Pathology, diagnosis and treatment of the diseases of women

Front matter

CORNELL UNIVERSITY

MEDICAL LIBRARY

ITHACA DIVISION.

Preface

. TO

THE FOURTH EDITION.

Ten years have elapsed since the last edition of this work was published. What I have gained from observation and experience during those ten years has been here faithfully and truly set down.

In the last edition of this work I endeavored to enunciate and demonstrate certain general principles as to the pathology of diseases of the uterus, more especially to show that the changes in the shape and position of the uterus are directly or indirectly responsible for the sufferings and discomforts attendant on the affections peculiar to the female sex. ■ The conclusions expressed ten years ago have been tested and verified by subsequent experience; and additional facts and observations on this subject will be found in this volume.

I have, however, in the present edition advanced a step further, and have explained, to my own satisfaction at all events, how and why it is that changes in the shape and position of the uterus are so liable to occur: what, in short, are their predisposing causes. An extended experience has enabled me to submit a further and, as I consider, a naost important generalization on the subject. What I have to say, in fact, amounts to this, that alterations in the shape and position of the uterus are rarely witnessed except in individuals whose general strength has become seriously impaired by a systematic, and often a lengthened, practice of taking little fo.od. The term " chronic starvation" appropriately designates this condition; and a long course of observations has convinced me that it is a most important factor in the production of the class of diseases above alluded to.

vi PREFACE TO THE FOURTH EDITION.

These considerations are fundamental in regard to the subject of the pathology of the uterus, and they underlie all that is to be said, or that can be said, on the matter. In the present work, much attention >.as been bestowed on the development and application of the above-mentioned principle, which is, of course, nothing more or less than this — the dependence of /^^fl/ ailments on general ones. If there be nothing very novel in this doctrine, it may be at all events of some service to giye it, in a more precise manner than has hitherto been attempted, a definite application to the class of maladies treated of in this work.

The question as to the nature of Hysteria and Hysteroepilepsy has much occupied my attention, and the present volume contains a collection of observations on the subject, together with deductions, which I submit to the candid and dispassionate consideration of my readers.

An important class of cases are those in which Pregnancy is associated with Flexion of the Uterus. This is a subject of great interest, as also a cognate one, viz., the cause of the^Vomiting of Pregnancy. In the present volume will be found essays on these subjects, and an accumulation of evidence in the shape of cases in proof of the truth of the doctrines I some years ago enunciated on this latter question.

A considerable number of new illustrations have been added to the new edition; and most of the new figures representing flexions and displacements of the uterus are drawn life size, and the various mechanical appliances for their treatment are drawn the actual size of the instruments, with the view of rendering the descriptions and directions for treatment more explicit and less liable to misinterpretation.

The greater part of this new edition has been re-written.

G. H.

36 Berkeley Square, October, 1883.

CONTENTS OF VOL. I.

Chapter I

t

GENERAL CONSIDERATIONS RESPECTING THE DISEASES OF THE SEXUAL ORGANS IN WOMEN.

Relations Subsisting between General and Local Diseases. — Importance of Maintenance of proper Nutritional Power as affecting the General Condition of the Patient — Nutritional Weakness of the Uterus a Cause of Softness of the Uterus, and an Important Factor in causing other Diseases of the Organ — Relative Importance of Affections of the Uterus and the Ovaries. -Pag' 33

Chapter II. Natural History Of The Uterus And Ovaries

Natural History of the Uterus. — Effects of Menstruation — Pregnancy — Sexual Intercourse.

Ovaries : Phisnomena of Menstruation and Ovulation. — Vascular and Erectile Apparatus of Female Sexual Organs: Bulb of the Vagina: Bulb of. the Ovary — Mechanism of Ovulation — Rouget's Researches — Menstrualion — Recent Researches by Kundrat. Engelmann, Williams and Leopold as to the Nature of Menstruation — Source of the Blood — ■ Phenomena observed — Age — Periodicity, Duration, Quantity, and Quality of the Discharge 37

Chapter III

examination of the uterus and ovaries.

Digital Examination of the Uterus from the Vagina. — Position of the patient.

Double Examination of the Uterus.

Digital Examination of the Os Uteri and of the Vaginal Part OF the Cervix Uteri. — Normal Condition of the Os and Cervix — Method of Examination — Apparent Absence of the Os Uleri; various Causes — Unusual Softness of the Os Uteri from Pregnancy or olher Causes — Unusual Hardness of the Lips of the Os Uteri; its Causes — ■ Size of the Os Uteri — Variations in the Length of ihe Vaginal Portion of the Cervix Uteri; Relation of Pregnancy to this Condition.

Examination of the Uterus by Means of the Soi/'nd. — The Instru-

8 CONTENTS OF VOL. 1.

ment; Method of Introduction — Variations in the Length and Direction of the Uterine Canal detected by the Sound.

Examination of the Os Uteri by Means of the Speculum. — General Rules — Method of Using the Instrument — Description of Various Instruments.

Examination of the Ovaries 60

Chapter IV. Symptomatology Of Diseases Of The Uterus

List of Symptoms Observed. — Uterine Dyskinesia, its Importance and Frequency — Hysterical Symptoms — Cerebral Symptoms 91

Chapter V. General Pathology Of The Uterus

Historical Summary. — The Mechanical System of Uterine Pathology — Definition — Laceration of the Cervix Uteri 94

Chapter VI

abnormal conditions of THE TISSUES OF THE UTERUS — MAL-NUTRITION OF THE UTERUS — ABNORMAL SOFTNESS.

MAL-NUTRITION OF THE UTERUS OR ABNORMAL SOFTNESS. — ItS ^true

Pathological Nature — Evidence of Existence of General Mal-nutrition in such Cases — Effects in Predisposing to, or Causing Distortions of, the Uterus — Symptoms observed — Typical Cases 100

CHAPTER VIL

CONGESTION OF THE UTERUS AND CONGESTIVE HYPERTROPHY,

Peculiarities of the Circulation of the Uterus. — Effect of Compression at the Centre of the Uterus in producing Congestion at its Two Extremities — General Congestion : Causes — Acute and Chronic Varieties — Relation of Acute Form to Gooch's " Irritable Uterus" — Effect of Flexions in causing Acute Congestion — Chronic Congestion: Causes and Effects — Increase in Size of Uterus — Association of Chronic Congestion with Flexions iio

Chapter VIII

sub-involution of the uterus — ATROPHY AND HYPERTROPHY OF THE UTERUS.

Sub-involution of the Uterus. — Nature and Treatment.

Atrophy of the Uterus ; the Result of Sexual Involution — Premature

Senile Atrophy or "Super-involution" of the Uterus — Mechanical

Atrophy.

Hypertrophy of the Uterus.— Result often of Defective Involution

after Delivery— Hypertrophy, with Elongation of the Cervix. . . . lai

CONTENTS OP VOL. I.

Chapter IX. Treatment Of The Various Textural Disorders Of The Uterus

MAL-NUTRITION OF THE UTERUS — CONGESTION, CONGESTIVE HYPER- TROPHY, ETC.

General Preventive Treatment— Dietary Necessary— Importance of Deficient Dietary as a Cause of Uterine Disease — Defects Qualitative and Quantitative — " Chronic Starvation" a Real Disease — Its Importance — Method of Dealing with it — Preventive Treatment as regards Menstruation — Preventive Treatment in Child-bed — Congestion of the Uterus and Congestive Hypertrophy— General Treatment— By Altering Position and Shape of Uterus — By Leeching, Scarifications, etc. — Use of Hot-water Injections— Baths and Watering-places— Astringent and Caustic Applications to the Os Uteri — Internal Remedies 128

Chapter X. Abnormal Conditions Of The Lining Of The Uterus

General Employment of Term Endometritis— Explanation of these Cases — Cause most frequently Retention in Uterine Cavity of Irritating Discharges, Retention being due to Uterine Distortion — Importance of Drainage of Uterine Cavity — Fungous Condition of the Lining of the Body of the Uterus shown to be really Congestive Hypertrophy of the Mucous Membrane 144

Chapter XI. Acute Inflammation Of The Uterus

Nature and Treatment 153

Chapter XII. Defective Development Of The Uterus — Congenital Malforma- Tions

Diagnosis.

List of Cases. — Absence of Rudimentary Formations of the Uterus — Infantile Uterus — Uterus Unicornis — Double Uterus — Absence of the Os Uteri 155

CHAPTER XIIL

DISPLACEMENTS, DISTORTIONS (FLEXIONS) OF THE UTERUS — I. NORMAL SHAPE, POSITION, AND MOVEMENTS OF THE UTERUS.

Normal Shape, Position, and Movements of the Uterus. — Form and Shape, how preserved in a State of Health — The Proper Position of the Uterus: Discussion of various Opinions on the Subject: Schultze, Schroeder, De Warker, etc. ^Conclusion arrived at — Normal Movements of the Uterus — Degree of Fixation of the Uterus — Motions De-

' scribed ; I. Descent ; 2. Rotation on Transverse Axis ; 3. Flexion — Effect of Evacuation of Contents of Bladder considered i6l lO CONTENTS OF VOL. I.

Chapter XIV

DISPLACEMENTS, DISTORTIONS (FLEXIONS) OF THE UTERUS— 2. PATHOLOGY AND GENERAL HISTORY.

Nomenclature — Flexion, Distortion, Version, Prolapsus — Complex Nature of Cases — Frequency of Distortions and Displacements — Statistics from Author's Hospital Practice— Statistics from Private Practice. 174

Chapter XV

DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS)—" 3. ETIOLOGY.

Etiology. — Statistics of Cases in Private Practice, showing Frequency of Mechanical or Physical Injury or Accident.

Classification of Causes. — i. Predisposing: Undue Softness of the Uterus from Mal-nutrition (Chronic Starvation) — from Sub involution — Physical Prostration — Rupture of Perineum — Previous Pregnancy — 2. Exciting : Accidents — Over-exercise — Special Exercises — Special Occupations — Marriage — 3. General Causes 179

Chapter XVI

DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS) — 4. CLASSIFICATION AND PATHOLOGICAL EFFECTS.

Classification of Flexions and Consequent Displacements. — Pathological Effects.

I. The Seat of the Flexion; 2. Variations in the Condition of the Tissues of the Uterus; 3. Various Kinds of Flexion or Version (Rotation); 4. Varieties in Position of Uterus as a Whole.

Pathological Effects of Flexions, Relation to Congestion, Relation to Hypertrophy of the Uterus — Contraction of the Cervical Canal — Changes in the Uterus, Atrophy, Compression at tlie Seat of the Bent, Sensitiveness at the latter Spot — Persistence of the Distorted Shape of the Uterus — Changes at the Os Uteri 188

Chapter XVII

DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS)^ 5. SYMPTOMS, INCLUDING STERILITY AND ABORTIONS.

Pain, Spontaneous — Pain on Locomotion (Uterine Dyskinesia) — Explanation of this Symptom : Its Great Importance — Undue Tenderness of the Uterus to Touch — The " Irritable Uterus" of Gooch shown to be Acute Flexion.

Dysmenorrhoea. Leucorrhoea, Menorrhagia, Amenorrhcea — Sterility — Abortions — Statistics of Sterility and Abortions in Hospital and Private Practice.

Disturbance of Functions of Bladder — of Rectum — Dyspareunia — Reflex Nervous Symptoms i^y

CONTENTS OF VOL. I. tl

Chapter XVIII

DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS) — 6. GENERAL PRINCIPLES OF TREATMENT.

Principles of Treatment. — i. Indications— Restoration of General Strength; 2. Restoration of Uterus to Proper Shape and Position.

Difficulties Encountered. — Question of Necessity for Examination — Definition of General and Local Treatment — Curability of Flexions — Various Causes of Difficulty.

General Treatment. — Restoration of Nutritional Power and Activity — Rest, how to be carried out — Utilization of Influence of Gravity — Attention to Condition of Bowels.

Local Treatment. — Positional or Postural Treatment — Prone Kneeling Position — Horizontal Position. Use of the Sound repeatedly — Cases adapted for it. Use of Sound combined with Dilatation of Canal by Means of a Dilating Sound. Treatment by Means of Stems: Cases requiring it — Its Value and Applicability. Use of Tents. Incision of the Uterine Canal. Vaginal Pessaries — General Method of Action — Cases suitable for. Necessity for conjoint Postural Treatment and Use of Sound. Other Requirements when Vaginal Pessaries are employed. Material of Vaginal Pessaries. General Summary. Palliative Treatment. Use of Hot-water Injections. Opiates. Treatment of the Accompanying Congestion 224

Chapter XIX

retroflexion and RETROVERSION OF THE UTERUS.

Severity of the Affection — Curability.

Frequency — In Hospital and Private Practice — Compared with Anteflexion — Single or Married.

Special Causes — Traumatic Influences — Dr. Squarey's Views — Influence of Bladder — Pregnancy — Straining Efforts in Defsecation.

Varieties — Basis for Classification. I. Degree of the Flexion, first, second, third ; 2. The Degree of Version (Rotation) — Substitution of Word "Rotation" for Version — Degrees, one, two and three; 3. Degree of Descent of Uterus as a Whole ; 4. Degree of Resistance to Replacement and Unbending ; 5. Degree of Congestion and Enlargement. ,

Progress.

Complications — Adhesions — Congestion — Not to be Confounded with Rigidity-^Prolapse of Ovary — Rupture of Perineum — Fibroid Tumor — Prolapsus of Rectum.

Symptoms — Pain, Dysmenorrhoea, Menorrhagia, Leucorrhoea, Amenorrhoea — Sterility — Abortions — Derangements of Bladder, of Rectum — ■ Reflex Disturbances.

Diagnosis v ^42

CHAPTER XX. RETROFLEXION AND RETROVERSION OF THE UTERUS — {Continued)

Treatment. — General — Local — Plan recommended — Outline and Details — Postviral Treatment — Mechanical Direct Reposition — Maintenance

12 CONTENTS OF VOL. I.

of Proper Position by Vaginal Pessary — Form of Pessary recommended — Various Sizes required.

Position of Patient— Use of tlie Sound — Conjoint Use of Sound and Pessary — Difficulties encountered in Treatment of Cases — Adjustment of Size of Pessary — How far Vaginal Pessaries are reliable — Action of the A. Smith Modification of Hodge Pessary — Necessity for Rest, and Gradual Elevation of Fundus in some Cases — Occasional Over-action of the Retroflexion Pessary — How long to be continued — Method of Introduction — Change of Pessary — ^Various Modifications of Retroflexion Pessary — Dilatation and Moulding for Cure of Retroflexion — Stem Pessary — Incision and Immediate Rectification — Radical Operation (Koeberlfe) — Oophorectomy 262

Chapter XXI

anteflexion and anteversion of the uterus.

Importance of Anterior Displacements and Flexions Considered. — Frequency with which these Conditions give Rise to Uterine Dyskinesia — Great Frequency of this latter Symptom as observed in Practice.

Definition. — Difficulty hitherto Experienced in Definition — Owing to Existence of slight Anteflexion in Normal Uterus — Owing also to Misapprehension of True Nature of Congestion of Uterus associated with Anteflexion — Author's Definition: Exceptional Cases when the Definition does not apply — Use of the Finger in making the necessary Exploration — Precautions to take.

Frequency. — Hospital and Private Practice compared — Single or Married — Age of 488 Cases in Private Practice.

Etiology. — Predisposing Causes — Discussion of Schultze's Views as to Movement of Uterus when Bladder is emptied — Author's Dissent from Schultze's Conclusions — Importance of Softness of Uterine Tissues and Want of Rigidity as causing Anteflexion — Previous Pregnancy — Rupture of Perineum — General Physical Weakness and Prostration — Special or Exciting Causes : Traumatic Causes, their great Frequency — Previous Attacks of Parametritis — Schultze's "Pathological Anteflexion" — General Perimetric Fixation result of Anteflexion of long standing 286

Chapter XXII

anteflexion and ANTEVERSION OF THE UTERUS — {Continued).

Varieties — l. In Degree of Flexion; 2. Degree of Rotation of Uterus ; 3. Degree of Descent of Uterus as a Whole; 4. Rigidity of Uterine Tissues — Various Combinations of these possible, hence Infinite Differences in Cases — Three Principal Degrees of Flexion — Some Leading Types Described — Various Conditions of Cervix — Anteflexion with Posterior Rotation — Severe Cases in which the Uterus is very low down, compressing the Rectum — Variations in Rigidity of Uterine Tissue and Connections— Clinical Features of Different Cases — Illustrative Cases given — Degree of Congestion present.

Complications. — Congestion, Accessions of Acute Congestion — Distension of Cavity — Adhesions — Cystocele — Cystitis — Constipation.

CONTENTS OF VOL. I. 1 3

Symptoms— Uterine Dyskinesia— Illustrative Facts in Regard to this observed in Thirty-three "Fertile" Women and in Thirty-five Single Cases — Spontaneous Pain — Tenderness of Uterus to Touch — Other Abnormal Sensations — Dysmenorrhoea, Menorrhagia, Leucorrhoea, Amenorrhoea — Sterility — Abortions — Dyspareunia — Reflex Nervous Symptoms — Symptoms referable to Bladder; to Rectum.

Diagnosis. — Various Difficulties— Method — Use of Sound — Precautions and Difficulties in introducing it in Different Cases 298

CHAPTER XXIII/

ANTEFLEXION AND ANTEVERSION OF THE UTERUS — {Continued).

Treatment. — Important Differentiation of Cases in regard to Cause of the Affection — The Age, the Duration of the Malady — Importance of General Treatment — Illustrations of Method of Treatment necessary in a Recent Case — Positional Treatment very Important: How to be carried out — Sitting Position to be avoided — A more Severe Case — Combination of Local and General Treatment — Use of " Cradle" Pessary and Sound — Case in which Uterus is very Rigid and Affection of some standing — Further illustrative Cases of Treatment of Anteflexion after Pregnancy.

Employment of. " Incisions'' of the Cervix — Former Misconceptions as to Stricture of the Cervical Canal — Utility of the Operation in Cases of Flexions considered — Necessity for Bougies or Stems afterward — The " Stem" Treatment considered — General Conclusions — Difficulties in Absolute Cure of Long-standing Cases 324

CHAPTER XXIV. ANTEFLEXION AND ANTEVERSION OF THE UTERUS — {Continued)

TREATMENT — {continued).

Pessaries for the Treatment of Anteflexion and Anteversion. — The Author's "Cradle" Pessary — Principle of its Action — Two Varieties, the "Bar Cradle" and "Crutch Cradle" — Various Sizes required — Various Materials — Modification in Use resembling Gehrung's Pessary— Introduction and Removal of the Cradle Pessary — Precautions in Regard to its Use — Dr. GaiUard Thomas's Pessaries — Other Pessaries: Playfair's, Galabin's, Fancourt-Barnes's, Galton's — The Air-ball Pessary 337

Chapter XXV

lateriflexion, lateral displacement and alternating ante- and retroflexion of the uterus.

Lateriflexion of the Uterus. — Treatment.

Alternating Ante- and Retroflexion. — Nature of these Cases — Condition of the Tissues of the Uterus — Treatment, General and Mechanical •••. • 351

14 CONTENTS OF VOL. I.

Chapter XXVI

-INCISION AND DILATATION OF THE CERVICAL CANAL OF THE UTERUS.— STEM PESSARIES.

Incision or Division of the as and Cervix Uteri.— Various Methods of performing the Operation— Means for mainiaining the Canal open afterwards— Dangers of the Operation— Treatment of Cases of Imperforate Os Uteri. , , t.

Dilatation of the Canal of the Uterus.— Dangers of the Procedure —Means of effecting Dilatation — Various Kinds of Tents— Method of Introduction— Metallic Dilators.

Stem Pessaries.— Various Kinds— Simple Stems— Stems with Supporting Vaginal Framework 35°

CHAPTER XXVII. association of pregnancy with flexions of the uterus.

General Observations. — Frequency of Abortions in such Cases: Reasons for this — Difficulty of Expansion of ihe Uterus.

Retroflexion and Retroversion of the Gravid Uterus. — i. Flexion Present before Pregnancy occurs — Natural History, Symptoms, and Effects; 2. Flexion occurring after Pregnancy has commenced — Diagnosis — Treatment — Reduction by Positional Treatment ; by other Means — Treatment of the Bladder.

Anteflexion of the Gravid Uterus. — A Frequent Condition and a Frequent Cause of Abortion — i. Cases where the Anteflexion occurs after Pregnancy has begun— 2. Anteflexion precedes the Pregnancy — History of these various Cases — Reasons why the Complication is not generally recognized as an Important One — Diagnosis — Severe Sickness a Common Symptom — Author's Views on this Subject — Retention of Portions of Ovum another Result of the Flexion — Treatment in various Cases according to Severity of the Case — Elevation of the Uterus, how to be effected — Relief of the Sickness — Modus operandi of the Treatment — Dr. Copeman's Method — Dilatation of the Cervix for Cure of Sickness discussed and explained.

Subsequent Treatment 37i

Chapter XXVIII. The Vomiting Of Pregnancy

Author's Explanation, and Paper on Subject in 1871.

Severe or Dangerous Vomiting in Pregnancy. —Historical and Critical Inquiry into the Subject, with Summary of Observations recorded by Others — Account of Cases published — Dr. Copeman's Cases: Explanation of these — Cases observed by the Author — Aubert's Observations on Influence of Movements of Uterus in producing Sickness — General Risumi of the Subject.

Treatment of the Vomiting of Pregnancy , 391

CONTENTS OF VOL. 1, 1 5

Chapter XXIX. Diseases And Injuries Of The Os And Cervix Uteri

The " Ulceration" Theory of Uterine Disease — Laceration of the Cervix Uteri : Its Effects and Results — Dr. Emmet's Views on the Subject — His Method of Treatment — Importance of Eversion of the Cervical Lining: Causes of the same — Hypertrophy, Cystic Degeneration of the Os Uteri, etc.

Ulcerations of the Os Uteri — Erosions — True Ulcerations — Syphilitic Ulcerations 415

Chapter XXX. Chronic Inversion Of The Uterus

Chronic Inversion of the Uterus. — Causes, Effects, and Varieties. Diagnosis.

Treatment. — Reduction by Systematic and Continuous Pressure aided by Ansesthesia — Treatment by Excision 426

CHAPTER XXXI. PROLAPSUS of the UTERUS

General Remarks on the Pathology of the Subject — Mechanism by which the Uterus is kept in its Place — The various Conditions present in Cases of Prolapsus — Illustrations of various Conditions and Complications — Mechanism of the Process — Relation to Cystocele, Rectocele, and Flexions — Hypertrophic Elongation of the Cervix and its Varieties — Symptoms and Progress of Prolapsus.

Diagnosis.

Treatment. — Must be adapted to the Peculiarities of the Case — Treatment of Prolapsus from Hypertrophy of the Cervix — Excision of the Part — Other Forms of Prolapsus — Measures directed (i) to the Condition of the Uterus; (2) To the Condition of the Uterine Supports — Artificral Means for maintaining the Uterus in its Proper Place in the Pelvis, by Pessaries, by External Appliances, by Constriction of the Vaginal Aperture, or the Canal itself — Description of various Operative Procedures 436

LIST OF ILLUSTRATIONS IN VOL. L

FIG. PAGE

1. Changes in Muscular Fibres of Uterus 40

2. The Ovary, with Pampiniform Plexus of Vessels (Savage) 44

3. Mucous Membrane of Uterus during Menstruation 49

4. Uterus during Menstruation. The Ovary exhibits a recently-

ruptured Graafian Follicle 50

5. A Graafian Follicle preparing for Rupture (A. Farre) 51

6. Section of Ovary and Follicle in Fig. 5 51

7. Virgin Os Uteri (A. Farre) 64

8. Section of Pelvis and Uterus showing position of Uterus (Life

size) 55

g. Os Uteri at Eight Months of Gestation (A. Farre) 67

10. Sectional View of Os Uteri at Eight Months of Gestation (A.

Farre) 71

11. Examination of Uterus by Means of Sound 73

12. Lateral Sectional View of Uterus (A. Farre) ' 76

13. Retroflexion of a somewhat enlarged Uterus 77

14. Bivalve Speculum, in situ 84

15. Examination of Uterus by Sims's Speculum. Os Uteri drawn

down by small hook 86

16. Bivalve Speculum (Cusco's modified by Weiss) 87

17. View (magnified) of Interior of Cervix Uteri (Tyler Smith). .. . 89

18. Lateral Sectional View of Uterus (A. Farre) ill

19. Transverse Section of Uterus at Internal Os (A. Farre) 112

20. Anteflexion of Uterus with Congestion 113

21. Retroflexion of the Uterus accompanied with Congestion 114

22. Anteflexion of Uterus with Congestion, in a Case of Severe

Chronic Vomiting 117

23. Chronic Congestive Hypertrophy with Anteflexion of the

Uterus. 118

24. General Hypertrophy of Uterus and Cervix '^5 v

25. Longitudinal Hypertrophy of Uterus (A. Farre) 126

26. Hypertrophy of Posterior Lip of Os Uteri 127

27. Defective Formation of Uterus (Rokitansky) 156

28. Uterus Unicornis (Pole) 158

2g. Double Uterus (Kussmaul) 159

30. Uterus Bilocularis (Kussmaul) 160

31. Normal Position of Uterus, Life size (see also Fig. 8) 165

32. Position of Uterus when Bladder is Empty (according to

Schultze) 171

33. Normal Range of Movement of Uterus forward or backward 172

34. Lateral Sectional View of Uterus (A. Farre) 190

I8 LIST OF ILLUSTRATIONS IN VOL. I.

35. Anteflexion of Uterus with Congestion igi

36. Acute, long-standing Retroflexion of Uterus 193

37. First Degree of Retroflexion of Uterus 205

38. Tiilrd Degree of Retroflexion of Uterus 205

39. Section of Pelvis, Life size, showing Severe Retroflexion with

Congestion of Uterus, Patient in a Vertical Position 207

40. Same as Fig. 39. Patient being in the Prone Position zo8

41. Severe Retroflexion of Uterus 212

42. Third Stage of Anteflexion with Distention of Cavity and

Thickness of Walls (Chronic Menorrhagia, etc.). - Patient

in Vertical Position 215

43.' Same as Fig. 42, but Patient is supposed to be in Dorsal Position 217

44. Outline of Patient in Genu-pectoral Position 230

45. Genu-pectoral Position showing Uterus Retroverted 230

46. Genu-pectoral Position. Position of Uterus changed by the

Attitude of Patient 230

47. Speculum or Air Tube (Campbell's) to Facilitate Change of

Position of Uterus in Genu-pectoral Position 231

48. Graily Hewitt's Uterine Dilator 233

49. Portion of Blades of Graily Hewitt's Dilator (actual size) 233

50. Tampons in Vaginal Canal (Thomas) 238

51. First Degree of Retroflexion of Uterus 248

52. -Second Degree of Retroflexion of Uterus 248

53. Third Degree of Retroflexion of Uterus 249

54. Second Degree of Retroflexion, with Second Degree of Pos-

terior Rotation of Uterus shown on Section of Pelvis (Life

size) 250

55. Third Degree of Retroflexion and Third Degree of Posterior

Rotation (Life size) 252

56. Three Degrees of Retroflexion of Uterus 253

57. Medium-sized Pessary as Employed by Author for Retro-

flexion, Ground Plan and Sectional View (actual size) 263

58. Various Sizes of Rings from which Pessaries can be made 264

59. Section of Pelvis showing action of the Retroflexion Pessary

(Life size) 265

60. Oblique View of a Medium Hodge Pessary (A. Smith type).. . 266

61. Five Sizes of the Retroflexion Pessary [ 267

62. Three larger Sizes of the Retroflexion Pessary ."....' 268

63. Gehrung's Retroflexion Pessary 273

64. Greenhalgh's Padded Retroflexion Pessary '.'..'... 274

65. Thomas's Modification of Cutter's Retrofle'xion Pessary. .'. .. . 275

66. (Author's) Combined Stem and Hodge Pessary for Treatment

of Retroflexion 270

67. Retroverted Uterus, with Simpson's Sound introduced '. . . 282

68. Retroverted Uterus, with a jointed Sound introduced 283

6g. Marked Anteflexion (a Museum Preparation) | 287

70. Acute Anteflexion and Congestion of Uterus 288

71. Normal Range of Movements of Uterus, in forward or back-

ward Direction 293

72. Position of Uterus according to Schultze, when the Bladder is

Empty 294

73. First Degree of Anteflexion of Uterus 299

74. Second Degree of Anteflexion oqq

LIST "OF ILLUSTRATIONS IN VOL. I. I9

75. Third Degree of Anteflexion 300

76. Complete Anteversion of Uterus 301

77. Three Degrees of Anteflexion of Uterus 302

78. Severe Anteflexion (Emmet) 303

7g. Anteflexion with Posterior Rotation of the Uterus; Section of

Pelvis 304

80. Outline of Uterus, Anteflexion with Posterior Rotation 305

81. Anteflexion of Uterus (Life size), First Degree, shown on Sec- .

tion of Pelvis 306

82. Second Degree of Anteflexion (Life size), Section of Pelvis., 307

83. Severe Chronic Anteflexion, showing much Hypertrophy. . . . 309

84. Anteflexion of Uterus and Congestion. (Case of severe Chronic

Vomiting) 311

85. Large Anteflexed Uterus 312

86. Chronic Anteflexion. Pouched Condition of Uterus 318

87. Author's Cradle Pessary, in situ 327

88. Cradle Pessary (large size), shown in Position, Uterus, etc.

(Lifesize) 328

8g. Triangles indicating Proper Relation of Sides of Cradle Pes-.

sary 338

90. Large size Bar Cradle Pessary 339

91. Large size Crutch Cradle Pessary 339

92. Outline of Cradle Pessary and Uterus (Life size), to show Ac-

tion of Pessary. 34°

93. Large size Crutch Cradle, seen from above 341

94. Profile View of three sizes of Cradle Pessary 341

95. Medium size Crutch Cradle Pessary 342

96. Full size Crutch Cradle Pessary 342

97. Extra thick No. 3 size Spring Cradle Pessary 343

98. Another View of Pessary shown in Fig. 97 343

99. Large size Spring Cradle Pessary in Action 344

100. A Special Mode of using Cradle Pessary 345

loi. Gehrung's Anteflexion Pessaries 347

102 and 103. Thomas's Anteflexion Pessaries 348

104. Mundfe's Modification of Thomas's Pessary 349

105 and 106. Pessary for Treatment of alternate Ante- and Retroflexion 355

107 and 108. Barnes's Tent Introducer 362

109 and iio. Graily Hewitt's Uterine Dilator 364

Priestley's Dilator 3^5

Marion-Sims's Dilator '. 3^5

Chambers's Stem, and Introducer 366

Granville Bantock's Stem, and Introducer 366

Godson's Stem 368

Lawson Tail's Stem 368

Graily Hewitt's Stem Pessary (so called " Padlock" Pessary). 369

Wynn Williams's Stem Pessary 37°

Gravid Uterus, in a State of Retroflexion 378

Anteflexion of Gravid Uterus at about Fourth Month 385

Retained Ovum, or Clots, with Anteflexion of Uterus 387

Double Lateral Laceration of Cervix Uteri (Emmet) 417

Watch-spring Tourniquet for Operation 'of Restoration of

Torn Cervix (Emmet) 4^9

20 LIST OF ILLUSTRATIONS IN VOL. I.

124. Shape of Raw Surfaces after Denudation. Operation for

Restoration of Torn Cervix (Emmet) 420

125. Tenaculum Forceps for Operation of Restoration of Torn

Cervix 421

126. White's Method of Replacing Inversion of Uterus 433

127. Aveling's Instrument for Replacing Inverted Uterus 434

128. Inversion of Uterus and large Polypoidal Tumor 435

l2g. Section of Pelvis, showing Relation of Uterus, Vagina, Perineum, etc. (Life size) 438

130. Complete Prolapsus with Retroflexion of Uterus 441

131. Anteflexion of Uterus with Cystocele 443

132. Chronic Retroflexion with Rectocele 444

133. Supra-vaginal Hypertrophy, with Prolapsus of the Uterus. . 445

134. Hypertrophic Elongation of Infra-vaginal Cervix Uteri with

Prolapsus 446

135. Another Case similar to that shown in Fig. 134 .-. 447

136. Hypertrophic Elongation of Cervix with Retroflexion 448

137. Prolapsus of Bladder with Prolapsus of Hypertrophied Cervix

(A. Farre) 451

138. Ecraseur with Annealed Steel Wire, for Amputation of Cervix

Uteri 455

139 and 140. Operation for Restoration of Perineum 463

141. Author's Method of Constricting Vagina, in Operation for

Restoration of Perineum 466

142. Marion-Siras's Operation for Constricting Vagina 467

143. 144, and 145, show Emmet's Plan for Restoring the Rectal

Sphincter in Cases of Laceration of Perineum 468

THE

Pathology, Diagnosis, and Treatment

OF THE

DISEASES OF WOMEN.

Chapter I

General Considerations respecting the Diseases of the Sexual Organs in Women.

Relations subsisting between General and Local Diseases. — Importance of Maintenance of proper Nutritional Power as affecting the General Condition of the Patient — Nutritional Weakness of the Uterus a Cause of Softness of the Uterus, and an Important Factor in causing other Diseases of the Organ — Relative Importance of Affections of the Uterus and the Ovaries.