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CLINICAL NOTES

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.

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.

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.

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,

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.

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.

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.

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.

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.

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.

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

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.

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

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_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.

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

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.

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

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.

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

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.

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.

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

WAV is

,;Vi ' ii'l

ft', 1 '
W;WJ,

Fig. 18.

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.

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.

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

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

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.

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.

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.

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

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.

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.

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\

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.

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

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.

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.

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.

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.

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

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.

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.

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-

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.

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

15
41

20
8
3

• • • •

14
46

53
3

1 was sacral

2 were on the posterior

Total

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)

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.

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

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-

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

7
2

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

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.

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

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 . . .

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

■ 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

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

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.

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

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>

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

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,

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,

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.

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

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

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.

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.

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 ;

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

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.

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