A practical treatise on the diseases of women
Zf^<~\ a-'TV y" <,''' [•'/&«•' "^ Davis, Clarke tc Co. I % BOOKSELLERS ^ ^ -- I *^ STATIONEBS, ^ ^ No. 93 Wood St., ^ ^ PittBburgli, Pa. ^ mTSBURGH ACADEMY OF MEDlCmE, 322 North Craig St., PITTSBURGH, PA. PRACTICAL TREATISE ON THE ^-1 A ^ DISEASES OF A¥OMEN. BY T. GAILLAED THOMAS, M.D., PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK ; PHYSICIAN TO BELLEVtJE HOSPITAL : CONSULTING PHYSICIAN TO THE STATE WOMAN'S HOSPITAL ; LATE PRESIDENT OF THE NEW YORK OBSTETRICAL SOCIETY ; MEMBER OP THE NEW YORK ACADEMY OF MEDICINE ; OP THE COUNTY MEDICAL SOCIETY, ETC. ETC. WITH TWO HUNDRED AND NINETEEN ILLUSTRATIONS. PHILADELPHIA: HEE"EY G. LEA. 1868. Entered according to Act of Congress, in the year 1868, by HENRY C. LEA, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania. PHILADELPHIA. COLLIXS, PRINTER, 705 JAYKE STREET. TO JOHI^ T. METCALFE, M.D., PROFESSOK OF CLINICAL MEDICINE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. My Dear Doctor — In the publication of this treatise I am secure of at least one pleasure, that of acknowledging my great indebtedness to you. Such an acknowledgment is usually merel}^ a matter of compli- ment, but in my case it is more. Your conduct towards me from the first moment of our acquaintance has been such, that I find myself called upon, in simple justice, to confess that whatever of profes- sional success has thus far attended me has been due much less to merit on my part, than to a generosity on yours which has known no bounds except those which I have been constantly forced to prescribe it. But not only has my connection with you yielded me many material advantages ; a constant association with 3^ou has furnished one of the chief pleasures of my life, and the privilege of calling yow friend has alwajs been to me a source of pride. I know that you will sincerely join me in the desire that our relations for the future may be as intimate as those of the past, and, like them, be undisturbed by anj' thought or word of reproach. Very truly yours, T. GAILLARD THOMAS. %\1'^ PREFACE. This work was undertaken with the conviction that a treatise, such as that which the Author has aimed to prepare, was needed as a text-book for the American student and a book of reference for the busy practitioner. No department of medicine has made greater advances within the last few years than Gynecology ; yet the record of its pro- gress is, for the most part, to be found only in special mono- graphs, journals, transactions of societies, &c., which are inac- cessible to the mass of the profession in this country. It has, therefore, seemed to the author that a volume which should, within a limited space, present the latest aspect of the subject in a systematic form, could scarcely fail to prove useful, while his position for the last thirteen years as a teacher in this depart- ment has encouraged him in the hope that his familiarity with the needs of the student may, to some extent, have fitted him to undertake the task. In the preparation of the treatise the Author has, therefore, striven to be as concise and practical as possible, and to bring the subject up to the level of the most recent improvements. Many chapters will, probably, appear very short when the im- portance of their subjects is considered; but it has been his effort to condense within the narrowest limits all that is of real value in reference to the matters treated. In furtherance of this view some very rare conditions have been omitted, as, for example, Physometra and Hydrometra. VI PREFACE. As the speciality of Gynecology is being rapidly separated from its sister branch, Obstetrics, this volume has been devoted to diseases of the non-pregnant woman ; such affections as phleg- masia dolens, puerperal fever, mammitis, &c., being properly referable to the province of the accoucheur. The discussion of all unsettled questions has been avoided, the writer preferring to state the views which he regards as correct rather than to risk confusion by entering upon lengthened argu- ments. The space allotted to historical sketches may be regarded by some readers as unnecessary; yet it has seemed to the Author that the information thus conveyed with respect to the progress of our art from the earliest times might not be unacceptable to the earnest student. At the same time, the Author would dis- claim any pretensions to profound research by confessing that he has drawn largely upon contemporaneous writers for his facts. He has more particularly availed himself of the publications of Drs. H. G. Wright, of London, John Watson, of this city, Colombat de ris^re, of France, and of Dr. Francis Adams's Notes to Paulus ^gineta. The works of Hippocrates, Paul of vEgina, Aetius, and some others have, indeed, been constantly by his side, but many which have been referred to have been quoted through modern writers. The Author takes much pleasure in acknowledging his in- debtedness to Dr. B. F. Dawson, of this city, for material assist- ance in preparing the work for the press. T. GAILLAED THOMAS, No. 86 Fifth Avenue, New York. Februaky, 1S6S. CONTENTS. CHAPTER I. HISTORICAL SKETCH OF UTERINE PATHOLOGY PAGE S3 CHAPTER II. THE ETIOLOGY OP UTERINE DISEASES IN AMERICA Want of Air and Exercise Excessive Development of the Nervous System Improprieties of Dress .... Imprudence during Menstruation Imprudence after Parturition. Prevention of Conception and Induction of Abortion Marriage with Existing Uterine Disease 53 54 55 57 57 58 59 CHAPTER III. DIAGNOSIS OF THE DISEASES OF THE FEMALE GENITAL  66 Conjoined Manipulation, or Bimanual Palpation . . .67 Abdominal Palpation . ......  and Tissues . 86 Vlll CONTENTS. CHAPTER lY. DISEASES OF THE VULVA Normal Anatomy Vulvitis Purulent Vulvitis. Follicular Vulvitis Gangrenous Vulvitis Inflammation of the Vulvo- Vaginal Gland. Eruptive Diseases of the Vulva Phlegmonous Inflammation of the Labia Majora Rupture of the Bulbs of the Vestibule Pudendal Hemorrhage Pudendal Hsematocele Pudendal Hernia . . . • Pruritus Vulv^ . . . • Coccyodynia . . . • • CHAPTER Y. RUPTURE OF THE PERINEUM PAGE 87 87 88 88 90 92 94 95 96 97 98 99 102 103 107 HI CHAPTER YI VAGINISMUS 121 CHAPTER YII VAGINITIS Simple Vaginitis Specific Vaginitis or Gonorrhoea Granular Vaginitis CHAPTER YIII. ATRESIA VAGINA. CHAPTER IX. PROLAPSUS VAGlNiE AND VAGINAL HERNIiE Prolapsus Vaginae Vaginal Hernice Cystocele. Rectocele. Enterocele. 126 128 130 133 136 142 142 146 146 147 147 CONTENTS. IX CHAPTER X. FISTULA OF THE FEMALE GENITAL ORGANS. Urinary Fistula .... Vesico-Vaginal Fistula Urethro- Vaginal Fistula Vesico-Uterine Fistulse Vesico-Utero-Vaginal Fistulie Treatment ..... Cauterization .... Suture ..... Preparation of the Patient Sims's Operation Bozeman's Operation. Mastin's Operation Elytroplasty .... Closure of the Vagina Urinary FisTULiE Requiring Special Treatment Vesico-Uterine Fistulae Vesico-Utero-Vaginal Fistulae Fistulae with Extensive Destruction of the Base of the Bladder PACE 151 151 152 152 152 153 165 165 165 165 166 174 177 179 179 181 181 182 183 Entero-Vaginal Fistulae Simple Vaginal Fistulae CHAPTER XI FECAL FISTULA . 184 . 187 . 187 CHAPTER XII. GENERAL REMARKS UPON INFLAMMATION OF THE UTERUS 189 Reasons for the Frequency of Failure in the Treatment of Uterine Diseases . 193 Inattention to General Management and Hygiene .... 194 CHAPTER XIII ACUTE ENDOMETRITIS. 197 CHAPTER XIV ACUTE METRITIS 200 CHAPTER XV. CHRONIC CERVICAL ENDOMETRITIS 205 COXTENTS. CHAPTER XVI. CHRONIC CERVICAL METRITIS Resume of Treatment of Cervical Metritis CHAPTER XVII. CHRONIC CORPOREAL ENDOMETRITIS CHAPTER XVIII. CHRONIC CORPOREAL METRITIS PAGE . 223 . 237 . 238 252 CHAPTER XIX. ULCERATION OF THE OS AND CERVIX UTERI 263 Varieties of Cervical Ulceration . . . •. 264  The Syphilitic Ulcer ....... 273 The Corroding Ulcer ^ ...... 275 The Cancerous Ulcer ....... 276 CHAPTER XX. GENERAL CONSIDERATIONS UPON DISPLACEMENTS OF THE UTERUS 278 CHAPTER XXI. ASCENT AND DESCENT OF THE UTERUS Ascent of the Uteeus ..... Descent ok Prolapsus of the Uterus. Methods of Replacing the Uterus. Methods of Sustaining the Uterus Means adapted to Decreasing the Weight of the Uterus Means for Strengthening Uterine Supports Elytrorrhaphy ..... Sims's Operation of Elytrorrhaphy CHAPTER XXII. VERSIONS OF THE UTERUS " Anteveesion ...... Means for Reduction .... Means for Retaining the Uterus in Position Elytrorrhaphy ..... Retroversion ...... Means for Reduction .... Means for Retention .... 285 285 286 291 291 292 293 297 298 803 303 307 308 309 310 314 315 CONTEXTS. XI CHAPTER XXIII FLEXIONS OF THE UTERUS Anteflexion ...... Means for Preventing a Recurrence Means of Obviating the Consequences of Flexion Retroflexion . .. Lateroflexion ...... 320 320 324 327 330 334 CHAPTER XXIV. INVERSION OF THE UTERUS. Methods of Replacing the Uterus .... Methods of Checking Hemorrhage, the Uterus being left in Situ Methods of Amputating ..... CHAPTER XX Y. PERI-UTERINE CELLULITIS 336 343 347 348 350 CHAPTER XXVI. PELVIC PERITONITIS CHAPTER XXVI I. PELVIC ABSCESS Methods of Operating. Means for Causing Closure of the Sac. 364 380 384 385 Methods of Operating CHAPTER XXVIII. PELVIC HEMATOCELE CHAPTER XXIX. FIBROUS TUMORS OF THE UTERUS CHAPTER XXX. UTERINE POLYPI CHAPTER XXXI. CANCER OF THE UTERUS 386 397 398 417 425 xn CONTENTS. CHAPTER XXXII. CANCROID TUMORS OF THE UTERUS. Fibro-plastic Tumors. Recurrent Fibroid Tumors PAHE 435 435 436 CHAPTER XXXIII. EPITHELIOMA, OR EPITHELIAL CANCER OF THE UTERUS Ulcerating Epithelioma, or Corroding Ulcer of the Uterus Vegetating Epithelioma, or Cauliflower Excrescence of the Uterus CHAPTER XXXIV. DISEASES RESULTING FROM PREGNANCY Uterine Moles ....... Cystic Degeneration of the Chorion, or Uterine Hydatids Subinvolution of the Uterus ..... Superiuvolution of the Uterus ..... CHAPTER XXXV. FUNCTIONAL DISORDERS OF THE UTERUS Dysmenorrhoea. Neuralgic Dysmenorrhoea. Congestive Dysmenorrhoea Inflammatory Dysmenorrhoea Obstructive Dysmenorrhoea Membranous Dysmenorrhoea CHAPTER XXXV I. MENORRHAGIA AND METRORRHAGIA. CHAPTER XXXVII. AMENORRHEA 438 439 443 449 449 452 454 456 458 458 459 462 463 464 471 473 479 CHAPTER XXXVIII LEUCORRHCEA. CHAPTER XXXIX. STERILITY. 487 403 CONTENTS. Xlll CHAPTER XL. AMPUTATION OF THE NECK OF THE UTERUS Varieties of the operation Methods of Performance Operation by Bistoury or Scissors Operation by the Ecraseur Operation by the Galvano-Caustic Operations by Drs. J. Kammerer and Guleke, at tlie German Dispen: ary PAGE 499 501 501 501 502 502 504 CHAPTER XLI. DISEASES OF THE OVARIES Imperfect Development Hypertrophy of the Ovaries Ovarian Apoplexy Dislocations of the Ovaries Ovaritis. Acute Ovaritis Chronic Ovaritis. Ovarian Abscess 506 509 513 515 516 517 518 524 525 CHAPTER LXII FLUID OVARIAN TUMORS. Hydatid Cysts .... Ovarian Cysts .... Tapping through the Abdominal Walls. Tapping through the Walls of the Vagina CHAPTER XLIII OVARIOTOMY 528 528 529 546 547 560 CHAPTER XLI V. OVARIAN TUMORS — CONTINUED Tnmors of the Broad Ligaments Solid Tumors of the Ovary 589 589 595 CHAPTER XLY. DISEASES OF THE FALLOPIAN TUBES. 606 LIST OF ILLUSTEATIOSS. 1, 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19 20 21 22, 23. 24. 25. 26. 27. 28. 29. Ancient valvular specula (Scultetus). Practice of conjoined manipulation (Sim.s) Fergusson's speculum. Thomas's telescopic speculum. Short cylindrical speculum Sims's speculum Sims's depressor Emmet's speculum Thomas's modification of Sims's speculum Sims's speculum with fixed depressor. Cusco's speculum modified Nurse holding Sims's speculum (Sims) Position for introduction (Sims) Sounds of Valleix and Kiwisch 30. 31. ) Sounds of Simpson and Sims compared (Sims Sims's probe, smallest size A sponge tent A sea-tangle tent Tenaculum for fixing the uterus Introduction of a tent (Sims) Follicular vulvitis (Huguier) Phlegmonous inflammation of the labia majora (Boivin and Dug^s) Plexus of veins of the vestibule (Kobelt) Sketch of the anatomical relations of the coccyx Normal perineum • . .. Ruptured perineum • . .. Baker Brown's operation for rupture of the perineum, showing the denuded surfaces (Brown) The same, showing the wound closed (Brown) Sims's vaginal dilator. PAGE 38 68 70 71 72 73 73 74 74 75 75 76' 76 77 79 80 82 83 84 84 91 97 98 109 112 112 117 118 .124 XVI LIST OF ILLUSTRATIONS. FIB. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67, 68, 69 70 71 Filiform papillse of the vagina (Kilian) Epithelium in all stages of development, in simple vaginitis (T. Smith) Hard rubber tube with piston, for placing medicated cotton or sup- positories in the vagina Abdominal supporters (Brown) Varieties of vesical fistulee Long-handled scissors. Bistoury for paring edges of fistula Paring the edges (Wielaud and Dubrisay) Diagram showing bevelling of edges Sims's sponge-holder with handle nine inches long (Sims) Needle held in forceps. Course of the needle Passing the needle (Wieland and Dubrisay) Forceps for drawing needle Twisting the sutures Fulcrum for supporting wire while it is twisted Fork with blunt points to aid the passage of sutures Hook for engaging needle Sutures twisted (Wieland and Dubrisay) Sims's sigmoid catheter Removal of the sutures (Sims) Bozeman's suture adjuster Sutures adjusted Button being passed Passing the shot Stohlmann's hollow neeedle Mastin's operation for fistulse of the female genital organs Wound closed . . . • Coghill's twister employed in the operation Example of a case requiring obliteration of vagina (Sims) Obliteration of the vagina (Wieland and Dubrisay). Vesico-uterine fistula, showing the cervix slit and the sutures passed Anterior lip of fistula united to anterior lip of cervix Anterior lip of fistiila united to posterior lip of cervix (Wielaud and Dubrisay) . . • • • Examination for fecal fistulse (Wieland and Dubrisay) Inflammation of the uterus, showing the dividing line between body and cervix Chronic cervical endometritis. Dr. Quain's representation of the cavities of body and cervix (Quain) Dr. Bennet's representation of uterine and cervical cavities (Bennet) One of the four longitudinal columns of rugse  covered by cylindrical epithelium and containing looped bloodvessels (T. Smith) 73. Rod eight or nine inches long, wrapped with cotton PAGE 127 129 135 149 152 167 167 168 168 168 169 169 169 169 170 170 170 170 171 172 173 175 176 176 176 177 178 178 178 179 180 181 182 182 185 192 206 207 207 208 208 215 LIST OF ILLUSTRATIONS, XVll FIG. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. Syringe for cleansing the cervix and vagina Silver probe with slide. Same instrument with cotton wrapped around it and Budd's elastic probe Lente's silver caustic probe Lente's cup for fusing nitrate of silver Cervical metritis Buttles's spear-poiuted scarificator Hard rubber cylinder for dry cupping the cervix uteri Davidson's syringe Tub for vaginal irrigation Scauzoni's irrigator Vaginal suppository tube >- Cauterizing irons 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. Cervix blistered by the warm iron in four spots Sims's caiistic holder .... Corporeal endometritis Lente's ointment syringe Corporeal metritis .... Abdominal supporter of jean or silk Abdominal supporter in which the pad covers the Operation for eversion of cervix Sims's tamjion placer .... Diagram representing the three degrees of prolapsus Prolapsus in the third degree (Boivin and Duges) Uterine mouth everted, bladder pulled down stretched in both vesico and recto-vaginal cul-de-sac Coxeter's pessary .... thread attache hypogastrium and peritoneum (Cruveilhier) l Zwanck's pessary Zwanck's pessary of box-wood Coxeter's modification of Zwanck's pessary Roser's pessary .... Scanzoni's pessary Hoflfman's pessary shaped like the pelvis Bourjeaud's pessary Gariel's pessary Sound with sharp points (Sims) Uterus fixed by the sound (Sims) Speculum and sound in position (Sims) Sims's operation of elytrorrhaphy, sutures in place Emmet's operation of elytrorrhaphy. 2 PAGE 216 218 218 219 220 220 223 228 228 229 230 230 231 233 234 235 238 249 252 258 258 269 270 286 287 290 295 295 295 296 29-6 296 296 297 297 298 299 299 300 300 XVlll LIST OF ILLUSTRATIONS. FIG. 119. Normal position of uterus (Wielaud and Dnbrisay) 120. Position of the pregnant uterus 121. The degrees of anteversion 122. Gariel's air pessary in place (Wieland and Dnbrisay) 123. Operation for shortening anterior vaginal wall (Sims) 124. Retroversion of the uterus 125. The degrees of retroversion 126. Sims's uterine repositor 127. Replacing a retroverted uterus (Sims) 128. Uterus hound down by false membrane (Picard) 129. Hodge's closed lever pessary. 130. Hodge's open lever pessary 131. Scattergood's pessary, with spiral sprint;? in branches 132. Sims's block-tin pessary 133. Cutter's pessary 134. Meigs's ring pessary 135. Anteflexion (Wieland and Dnbrisay) 136. Peaslee's stem pessary 137. Detschy's stem pessary (Wieland and Dnbrisay) 138. Creation of new uterine axis. 139. Sims's knife .... 140. Posterior section of the cervix (Sims) 141. The uterus descending changes its axis 142. Scattergood's pessary in position (Peaslee) 143. Partial inversion of the uterus 144. Complete inversion (Horteloup) 145. Uterus inverted by a fibroid attached to fundus (McCliutock) 146. Polypus .... 147. Inversion .... 148. Sessile fibroid .... 149. Partial inversion 150. Reducing an inverted uterus (Sims). 151. Plug for making counter-pressure in inversion 152. Pelvic peritonitis, showing roof of pelvis 153. Subperitoneal haematocele (Simpson). 154. Peritoneal haematocele. 155. Submucous fibroid (Sims) 156. Subserous fibroids (Boivin and Dugis) 157. Interstitial fibroid 158. Submucous fibroid (Sims) 159. Aveling's polyptome 160. Nelaton's forceps (Wieland and Dnbrisay) 161. The ecraseur, straight and curved 162. The arms of Sims's porte-chaine (Sims) 163. Sims's porte-chaine ready for encircling a tumor (Sims) 164. Ecraseur with joints and elastic arms 165. Gooch's canula armed with a ligature LIST OF ILLUSTRATIOXS. 213. 214 215 216 217 Koeberle's coustrictor Storer's clamp shield . . . • • Closure of the abdominal wound (Wi«laud and Dubrisay) Tubal dropsy (Hooper) . . . • 218. Tubal dropsy (Boivin and Duges) 219. Tubal dropsy (Simpso<i) . . • • PAGE 579 580 583 590 607 608 THE DISEASES OF WOMEN CHAPTER I. ^ HISTORICAL SKETCH OF UTERINE PATHOLOGY. Nothing adds more to the interest of the student who investi- gates the present condition of any department of science than a knowledge of what was done in reference to it, and what was known concerning it in previous ages. This alone would be suf- ficient to call for the present chapter in advance of others of a more practical character. Any attempt, however, at a full and complete review of this subject would be out of keeping with the plan of this work. That a knowledge of medicine as a science was possessed by the ancient Egyptians there can be no doubt, since Pliny informs us that in the time of the Ptolemies a medical school was estab- lished at Alexandria, and dissections pf the human body com- manded. As to the extent of their acquaintance with it, however, we have no information, as the literature of that remarkable people has been entirely closed to us, until, within a few years past, the genius of Champollion has discovered a key for its com- prehension. Thus far the deciphering of papyri and tablets has failed to enlighten us as to any knowledge which they possessed in Gyne- cology ; though we may reasonably hope for such a result in the future, as Herodotus^ distinctly announces the fact of specialties existing among them. " Here," says he, " each physician applies himself to one disease only, and not more. All places abound in ' Book II. c. 84. 34 HISTORICAL SKETCH physicians; some for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal diseases." From Hebraic literature, which is so abundantly at our com- mand, Ave learn almost as little upon our subject; and from the time of Moses, about 1500 B. C, to that of Hippocrates, 400 B. C, all testimony of knowledge upon it is utterly wanting. And yet the learning which the latter evinces in reference to it was surely handed down to him from previous ages, for the Greeks were instructed by the Egyptians, as the Eomans subsequently were by the Greeks. With the writings of Hippocrates commences the literature of Gynecology. He devoted to it three volumes, in which he discusses metritis, induration, menstrual disorders, displacements, &c. Aretseus, Galen, Archigenes, and Celsus, who probably lived in the first and second centuries, all treated of the sub- ject; the first describing accurately the vaginal touch, the varie- ties of leucorrhcea, and ulceration of the womb ; while the second makes the first allusion on record to the speculum, vagina, as being a distinct instrument from the speculum ani, and the third gives an excellent description of peri-uterine cellulitis. From this time, for centuries,' there is abundant evidence that the study of the subject was pursued with vigor, but so many of the works of the authors of those periods exist only in fragments, and so many are strongly suspected of being fictitious, that we pass them over to stop at. the faithful compilation of Aetius,^ who flourished at Alexandria in the sixth century after Christ. His works, compiled in the great library at Alexandria, contain a digest of what was known and done by his predecessors and con- temporaries, and offer the fullest and most reliable evidence con- cerning the knowledge of those times. In quoting him, and his immediate successor, Paulus ^gineta, who was also a compiler, though a far less conscientious one, I must be understood as re- cording, not the views of these individuals, but those entertained by physicians who lived from the time of Hippocrates to theirs, a period of about one thousand years. ' I am indebted to the library of the N. Y. Hospital for an opportunity of fully consulting this and other rare works which were accumulated by the late Dr. John Watson. OF UTERINE PATHOLOGY. 35 In his XYI. book Aetiiis treats of tlie diseases of women in such a manner as to leave no doubt as to his having had a thorough knowledge of many disorders and means of investigation and treatment, which being rediscovered thirteen hundred years after- wards, have, in many instances, been regarded by us as entirely new. Thus he speaks of the speculum, sponge-tents, peri-uterine cellulitis, medicated pessaries, vaginal injections, caustics for ulcers of the cervix, dilatation of the constricted cervix, a sound for replacing the uterus, &c. As I have already stated, Galen speaks of the speculum vaginaj in the second century ; but Aetius still more clearly mentions it and gives rules for its introduction, which are copied almost ver- batim by Paulus without acknowledgment.* The use of spono-e tents he very fully describes, telling of their mode of preparatio°n, and even advising that a thread should be passed through them,' for removal, and that a succession should be employed till com- plete dilatation is accomplished. The importaiice of injections, the douche, hip-baths, and application of caustics to ulcers of the cervix, he also dwells upon, and advises the dilatation of a con- stricted cervix by means of a tin tube. The variety of vaginal injections in use among the Greeks was as great as that of to°day. As astringents, pomegranate rind, galls, plantain, rose oil, alum, sumach, &c., were employed, and as emollients, linseed, poppies,' barley, &c., exactly as we use them now. Upon the use of medi- cated pessaries they relied to a great extent in the cure of ulcera- tions and inflammatory engorgements, employing wool covered with wax, or butter mixed with saffron, verdigris, litharge, &c. Octavius Horatianus even goes so far as to advise a mixture of arsenic, quicklime, and sandarach in very foul ulcers. In addition to injections and pessaries, Aetius mentions the use of vapor, medicated or simple, conducted up to the cervix by means of a reed passed up the vagina. The use of a uterine sound, passed into the uterus and employed as a repositor, is likewise alluded to by this author, in a passage where he advises that displacements of the uterus should be cor- rected specillo et digito. Paul of ^gina, who succeeded Aetius, alludes distinctly to the ' Dr. H. G. Wright, Med.-Chir. Rev., No. Ixxi. -36 HISTORICAL SKETCH speculum as to an instrument in general use before liis time. "If, therefore," says lie, "the ulceration be within reach, it is detected by the dioptra ; but if deep-seated, by the discharges." And again: "The person using the speculum should measure with a probe the depth of the woman's vagina, lest, the tube of the speculum being too long, it should happen that the uterus be pressed upon." It is curious to see how, even in many minor matters, the ancients anticipated discoveries which our contemporaries have brought forward as entirely new.. For example, the air-pessary, made so popular in France and other countries by Gariel, is described and recommended by the Greeks. Colombat' declares that " the ancient Greek physicians made use of pessaries like those just mentioned (air-pessaries), of the form and length of the male organ, which is the reason why they are called npio?tioxwra, or priapiform pessaries." Albucasis, in 1104, advised the use of an inflated pig's-^ladder for the same purpose. The last-named author also describes herpes uterinus, and uterine haemorrhoids are alluded to by Paulus -^gineta^ in this explicit manner : " HjBmorrhoids form about the mouth and neck of the uterus, which will be discovered by the speculum." And thus it is with so many other modern suggestions, that the student of ancient medical literature is most williug to admit the truth of the propo- sition, formulated by Aristotle over two thousand years ago, that "probably all art and all wisdom have often been already fully explored and again quite forgotten." The learning of the Greek School was appropriated by the Eoman, which was an offshoot from it, as the writings of Celsus, Aspasia, Moschion, and Antyllus abundantly testify. But the knowledge of the schools of Greece and Eome was destined to be scattered abroad. At the period of the subjugation of Egypt and the destruction of the celebrated library at Alexandria by the Saracens, A. D. 640, it j^assed as a trophy of war into the hands of the Moslem invaders. "In a few centuries the fanatics of Mohammed had altogether changed their appearance," says the learned Draper.' " When the Arabs conquered Egypt, their ' Diseases of Females, Meigs' translation, p. 152. ^ Sydenham Society's edition, vol. i. p. 645. ^ Intellectual Development of Europe, p. 2S5. OP UTERINE PATHOLOGY. 87 conduct was that of bigoted fanatics ; it justified the accusation made by some against them, that they burned the Alexandrian library for the purpose of heating the baths. But scarcely were they settled in their new dominion, when they exhibited an ex- traordinary change. At once they became lovers and zealous cultivators of learning." The physicians of Alexandria were greeted by them as instructors, and from the seed thus planted sprang up the Arabian School. With other information, of course, they gained that pertaining to Gynecology, but, the Ma- homedan laws forbidding the examination of women by one of the opposite sex, the study languished in their hands ; and although Ehazes, Avicenna, and their successors copied from Greek writers upon it, a want of zeal, due to want of personal observation and experience, allowed a retrograde movement to occur which left the subject enveloped in darkness for centuries afterwards. Al- bucasis, one of the last of this school, flourished at the end of the eleventh century, and after him, although from time to time writers of greater or less merit appeared on diseases peculiar to women, nothing worthy of special note occurs, except the occa- sional allusion to the speculum, which had evidently fallen almost entirely into disuse. Although these facts prove that the physicians who flourished from the foundation of the Greek School of Medicine, 400 years before Christ, to the dispersion of the Alexandrian School by the Saracens, 640 years after Christ, were well informed in Gyne- cology, and were familiar with means of investigation which were subsequently lost or ceased to be appreciated, it must by no means be supposed that their knowledge was of the same exact and scientific nature as that which has prevailed since the modern introduction of the speculum. They did not sufficiently separate inflammations of the pregnant and non-pregnant uterus, confounded affections of that organ with those of the pelvic areolar tissue, and made no distinctions between mucous and parenchymatous metritis and morbid states of the neck and body. Among their remedies were numerous articles which to-day we regard as inert or even injurious — as pigeon's dung, wom'an's milk, stag's marrow, &c. ; and Aetius and Paulus seem to have been as partial to the "grease of geese" as our Milesian popu- lation is at present. 38 HISTOinCAL SKETCH The learning of the Arabians was in time, as that of the rest of the world, gradually enshrouded by the ignorance and super- stition of the period termed the "Dark Ages." During that time many of their writings, like those of the Greek and Koman schools, were destroyed or lost ; but as society emerged from the darkness which overshadowed its intelligence, we see the thread at once taken up and followed, though languidly and without vigor, to the beginning of the nineteenth century. Toward the middle of the seventeenth century we find very special and full allusion made to the speculum and its uses by Ambrose Pare and Scultetus ; the instrument being very well represented by diagrams, with descriptions attached. Fig. 1. Ancient valvular specula. (Scultetus.) "Fig. 1," says the author, "is an instrument which they call 'speculum ani et vaginae uteri,' in that by its help ulcers of the rectum, vagina, and uterus may be seen, to be carefully observed according to their extent and kind." [ScuUetiLS.) Aetius and Paulus evidently knew of a tubular speculum, since they say, "lest the tube of the speculum be too long," &c.; but Scultetus figures a bi- valve and quadri- valve closely resembling those in our hands at present. It is worthy of mention, in this connection, that there is now preserved in the Museo Borbonico OF UTEEINE PATHOLOGY. 39 at Naples a bi-valve speculum whicli was removed from tlie ruins of Pompeii. It has already been stated tliat Aetius makes an obscure refer- ence to a sound for replacing the uterus. This is by no means the first notice of this useful instrument, for it is repeatedly men- tioned by Hippocrates, and Avicenna, the Arabian, likewise alludes to it. Prof. Simpson^ asserts, however, that it was used only for dilatation of the cervix, and not for exploration and measurement. In 1657 a probe, used as we now employ the uterine sound, and intended especially for uterine exploration, was accurately de- scribed by Wierus,^ and alluded to by Hilken, Cooke, and others. As we pass in review the chief works which appeared upon our subject in the eighteenth century, we find frequent mention of the speculum, which is spoken of as a matter of course in the treatment of uterine affections, and yet was evidently not so employed as to render it really a valuable aid in diagnosis or treatment. This constitutes one of the most curious episodes met with in the history of any discovery with which we are acquainted. A most simple and useful instrument was not only well knoAvn in ancient times and subsequently fell into disuse, but fell into disuse without having ever been really forgotten. It was described by successive writers up to the nineteenth century in language as distinct as words could make it, and yet not only did they who read, but they who wrote it, not comprehend its meaning or appreciate its significance. Like the Indians possessed of the diamond, all saw and yet none valued. How could Ambrose Pare, for example, writing in 1640, have indicated its use more clearly than when he tells us, in chapter xix., that ulcers of the womb may be recognized, "by the sight, or by put- ting in a speciilinii''' ? In a copy of his works in the library of Dr. W. A. Hammond the word speculum is italicized in this sen- tence. Scultetus, as we have seen, not only described but figured the instrument in 1683. In 1761, Astruc,^ " Koyal Prof, of Physic at Paris," in de- scribing occlusion of the vagina and obstruction to the menstrual flow, says : " There is nothing more required than to examine ' Obstetrical Works. •^ Dr. H. Ct. Wright, Joe. cit. ' Dis. of Women, Eug. ed., vol. 1. p. 135. 40 HISTORICAL SKETCH the vagina by introducing the finger into it, rubbed previously with oil or pomatum ; but, if that be not sufficient, a speculum uteri may be used, or some other more simple instrument for dilatation, in order to be able, by means of the dilatation of the vagina, to judge by the sight of what the touch could not decide." In 1801, according to Becquerel,^ forty years after this, Reca- mier " discovered the speculum." Nothing is farther from my mind than the wish to cast the slightest discredit upon the inte- grity of the labors of this great man, who was really the founder of the modern school of Gynecology ; but after the evidence which I have adduced, I feel fully justified in asserting that the instrument was not his discovery. Guided by the advice found in many works which his library must have contained — works with which to suppose hira not to have been perfectly familiar, would be to cast a slur upon his medical research — he employed a speculum vaginae in 1801. Like his predecessors, he did not appreciate the great results which were to floAV from it; nor did he appear to have regarded himself as having invented it. It was not until 1818 that he introduced it to the profession, and gave it its place as a valuable addition to science. Can any one suppose that it could have required seventeen years of experi- mentation and study for a man, with the talent of Eecamier, to have applied this simple and useful instrument to purposes of utility ? Is it not more likely that the experience of seventeen years taught him the full value of the instrument ? The credit Avhich belongs to Recamier is not that of a discoverer, but that which is equally great, of having recognized the value of what was well known, but badly appreciated before his time. Even before this fortunate revival, as the eighteenth century approached its close, the glimmer of the new era which was about to dawn, could clearly be detected in the advanced views which were promulgated by Garangeot and Astruc in France, and Denman, John Clark, and Hamilton in England. The early part of the nineteenth century found the field occupied chiefly by Sir Charles Clarke and Dr. Gooch in England, and Recamier and Lisfranc in France. These were not the only eminent writers ' Mai. de 1' Uterus, vol. i. p. 9. OF UTERINE PATHOLOGY. 4i of that time, but tliej were unquestionably tliose who chiefly moulded professional opinion. Even at that period Gynecologists ranged themselves into two parties, which, so late as at our day, have scarcely coalesced. In England the feeling was strongly in favor of regarding the local disorder as the result and not the cause of concomitant constitu- tional derangement ; while in France the uterine disease was viewed as the main element, and the general condition as de- pendent upon and resulting from it. The great advantages of the speculum secured its rapid adop- tion in France. More slowly it forced its way through many prejudices into Great Britain, and before a great many years had passed it was, throughout the civilized world, placed upon an enduring basis as one of the boons bestowed by medicine upon humanity. The way being opened for investigation by this instrument, new aids to diagnosis and treatment were rapidly advanced. In 1826 Guilbert read before the Academy of Medi- cine of Paris an essay proposing the application of leeches to the cervix. In 1828 Samuel Lair read before the same body a paper in which he counselled the use of the uterine sound. In 1882 M. Melier presented an essay, in which he offered two new sug- gestions in the treatment of uterine diseases — one, injections into the cavity of the cervix; the other, local applications in the vagina by dossils of lint saturated with astringents, narcotics, &c. His views are quoted extensively by French writers, and Nonat says that the author recognizes, " avec une franchise qui I'honore," that Boyle, Chaussier, Guillou, and others, had a short time before him used similar means. Very curiously neither Melier nor his commentators mention that both these sugges- tions are made and fully elaborated by Astruc, in his excellent article upon " Ulcers of the Uterus." He describes these appli- cations of medicated charpie very carefully, remarking that it is advisable to "tie a thread to every pledget, in order to draw it out again when it is proper to renew the dressing." And he not only advises injections of water, impregnated with different substances, into the cavitj of the womb, but also the juices of plantain, houseleek, nightshade, &c. "For," says he, "as it is of consequence that these injections should enter into the uterus, where the ulcer has its seat, it is proper they should be made by 42 HISTORICAL SKETCH a professor of midwifery, capable of introducing skilfully the end of the canula into the orifice of the uterus," &c. At this time arose the question as to cancer of the uterus, whether it was the local manifestation of a general blood state, or the result of an inflammatory engorgement long neglected; a question which excited warm discussion, and brought forth the most opposite views. The ambition of Recamier was not satisfied with exposing the cervix uteri to view. He had the boldness to explore the cavity of the body of the organ, almost establishing the use of the sound, and even, by means of a species of scoop called a curette, ventured in certain cases to scrape off' its investing mucous mem- brane. In addition he described, through one of his students, pelvic cellulitis, and gave the first intimation which modern observers have had of the possibility of pelvic hasmatocele. These discoveries on the part of the French physician mark an era in Gynecology ; one no less important was created by the appearance in the field of labor of Professor, now Sir James Simpson, of Edinburgh, About the year 1843 he rapidly deve- loped and recommended to the profession several of the most important means of diagnosis now at our command. The utiliza- tion of the uterine sound, which Lair had never succeeded in introducing into general practice, and the dilatation of the canal of the cervix by sponge-tents, so that the body may be exam- ined, are both due to his genius and enterprise. He likewise contribated from time to time original and valuable papers upon pelvic cellulitis, hasmatocele, uterine flexions, &c. His articles, indeed, first excited the study of uterine displacements in Great Britain, and to his efforts may be traced, in a great degree, the interest which has been of late years aroused in that country with reference to uterine pathology. Until this time the subject had attracted very little attention there, and advances which had been made in it were due almost entirely to French pathologists. It is true that the excellent work of Sir Charles Clarke existed; but that warm and zealous interest which has since resulted in so much benefit to Gynecology, had not then been excited. But Prof. Simpson was not alone in this work. Dr. J. H. Beunet, of London, at that time a young physician, who had for some years served as interne in the hospitals of Paris, returned to his own OF UTERINE PATHOLOGY. 43 country imbued with the views which Recamier and Lisfranc had disseminated among a large circle of followers. In 1845 the iirst edition of his work on Inflammation of the Uterus appeared, and it is safe to assert that no work of modern times, written upon any subject connected with our profession, has exerted a more decided and profound influence. Taking up the subject with a vigor and energy which forced attention, if not conviction, he produced an undeniable impression upon the profession, not only in his OAvn country, but in Germany, France, and America. However others may differ from him, no candid mind can deny him the obligation under which he has placed his brethren by arousing their attention and directing their investigations into proper channels. The chief points insisted upon in his work are these: 1. That inflammation is the primum mobile in uterine affections, and that ffom it follow as results, displacements, ulcerations, and affections of the appendages. 2. That menstrual troubles and leucorrhoea are merely symptoms of this morbid state. 3. That in the vast majority of cases, inflammatory action will be found to confine itself to the cervical canal, and not to have affected the cavity of the body. 4. The propriety of attack- ing the disease in its habitat by strong caustics. About this time a discussion sprang up between Dr. Bennet on one side, and Drs. Robert Lee, West, and Tyler Smith on the other, with reference to the true character of ulceration of the neck; Dr. Bennet supporting the view that the cervix is often affected by inflammatory ulceration, and his opponents denying it. The discussion, looked at calmly by posterity — nay, even at the present time — will be pronounced a polemic disputa- tion, which has not served to clear up the subject, nor to have accomplished any really good end. One further benefit which Dr. Bennet conferred in his work, was in placing upon a surer basis than it had yet occupied, the differentiation of inflammatory engorgement and induration from commencing cancer of the neck. It would be well before proceeding farther to state as succinctly as possible the different pathological views which from this time, and even somewhat before it, were offered to the profession, and more or less generally adopted. They may be thus enumerated: — 44 HISTORICAL SKETCH 1st. That inflammation is the starting point of most of the affections of the uterus, and that a large number of evils follow this morbid state as results. 2d. That uterine disorder is dependent upon a constitutional derangement, and would yield without other treatment than that directed to the removal of the general condition. 3d. The view of Dr. Bennet, which is similar to the first men- tioned, with this additional point, that metritis generally limits itself to the neck, and only exceptionally affects the body. 4th. The view of Dr. Tyler Smith, that leucorrhoea arising from glandular inflammation in the cervix is the cause of granu- lar degeneration of this part, and of subsequent engorgement. 6th. The view that uterine disorders often, if not generally, commence in displacement, which is a primary and not a sec- ondary condition, and that to relieve the train of morbid symp- toms, this, its exciting cause, should be first removed. 6th. The view that uterine disorder is commonly the result of ovarian inflammation, which reacting on the womb is the prime mover, in many cases, of its morbid states. I have no intention of discussing here the merits of these the- ories, but will limit myself to a few words connected with the history of each. The theory mentioned first in this enumeration is the oldest on record, the writers of the Greek School even adopting it. Thus Paulus JEgineta heads his chapter on this subject, "Inflammation of the uterus and change of its position." One of the symptoms of such inflammation he considers to be retroversion of the uterus. In the beginning of the present century this was gene- rally accepted in France. Lisfranc and Recamier adopted it, and it was transferred to, and advocated in Great Britain by the writ- ings of Dr. Bennet. I do not believe that I state too much in asserting that the great majority of Gynecologists in this country accord in it ; though of course I admit that the statement is open to error, as every other statement of this kind is when not forti- fied by statistical proof. No one can devote himself to the practical study of uterine diseases without being impressed with the strong grounds which exist for the maintenance of the second of the theories mentioned. 