical Medicine," article Leucorrhcea.
 
 380 UTERINE SURGERY. 
 
 party or the other having contracted gonorrhoea from 
 impure connection." 
 
 I am unhappily able to substantiate fully all that is 
 here stated on this point by this distinguished authority; 
 for I have seen many cases of urethral inflammation in 
 the husband, that were unquestionably contracted from 
 the wife, who, however, had merely a leucorrhcea of an 
 acrid character. 
 
 The treatment of vaginitis is now reduced to great 
 simplicity. I have found Demarquay's plan to answer 
 admirably. It consists in introducing a tampon of cot- 
 ton or lint saturated with a solution of tannin in glyce- 
 rine, from two to four drachms to the ounce. This dress- 
 ing may be retained three or four days. According to 
 Demarquay, the average time of treatment by this 
 method is about a fortnight. 
 
 Recently Dr. John J. Black,* of the Philadelphia 
 Hospital, Blockley, has made some experiments in the 
 treatment of vaginitis with medicated suppositories that 
 produced most satisfactory results. He experimented 
 with persulphate of iron, alum, tannin, copaiba, and a 
 variety of other remedies, and arrived at the conclusion 
 that the suppository plan of treatment was superior to 
 all other methods in efficiency, cleanliness, portability, 
 and ease of application at any time, and without the aid 
 of instruments. Subjoined is one of Dr. Black's formu- 
 lae for their preparation : 
 
 3 01. Theobromae, 3 xii. 
 
 Morphias Sulph., gr. vi. 
 
 Liq. Ferri Persulph., gtt. cxliv. 
 
 Cerat. Adipis, 3 iij ss. 
 M Et fiant Suppositoria xii. 
 
 * American Journal of the Medical Sciences, No. XCIX. July ,1865, p. 63.
 
 VAGINITIS. 381 
 
 Of these, one is to be introduced into the vagina 
 every other day, except during menstruation. Dr. Black 
 says : " The average number of days required for the cure 
 was as follows : — Liq. ferri persulph., nine days ; alum 
 and tannin, nine days and a half; ol. copaibse, twelve 
 days; comp. iodine ointment, thirteen days; citrine oint- 
 ment, fourteen days ; chloride of zinc, nineteen days.' 1 
 The very strong preparations were inferior to the milder. 
 
 This is certainly far better than the old plan by ni- 
 trate of silver and vaginal washes, which was always 
 tedious and most unsatisfactory. I do not know that 
 vaginitis, properly speaking, is absolutely opposed to 
 the vitality of the spermatozoa. According to Donne 
 they live in pus and blood, and a variety of other fluids. 
 I have frequently seen conception to happen where the 
 cervix uteri was the seat of profuse suppuration, so that 
 pus, per 6-6, is no hindrance of this. The most trouble- 
 some obstacle of this sort is to be found, not in the 
 quantity but in the character of the vaginal secretion. 
 This, as before stated, should be slightly acid; if it is 
 very acid it kills the spermatozoa instantly. I have seen 
 many cases in which they were all dead within five or 
 six minutes after coition. In all these cases the vaginal 
 mucus was by no means abundant, but the surface of the 
 vagina always had a reddish look, and its papillae were 
 prominent. 
 
 By simply inspecting the surface of the vagina, and 
 testing the degree of acidity with litmus-paper, I have 
 sometimes been able to say that the vaginal mucus would 
 probably poison the spermatozoa. The blue litmus 
 should be slowly turned to a faint pink when the secre- 
 tion is normal ; but when it is abnormal, the litmus-paper 
 turns quickly to a deeper pink colour. I have seen con- 
 ception twice where the vaginal mucus poisoned the
 
 382 UTERINE SURGERY. 
 
 sperm atozoa. One was remedied by slightly alkaline 
 washes used before sexual congress. In the other it oc- 
 curred in this way. A lady, aged twenty-eight, was 
 married six years without issue. She had a contracted 
 os. It was incised ; but she did not conceive. She had. 
 an indurated cervix, the consequence of cystic disease. 
 For this she was under treatment for nearly two months. 
 It was cured ; and her husband came to take her home. 
 Wishing to see the character of the semen, I examined 
 the vaginal mucus four or five hours after coition. The 
 spermatozoa were all dead. On the next day I examined 
 them in five or six minutes afterwards, and could not find 
 one alive. I then placed in the vagina a small tampon 
 of cotton moistened with a little glycerine, which held 
 in solution some of the bicarbonate of soda (twenty 
 grains to the ounce). This application was repeated on 
 the next day. The cotton was tied with a string for its 
 easy removal. This was worn from about two o'clock 
 p.m. till eight the next morning. Its removal was fol- 
 lowed by connection. Living spermatozoa were after- 
 wards found in the greatest abundance. Indeed, there 
 were no dead ones at all. Conception dated from that 
 moment, being just two days before the expected return 
 of the menses, which, however, did not recur. There 
 had been no sexual intercourse for nearly two months 
 before. Labour came on at the fulness of time ; and 
 the delivery was safe. 
 
 According to Kolliker, the phosphate of soda is 
 peculiarly favourable to the movements of spermatozoa ; 
 and this would probably be a good application in such 
 cases as the above. But as yet I have had no experience 
 with it. 
 
 2. Of cervical leucorrhcea. 
 
 Dr. Bennet has done much for the treatment of the
 
 LEUCORRHXEA. 3g£ 
 
 diseases of the cervix uteri; and Dr. Tyler Smith's 
 contributions to the Pathology of Leucorrhcea* are 
 of the greatest importance. With these and the com- 
 prehensive treatises of West, of Churchill, of Hewitt, 
 and of McClintock now before us, and all fresh from 
 the press, I can here afford to pursue pretty much the 
 same course as that which I have followed all along, 
 viz., to give a few clinical illustrations of merely surgical 
 and manipulatory processes. 
 
 Cervical leucorrhcea may be a hyper-secretion from 
 the lips of the os, or from the cavity of the cervix. It 
 is almost always of albuminous consistence, and very 
 difficult of removal. Under the microscope it presents 
 the characteristics of muco-pus. Sometimes it is merely 
 an exaggerated secretion seemingly without any abnor- 
 mal qualities. It interferes with conception in two 
 ways — mechanically and chemically. Mechanically in 
 blocking up the canal of the cervix, and preventing the 
 passage of the spermatozoa ; chemically by poisoning 
 or killing them. I have frequently seen conception 
 happen while using the nitrate of silver for granular 
 erosion of the os and cervix uteri. Unless there is 
 some special reason for it, I never interdict sexual 
 congress during the treatment of ordinary cases of cer- 
 vical engorgement. Where conception has taken place 
 under these circumstances, I am satisfied that sexual 
 intercourse must have occurred within ten or twelve 
 hours after the use of the remedy, or at least before its 
 eschar began to separate, which is always attended with 
 a secretion of muco-pus that would be fatal to the 
 spermatozoa. 
 
 * "The Pathology and Treatment of Leucorrhcea." By W. Tyler 
 Smith, M.D., Professor, &c, 1855.
 
 334 UTERINE SURGERY. 
 
 Nitrate of silver will probably retain the good repu- 
 tation it has acquired in the treatment of granular 
 erosions of the cervix. In some cases it unfortunately 
 provokes haemorrhage, and this is one of the objections 
 to its use. Dr. Wright,* of the Samaritan Hospital, 
 has recently called the attention of the profession to 
 the use of a compound of the iodide and nitrate of 
 silver as they exist in u an old photographic nitrate- 
 ba:h, still bright and clear, but which had been so long 
 worked that it had become saturated with iodide of 
 silver, and contained a considerable amount of ether." 
 Accident led him to the use of this preparation, and 
 he has found it far more efficacious in the various 
 forms of stomatitis and analogous affections of the 
 uterus than the more concentrated solutions of the pure 
 nitrate of silver. Dr. Gibb has also used it topically 
 with marked benefit in affections of the throat and 
 larynx. This " old bath solution " may be obtained of 
 any respectable photographer. 
 
 I know of no caustic application of more value in 
 these cervical engorgements than the chromic acid, as 
 already set forth on page 43. 
 
 Potassa cum calce I now seldom employ, and think 
 it should be used with great caution. In the practised 
 hands of such men as Bennet and Tilt I have no fear of 
 it. We know very well that we can by long experience 
 acquire a tact in the management of powerful remedies 
 whereby they are perfectly harmless. Any one must 
 have been struck with this fact who has followed the 
 distinguished surgeon Jobert (de Lamballe) through 
 his wards in the Hotel Dieu, and seen with what skill 
 
 * The Lancet, March 18, 1865, p. 282 : * The Topical Use of Silver Solu- 
 tions." By Henry G. Wright, M.D.
 
 LEUCORRHCEA. 3§5 
 
 he wielded the potential cautery in the kind of cases 
 that we are now considering. 
 
 There are many hypertrophied and granular condi- 
 tions of the cervix that obstinately resist all local stimu- 
 lating, or escharotic applications. Scanzoni recommends 
 excision or amputation of the affected portion when this 
 is the case. For many years I have been in the habit 
 of doins: this, and have thus often cured cases in a week 
 or a fortnight that had been uuder treatment for months 
 without improvement. 
 
 Vaginal washes are of some importance in the con- 
 ditions of the cervix that give rise to leucorrhoeal dis- 
 charges. They are to be made with a syringe that is 
 capable of throwing in a sufficient quantity of water 
 without fatigue to the patient. Solutions of alum, of 
 zinc, of lead, of iron, of tannin, and of other astringent 
 remedies, may be used from time to time. We should 
 never use cold vaginal washes. I am sure I have seen 
 great harm produced by them. They are valuable in 
 controlling leucorrhoeal discharges, but they favour to a 
 great degree the production of an indurated condition 
 of the cervix, which is to be avoided if possible. Vagi- 
 nal injections should always be tepid, let them contain 
 what they may in solution. 
 
 It has been thought that they could produce but 
 little effect on the condition of the cervix ; but this is a 
 great mistake. Remedies thus applied act by osmosis, 
 and produce not only a local, but, in some instances, a 
 constitutional effect. I have often heard patients com- 
 plain of the taste of tannin a few minutes after its 
 application to the cervix uteri. It might be supposed, 
 that this was an effect of imagination, or that the 
 odour of it was confounded with the taste. But this 
 could not be so, when the application was made without 
 
 25
 
 g36 UTERINE SURGERY. 
 
 the patient knowing what it was ; and if the scent of 
 it was mistaken for the taste, the mother, or aunt, or 
 nurse present would have been as liable to be thus 
 deceived as the patient, which was never the case. 
 I am perfectly satisfied that I have known patients 
 to experience the taste of tannin in the mouth only 
 two or three minutes after it was applied to the cervix 
 uteri. 
 
 Great care is necessary in the use of the syringe. 
 How often have I seen vaginal injections given without 
 their ever reaching the posterior cul-de-sac ; occa- 
 sionally not even the anterior. Why any one should 
 ever have made a curved vaginal tube I cannot under- 
 stand ; and yet we find them in all the shops. If a 
 curved tube be introduced into the vagina with its con- 
 cavity upwards the distal end will strike against the 
 anterior wall of the vagina before it reaches the cervix 
 uteri ; if, on the contrary, it be turned backwards, it 
 will as invariably rest upon the posterior wall of the 
 vagina without passing under the cervix, and in either 
 case it fails totally in the object of its use. A vaginal 
 syringe tube should be about the size of the little finger, 
 and full four inches long. The patient should be taught 
 to use it for herself. It should be passed into the 
 vagina, and directed downwards and backwards as if it 
 were to be passed in the direction of the os coccygis. 
 It should be pushed gently on almost by its own gravity, 
 if the patient is in the recumbent posture, till it seems 
 to be arrested by an elastic resistance, which is the 
 posterior cul-de-sac. We shall then know that the 
 end of the tube is under and beyond the cervix uteri. 
 
 When we, then, begin to inject the water, we shall 
 feel confident that it will in its regurgitation bring away 
 wb^tfver secretions may be lying in the vagina, whether
 
 VAGINAL INJECTIONS. 33 7 
 
 high up or low down. We cannot be too careful in oui 
 directions about the use of vaginal washes, for if not 
 properly applied they may not only fail to accomplish 
 all that we expect from them, but they may produce 
 most painful if not dangerous consequences. We all 
 know what a serious matter it once was to throw the 
 blandest fluid into the cavity of the uterus ; indeed, 
 many of us had altogether given up the practice of 
 injecting this cavity with any fluid whatever till Dr. 
 Savage showed how safe it was after the dilatation of 
 the os internum by sponge tents. The accident that I 
 allude to as sometimes happening from the use of the 
 vaginal syringe is that of suddenly throwing a jet of 
 water forcibly into the cavity of the uterus, which pro- 
 duces a dreadful uterine colic, attended with the -most 
 distressing symptoms of prostration. "No man who has 
 unfortunately witnessed the perfect collapse following 
 such an occurrence, whether bv accident or design, can 
 ever forget the feeling of dread that seized his own soul 
 as he saw his patient launched in a moment from a com- 
 parative state of ease and comfort into the very jaws of 
 death, as it were. I have never known any one to die 
 as a consequence of uterine injection, but he is a rash 
 man who runs the risk of his patient's life after once 
 witnessing the painful results of such a thing under the 
 old regime. 
 
 The uterine colic accidentally produced by the self- 
 injecting syringe has always happened under my obser- 
 vation in cases of retroversion. In these, the os tincse 
 presented in the line of the axis of the vagina ; the end 
 of the tube entered the open os, and the water was 
 thrown directly into the cavity of the uterus. It is, 
 therefore, most important in cases of retroversion, to 
 teach the patient the art of using the syringe properly
 
 388 UTERINE SURGERY. 
 
 and safely as well as efficiently. To prevent any acci- 
 dent it would be well to close the little hole in the end 
 of the tube, leaving the lateral ones open. 
 
 Amongst other vaginal washes for cervical secretions, 
 I must not omit to mention Dilute Hydrochloric Acid. 
 I gave Mr. Swann, of Paris, several samples of muco- 
 purulent albuminoid-looking secretions from the cervical 
 cavity, for experimental observation, and he found that 
 dilute hydrochloric acid was the only chemical capable 
 of dissolving it, that could be used locally as a wash. 
 Where there is no vaginal irritation or epithelial abra- 
 sion, this may be used with advantage according to the 
 following formula : — 
 
 5 Dilute Hydrochloric Acid, § j. 
 . Distilled water, § vij. 
 
 A tablespoonful in a pint of tepid water to be thrown into the vagina 
 night and morning. 
 
 But vaginal injections are only adjuvants of treat- 
 ment. We cannot depend upon them wholly for cura- 
 tive results. They are valuable in their way, and not to 
 be ignored. I know of nothing more difficult of cure 
 than an old cervical leucorrhcea ; and notwithstanding 
 the vaunted success of this or that remedy, I fear that 
 the young practitioner will often be disappointed in their 
 application. 
 
 Professor Courty, of Montpelier, foiled in the treat- 
 ment of cervical leucorrhcea by the ordinary routine, 
 resorted to the expedient of leaving a bit of nitrate of 
 silver in the canal of the cervix for several days, and 
 describes good results from it. Dr. Simpson has lately 
 been applying various remedies in the vagina in the form 
 of suppositories, made of the butter of cocoa. I have
 
 VAGINAL INJECTIONS. 339 
 
 recently had made little suppositories of cocoa butter, an 
 inch and a quarter long, and small enough to pass along 
 the cervix, medicated with various remedies so as to 
 bring these into permanent contact with the diseased 
 surface. - For instance, I have had them made, contain- 
 ing severally morphine, atropine, alum, tannic acid, 
 persulphate of iron, &c, in appropriate doses, and think 
 they promise very satisfactory results. 
 
 A very convenient way of applying remedies topi- 
 cally to the cervix uteri is that introduced, I believe, by 
 Kiwisch, of using a tampon of cotton or lint, saturated 
 with a solution of the remedy to be so used. I have for 
 a long time adopted this plan, and have every reason to 
 be satisfied with it. 
 
 If I were asked what next to mere mechanical 
 obstruction of the cervix uteri constitutes the greatest 
 obstacle to conception, I would have no hesitation in 
 saying that it was an abnormal secretion from the 
 cervix. 
 
 We often see the cervical mucus in such large quan- 
 tities that its mere abundance will mechanically prevent 
 the passage of the semen to the cavity of the uterus. 
 Sir Joseph Olliffe has informed me of the case of the 
 wife of a medical man, who had been sterile for many 
 years, and whose cervix uteri always presented a little 
 mass of ropy mucus hanging from the os that obstructed 
 mechanically this canal. At last, the doctor had the 
 rational surgical idea to exhaust the cervix of its inspis- 
 sated mucus, and sexual congress with his wife immedi- 
 ately afterwards was followed by conception. 
 
 I knew but little about the effects of the mucous 
 secretion of the vagina and the cervix upon the vitality 
 of the spermatozoa until within the last three or four 
 years; and I am now satisfied that the cervical secre-
 
 390 UTERINE SURGERY. 
 
 tiou is often poisonous to the spermatozoa, even when it 
 would seem to be almost normal in appearance. This 
 must depend upon some other quality than mere alka- 
 linity, for I have often found all the spermatozoa in the 
 cervical mucus dead while it manifested no unusual 
 degree of alkalinity when tested by litmus-paper. But 
 when placed under the microscope it showed an uncom- 
 mon number of epithelial scales. This demonstrated 
 an abnormal action in the glandular apparatus that 
 gave rise to this secretion, which seemed to kill the 
 spermatozoa more by its density than by its chemical 
 action ; for I have noticed that they lived longer in 
 that portion of the mucus that had the fewest number 
 of epithelial scales ; and, vice versa, died quicker in 
 that portion that had the most; and that, too, when 
 litmus-paper showed no difference in the chemical 
 character of the two. 
 
 In these cases^ in almost every instance after the use 
 of a sponge-tent, for six or eight hours I have been able 
 to detect by the sense of touch a small gristly growth 
 at some point in the course of the canal of the cervix 
 that was evidently the seat of this abnormal hyper- 
 secretion. Sometimes this is confined to a single spot ; 
 again, it may be spread over a surface of greater or less 
 extent. Occasionally the whole of the lining membrane 
 of the canal may be a muco-pyogenic surface. What 
 are we to do when this is the case? As said before, I 
 know of nothing more difficult to remedy. Professor 
 Courty's plan of prolonged cauterization may hold out 
 some hopes of a cure ; or the method of intra-cervical 
 suppositories already alluded to may be of service. But 
 I am disposed to believe that we shall do better by ignor- 
 ing caustics and caustic applications altogether, and 
 resorting to some method of modifying this secretory
 
 ENDO-cfiitvicms. 391 
 
 surface by pressure. My countryman, Professor By ford* 
 speaking of Endocervicitis, says : " A bougie of slippery 
 elm large enough to fill the cervical cavity, introduced 
 as high as the inflammation extends, and allowed to re- 
 main for twenty-four or thirty-six hours, not only prepares 
 the way for other applications, but favourably modifies 
 the disease by its pressure upon the capillaries. The 
 use of the stem pessary proves beneficial too, I think, in 
 some instances, on account of the stem pressing upon the 
 inflamed part inside the cavity of the cervix, and thus 
 changing the character of the capillary action." 
 
 I am quite prepared to accept Professor Byford's 
 teachings on this point, for I have known many cases of 
 conception to follow the use of the intra-uterine stem, 
 and I have now but little doubt that its curative action 
 was more in relieving that condition of the cervical 
 membrane that gave rise to abnormal secretions, than in 
 merely mechanically dilating the os internum. 
 
 I have, in the early part of this volume, objected to 
 the use of the intra-uterine stem ; but there is a modifi- 
 cation of it by Dr. Greenhalgh that I have occasionally 
 used with good results. Its advantage over its proto- 
 type is, that it is tubular and self-retaining. It allows 
 the secretions from the cavity of the uterus to pass 
 through it, and at the same time it is not so liable to 
 slip out. 
 
 Fig. 142 represents the instrument of full size. It is 
 from two to two inches and an eighth lon^. It is intro- 
 duced with the wings drawn into a straight line by 
 means of a stilet, as shown in the figure. As soon as 
 
 * " The Practice of Medicine and Surgery, applied to the Diseases and Ac- 
 cidents incident to Women." By Win. H. Byf'ord, M.A., M.D., Professor, 
 &c. Philadelphia: Lindsay & Blakiston. 1865. Page 262.
 
 392 
 
 UTERINE SURGERY. 
 
 it is passed to the requisite depth, the stilet is with 
 drawn ; the wings spring back within the cavity of the 
 fe /^l ^ uterus ; the os internum grasps the instru- 
 ment at its bifurcation, and the lower end 
 rests against the os tincse. Of course, this 
 instrument can only be used after an in- 
 cision of the cervix or a dilatation of it 
 by a sponge or a sea-tangle tent. It may 
 be made of steel and silver plated ; but I 
 prefer it of vulcanite.* 
 
 I have seen cases in which this instru- 
 ment was worn with great comfort ; and 
 again I have seen others that could not 
 tolerate its presence for a moment. In 
 these last we shall find the cause of into- 
 lerance to be an endo-rnetritis which had 
 not, perhaps, been suspected before. Dr 
 Coghlan'sf plan of using a tube of sheet- 
 lead I have found to answer a very good 
 purpose. 
 
 I have not been able to arrange any 
 apparatus for withdrawing in an isolated form the secre- 
 tions of ;the cavity of the uterus for microscopic and 
 chemical examination. It is highly probable that this 
 will be done at some time or other, and w r e shall then be 
 able to determine more about the condition of its secre- 
 tions as influencing the life or death of the spermatozoa. 
 We have already made great advances in studying the 
 effects of the vaginal and cervical secretions upon them ; 
 
 Fig. 142. 
 
 * Made by Mayer, of Great Portland Street ; also by "Weiss. 
 
 f " On Dysmenorrhcea and Sterility ; with Wood-cuts of New Instru- 
 ments." By John Oghlan, M.D. Medical Times and Gazette, 1861, '62, 
 and '64.
 
 ENDOCERVTCITIS. 393 
 
 and I belong to that sausmine class of medical mea who 
 look forward with great Lope to enlarged views and 
 more certain methods, not only in this but in every 
 department of medicine. 
 
 I have said a good deal about semen and its exami- 
 nation, and it is time that I should say something about 
 the measures preparatory to this. Suppose we wish to 
 examine the vaginal mucus soon after coition — say with- 
 in an hour; we direct the patient to empty the bladder 
 before the act, and to retain quietly the recumbent pos- 
 ture after it. The dorsal decubitus is the best. To re- 
 move a few drops of the contents of the vagina, pass the 
 index finger into it, press the posterior wall downwards 
 and backwards, just under the cervix uteri ; hold it so 
 for a minute or two ; the semen will necessarily gravitate 
 to the pouch made by this pressure ; then introduce the 
 nozzle of the syringe along the finger; let it project 
 slightly over the end of the finger-nail, and it will be 
 easy enough to obtain what we want if there is any se- 
 men in the vagina. I am thus minute in explaining this 
 simple operation, because we may fail in it entirely, even 
 when the vagina contains large quantities of semen, if 
 we neglect these miuutiae. And in this way. If we 
 pass in the syringe in a haphazard manner, and begin to 
 draw the piston, the mucous membrane of the vagina is 
 sucked up into the end of the tube, and thus it is possible 
 for us to slide it around in various directions, without 
 getting a drop of mucus of any sort. But suppose we 
 fail even with properly directly efforts; then the left 
 lateral position and my speculum will in a moment show 
 us the whole of the contents of the vagina, and we can 
 with the svrin^e remove what we want. 
 
 When we wish to examine the cervical mucus, we 
 should resort at once to the speculum and the proper
 
 39-1 UTERINE SURGERY. 
 
 position. It is well enough, then, to sponge away all 
 the mucus from the vagina, and especially from about 
 the cervix uteri. We then pass the nozzle of the syringe 
 just within the os tincse, and draw up a drop of its mu- 
 cus. To do this it is necessary first to pull the cervix 
 forwards, so as to be able to look into it and to see ex- 
 actly what we are doing. If the cervical mucus is very 
 tenacious we may fail to get it away. Then it will at 
 the next attempt be necessary, after introducing the 
 syringe, and drawing up the mucus, to pass the left in- 
 dex finger to the edge of the os tincse, and slide the end 
 of the syringe on to the end of the finger without raising 
 it from the surface of the cervix, or breaking its suction 
 power. This may seem to be a little thing to describe 
 so minutely, but really it is a most important matter to 
 know and to do, if we expect to be exact in our investi- 
 gations. The nicety of this manipulation renders it the 
 more important for us to clear away all the vaginal mu- 
 cus before we undertake it, lest we get some of this 
 drawn up into the syringe, which would, of course, mar 
 the precision of our observations. 
 
 Suppose we succeed in this; then we may wish to 
 pass the syringe up for an inch into the cervix to get a 
 portion of mucus nearer the cavity of the uterus. This 
 operation is quite as delicate and quite as important as 
 the first, and is to be conducted in the same way. There 
 is an object in having the end of the syringe bulb-shaped, 
 as represented in fig. 140. This bulb fills up the os or 
 the canal of the cervix, and prevents the air from beino- 
 drawn into the instrument, as sometimes happened with 
 me when it was slender and more pointed. For carry- 
 ing a fluid of any sort into the cavity of the uterus, 
 of course we need the nozzle of the syringe more 
 like that represented in fig. 141 ; but for remov-
 
 CERVICAL MUCUS. 395 
 
 ing anything from the cervix the bulb form is the 
 best. 
 
 As illustrating the exactness and the importance of 
 this method of investigation, I will give an example. 
 
 Dr.JFauvel, the distinguished laryngoscopist, of Paris, 
 requested me to see a patient of Ins, who had been 
 married twice, and had had one child by the first mar- 
 riage ; none by the second. She was thirty-five years 
 of age, the picture of good health, and menstruated 
 regularly and normally. The uterus was slightly ante- 
 verted. She had no leucorrhcea, properly speaking ; but 
 the cervical mucus seemed to be slightly in excess of a 
 normal quantity. What was the cause of her persistent 
 sterility for the last eight years, and, indeed, for the last 
 four years of her first marriage ? 
 
 The questions to be answered were, Was the semen 
 normal? Did the secretions of the vagina or cervix 
 poison the spermatozoa ? Did these enter the canal of 
 the cervix ? 
 
 The vagina was examined an hour after sexual inter- 
 course. Its mucus contained living spermatozoa in 
 abundance. The cervical mucus was full of them, but 
 they were all dead. 
 
 On another occasion, a microscopic examination 
 made but a few minutes (eight or ten) after coition, 
 proved that the mucus of the cervical canal was full of 
 dead spermatozoa, while in the vagina they were living. 
 Here the litmus test was valueless; but the microscope 
 demonstrated a superabundance of epithelial casts, the 
 result of a slightly congested condition of some portion 
 of the lining membrane of the cervix. 
 
 As said before, all abnormal secretions from the va 
 gina have been classed under the generic term leucor- 
 rhoea, whether they emanate from the vagina, from the
 
 396 UTERINE SURGERY. 
 
 canal of the cervix, or from the cavity of the uterus. 
 Having already hurriedly glanced at the conditions of 
 the first two that ordinarily give rise to such discharges, 
 it only remains to notice those of the third, — viz., the 
 cavity of the womb. We all know that muco-pus is the 
 almost constant accompaniment of polypus, but as this 
 has already been the subject of discussion we have here 
 nothing more to say on it. 
 
 The cavity of the uterus sometimes becomes a regu- 
 lar abscess, as it were. This condition has been particu- 
 larly described by Dr. J. Matthews Duncan, of Edin- 
 burgh. 
 
 Dr. West* (p. 137) says, "A peculiar form of uterine 
 leucorrhoea, limited in its occurrence to the aged, and 
 associated with dilatation of the cavity and atrophy of 
 the walls of the uterus, has been described by Dr. Mat- 
 thews Duncan, in the Edinburgh Medical Journal, 
 March, 1860. Its characteristic symptoms appear to 
 be peculiar lumbar and pelvic pain, accompanied by a 
 sense of constriction, and the discharge of muco-pus. 
 Its cure seems to require the dilatation of the contracted 
 internal os by the sound, and the application of nitrate 
 of silver to the interior of the womb. I believe that I 
 have met with this condition on one or two occasions ; 
 but the patients, having their minds relieved with refer- 
 ence to the existence of uterine cancel', preferred putting 
 up with the discomfort to submitting to treatment for 
 its cure." 
 
 I have seen one well-marked case of this sort. The 
 patient was about sixty years of age, and had had a 
 purulent discharge from the vagina for twelve months or 
 
 * " Lectures on the D seases of Women." By Charles West, M.D., Fel- 
 low, &c. Third Edition 1864.
 
 ENDO-MfiT-CTTIS. 
 
 39* 
 
 more. She was the mother of a large family of grown- 
 up children, and had ceased to menstruate at about forty- 
 five. The discharge from the vagina was pure pus; and 
 it had almost a cancerous odour. On examination, I 
 fouud the vagina full of pus, and it3 whole surface and 
 that of the cervix were excoriated and granular. The 
 uterus was retroverted, and of rather unusual size for 
 the period of life. I did not detect the true nature of 
 the disease for some time; not till I had succeeded in 
 restoring the vagina and the cervix to a perfectly healthy 
 condition. Then I discovered that the os, which was 
 very small, gave issue to a slight though constant dis- 
 charge of pus, and that this was the cause of the vagi- 
 nitis, which I had mistaken for and treated as the origi- 
 nal disease. The cervical canal was very narrow, flexed, 
 and contracted at the os internum, so that the uterus, a3 
 it was bent backwards, always held about an ounce of 
 pus. As the first step in the treatment, the cervix was 
 dilated ; the pus was then evacuated ; the cavity of the 
 uterus was washed out with warm water, injected through 
 a tube small enough for the stream of water to regurgi- 
 tate easily by its side ; and then the pyogenic cavity was 
 injected sometimes with the Tr. of Iodine, and some- 
 times with a solution of the Persulphate of Iron. The 
 patient soon began to improve, and was finally cured. 
 
 We can thus medicate the cavity of the uterus with 
 the greatest safety, if we are only careful to provide an 
 easy retrogression of the injected fluid, either by the 
 sponge-tent, or by forcible instrumental dilatation with 
 Priestley's or Ellis's dilator or some modification of 
 these. 
 
 Endo-metritis has recently been the subject of con- 
 siderable investigation. Scanzoni, Routh, and others, 
 have written much upon it; Dr. Hall Davis has ex-
 
 398 UTERINE SURGERY. 
 
 bibited, at the Pathological Society, the uterus of a 
 woman who died of this affection ; and Dr. Oldham 
 has shown me a number of valuable specimens in the 
 extensive Museum of Guy's Hospital illustrative of the 
 varieties of this disease, which may exist in various 
 degrees of intensity, from a merely congested and 
 eroded state of the uterine mucous membrane to the 
 extent of great disorganization. 
 
 General constitutional remedies are, of course, in- 
 dicated, but are here never of any great value without 
 local treatment. Nothing in uterine disease is more 
 difficult to remedy than endo-metritis. The first great 
 principle to guide us is that of insuring a very free 
 exit from the cavity of the uterus for the secretions 
 therein generated. The second is that of appropriate 
 local applications to this cavity for the purpose of 
 modifying or healing, as it were, its diseased surface. 
 Where the canal of the cervix is contracted, I have 
 freely divided it, as in cases of dysmenorrhcea depen- 
 dent upon mechanical obstruction ; and this with great 
 relief. Indeed, while menstruation continues, it is 
 almost impossible to treat successfully a case of endo- 
 metritis, without adopting this principle of practice in 
 some form. The uterine secretions must not remain 
 pent up in its cavity. With a patulous cervix, we may 
 use medicated injections, or apply nitrate of silver in 
 ointment, as recommended and successfully done by 
 Professor Fordyce Barker, of New York. There is a 
 mild form of endo-metritis that seemingly gives rise to 
 no secretions whatever, which, nevertheless, is attended 
 with great suffering, and often passes unnoticed, or 
 rather undetected for a long time. Dr. Routh has 
 particularly noticed this form, and calls it fundal endo- 
 metritis. We can diagnose this with great accuracy.
 
 ENDOMETRITIS. 399 
 
 Place the patient in the left lateral semi-prone position ; 
 introduce the lever speculum, hook a tenaculum slightly 
 in the anterior lip of the os tincse; draw this gently 
 forwards, pulling the os open so as to be able to look 
 right into it ; then pass the sound, previously warmed, 
 gently along the cervix, using no force whatever, but 
 almost letting it go by its own gravity, as it were, to 
 the fundus. This is attended with no pain whatever till 
 the sensitive point be reached, when it produces the most 
 intense agony, a pain that does not cease sometimes for 
 hours after the experiment. I have seen many cases of 
 this sort. And I now call to mind a most accom- 
 plished lady from one of the Southern States who had 
 been married for six or seven years without issue ; and 
 who, soon after marriage, passed into a state of chronic 
 bad health, and became a confirmed invalid. For three 
 or four years she did not pretend to walk ; and was 
 always carried from the house to the carriage whenever 
 she drove out. Indeed her time was spent mostly in 
 bed or on a lounge. Fortunately she was able to eat, 
 and so her strength and embonpoint were kept up in 
 spite of her sufferings. Her greatest agony was to he 
 found in a never-ceasing pain in the left hip about the 
 joint. She had a granular erosion of the os and cervix, 
 attended with a leucorrhceal discharge, which were 
 cured in the course of two months. But the pain in 
 the left hip, and her utter inability to walk, continued 
 in spite of all we did. Thinking that the diseased con- 
 dition of the cervix was the principal source of all her 
 troubles, and that the pain in the hip furnished merely 
 an example of Sir Benjamin Brodie's hysterical joint, 
 I had made no further uterine explorations, and was 
 quite surprised to find my patient no better in any 
 particular after the cervical erosion and its discharge
 
 400 UTERINE SURGERY. 
 
 were cured. And now, for the first time, I explored 
 the cavity of the uterus. When the sound passed 
 the os internum my patient complained of intense 
 agony, but almost the whole of it was referred to the 
 left hip. 
 
 Dr. Alonzo Clark was called in consultation, and 
 agreed to the line of treatment to be adopted, viz., 
 that of applying remedies to the uterine cavity. The 
 canal of the cervix was dilated, and the disease, with 
 its painful symptoms, was perfectly cured in a few 
 weeks, simply by injecting the cavity of the uterus 
 with a few drops of glycerine two or three times a 
 week. This was in 1858. In the course of a year after 
 this, our patient became a mother and has had other 
 children since. 
 
 Mr. Holmes Coote and Dr. Greenhal^h are at this 
 moment attending a case of endo-metritis with me, 
 where the pain is almost wholly in the left hip and left 
 inguinal region. By touching even the canal of the 
 cervix with the sound in the gentlest manner possible, 
 a most intense pain shoots at once to the left hip and 
 groin. Here there is not only pain but tumefaction of 
 the affected parts, as we often see in some forms of 
 hysterical hyperesthesia. 
 
 A short time ago, I saw a patient with Dr. Thierry- 
 Meig, in Paris, who, besides other evidences of uterine 
 trouble, complained greatly of pain in the left ovarian, 
 left mammary, and epigastric regions. Her symptoms, 
 as a whole, all pointed to the uterus as their origin ; 
 but a superficial examination failed to demonstrate their 
 relationship. The position of the organ was normal ; 
 there was apparently no hypertrophy of the fundus ; 
 there was no leucorrhcea, and no engorgement of the 
 cervix; but by placing the patient in the proper
 
 ENDOMETRITIS. 401 
 
 position, and making the exploration of the cavity as 
 above directed, the gentle passage of the sound along 
 the canal of the cervix was attended by a sudden ex- 
 udation of blood in small quantity, and a severe pain, 
 which became more severe as the sound reached the 
 fundus uteri, from which point the pain radiated to 
 the other foci of suffering above indicated. The exuda- 
 tion of a small quantity of blood, by the passage of the 
 sound along the canal of the cervix, is a common sign 
 of subacute inflammation of the utero-cervical canal. 
 
 In this case a single sponge-tent, followed by the 
 injection of half a drachm of the officinal Tr. of Iodine, 
 produced almost complete relief at once. A repetition 
 of the same, ten or twelve days afterwards, produced a 
 perfect cure. For the past two years this patient had 
 been under the treatment of several other physicians, 
 without the least benefit. 
 
 I think it highly probable that many unexplained 
 neuralgic pains may yet be found out to be symptomatic 
 of some slight eudo-metritic alfection ; of which the 
 case last mentioned may be taken as a type. 
 
 It is very probable that when we shall turn our 
 attention more to the investigation of the condition of 
 the cavity of the womb, we shall be able to detect, to 
 explain, and to remedy its abnormal states with as 
 much certainty as we now treat many affections of the 
 cervix and its canal. 
 
 In many cases in which the spermatozoa are found 
 to die quickly in the canal of the cervix, the real source 
 of the mischief may yet be found to exist in the cavity 
 of the uterus. 
 
 26
 
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